Preference Signaling in the Urology Match.

PURPOSE: This manuscript summarizes the introduction, evolution and current outcomes for preference signaling in Urology as well as its use in other medical specialties. Overapplication plagues the residency recruitment process and PS has emerged as a process to improve the bottleneck of the interview selection process. RECENT FINDINGS: PS has been shown to be associated with a higher likelihood of interview among many subspecialties. Applicants and programs report satisfaction with the process. Further solutions are needed to increase transparency of program information and selection criteria to applicants so that critical decisions on which programs an applicant should apply to can be data driven.

Ureteral stenting practices following routine ureteroscopy: an international survey.

PURPOSE: Stent omission after routine ureteroscopy (rtURS) is accepted by current guidelines and may result in decreased patient morbidity and treatment costs. In a value-based healthcare model, the added morbidity and cost of routine stent placement may be scrutinized. Furthermore, data are limited on urologist cost knowledge and it is effect on ureteral stent placement. As such, we seek to describe ureteral stenting practices and urologist cost knowledge amongst US and non-US-based urologists. METHODS: The ureteroscopic practice patterns and cost awareness of members of the Endourological Society were surveyed using an international email listserv. Respondents were grouped by practice location (US vs non-US). Logistic regression was used to evaluate the associations of surgeon practice location with stenting practices. RESULTS: 233 completed responses were received with a response rate of 13.5%. Results revealed that 55% and 71% of respondents reported ureteral stent insertion after rtURS more than 75% of the time for ureteral and renal stones, respectively. Reporting stent insertion following more than 75% of rtURS was more common among US participants for both ureteral and renal stones. Overall, reported cost knowledge was high, but lower among US participants. On multivariable analysis, US respondents were more likely to place ureteral stents after rtURS for ureteral stones more than 75% of the time when compared to those abroad (OR 3.43 p < 0.01). CONCLUSION: Ureteral stenting after rtURS is over utilized in the US compared to other countries. While this phenomenon is multifactorial in nature, cost knowledge may be under recognized as a determinant of ureteral stent placement following rtURS.

Contemporary Assessment of Match Violations within Urology: an Opportunity for Ethical Leadership.

PURPOSE OF REVIEW: The primary aim of this review is to: (1) adequately define Match violations, (2) thoroughly examine the nature and scope of Match violations in the American Urologic Association (AUA) Urology Match, and (3) propose and recommend policy guidelines, including consequences for applicants and programs, as it pertains to Match violations. These recommendations are intended to affect change at the level of the AUA and Society of Academic Urology (SAU) that more effectively mitigates future violations, intentional or not. RECENT FINDINGS: There is a paucity of specific guidelines published by the AUA on what constitutes a Match violation. Furthermore, in contrast to the National Resident Matching Program (NRMP), the AUA is surprisingly lenient in their existing guidelines. The Match violations most frequently reported were programs asking applicants illegal and restricted questions as well as inappropriate post-interview communication between applicants and programs. Review of current Match policies and violations suggest several areas for improvement, particularly regarding the specificity of AUA guidelines to define Match violations, the asking of illegal interview questions, and post-interview communication. The obligation to uphold a fair and equitable Match is an ethical imperative for the urologic community.

Complications: The Experience of the Urologic Surgeon.

INTRODUCTION: Most urologic surgeons will experience surgical complications during their career. These complications can traumatize the surgeon. A national survey of AUA members was conducted to better understand the impact of surgical complications on mental, emotional, and physical health. METHODS: An anonymous survey was distributed to a random sample of 4528 AUA members (US urologists and trainees). Survey items were designed to identify the prevalence of surgical complications, and consequential mental, emotional, and physical impact on the surgeon. Also assessed was the support infrastructure available to urologists who experienced complications. RESULTS: The survey was completed by 467 urologists (10.3% response rate), 432 (95%) of whom reported having experienced a serious complication. The most common mental/emotional experiences were anxiety (85%), guilt/shame (81%), and grief/sadness/depression (71%). The most common physical symptoms reported were insomnia (62%), loss of appetite (23%), and headache (13%). Approximately 94% of respondents reported that they did not receive any counseling, and 69% reported not receiving any emotional support following the incident. Urologists reported that shame, lack of administrative time, fear, stigma, and guilt were barriers to seeking support. CONCLUSIONS: The overwhelming majority of urologists experience significant complications. These complications are associated with a high incidence of physical and emotional distress, and there is poor access to support. There is an opportunity for the AUA and other agencies to address barriers to seeking and accessing care for urologists who experience mental, emotional, and physical distress after experiencing surgical complications.

Investigation of Disparity of Urologic Fellowship Match Rates by Gender and US Versus International Medical Graduates Over the Past Decade.

OBJECTIVE: To investigate the influence of postgraduate medical education (US vs. international) and gender on applicant matching for postgraduate training across different urologic sub-specialties. METHODS: Match statistics of five societies that participated in the AUA fellowship match between 2010-2024 were retrospectively reviewed. Societies included: Endourology Society (EUS), Society for Urological oncology (SUO), American Society of Andrology (AMA), Society of Genitourinary Reconstructive Surgeons (GURS), and Society of Pediatric Urology (SPU). Candidates were classified based on gender (male/female) and their postgraduate medical education: local graduates from the United States or Canada (US/Ca) and international medical graduates (IMG). The match odds were analyzed using the Chi-square test, while trends were assessed through the Mann-Kendall test. RESULTS: Overall, 2429 applicants applied for 1627 programs from 2010 to 2024, comprising 1998 males (81.8%), 399 females (16.4%), and 42 undisclosed (1.7%). There were 1486 US/Ca graduates (60.8%) and 953 IMGs (39.2%). 1471 (60.6%) applicants were matched with a program, compared to 958 (39.4%) unmatched. The likelihood of US/Ca graduates matching (83.8%) was significantly higher than IMGs (23.3%), OR = 17.5, 95% CI: (14.3, 21.5), p < 0.001. IMGs had the highest match rate with GURS (33.8%, 47/118) and the lowest with SPU (7%, 1/14). Female applicants had a significantly higher chance of matching 324/399 (81.2%) than male applicants 1139/1998 (57%), OR = 3.26, 95% CI: (2.5, 4.3), p < 0.001. US/Ca-to-IMGs ratios and the male-to-female ratios were stable throughout the match years. CONCLUSIONS: Compared to IMGs, U.S./Ca graduates had remarkably higher matching rates. Matching outcomes were also significantly better for female applicants. Further assessment of international involvement and diversity in urological subspecialty roles is warranted.

Impact of Dobbs v. Jackson Women's Health Organization on Professional Decision-Making Among Urology Applicants.

MATERIALS AND METHODS: An Institutional Review Board-exempt REDCap survey was distributed through the Society of Academic Urologists to all 508 applicants registered for the 2023 Urology Match following the rank list submission deadline on January 10, 2023. The survey closed on February 1, 2023. Responses were anonymized, aggregated, and characterized using descriptive statistics. Thematic mapping of open text comments was performed by 2 reviewers. RESULTS: The response rate was 42% (215/508). Eighty-eight percent of respondents disapproved of the Dobbs ruling. Twenty percent of respondents (15% male/24% female) eliminated programs in states where abortion is illegal. Fifty-nine percent (51% male/70% female) would be concerned for their or their partner's health if they matched in a state where abortion was illegal, and 66% (55% male/82% female) would want their program to assist them or their partner if they required abortion care during residency. Due to the competitive nature of Urology, 68% of applicants reported feeling at least somewhat obligated to apply in states where abortion legislation conflicts with their beliefs. Of the 65 comments provided by respondents, 4 common themes emerged: (1) avoidance of states with restrictive abortion laws; (2) inability to limit applications because of the competitiveness of urology; (3) impacts on personal health care; and (4) desire for advocacy from professional urology organizations. CONCLUSION: The Dobbs ruling will impact the urology workforce by affecting urology applicants' decision-making regarding residency selection and ranking. Although the competitiveness of the Urology Match pressures applicants to apply broadly, many are taking reproductive health care access into consideration.

Highlighting Gender Differences in RLS: Analysis of Gender in Robotic and Laparoscopic Surgical Volume in Urology Vs Other Subspecialties.

OBJECTIVE: To evaluate the involvement of women surgeons in RLS over time and across fields. While women are an increasing proportion of the urological workforce, the overall percentage of women urologists remains low. As robotic/laparoscopic surgery (RLS) has become first-line for many surgical problems, we hypothesized that women in urology may have lower participation than other specialties. MATERIALS AND METHODS: We obtained country-wide data by surgeon from the Data.CMS.gov database for 2014-2019 for major RLS procedures in colorectal surgery, gynecology, thoracic surgery, and urology. Data were sorted by gender and CPT code. Temporal trends were assessed, and estimation was performed by exponential regression comparing means and rates of change between departments and surgeon genders. RESULTS: Surgeons across disciplines and genders showed increases in RLS volume over time (P <.05). There were significant differences between men and women surgeons between specialties in average number of surgeons (P <.0001) and rate of change over time (P = .0035). The difference of the rate of increase in the number of surgeons performing RLS between genders was significant for all disciplines, suggesting women were entering RLS surgery faster than men across specialties (P <.05). CONCLUSION: There is a disparity in RLS procedure performance in men vs women across surgical disciplines. The greatest discrepancy in participation between genders existed in Urology, despite the field having a higher percentage of women physicians than other some subspecialties. Targeted action to address barriers to women surgeons' participation in RLS will increase diversity of thought and improve clinical care.

The Impact of the Virtual Interview on Candidate Experience and Outcomes: Society of Academic Urologists National Survey of Interns Who Participated in the 2020-2021 Urology Match.

OBJECTIVE: To examine retrospective experiences with the virtual interview (VI) process among postgraduate year 1 (PGY1) urology residents who participated in the 2020-2021 American Urologic Association (AUA) Match cycle. METHODS: A 27-question survey created by a Society of Academic Urologists Taskforce on VI was distributed to PGY1 residents from 105 institutions between February 1, 2022 and March 7, 2022. The survey asked respondents to reflect on the VI process, cost concerns, and how experiences at their current program aligned with prior VI representation. RESULTS: A total of 116 PGY-1 residents completed the survey. The majority felt the VI represented the following domains well: (1) institution/program culture and strengths (74%), (2) representation of all faculty/disciplines (74%), (3) resident quality of life (62%), (4) personal fit (66%), (5) quality of surgical training and volume (63%), and (6) opportunities to meet residents (60%). Approximately 71% of respondents did not match at their home program or a program they visited in-person. Within this cohort, 13% agreed important aspects of their current program were not translated virtually, and they would not have prioritized the program had they been able to visit in-person. In total, 61% ranked programs they ordinarily might not have listed during an in-person interview season. Overall, 25% deemed financial costs a "very important" consideration during the VI process. CONCLUSION: The majority of PGY1 urology residents reported key components of their current program translated well from the VI process. This platform offers a method of overcoming conventional geographic and financial barriers associated with the in-person interview process.

Gender Disparities and Differences Among Urologists Included in Top Doctor Lists.

OBJECTIVE: To understand gender trends among urologists included in "Top Doctor" lists as more women practice urology, we (1) Evaluated whether Top Doctor lists reflect a contemporary distribution of urologists by gender; (2) Describe regional differences in gender composition of lists; (3) Report similarities and differences among men and women Top Doctors. METHODS: All urologists in regional Top Doctor Castle Connolly lists published in magazines between January 1, 2020 and June 22, 2021 were included. Physician attributes were abstracted. American Urological Association (AUA) census data was used to compare the number of men and women Top Doctor urologists to the number of practicing men and women urologists within each list's zip codes. Log odds ratios (OR) and (95% confidence intervals) were used to compare likelihood of list inclusion by gender overall and by region. RESULTS: Four hundred and ninety-four Top Doctor urologists from 25 lists were analyzed, of which 42 (8.50%) were women. Women urologists comprised 0%-27.8% of each list, with 7 lists (28.0%) including zero women urologists. Using AUA census data, OR for list inclusion of men urologists compared to women was 1.31 (1.01, 1.70) overall, with OR = 0.78 (0.36, 1.72) in the West, OR = 1.39 (1.03, 1.89) South, OR = 1.46 (0.8, 2.67) Northeast, OR = 1.90 (0.50, 7.18) Midwest. Women top urologists completed fellowship more often than men (66.7%, 55.1%) and were significantly more likely to complete female pelvic medicine and reconstructive surgery (FPMRS) fellowship (P <.001). CONCLUSION: Men urologists were significantly more likely to be included in Top Doctor lists than women urologists. Top women urologists were significantly more likely to complete FPMRS fellowship.

Applying Representation Quotient Methodology to Racial, Ethnic, and Gender Trends of Applicants and Matriculants to Urology Residency Programs From 2010-2018.

OBJECTIVE: To accurately examine the trends in the racial and gender composition of medical students applying and matriculating to urology residency programs. METHODS: Reports on race/ethnicity and gender for medical school graduates, and urology residency applicants and matriculants were obtained for years 2010-2018. The proportions of individuals representing different racial and gender identities among urology applicants and matriculants were divided by a denominator of their proportion in medical school graduating classes to produce representation quotients (RQapp and RQmat, respectively). Linear regression models were performed on yearly RQs to estimate the RQ changes over time. Nonparametric testing was used to evaluate for differences in applicant to matriculant representation within each identity. ANOVA was performed separately on RQapp and RQmat values to assess differences in representation between identities in the applicant and matriculant populations. RESULTS: Asian men experienced increases in representation among urology applicants (RQapp: slope 2.04 × 10-2; P = .03) and matriculants (RQmat slope: 7.46 × 10-2; P = .0076) during the study period. Black men trended towards under-representation among applicants (RQapp slope -1.51 × 10-1; P = .03) and matriculants (RQmat slope: -1.71 × 10-1; P = .02). When examining genders, both men (RQapp=1.43 vs RQmat=1.44; P = .80) and women (RQapp=0.52 vs RQmat = 0.51; P = .67) had unchanged representation in the applicant and matriculant cohorts, but women severely underrepresented on average. CONCLUSIONS: Women and Black men are underrepresented in the urology workforce. These concerning findings demonstrate the dire need for initiatives regarding recruitment into urology to support and to ensure successful entry into the field for minority groups.

Understanding the Urology Program Directors Perspective on the Current Resident Selection Process: The Society of Academic Urologists National Survey of Urology Program Directors.

OBJECTIVE: The traditional residency selection process was altered dramatically by the SARS CoV-2 (COVID-19) pandemic. For the 2020-2021 application cycle in-person interviews were transitioned to the virtual format. What was thought to be a temporary transition has now become the new standard with continued endorsement from the Association of American Medical Colleges (AAMC) and the Society of Academic Urologists (SAU) for virtual interviews (VI). We sought to assess the perceived efficacy and satisfaction of the VI format from the urology residency program director's (PDs) perspective. DESIGN: A designated SAU Taskforce on "Optimizing the Applicant Experience in the Virtual Interview Era" developed and refined a survey composed of 69 questions on VI and was distributed to all urology program directors (PD) of member institutions of the SAU. The survey focused on candidate selection, faculty preparation, and interview day logistics. PDs were also asked to reflect on the impact of VI on their match results, recruitment of underrepresented minorities and female gender, and what their preference would be for future applications cycles. PARTICIPANTS: Urology residency PDs (84.7% response rate) between January 13, 2022 - February 10, 2022 were included in the study. RESULTS: Most programs interviewed a total of 36 to 50 applicants (80%), with an average of 10 to 20 applicants per interview day. The top 3 ranked criteria for interview selection reported by urology PDs surveyed included letters of recommendation, clerkship grades, and USMLE Step 1 score. The most common areas of formal training for faculty interviewers were diversity, equity and inclusion (55%), implicit bias (66%), and review of the SAU guidelines on illegal questions (83%). Over half (61.4%) of PDs believed that they were able to accurately represent their training program through the virtual platform, while 51% felt that VI did not afford similar assessments of applicant as in-person interviews. Two-thirds of PDs believed the VI platform improve access for all applicants to attend interviews. Focusing on the impact of the VI platform for recruitment of underrepresented minorities (URM) and female gender applicants, 15% and 24% reported improved visibility respectively for their program, and 24% and 11% reported increased ability to interview URM and female gender applicants respectively. Overall, in-person interviews were reported to be preferred by 42%, and 51% of PDs desired VIs to be included in future years. CONCLUSIONS: PDs opinion and role of the VIs into the future is variable. Despite uniform agreement of cost savings and belief that VI platform improves access for all, only half of PDs expressed interest of the VI format being continued in some form. PDs note limitation of VI in the ability to comprehensively assess applicants as well as the in-person format. Many programs have begun to incorporate vital training in the areas of diversity equity and inclusion bias, and illegal questions. There is a role for continued development and research on ways to optimize virtual interviews.

The Role of Alumni Networks and Career Advising in Early Career Stability of Urologists: Results of a Multi-institutional Study.

OBJECTIVE: To characterize training program and early career factors that impact decision-making and job retention following graduation in a diverse population of urologists. MATERIALS AND METHODS: We performed a computer-based survey distributed to residency graduates from 25 urology training programs. Five focus institutions were identified with a goal >30% response rate. The survey included questions about training program specifics and post-training employment characteristics. RESULTS: We obtained 180 responses from urology residency graduates of 25 programs. Overall, 72% (N = 129) remain in their initial post-training position at a median of 6years postgraduation (Interquartile Range (IQR) 3-10). On Cox-regression analysis stronger trainee-rated formal career advising was associated with lower risk of changing jobs (HR 0.77, 0.60-0.99, P = .048). Location/proximity to family was the most consistently cited as the top reason for selecting a job (41%). Sixty-three respondents (35%) joined practices employing graduates of the same residency program. Cox regression analysis showed that joining a practice with alumni of the same program was associated with lower risk of changing jobs from one's initial post-training position (HR 0.39, 95% CI 0.17-0.91, P = .03). CONCLUSION: In this multi-institutional study of urologists, we observed a high rate of job retention out to a median of 6years following completion of training, with formal career advising and joining alumni in practice being associated with job retention. Collectively, our data highlights that training programs should emphasize advising programs and alumni networking in guiding their graduates in the job search process.

Defining the Variance: The Current State of Female and URM Concordance of Urology Resident Workforce to the General U.S. Population.

OBJECTIVE: To compare the current representation of women and underrepresented minorities in medicine (URM) of the urologic resident workforce to the general U.S. MATERIALS AND METHODS: Data on current gender and racial distribution of U.S. urology residents was obtained from the 2019-2020 ACGME Data Resource Book and compared to the projected 2019 U.S. population as reported in the U.S. Census data. In this study, URM status included Black/African American, Hispanic/Latino, Native American/Alaskan, Native Hawaiian or Pacific Islander and Other. For each gender and race/ethnicity, the percent differences in representation were calculated by subtracting the frequency in the general U.S. population from that of the urology resident workforce and two sample z-tests were performed. RESULTS: 1734 urology residents were identified in 2019-2020, of which 471 (27.2%) were female and 258 (14.9%) were URM. Two sample z-tests revealed a significantly lower representation in urologic residency programs for women (-23.6%, P-value < .05) and URMs (-19.1%, P-value < .05). Race/ethnicity subgroup analyses revealed underrepresentation of Black/African American (-9.7%, P-value < .05), Hispanic/Latino (-14.2%, P-value < .05), Native American/Alaskan (-1.1%, P-value < .05). CONCLUSION: Women and URMs continue to be significantly underrepresented in urology residency relative to the general U.S. POPULATION: Further study should better understand barriers to entering the urologic workforce and identify strategies to encourage interest in urology among female and URM prospective trainees.

Leukocytoclastic vasculitis leading to penile necrosis and ischemia of the bladder and urethra.

We report a case of leukocytoclastic vasculitis-induced penile necrosis in a 69-year-old male with no previous urologic history. After suffering an ischemic event to the distal shaft of the penis as well as an ischemic event involving the right side of the bladder, he underwent suprapubic tube placement for urinary diversion. Despite attempts at anticoagulation for penile salvage, he lost the distal aspect of the glans penis to auto-necrosis. Ultimately, the underlying disease was determined to be systemic ANCA-associated vasculitis, and the patient was treated with rituximab and prednisone as well as penile wound debridement.

Diversifying Graduate Medical Education & the Urology Workforce: Re-imagining our Structures, Policies, Practices, Norms, & Values.

This article offers a framework for critically examining the structures, policies, norms, practices, and values that shape the Urology Match as a foundation for interventions to improve diversity, equity, inclusion, and justice in the workforce. Points of leverage for transformational change in the urology workforce diversification include modifying the structure of the urology application process, optimizing reviewer factors, addressing Under-Represented in Medicine applicant experience, providing resources to applicants, and evaluating selection criteria. To achieve an inclusive diverse urology workforce, we must change policy and practice, expand what we include in the norm, which will translate into increased value ascribed to a more varied cohort of applicants, leading to the establishment of structures that accommodate true diversity.

Preference Signaling Pilot in the Urology Match: Outcomes and Perceptions.

OBJECTIVE: To assess the perceptions and outcomes of the A preference signaling (PS) pilot implemented by the Society of Academic Urology in the 2021-2022 Urology Match cycle. METHODS: Five non-weighted signals were provided to each applicant, and signals were delivered to programs by the American Urological Association to provide an applicant-centered formal and equitable process to express genuine interest in residency programs. Applicant and program perception and behavior was assessed through surveys. Signal distribution, mean, range, and interview offer rates for overall, signaled, and non-signaled programs were calculated. RESULTS: In the 2021-2022 Urology Match cycle, 566 applicants completed signaling; 2829 total signals were sent to programs with 97% applicant and 100% program participation. Each program received a mean number of 19 signals (range of 1-62), and 25% of programs received 49% of all signals. The overall interview-offer rate for the cohort was 12.5% (6019 interviews held/47,989 applications received); the signaled interview rate was 51% (1443/2829), and the non-signaled interview rate was 10% (4576/45,160) with an approximate 4-fold increase in rate of interview for signaled programs compared to non-signaled programs. There was moderate to high levels of satisfaction from applicants and programs on the overall process. 48% of programs incorporated PS into initial application review. CONCLUSION: Preference signaling was demonstrated to be feasible and successful in providing a novel applicant-directed, formal, equitable, and credible structured process for applicants to express genuine interest in programs. Additionally, programs were able to incorporate PS into their interview selection and recruitment process.

Improving The Match: Use of Preference Signaling to Optimize the Urology Match Interview Process.

OBJECTIVES: To outline the principles and premise, pros and cons of the use of preference signaling (PS) in the Urology Match. METHODS: PS is a standardized system in which a student may send a signal or token to a particular program to demonstrate genuine interest in advance of application review and interview selection. The available literature of the use of PS in other fields was assessed and applied to the unique construct of the Urology Match. Potential benefits and challenges are discussed and a process and timeline for implementation are presented. RESULTS: PS requires a limited number of signals to maintain value, a transparent system to disclose and distribute signals and continuous data assessment for optimization. It standardizes pre interview communication and highlights for programs which applicants have sincere interest although it does not directly address application overload. CONCLUSION: PS is a viable and equitable method for applicants to indicate interest directly, confidentially and intentionally indicate interest in a program which can allow a program to maximize scarce resources such as time and interview slots in the match process.

Gender Disparities in Industry Payments to Urologists.

OBJECTIVE: To analyze and compare industry payments to urologists in the Open Payments Database by gender. We hypothesized that industry payments might be greater to male vs women urologists. METHODS: The Open Payments Database was analyzed from 2013-2017 and gender determined for all urologists receiving payments in the following categories: (1) research (made in connection to a research program or protocol), (2) ownership (ownership or investment interests held by the physician or immediate family member), and (3) general. Payment form and amount was collected and average payment per category, by gender, was calculated. RESULTS: A total of 12,161 urologists received industry payments from 2013-2017, of which 90% were male. Over the study period, there was a greater proportional increase in female urologists participating in industry payments: 46.8% for female urologists, vs 12.3% for male urologists (P <.01). Male urologists earned twice as much as women in all categories except for Ownership. Average payment (USD) per urologist was $3,106 vs $1338, $34, 494 vs $16,020, and $39,062 vs $252,710 for General, Research, and Ownership, respectively. Although the number of female urologists receiving industry payment increased during the study period, the average payment amount increased by 14.6% for women, compared to 107.8% for men (P <.01). CONCLUSION: Analysis of the Open Payments Database shows that on average women urologists earned half as much as men in their industry reported payments.

Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce.

The number of practicing female urologists has increased from < 2% in 1980 to 9.2% in 2018. Despite this increase, urology trails far behind medical fields overall and surgical subspecialties, in achieving gender parity. Barriers, such as pervasive biases and institutional policies, exist at the medical student, resident, and practicing urologist levels. Once recognized as detrimental, action can be taken to combat these forces to allow for advancement of women in the field of urology. This will result in a richer workforce better able to serve its patient population and advance the field.