Positive environmental impact of remote teleconsultation in urology during the COVID-19 pandemic in a highly populated area.

INTRODUCTION: Greenhouse gas (GHG) emissions are a serious environmental issue. The healthcare sector is an important emitter of GHGs. Our aim was to assess the environmental cost of teleconsultations in urology compared to face-to-face consultations. MATERIALS AND METHODS: Prospective study of all patients who had a remote teleconsultation over a 2-week period during COVID-19 pandemic. Main outcome was the reduction in CO2e emissions related to teleconsultation compared to face-to-face consultation and was calculated as: total teleconsultation CO2e emissions-total face-to-face consultation CO2e emissions. Secondary outcome measures were the reduction in travel distance and travel time related to teleconsultation. RESULTS: Eighty patients were included. Face-to-face consultations would have resulted in 6699km (4162 miles) of travel (83.7km (52 miles) per patient). Cars were the usual means of transport. CO2e avoided due to lack of travel was calculated at 1.1 tonnes. Teleconsultation was responsible for 1.1kg CO2e while face-to-face consultation emitted 0.5kg of CO2e. Overall, the total reduction in GHGs with teleconsultation was 1141kg CO2e, representing a 99% decrease in emissions. Total savings on transport were 974 € and savings on travel time were 112h (1.4h/patient). CONCLUSIONS: Teleconsultation reduces the environmental impact of face-to-face consultations. The use of teleconsultation in our urology departments resulted in the avoidance of more than 6000km of travel, equivalent to a reduction of 1.1 tonnes of CO2e. Teleconsultation should be considered for specific indications as the healthcare system attempts to become greener. LEVEL OF EVIDENCE: 3.

Predictive Factors of Ureterorenoscopy Outcomes in Proximal Ureteral Stones: A Multicenter Study of Aegean Study Group of the Society of Urological Surgery.

INTRODUCTION: We aimed to evaluate the predictive factors in a holistic manner for ureterorenoscopy (URS) outcomes in proximal ureteral stones by a multicenter study. MATERIALS AND METHODS: The data of patients who underwent URS for proximal ureteral stones between the years 2015 and 2018 in eight centers were recorded retrospectively. Patients were divided into two groups according to URS success: Group 1 consisted of patients with successful URS, and Group 2 consisted of patients with unsuccessful URS. The two groups were compared in terms of risk factors, stone, and clinical characteristics of patients. RESULTS: A total of 638 patients were included in the study. Group 1 consisted of 527 (82.6%) patients, and Group 2 consisted of 111 (17.4%) patients. In multivariate logistic analysis, the key risk factors for URS success was found to be age (OR = 0.980, 95% [CI] = 0.963-0.996, p = 0.018), stone area (OR = 0.993, 95% [CI] = 0.989-0.997, p = 0.002), and operation time (OR = 0.981, 95% [CI] = 0.968-0.994, p = 0.005). CONCLUSIONS: To make the treatment decision of proximal ureteral stones, it is necessary to examine several parameters including available equipment, stone, and patient characteristics. Physicians should keep these risk factors in mind in the decision of treatment options.

Implementation and strategies to ensure adequate coordination within a Urology Department during the COVID-19 pandemic.

PURPOSE: to provide an update on the management of a Urology Department during the COVID-19 outbreak, suggesting strategies to optimize assistance to the patients, to implement telemedicine and triage protocols, to define pathways for hospital access, to reduce risk of contagious inside the hospital and to determine the role of residents during the pandemic. MATERIALS AND METHODS: In May the 6th 2020 we performed a review of the literature through online search engines (PubMed, Web of Science and Science Direct). We looked at recommendations provided by the EAU and ERUS regarding the management of urological patients during the COVID-19 pandemic. The main aspects of interest were: the definition of deferrable and non-deferrable procedures, Personal Protective Equipment (PPE) and hospital protocols for health care providers, triage, hospitalization and surgery, post-operative care training and residents' activity. A narrative summary of guidelines and current literature for each point of interest was performed. CONCLUSION: In the actual Covid-19 scenario, while the number of positive patients globally keep on rising, it is fundamental to embrace a new way to deliver healthcare and to overcome challenges of physical distancing and self-isolation. The use of appropriate PPE, definite pathways to access the hospital, the implementation of telemedicine protocols can represent effective strategies to carry on delivering healthcare.

Delivery of urological services (telemedicine and urgent surgery) during COVID-19 lockdown: experience and lessons learnt from a university hospital in United Kingdom.

BACKGROUND AND AIMS: Our departmental planning for COVID-19 was actioned a week before the lockdown (13th March 2020). We look at a 7- week lockdown activity for all scheduled outpatient clinics and urgent procedures. METHODS AND RESULTS: A total of 2361 outpatient clinic slots (52.6% oncology slots and 47.4% benign urology slots) were scheduled during this period. The oncology slots included 330 (26.5%) flexible cystoscopy, 555 (44.7%) prostate cancer and 357(28.8%) non-prostate cancer slots. The benign urology slots included 323 (28.8%) andrology, 193 (17.2%) stones and 603 (54%) lower urinary tract symptoms (LUTS) slots. Of the total oncology outpatient slots (n = 1242), 66.3% were virtual consultations, 20% were face-to-face and 13.6% were cancelled. Of the total benign outpatient slots (n = 1119), 81% were virtual consultations, 9.7% were face-to-face and 9.3% were cancelled. A total of 116 anaesthetic surgical procedures were carried out, of which 54 (46.5%) were oncological procedures, 18 (15.5%) were benign urological procedures, and 44 (38%) were diagnostic procedures. CONCLUSIONS: Hospitals and urologists can benefit from the model used by our hospital to mitigate the impact and prioritise patients most in need of urgent care. Reorganisation and flexibility of healthcare delivery is paramount in these troubled times and will allow clinical activity without compromising patient safety.

[French Association of Urology. COVID-19: Recommendations for functional urology]. / Recommandations jointes des comités de l'AFU (neuro-urologie, CUROPF, CTMH) pour l'urologie fonctionnelle durant la crise sanitaire liée au COVID-19.

AIM: The management of urology patient is currently disrupted by the COVID-19 epidemic. In the field of functional urology, there are clinical situations with a high risk of complication if management is delayed and a great heterogeneity of advisable reprogramming times after cancellation. A prioritization of functional urology procedures is necessary to adapt management during the COVID-19 crisis and to better organize post-epidemic recovery. MATERIAL AND METHODS: The advice of AFU scientific committees in the field of functional urology (neuro-urology, female and perineology, male LUTS) was requested and supplemented by a review of the currently available recommendations on the subject of urology and COVID-19. These opinions were combined to draw up temporary recommendations to help reorganize practices during the epidemic and prepare the post-critical phase. RESULTS: Most of the recommendations available on career-oriented social networks (Twitter, LinkedIn) or in literature concern cancer or general urology. Eight out of ten propose a cancellation of all functional urology procedures without distinction. But the 3 AFU committees covering the field of functional urology have identified three clinical situations in which surgical procedures that can be maintained during the COVID-19 epidemic (priority level A): conclusion of a neuromodulation test in progress (implantation or explantation), botulinum toxin A bladder injections for unbalanced neurologic bladder, cystectomy and ileal conduit for urinary fistula in perineal bedsore or refractory unbalanced neurologic bladder with acute renal failure and vesico-enteric or prostato-pubic fistulas. Management adaptation of the other pathologies are proposed, as well as the application of 3 priority levels (B, C, D) for rescheduled procedures for a better management of the post-crisis activity resumption. CONCLUSION: The joint functional urology committees indicate that there are specific clinical situations in this field that demand non-delayed care during COVID crisis. They underline the need to establish a hierarchy for the cancelled surgeries, in order to reduce the arm of long reschedule delays and to optimize post-lockdown activity resumption.

Strategies for Attracting Women and Underrepresented Minorities in Urology.

PURPOSE OF REVIEW: This article summarizes the current state of underrepresented minorities (URM) and women within urology. Specific strategies to promote the recruitment and retention of URM and women within urology are discussed. RECENT FINDINGS: Minorities and women remain underrepresented within urology, a disparity that has roots as early as medical school and persists throughout residency and practice. This is likely due to implicit and explicit bias, lack of role models, and persistent disparities in compensation and promotion. Strategies to improve recruitment and retention of these individuals should focus on increasing early exposure to urology, opportunities for mentorship, and support in professional development. Creation of a supportive institutional culture, consideration of alternative career advancement paths, and intentional diversity-focused recruitment efforts are also critical. Successful recruitment and retention of URM and women in urology requires specific, directed efforts to increase opportunities for exposure, mentorship, and career promotion at a programmatic, institutional, and national level.

Telehealth for the Assessment of Patients Referred for Pediatric Urological Care: A Preliminary Cost Savings Analysis and Satisfaction Survey.

Background: Almost one-fifth of the population of Saudi Arabia lives in rural areas and may still lack access to specialty healthcare. Because of the growing demand for telehealth services, we initiated the virtual clinic (VC) concept for new referrals to the pediatric urology clinic (PUC), the primary tertiary care unit in Riyadh. Methods: We conducted a retrospective analysis of costs and timing involved with the VC practice for a 1-year period. The cost analysis is based on savings realized by patients as a result of the VC evaluation. A 15-question nonvalidated satisfaction survey was also conducted by an independent observer. Results: Of 105 patients assessed through the VC program, 44 were accepted for surgery and further investigation. The number of trips to the center saved by the virtual encounter were 203, resulting in a savings of 740,950 Saudi Arabian Riyals (SAR) minus the cost of the VC. The cost of conducting most of the investigations at the referring hospital instead of the PUC represented a savings of 639,970 SAR. Thus, the overall cost savings to patient and family and to the PUC was 1,311,570 SAR. An additional benefit was the reduction in the time for treatment from 6.6 to 3.9 months. The overall satisfaction rate was 89%. Conclusions: Although preliminary, our study indicates that telemedicine can achieve a cost savings without compromising the safety or adversely affecting patient management. Further studies should more clearly define the benefits and any limitations, and reveal how the technology could be used most effectively.

Leveraging the clinical collaborative model to drive value improvement.

PURPOSE OF REVIEW: Physician-led quality improvement collaboratives have emerged across surgical disciplines as a means to measure and subsequently improve the quality and cost of care. In this review, we will provide an overview of recent successes within quality improvement collaboratives, as well as discuss future opportunities for such initiatives. RECENT FINDINGS: Successful quality improvement collaboratives have coupled data registries with a collegial environment to achieve data-driven improvements in care across diverse practice settings. Such efforts have a track record for accomplishing specific patient safety gains, and have more recently addressed complex care scenarios where data and consensus building have been leveraged to clarify optimal care pathways. Collaboratives are currently exploring mechanisms to meaningfully impact increasingly complex elements of care delivery, such as individual surgeon performance. SUMMARY: Quality improvement collaboratives are in a unique position to understand patterns in care across populations, lead evidence-based assessments of variation in quality, and to attempt to intervene to improve outcomes based on the data they accumulate. As healthcare increasingly shifts to emphasize quality of care, physician-led collaboratives represent an important mechanism to drive improvement.

Measuring quality of urology care using a qualified clinical data registry.

PURPOSE OF REVIEW: Qualified clinical data registries (QCDRs) serve as a framework for quality improvement efforts, clinical research endeavors, and participation in reimbursement incentive programs. However, the measurement of quality and the recommendations to guide QCDRs in developing new quality measures is a complex process. In this review, we highlight the government policies that lead to the creation of QCDRs, how QCDR quality measures are developed, and the current QCDRs that focus on urological care. RECENT FINDINGS: QCDRs facilitate participation in the merit-based incentive payment system for reimbursement adjustments. Most QCDRs leverage existing clinical guidelines in the development of new quality measures. In 2018, there are four urology QCDRs with quality measures for many urological conditions. These QCDRs form the infrastructure for quality improvement and provide new resources for research endeavors. SUMMARY: Quality measurement within QCDRs will allow urologists to focus improvement efforts to deliver high-quality urological care while also facilitating reimbursement incentives and creating novel research datasets.

Engaging telehealth to drive value-based urology.

PURPOSE OF REVIEW: Telehealth, or the remote delivery of healthcare services using telecommunications technology, has the potential to revolutionize the delivery of healthcare and contribute to ongoing efforts to provide high-value care. RECENT FINDINGS: We discuss several categories of telehealth that have been applied to healthcare. Several of these approaches, in particular video visits and teleconsultations, have promising early data demonstrating the significant benefits of telehealth technology with respect to the quality of care, access, cost savings, and patient experience. Nonetheless, considerable knowledge gaps still exist regarding how and for which patients and diseases telehealth modalities should be applied. Finally, we discuss the barriers to widespread adoption at the institutional, state, and federal levels. SUMMARY: Maximizing the value of healthcare is an important goal for hospitals, physicians, and policymakers. Telehealth leverages advances in technology and the widespread availability of telecommunications devices to make healthcare communication more available, more convenient, and more efficient for patients and providers. With appropriate policies and incentives, telehealth initiatives can improve the value of urologic care and smooth the transition to a value-based healthcare system.

The National Physicians Cooperative: transforming fertility management in the cancer setting and beyond.

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines - oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health - in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Training of Tunisian future urologists: how to improve it ?

BACKGROUND: The lack of continuous evaluation of training tools in medicine, especially in developing countries, represents a brake to the development of the latter. AIM: To establish an inventory of the training facilities available to residents in urology in Tunisia, to assess their satisfaction and their expectations, and to propose solutions to improve residents training. METHODS: An anonymous questionnaire was sent by E-mail in 2015 to all residents in urology in Tunisia. The questionnaire addressed demographic characteristics, educational resources used and desired, the current medical and university curriculum and evaluation of the training. RESULTS: Among 33 residents, 66.6% responded to the survey. Medical staff, courses organized by the national college of urology, reading french-language articles and daily activity in operating room were the most used pedagogic resources. Training was judged unsatisfactory by 59.1% of respondents because of a lack of theoretical training in 18.1% of cases, a lack of practical training in 13.6% of cases and both of them in 27.2% of cases. Training on animals and simulator, creation of an educational booklet, use of online course materials, and the institution of a mentoring process during residency were rated favorable by the majority of respondents. CONCLUSION: The majority of residents in urology in Tunisia believe their training is unsatisfactory. The E-learning, improved access to surgical training in animals and simulator, better information on existing resources and strengthening of companionship through tutoring should enhance satisfaction.

[Non-palpable testicular tumors in adults: A management based on imaging? Issue from the French Urologic Association Genital Cancer committee's edit]. / Tumeurs testiculaires non palpables chez l'adulte : vers une prise en charge guidée par l'imagerie ? Une mise au point du Groupe organe génitaux externes du comité de cancérologie de l'Association française d'urologie.

BACKGROUND: Help in management of non-palpable testicular tumors. French Urologic Association Genital cancer committee's Edit. OBJECTIVES: To review their characterization at imaging findings of non-palpable testicular tumors. DOCUMENTARY SOURCES: Literature review (PubMed, Medline) of urological and radiological studies dealing with testicular tumors using keywords: non-palpable/incidental testicular tumors; color Doppler ultrasound; US elastography; magnetic resonance imaging; contrast enhanced sonography; partial surgery. RESULTS: Color Doppler is the basic exam. The size, the presence of microlithts/microlithiasis/macrocalcifications, the vascular architecture are major semiological findings to suggest the benign or the malignant nature of the lesion. Other techniques like multiparametric MRI, contrast-enhanced sonography, sonographic elastography are still in evaluation. The frequency of benign tumors such as Leydig cell tumors lead to preservation management, through improved characterization, monitoring or tumorectomy. LIMITS: Non-randomized study - a very few prospective studies. CONCLUSION: The era of total orchiectomy for any uncertain testicular lesion is over. We try the challenge of characterization, and define management's algorithms based on the suspected nature of the tumors.

[A.P. Frumkin: a prominent founder of soviet urology. On the 120th anniversary].

This article pays tribute to Anatoly Pavlovich Frumkin on the 120th anniversary of his birthday. It describes his life, the creative scientific path of a prominent researcher, military urological surgeon, founder of a urological school and the first in the Soviet Union Head of the Department of Urology at the S.P. Botkin hospital, author of fundamental studies in the field of military urology, endoscopic and radiologic diagnostics in urology, the founder of the first in the Soviet Union Department of Pediatric Urology at the St. Vladimir Childrens Hospital.

Appropriateness Criteria for Active Surveillance of Prostate Cancer.

PURPOSE: The adoption of active surveillance varies widely across urological communities, which suggests a need for more consistency in the counseling of patients. To address this need we used the RAND/UCLA Appropriateness Method to develop appropriateness criteria and counseling statements for active surveillance. MATERIALS AND METHODS: Panelists were recruited from MUSIC urology practices. Combinations of parameters thought to influence decision making were used to create and score 160 theoretical clinical scenarios for appropriateness of active surveillance. Recent rates of active surveillance among real patients across the state were assessed using the MUSIC registry. RESULTS: Low volume Gleason 6 was deemed highly appropriate for active surveillance whereas high volume Gleason 6 and low volume Gleason 3+4 were deemed appropriate to uncertain. No scenario was deemed inappropriate or highly inappropriate. Prostate specific antigen density, race and life expectancy impacted scores for intermediate and high volume Gleason 6 and low volume Gleason 3+4. The greatest degree of score dispersion (disagreement) occurred in scenarios with long life expectancy, high volume Gleason 6 and low volume Gleason 3+4. Recent rates of active surveillance use among real patients ranged from 0% to 100% at the provider level for low or intermediate biopsy volume Gleason 6, demonstrating a clear opportunity for quality improvement. CONCLUSIONS: By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community-wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted.

Implementation rates of uro-oncology multidisciplinary meeting decisions.

OBJECTIVES: To assess implementation rates of the consensus plans made at the uro-oncology multidisciplinary meeting (MDM) of an Australian tertiary centre, and analyse obstacles to implementation. METHODS: A retrospective review was performed of all patients discussed at the uro-oncology MDM at our institution between 1 January and 30 June 2015. Rates of referral for MDM discussion after a new histological diagnosis of malignancy, categorised by tumour type, were assessed. Patient records were interrogated to confirm MDM plan implementation, with the outcomes examined being completion of MDM plan within 3 months and factors preventing implementation. RESULTS: During the enrolment period, from 291 uro-oncological procedures, 240 yielded malignant histology of which 160 (67%) were discussed at the MDM. Overall, 202 patients, including 32 females, were discussed at the uro-oncology MDM. MDM consensus plans were implemented in 184 (91.1%) patients. Reasons for deviation from the MDM plan included delay in care, patient deterioration or comorbidities, patient preference, consultant decision, loss to follow-up, and change in patient scenario due to additional new information. CONCLUSION: The MDM is increasingly important in the care of uro-oncology patients, with about two-thirds of new diagnoses currently captured. There appear to be few barriers to the implementation of consensus plans, with nearly all patients undergoing the recommended management.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction.

INTRODUCTION AND HYPOTHESIS: The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report. METHODS: This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSIONS: A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research.