Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Effect of Holistic Review, Interview Blinding, and Structured Questions in Resident Selection: Can we Predict Who Will Do Well in a Residency Interview?

OBJECTIVE: To examine the Urology residency application process, particularly the interview. Historically, the residency interview has been vulnerable to bias and not determined to be a predictor of future residency performance. Our goal is to determine the relationship between pre-interview metrics and post-interview ranking using best practices for Urology resident selection including holistic review, blinded interviews, and structured behaviorally anchored questions. METHODS: Applications were assessed on cognitive (Alpha Omega Alpha, class rank, junior year clinical clerkship grades) and non-cognitive attributes (letters of recommendation [LOR], personal statement [PS], demographics, research, personal characteristics) by reviewers blinded to USMLE scores and photograph. Interviewers were blinded to the application other than PS and LORs. Interviews consisted of a structured behaviorally anchored question (SBI) and an unstructured interview (UI). Odds ratios were determined comparing pre-interview and interview impressions. RESULTS: Fifty-one applicants were included in the analysis. USMLE step 1 score (average 245) was associated with Alpha Omega Alpha, class rank, junior year clinical clerkship, and PS. The UI score was associated with the LOR (P = .04) whereas SBI scores were not (P = .5). Faculty rank was associated with SBI, UI, and overall interview (OI) scores (P < .001). Faculty rank was also associated with LOR. Resident impression of interviewees were associated with faculty interview scores (P = .001) and faculty rank (P < .001). CONCLUSION: Traditional interviews may be biased toward application materials and may be balanced with behavioral questions. While Step 1 score does not offer additional information over other PI metrics, blinded interviews may offer discriminant validity over a PI rubric.

Evaluating the Whole Applicant: Use of Situational Judgment Testing and Personality Testing to Address Disparities in Resident Selection.

PURPOSE OF REVIEW: Urology program directors are faced with increasing numbers of applications annually, making holistic review of each candidate progressively more difficult. Efforts to streamline evaluation using traditional cognitive metrics have fallen short as these do not predict overall resident performance. Situational judgment tests (SJTs) and personality assessment tools (PATs) have been used in business and industry for decades to evaluate candidates and measure non-cognitive attributes that better predict subsequent performance. The purpose of this review is to describe what these assessments are and the current literature on the use of these metrics in medical education. RECENT FINDINGS: SJTs relative to PATs have more original research. Data suggests that SJTs decrease bias, increase diversity, and may be predictive of performance in residency. PATs are also emerging with data to support use with ability to assess fit to program and certain traits identified more consistently among high-performing residents and correlation to performance on ACGME milestones. PATs may be more coachable than SJTs. SJTs and PATs are emerging as techniques to supplement the current resident application review process. Early evidence supports their use in undergraduate medical education as does some early preliminary results in graduate medical education.

Urinary tract infection and drug-resistant urinary tract infection after intradetrusor onabotulinumtoxinA injection versus sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX) and sacral neuromodulation (SNM) are effective treatments for refractory urgency urinary incontinence/overactive bladder (UUI/OAB). BTX carries a risk of urinary tract infection (UTI), which is concerning for the development of multidrug resistant (MDR) UTI. We hypothesized that BTX might carry a higher risk of UTI and MDR UTI compared with SNM and that UTI and MDR UTI risk might increase after repeat BTX injection. METHODS: This retrospective cohort study included women undergoing BTX or SNM for refractory UUI/OAB in 2012-2016. UTI and MDR UTI were assessed up to 1 year post-treatment or until repeat treatment and compared between initial BTX and SNM and between repeat BTX injections. Univariate analyses included Chi-squared and Fisher's exact tests and generalized linear models (GLM) with logit link function. Multivariate analyses used GLM to assess the best predictor variables for any UTI. RESULTS: One hundred and one patients were included (28 BTX, 73 SNM). Rates of UTI (39.3% [95% CI 21.5, 59.4] BTX vs 37.0% [95% CI 26.0, 49.1] SNM) were similar in the two groups at all time intervals. One MDR UTI occurred after SNM. Risk of UTI did not increase with repeat BTX (11 out of 28 [39.3%], 6 out of 17 [35.3%], and 4 out of 7 [57.1%] after 1, 2, and ≥ 3 treatments respectively; p = 0.62). Multivariate analysis found that history of recurrent UTI (OR 2.5, 95%CI 0.98-6.39) and prolapse repair (OR 4.6, 95%CI 1.23-17.07) had increased odds of UTI. CONCLUSIONS: Rates of UTI were similar in patients undergoing BTX and SNM. MDR UTI was rare. Patients with prior prolapse repair or recurrent UTI may be at a higher risk of UTI after either procedure.

Prospective Randomized Feasibility Study Assessing the Effect of Cyclic Sacral Neuromodulation on Urinary Urge Incontinence in Women.

OBJECTIVES: The aim of this prospective, randomized, multicenter, single-blind, 4 × 4 crossover study was to estimate the effect of 4 InterStim cycling settings (continuous, 16 seconds on/8 seconds off, 10 minutes on/10 minutes off, and 30 minutes on/23.5 hours off) on efficacy, Global Response Assessment, and safety. METHODS: Eligible women implanted for at least 3 months for urgency urinary incontinence (UI) were enrolled, and daily diaries were collected. General linear mixed models were used to estimate the cycling effect on efficacy. Quality of life measured by Global Response Assessment (subjects' perception of effectiveness) and safety were summarized. RESULTS: Primary efficacy analysis was based on the first 24 subjects who completed unique randomization sequences. Mean age was 64 years, and mean implant duration was 2.8 years. Results showed no significant cycling (P = 0.3773) or period (P = 0.0800) effect on UI. There was a statistically significant interaction between cycling and period (P = 0.0032). In the first period, subjects on 10 minutes on/10 minutes off had significantly fewer UI episodes compared with subjects on 16 seconds on/8 seconds off (P = 0.0026); this difference was not observed in any other period or sensitivity analyses. No cycling effect was found on urgency or pad usage. When programmed to 10 minutes on/10 minutes off, 54% of subjects felt their incontinence symptoms improved compared with when they entered the study, followed by 42% on 30 minutes on/23.5 hours off, 38% on 16 seconds on/8 seconds off, and 29% on continuous. Safety was similar across cycling settings. CONCLUSIONS: The results suggest that patients with overactive bladder who have been implanted with sacral neuromodulation devices and are receiving substantial benefit may perceive further optimization by switching to cycling settings.

Prostatitis: diagnosis and treatment.

Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.