Evaluation of urology trainee preferences in didactic education: a choice-based conjoint analysis.

Purpose: Didactic lectures are a commonly used educational tool during urology residency training. Recently, there has been a rapid introduction of online, collaborative didactics as a new model for resident teaching. The aim of this study is to determine which attributes of didactics education are most preferred by contemporary urology trainees. Methods: Urology trainees were invited to complete an online choice-based exercise assessing combinations of four attributes associated with didactics education: mode of communication, learning style, presenter credentials, and curriculum design. The survey was distributed via social media platforms and the Urology Collaborative Online Video Didactics (COViD) website. A choice-based conjoint analysis was used to identify how the trainees valued different combinations of didactic education. Results: Seventy-three trainees completed the conjoint analysis exercise. Mode of communication was rated as significantly more important than curriculum design (relative importance 28.6% vs. 19.9%). Overall, the majority preferred online/virtual presentations to in-person presentations. Respondents preferred national experts to faculty members from their local institutions, and preferred cased based lectures to didactics style lectures. A nationally standardized curriculum was also preferred over curriculum designed by local institutions. Finally, when segmented by level of training, there was increased preference for overall favored options as PGY year increased. Conclusion: This conjoint analysis shows clear preference by trainees for online, recorded didactics, nationally standardized with national experts, and preferably in a case-based format. Academic societies in urology and program directors should consider utilizing the shared experience of previously created collaborative online lectures in developing future didactic curriculum that can meet the needs of current trainees.

A magnetic hydrogel for the efficient retrieval of kidney stone fragments during ureteroscopy.

Only 60-75% of conventional kidney stone surgeries achieve complete stone-free status. Up to 30% of patients with residual fragments <2 mm in size experience subsequent stone-related complications. Here we demonstrate a stone retrieval technology in which fragments are rendered magnetizable with a magnetic hydrogel so that they can be easily retrieved with a simple magnetic tool. The magnetic hydrogel facilitates robust in vitro capture of stone fragments of clinically relevant sizes and compositions. The hydrogel components exhibit no cytotoxicity in cell culture and only superficial effects on ex vivo human urothelium and in vivo mouse bladders. Furthermore, the hydrogel demonstrates antimicrobial activity against common uropathogens on par with that of common antibiotics. By enabling the efficient retrieval of kidney stone fragments, our method can lead to improved stone-free rates and patient outcomes.

Kidney Stone Events after Kidney Transplant in the United States.

BACKGROUND: Kidney stone disease is common and can lead to complications such as AKI, urinary tract obstruction, and urosepsis. In kidney transplant recipients, complications from kidney stone events can also lead to rejection and allograft failure. There is limited information on the incidence of kidney stone events in transplant recipients. METHODS: We identified 83,535 patients from the United States Renal Data System who received their first kidney transplant between January 1, 2007, and December 31, 2018. We examined the incidence of kidney stone events and identified risk factors associated with a kidney stone event in the first 3 years after transplantation. RESULTS: We found 1436 patients (1.7%) who were diagnosed with a kidney stone in the 3 years after kidney transplant. The unadjusted incidence rate for a kidney stone event was 7.8 per 1000 person-years. The median time from transplant to a kidney stone diagnosis was 0.61 (25%-75% range 0.19-1.46) years. Patients with a history of kidney stones were at greatest risk of a kidney stone event after transplant (hazard ratio [HR], 4.65; 95% confidence interval [CI], 3.82 to 5.65). Other notable risk factors included a diagnosis of gout (HR, 1.53; 95% CI, 1.31 to 1.80), hypertension (HR, 1.29; 95% CI, 1.00 to 1.66), and a dialysis of vintage of ≥9 years (HR, 1.48; 95% CI, 1.18 to 1.86; ref vintage ≤2.5 years). CONCLUSIONS: Approximately 2% of kidney transplant recipients were diagnosed with a kidney stone in the 3 years after kidney transplant. Risk factors of a kidney stone event include a history of kidney stones and longer dialysis vintage.

National Imaging Trends for Suspected Urinary Stone Disease in the Emergency Department.

This cohort study examines the use of an ultrasonography-first strategy for urinary stone disease.

Evaluation of the Educational Impact of the Urology Collaborative Online Video Didactics Lecture Series.

OBJECTIVE: To assess the impact of the Urology Collaborative Online Video Didactic (COViD) lecture series series on resident knowledge as a supplement to resident education during the coronavirus disease 2019 pandemic. METHODS: One hundred thirty-nine urology residents were voluntarily recruited from 8 institutions. A 20-question test, based on 5 COViD lectures, was administered before and after watching the lectures. Pre- and posttest scores (percent correct) and score changes (posttest minus pretest score) were assessed considering demographic data and number of lectures watched. Multiple linear regression determined predictors of improved scores. RESULTS: Of residents recruited, 95 and 71 took the pre- and posttests. Median number of lectures watched was 3. There was an overall increase in correct scores from pretest to posttest (45% vs 57%, P < .01). Watching any lectures vs none led to higher posttest scores (60% vs 44%, P < .01) and score changes (+16% vs +1%, P < .01). There was an increase in baseline pretest scores by post-graduate year (PGY) (P < .01); however there were no significant differences in posttest or score changes by PGY. When accounting for lectures watched, PGY, and time between lecture and posttest, being a PGY6 (P = .01) and watching 3-5 lectures (P < .01) had higher overall correct posttest scores. Watching 3-5 lectures led to greater score changes (P < .001-.04). Over 65% of residents stated the COViD lectures had a large or very large impact on their education. CONCLUSIONS: COViD lectures improved overall correct posttest scores and increased knowledge base for all resident levels. Furthermore, lectures largely impacted resident education during the coronavirus disease 2019 pandemic.

Medical Treatment and Prevention of Urinary Stone Disease.

The pathophysiology underlying urinary stone formation remains an area of active investigation. There are many pharmacotherapies aimed at optimizing metabolic factors and reducing urinary supersaturation of stone components that play an important role in urinary stone prevention. In addition, medical expulsive therapy for ureteral stones and medical dissolution therapy for uric acid-based urinary stones are helpful treatment tools and are used alongside surgical treatments in the management of urinary stones.

Risk of Postpartum Urinary Stone Disease in Women with History of Urinary Stone Disease During Pregnancy.

Objective: To determine the risk of postpartum urinary stone disease in women with a history of stone disease during pregnancy. Methods: Using the Optum® de-identified Clinformatics® Datamart we identified pregnant women with urinary stone disease in the United States between January 2003 to December 2017 by standardized International Classification of Diseases Ninth and Tenth Editions (ICD-9 and ICD-10), and Current Procedural Terminology code criteria. We limited the cohort to include women without evidence of urinary stone disease before pregnancy. We abstracted patient demographic characteristics, clinical risk factors for stone disease, and data for urinary stone disease encounters and related procedures after pregnancy. Encounters occurring within 1 year of pregnancy were excluded. Cox proportional hazard models were used to analyze for significance. Results: We identified a total of 1,395,783 pregnant women with a median postpartum follow-up of 4.0 years, including 5971 (0.4%) women with a urinary stone during pregnancy. Of these, 736 (12.3%) had an additional urinary stone diagnosis claim after pregnancy, compared with 13,275 (0.95%) women without a history of stone disease during pregnancy (p < 0.0001). In multivariable proportional hazards models urinary stone disease during pregnancy (hazards ratio 12.8, 95% confidence interval [11.8-13.8]) was independently associated with a higher hazard of urinary stone disease after pregnancy. Conclusion: Women with urinary stone disease during pregnancy were more likely to present with recurrent urinary stone disease after pregnancy. Given the one in eight chance of needing further care, women with history of stone disease during pregnancy may benefit from risk counseling, surveillance, or secondary prevention efforts in the postpartum period.

Online Collaborative Learning in Urology.

REASON FOR REVIEW: A recent shift towards use of telehealth and remote learning has significant implications on resident and fellow education in urology. Implementation of multi-institutional online didactic programs, spurred on by the COVID epidemic, has changed the traditional resident teaching paradigm from individual institutional silos of knowledge and expertise to a shared nationwide database of learning.  RECENT FINDINGS: In this article, we explore the current trend towards virtual education and its progress to date, lessons learned on the optimization of this teaching modality, and future direction and sustainability of collaborated, standardized and accessible didactic education in urology. Multi-institutional collaborative remote video didactics has emerged as a critical part of resident education. These lectures have been overwhelmingly successful and have persisted beyond the pandemic to become a part of the urologic training curricula. This collaborative and standardized approach to resident education provides access to national and international experts, encourages cross-institutional collaboration and discussion, and builds a repository of lectures with easy access for learners. Utilization of this teaching modality will continue to be impactful in urologic training and will require ongoing efforts and input from both collaborating intuitions and professional societies to continue to improve on and engage in this important learning tool.

Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol.

BACKGROUND: Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis. MATERIALS AND METHODS: A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain. RESULTS: Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED (p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort (p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group (p < 0.001). Overall, there was no difference in postoperative pain related phone calls (p = 1.0) or emergency room visits (p = 1.0). CONCLUSIONS: An opioid-free discharge protocol can dramatically reduce opioid prescription at discharge following ureteroscopy for urinary calculi without affecting postoperative measures such as phone calls, clinic visits, or subsequent prescriptions.

Efficacy of three BCG strains (Connaught, TICE and RIVM) with or without secondary resection (re-TUR) for intermediate/high-risk non-muscle-invasive bladder cancers: results from a retrospective single-institution cohort analysis.

PURPOSE: (I) To evaluate the clinical efficacy of three different BCG strains in patients with intermediate-/high-risk non-muscle-invasive bladder cancer (NMIBC). (II) To determine the importance of performing routine secondary resection (re-TUR) in the setting of BCG maintenance protocol for the three strains. METHODS: NMIBCs who received an adjuvant induction followed by a maintenance schedule of intravesical immunotherapy with BCG Connaught, TICE and RIVM. Only BCG-naïve and those treated with the same strain over the course of follow-up were included. Cox proportional hazards model was developed according to prognostic factors by the Spanish Urological Oncology Group (CUETO) as well as by adjusting for the implementation of re-TUR. RESULTS: n = 422 Ta-T1 patients (Connaught, n = 146; TICE, n = 112 and RIVM, n = 164) with a median (IQR) follow-up of 72 (60-85) were reviewed. Re-TUR was associated with improved recurrence and progression outcomes (HRRFS: 0.63; 95% CI 0.46-0.86; HRPFS: 0.55; 95% CI 0.31-0.86). Adjusting for CUETO risk factors and re-TUR, BGC TICE and RIVM provided longer RFS compared to Connaught (HRTICE: 0.58, 95% CI 0.39-0.86; HRRIVM: 0.61, 95% CI 0.42-0.87) while no differences were identified between strains for PFS and CSS. Sub-analysis of only re-TUR cases (n = 190, 45%) showed TICE the sole to achieve longer RFS compared to both Connaught and RIVM. CONCLUSION: Re-TUR was confirmed to ensure longer RFS and PFS in intermediate-/high-risk NMIBCs but did not influence the relative single BCG strain efficacy. When routinely performing re-TUR followed by a maintenance BCG schedule, TICE was superior to the other strains for RFS outcomes.

The emerging landscape of tumor marker panels for the identification of aggressive prostate cancer: the perspective through bibliometric analysis of an Italian translational working group in uro-oncology.

Molecular heterogeneity and availability of different therapeutic strategies are relevant clinical features of prostate cancer. On this basis, there is an urgent need to identify prognostic and predictive biomarkers for an individualized therapeutic approach. In this context, researchers focused their attention on biomarkers able to discriminate potential life-threatening from organ-confined disease. Such biomarker could provide aid in clinical decision making, helping to choose the treatment which ensures the best results in terms of patient survival and quality of life. To address this need, many new laboratory tests have been proposed, with a clear tendency to use panels of combined biomarkers. In this review we evaluate current data on the application in clinical practice of the most promising laboratory tests: Phi, 4K score and Stockholm 3 as circulating biomarkers, Mi-prostate score, Exo DX Prostate and Select MD-X as urinary biomarkers, Confirm MDx, Oncotype Dx, Prolaris and Decipher as tissue biomarkers. In particular, the ability of these tests in the identification of clinically significant PCa and their potential use for precision medicine have been explored in this review.

Osteoporosis, Fractures, and Bone Mineral Density Screening in Veterans With Kidney Stone Disease.

Whether a link exists between kidney stone disease and osteoporosis or fractures remains an open question. In this retrospective cohort study, we sought to determine the prevalence of osteoporosis and fractures and rate of bone mineral density screening by dual-energy X-ray absorptiometry (DXA) in patients with kidney stone disease. We examined nationwide data from the Veterans Health Administration and identified 531,431 patients with kidney stone disease between 2007 and 2015. Nearly 1 in 4 patients (23.6%, 95% confidence interval [CI] 23.5-23.7) with kidney stone disease had a prevalent diagnosis of osteoporosis or fracture. In patients with no prior history of osteoporosis or bone mineral density assessment before a kidney stone diagnosis, 9.1% were screened with DXA after their kidney stone diagnosis, of whom 20% were subsequently diagnosed with osteoporosis. Our findings provide support for wider use of bone mineral density screening in patients with kidney stone disease, including middle-aged and older men, a group less well recognized as at risk for osteoporosis or fractures. © 2021 American Society for Bone and Mineral Research (ASBMR).

Typical within and between person variability in non-invasive ventilator derived variables among clinically stable, long-term users.

BACKGROUND: Despite increasing capacity to remotely monitor non-invasive ventilation (NIV), how remote data varies from day to day and person to person is poorly described. METHODS: Single-centre, 2-month, prospective study of clinically stable adults on long-term NIV which aimed to document NIV-device variability. Participants were switched to a ventilator with tele-monitoring capabilities. Ventilation settings and masking were not altered. Raw, extensible markup language data files were provided directly from Philips Respironics (EncoreAnywhere). A nested analysis of variance was conducted on each ventilator variable to apportion the relative variation between and within participants. RESULTS: Twenty-nine people were recruited (four withdrew, one had insufficient data for analyses; 1364 days of data). Mean age was 54.0 years (SD 18.4), 58.3% male with body mass index of 37.0 kg/m2 (13.7). Mean adherence was 8.53 (2.23) hours/day and all participants had adherence >4 hours/day. Variance in ventilator-derived indices was predominantly driven by differences between participants; usage (61% between vs 39% within), Apnoea-Hypopnoea Index (71% vs 29%), unintentional (64% vs 36%) and total leak (83% vs 17%), tidal volume (93% vs 7%), minute ventilation (92% vs 8%), respiratory rate (92% vs 8%) and percentage of triggered breaths (93% vs 7%). INTERPRETATION: In this clinically stable cohort, all device-derived indices were more varied between users than the day-to-day variation within individuals. We speculate that normative ranges and thresholds for clinical intervention need to be individualised, and further research is necessary to determine the clinically important relationships between clinician targets for therapy and patient-reported outcomes.

Safety and Feasibility of Outpatient Surgery in Benign Prostatic Hyperplasia: a Systematic Review and Meta-Analysis.

Purpose: Most of the endourologic procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for benign prostatic hyperplasia (BPH). This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. Materials and Methods: PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. Methodological index for nonrandomized studies (MINORS) tool was utilized to assess the quality of included studies, and a pooled measure of failure rate (FR) or event rate (ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Results: Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2-10.3); Heterogeneity: Q = 76.85; degree of freedom = 17, p < 0.001; I2 = 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95% CI: 1-4.9), 7.1% (95% CI: 3.9-10.4), and 11.8% (95% CI: 7-16.7) for transurethral resection of the prostate, Green-light, and holmium laser vaporesection, respectively (p < 0.001). At meta-regression analysis, none of the retrieved covariates was able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95% CI: 13.2-23.9) and 7.7% (95% CI: 4.3-11), respectively. Conclusions: Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard to type of surgical procedure, perioperative prostate volume, and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct.

A Novel Method for Repositioning Suboptimally Preoperatively Placed Nephrostomy Tubes for Percutaneous Nephrolithotomy Without Renal Repuncture.

Objective: Nephrostomy tubes (NTs) inserted in emergency settings by interventional radiologists are frequently unsuitable for subsequent percutaneous nephrolithotomy (PCNL). We report a novel method of adjusting these NTs to be used as PCNL tracts and avoid renal repuncture. Patients and Methods: A retrospective search of 981 consecutive PCNLs performed in our institution between 2002 and 2017 identified all patients with preoperatively inserted NTs. The NTs unsuitable for PCNL were adjusted by a novel approach in which a 5-mm incision was made at the ideal puncture location (IPL) as indicated under fluoroscopic guidance. The preinserted NT was removed after passing a guidewire into the kidney. A dissector clamp was introduced through the entry wound of the removed NTs to bluntly dissect a retroperitoneal tunnel and pull out the distal tip of guidewire through the IPL, while its proximal segment was maintained in the kidney. The newly positioned guidewire was used for PCNL tract preparation without repuncturing the kidney. Results: The NTs were located in the mid calix, lower calix, and renal pelvis in 6 (26%), 13 (57%), and 4 (17%) cases, respectively. The NT was suitable for PCNL in 5 (22%) cases, a new renal access was performed in 3 (13%), and the novel adjustment approach was used in 15 (65%), all successfully. The place of entry was moved an average of 6 cm (range 47) and the angle between the tract axis and the calix axis was reduced by 65° in average. The procedure was done uneventfully in an average of 4 minutes. Conclusions: The novel method of adjusting preoperatively inserted NTs for PCNL by repositioning their original entry location to the IPL offers the possibility of avoiding kidney repuncture. It is feasible, safe, and easy to implement, and it spares potential morbidity related to additional puncturing of the kidney.

Evaluation of Patient Treatment Preferences for 15 to 20 mm Kidney Stones: A Conjoint Analysis.

Introduction and Objective: Ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) are standard treatments for intermediate-size (15-20 mm) kidney stones but differ in their postoperative recovery, stone-free rates, and complication risks. We aimed to evaluate what affects patient treatment preferences. Methods: Patients with urinary stone disease completed a choice-based conjoint analysis exercise assessing four treatment attributes associated with URS and PCNL. A sensitivity analysis using a market simulator was performed, and the relative importance of each attribute was calculated. Differences in treatment preferences by demographic subgroup were assessed. Results: A total of 58 patients completed the conjoint analysis exercise. Stone-free rate was the most important treatment attribute, while the length of hospital stay and cosmesis were less important. Overall, sensitivity analysis based on market simulation scenarios predicted an almost equal preference for URS (52.4%) compared with PCNL (47.6%) for treatment of an intermediate-size stone. Older patients (>65 years old) expressed their stronger preferences for lower infection rates and shorter hospital stays, and were more likely to prefer URS (67.2%, 95% confidence interval [CI]: 52% to 82.5%) compared with younger patients (20-34 years old) (20.3%, 95% CI: 0% to 41.5%) who preferred higher procedure success rates and fewer repeat procedures. Conclusion: Conjoint analysis predicts nearly equal patient preference for URS or PCNL for the treatment of intermediate-size kidney stones. Older patients prefer the lower urinary tract infection risk and shorter hospital stay associated with URS, while younger patients prefer higher stone-free rates associated with PCNL. These results can help guide urologists in counseling patients and improve the shared decision-making process.

Capturing the Perspective of Prospective Urology Applicants: Impacts of COVID-19 on Medical Education.

OBJECTIVE: To capture the perspective of prospective urology applicants experiencing unique challenges in the context of COVID-19. METHODS: A voluntary, anonymous survey was distributed online, assessing the impact of COVID-19 on a large sample of US medical students planning to apply to urology residencies. Themes of (1) specialty discernment, (2) alterations to medical education, and (3) the residency application process were explored. RESULTS: A total of 238 medical students, 87% third and fourth years, responded to the survey. While 85% indicated that the pandemic had not deterred their specialty choice, they noted substantial impacts on education, including 82% reporting decreased exposure to urology. Nearly half of students reported changes to required rotations and 35% reported changes to urology-specific rotations at their home institutions. Students shared concerns about suspending in-person experiences, including the impact on letters of recommendation (68% "very concerned) and program choice (73% "very concerned"). Looking to the possibility of virtual interactions, students identified the importance of small group and one-on-one communication with residents (83% "very important") and opportunities to learn about hospital facilities (72% "very important"). CONCLUSION: Despite the impacts of COVID-19 on medical education, prospective urology applicants appear to remain confident in their specialty choice. Students' biggest concerns involve disruption of away rotations, including impacts on obtaining letters of recommendation and choosing a residency program.

Prostate Artery Embolization Used in the Management of Transfusion-Dependent Hematuria After Prostatic Urethral Lift Procedure in a Patient with Thrombocytopenia: A Case Report.

Background: The prostatic urethral lift (PUL) procedure is a novel therapeutic method to treat lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Gross hematuria after this procedure has been reported to be mild and transient. This report highlights a case of refractory transfusion-dependent hematuria after the PUL procedure in addition to its management with selective prostatic arterial embolization (PAE). Case Presentation: A 78-year-old Caucasian man with a history of myelodysplastic syndrome, thrombocytopenia, and intermittent urinary retention secondary to BPH underwent a PUL procedure. Before the procedure he received a platelet transfusion making his platelet count 58,000/µL. The day after the procedure he was admitted to a hospital for gross hematuria with clot retention. He was started on continuous bladder irrigation and taken to the operating room for clot evacuation and fulguration of prostate. His thrombocytopenia and anemia were managed with transfusions. He was treated with desmopressin, aminocaproic acid, and intravesical 1% alum without improvement. He returned to the operating room for clot evacuation in addition to photoselective vaporization of the prostate laser ablation of the prostatic fossa. He eventually required a total of four transurethral fulgurations without improvement in transfusion-dependent hematuria. Ultimately, resolution of the hematuria was achieved through bilateral PAE with Embosphere® Microspheres performed by interventional radiology. He was discharged home 2 days after the embolization procedure without recurrence of hematuria or urinary retention at a 6-month follow-up visit. Conclusion: The PUL procedure has been shown to be an effective alternative to more invasive surgical options for LUTS caused by BPH. Despite careful consideration in an attempt to alleviate urinary retention, PUL still resulted in significant bleeding in this patient with thrombocytopenia. This is the first report to highlight the use of bilateral PAE as a method for achieving control of severe refractory hematuria after PUL.