Predictors of Excellent Urology Residents at the Time of the Urology Match.

OBJECTIVE: To update our experience and report on features predictive of high-quality urology residents at the time of the urology match, because data predicting which medical students will mature into excellent urology residents are sparse. METHODS: We reviewed our experience with 84 urology residents who graduated from 2006 to 2023. Residents were independently scored 1-10 based on overall quality by the current and former Program Director. Discrepant scoring by >2 was resolved by an independent review. Associations of features from the medical student application with an excellent score (defined as 8-10) were evaluated with logistic regression. RESULTS: Discrepant scoring >2 was noted in only 5 (6%) residents. Among the 84 residents, the median overall score was 7 (range 1-10) and 36 (43%) residents had an excellent score of 8-10. Univariably, higher USMLE step II score (P = .03), election to alpha omega alpha (P = .004), no negative interview comments (P = .002), honors in OB/Gyn (P = .048) and psychiatry clerkships (P = .04), and honors in all core clinical clerkships (P < .001) were significantly associated with an excellent score. In a multivariable model, no negative interview comments (P = .003) and honors in all core clinical clerkships (P = .001) were independently associated with an excellent score (c-index 0.76). There were several notable features (sex, letters of recommendation, USMLE step I, externship at our institution, surgery clerkship grade, and rank list) that were not significantly associated with excellent residents. CONCLUSION: We demonstrate features associated with excellent urology residents, most notably no negative interview comments and an honors grade in all core clinical clerkships.

Causes of death among people with myelomeningocele: A multi-institutional 47-year retrospective study.

PURPOSE: This study aimed to analyze organ system-based causes and non-organ system-based mechanisms of death (COD, MOD) in people with myelomeningocele (MMC), comparing urological to other COD. METHODS: A retrospective review was performed of 16 institutions in Canada/United States of non-random convenience sample of people with MMC (born > = 1972) using non-parametric statistics. RESULTS: Of 293 deaths (89% shunted hydrocephalus), 12% occurred in infancy, 35% in childhood, and 53% in adulthood (documented COD: 74%). For 261 shunted individuals, leading COD were neurological (21%) and pulmonary (17%), and leading MOD were infections (34%, including shunt infections: 4%) and non-infectious shunt malfunctions (14%). For 32 unshunted individuals, leading COD were pulmonary (34%) and cardiovascular (13%), and leading MOD were infections (38%) and non-infectious pulmonary (16%). COD and MOD varied by shunt status and age (p < = 0.04), not ambulation or birthyear (p > = 0.16). Urology-related deaths (urosepsis, renal failure, hematuria, bladder perforation/cancer: 10%) were more likely in females (p = 0.01), independent of age, shunt, or ambulatory status (p > = 0.40). COD/MOD were independent of bladder augmentation (p = >0.11). Unexplained deaths while asleep (4%) were independent of age, shunt status, and epilepsy (p >= 0.47). CONCLUSION: COD varied by shunt status. Leading MOD were infectious. Urology-related deaths (10%) were independent of shunt status; 26% of COD were unknown. Life-long multidisciplinary care and accurate mortality documentation are needed.

One-Year Results for the ROBUST III Randomized Controlled Trial Evaluating the Optilume® Drug-Coated Balloon for Anterior Urethral Strictures.

PURPOSE: The Optilume® drug-coated balloon (DCB) is a urethral dilation balloon with a paclitaxel coating that combines mechanical dilation for immediate symptomatic relief with local drug delivery to maintain urethral patency. The ROBUST III study is a randomized, single-blind trial evaluating the safety and efficacy of the Optilume DCB against endoscopic management of recurrent anterior urethral strictures. MATERIALS AND METHODS: Eligible patients were adult males with anterior strictures ≤12Fr in diameter and ≤3 cm in length, at least 2 prior endoscopic treatments, International Prostate Symptom Score ≥11 and maximum flow rate <15 ml per second. A total of 127 subjects were enrolled at 22 sites. The primary study end point was anatomical success (≥14Fr by cystoscopy or calibration) at 6 months. Key secondary end points included freedom from repeat treatment, International Prostatic Symptom Score and peak flow rate. The primary safety end point included freedom from serious device- or procedure-related complications. RESULTS: Baseline characteristics were similar between groups, with subjects having an average of 3.6 prior treatments and average length of 1.7 cm. Anatomical success for Optilume DCB was significantly higher than control at 6 months (75% vs 27%, p <0.001). Freedom from repeat intervention was significantly higher in the Optilume DCB arm. Immediate symptom and urinary flow rate improvement was significant in both groups, with the benefit being more durable in the Optilume DCB group. The most frequent adverse events included urinary tract infection, post-procedural hematuria and dysuria. CONCLUSIONS: The results of this randomized controlled trial support that Optilume is safe and superior to standard direct vision internal urethrotomy/dilation for the treatment of recurrent anterior urethral strictures <3 cm in length. The Optilume DCB may serve as an important alternative for men who have had an unsuccessful direct vision internal urethrotomy/dilation but want to avoid or delay urethroplasty.

Detrusor overactivity assessment using ultrasound bladder vibrometry.

Objective. Detrusor overactivity (DO) is a urodynamic observation characterized by fluctuations in detrusor pressure (Pdet) of the bladder. Although detecting DO is important for the management of bladder symptoms, the invasive nature of urodynamic studies (UDS) makes it a source of discomfort and morbidity for patients. Ultrasound bladder vibrometry (UBV) could provide a direct and noninvasive means of detecting DO, due to its sensitivity to changes in elasticity and load in the bladder wall. In this study, we investigated the feasibility and applying UBV toward detecting DO.Approach. UBV and urodynamic study (UDS) measurements were collected in 76 neurogenic bladder patients (23 with DO). Timestamped group velocity squared (cg2) data series were collected from UBV measurements. ConcurrentPdetdata series were identically analyzed for comparison and validation. A processing approach is developed to separate transient fluctuations in the data series from the larger trend of the data and a DO index is proposed for characterizing the transient peaks observed in the data.Main Results.Applying the DO index as a classifier for DO produced sensitivities and specificities of 0.70 and 0.75 forcg2data series and 0.70 and 0.83 forPdetdata series respectively.Significance. It was found that DO can be feasibly detected from data series of timestamped UBV measurements. Collectively, these initial results are promising, and further refinement to the UBV measurement process is likely to improve and clarify its capabilities for noninvasive detection of DO.

Non-invasive assessment of urinary bladder compliance using ultrasound: first validation study based on clinical urodynamic study.

BACKGROUND: This study aims to validate a recently introduced non-invasive method, ultrasound bladder vibrometry (UBV), for the assessment of detrusor compliance in patients with neurogenic bladders. METHODS: The study was carried out on 79 adult patients with neurogenic bladders (60 male and 19 female). The UBV test was performed on each patient to measure the Lamb wave group velocity (cg ) in the anterior bladder wall at every 50mL volume increment throughout the filling phase. Bladder compliance was assessed based on the trend of Lamb wave group velocity squared (cg 2 ) versus volume. A compliance index was defined to differentiate between the compliant and non-compliant bladders. Results of the UBV compliance assessment were validated using the readings of the corresponding urodynamic studies as the clinical gold standard. RESULTS: The Patients' bladders were divided into non-compliant and compliant groups by an experienced urologist using the information in the urodynamic study (UDS) recordings. The compliance index defined on the basis of cg 2 showed a significant difference (P<0.008) between the compliant and non-compliant groups. The areas under the receiver operating characteristic curve were 0.813, with 95% CI ranging from 0.709 to 0.892. Under the optimal criterion, the bladder was considered as non-compliant if the compliance index was less than 100 mL∙s2/m2, resulting in a sensitivity and specificity of 86.4% and 71.9%, respectively. CONCLUSIONS: The results of this study demonstrate that UBV can be used as a non-invasive method for the determination of bladder compliance; thus, it can potentially serve as an alternative method to UDS for the appropriate patient groups.

The American Board of Urology: In Pursuit of Diversity, Equity, and Inclusion.

INTRODUCTION: The purpose of this manuscript is to describe the methods we employ to build a foundation of diversity, quality and inclusion within the American Board of Urology and its certifying processes. METHODS: The American Board of Urology consists of 3 major committees: the Trustees of the Board and the Written and Oral Exam Committees. Yearly, before selecting new members to these committees, a Gap analysis is performed to evaluate discrepancies between the committee structure and the constituents we serve. The selection of new committee members is based on both the individual's merit and an attempt to match or supersede the diversity ratios described within the most current national census conducted by the American Urological Association. RESULTS: This year's evaluation revealed our committee structure consisting of 85% (98/115) male and 15% (17/115) women: National Census 90% and 10% respectively. Regarding race and ethnicity, White nonHispanic: 74% (85/115) compared to 81% (National Census); Hispanic: 1% (1/115) compared to 4%; Asian: 22% (25/115) compared to 12%; Black/African American 3% (4/115) compared to 2%. CONCLUSIONS: The American Board of Urology recognizes that the evaluation of ratios is an excellent initial step to establish diversity; however, ratios alone may not change behavior or attitudes. To reach our eventual goal, we must include educational efforts that inform our diplomates and committee members regarding the benefits of diversity. We also acknowledge that establishing and maintaining diversity within any governing board is an imperative that requires continuous and structural processes to be sustained.

Malpractice Litigation in Iatrogenic Ureteral Injury: a Legal Database Review.

OBJECTIVE: To examine the factors associated with iatrogenic ureteral injury litigation and outcomes. METHODS: The Westlaw legal database was queried for all iatrogenic ureteral injury cases. Variables extracted included available clinical factors, method of settlement, and litigation outcomes. Linear regression analysis was conducted to examine factors associated with award amount. RESULTS: A total of 522 cases from 1961 to 2019 were included in the study. The most common specialty named was gynecology (353/512, 68.9%), followed by urology (89/512, 17.4%). The most common claim was intraoperative negligence (474/522 cases, 90.8%). Fifty two cases were settled or arbitrated and 470 went to trial. Settlement or arbitration was more likely in cases involving institution-only defendant (15.4% vs 7.3%, P< .01), academic institution (19.7% vs 7.1%, P < .01), and patient death (42.9% vs 10.7%; P < .001). Of cases that went to trial, the verdict favored the defendant in 339/470 cases (72.1%). The median award was $552,822.96 (interquartile range 187,007-1,063,603). Duration of temporary drainage ($5050/day, P = .02), delayed repair (P = .03), claim of inadequate workup (P = .03), and claim of failure to supervise trainee (P < .001) were significantly associated with increasing award amount. CONCLUSION: The majority of ureteral injury litigation ruled in favor of the defendant. However, when awarded, the amount was substantial and correlated with drainage duration, delayed repair, claim of inadequate workup, and failure to supervise trainee. These findings highlight factors perceived to be associated with significant distress and reflect trends in medicolegal decision-making.

Enhanced ambulatory male urethral surgery: a pathway to successful outpatient urethroplasty.

BACKGROUND: Length of stay following anterior urethroplasty (AU) surgery has progressively shortened over the past two decades with most patients discharging the day of surgery or following overnight observation. We sought to assess overall analgesia and patient satisfaction with same-day discharge after AU surgery. METHODS: Our prospectively maintained anterior urethroplasty database was reviewed. Men were identified who underwent anterior urethroplasty surgery by a single surgeon (B.R.V.) with the Enhanced Ambulatory Male Urethral Surgery (EAMUS) protocol followed by same-day discharge. Patients were contacted within 3 weeks of surgery and completed validated assessment tools to characterize satisfaction with the outpatient experience and with analgesia management. A statistical analysis was performed to assess predictors of overall satisfaction with same-day discharge following AU surgery. RESULTS: Fifty-seven patients with median age 52.2 years underwent same-day AU surgery between August 2017 and October 2018. In total, 46 patients (80.7%) responded to post-discharge surveys assessing overall outpatient satisfaction and satisfaction with analgesia. Median satisfaction with outpatient experience (scale 1-5) was 5 (IQR 4, 5) with 93.4% of patients indicating they were satisfied to very satisfied (4 or 5). Median patient satisfaction with analgesia (scale 1-6) was 6 (IQR 5, 6) with 93.4% of patients indicating a satisfaction with analgesia score of ≥5 (satisfied to very satisfied). Median number of 5 mg oxycodone tablets used following discharge was 3 (IQR 0.75, 5). Postoperative complications occurred in 14 patients (25%) with 12 (86%) being low grade complications (Clavien-Dindo Classification ≤ II). CONCLUSIONS: With appropriate preoperative education and peri-operative analgesia, anterior urethroplasty surgery can be performed with same-day discharge with comparable postoperative complication rates while maintaining excellent patient satisfaction. Additional high volume, prospectively collected studies are necessary to verify short-term satisfaction rates while confirming long-term urethroplasty success rates remain comparable to AU surgery performed with next day discharge.

Pelvic fracture urethral injuries associated with rectal injury: a review of acute and definitive urologic and bowel management with long term outcomes.

BACKGROUND: Pelvic fracture urethral injuries (PFUI) with simultaneous rectal lacerations are unique rarely reported injuries. This paper serves to define our management, outcomes and make recommendations to improve the care of these patients. METHODS: We retrospectively reviewed all patients with a PFUI and concurrent rectal injury treated from 1990-2018, initial surgical treatments, along with definitive surgical repair were reviewed. Statistical analysis considered P values <0.05 as significant. RESULTS: Eighteen patients were identified; median follow-up post injury is 4 years, range 1-12 years. Injuries that impacted urologic care included concurrent bladder neck lacerations (BNL) in 50% (9/18) and concurrent neurologic injuries in 28% (5/18). In the nine patients with a simultaneous BNL, 44% (4/9) underwent a primary sutured anastomotic repair of the BNL and urethra, 33% (3/9) underwent primary closure of the bladder neck and SPT drainage and 23% (2/9) had primary repair of BNL with urethral realignment. Continued urinary extravasation through the BN despite the initial surgery resulted in life threating pelvic sepsis in 56% (5/9) versus 0% (0/9) in the patients without a bladder neck laceration, P=0.012. Long term follow up revealed, 22% (2/9) are currently voiding per urethra, neither are continent, one with chronic diaper dependent incontinence, one with stress incontinence. Urinary continence was eventually obtained in 44% (4/9) with either closure of the bladder neck and creation of a continent catheterizable stoma (3 pts) or with cystectomy and creation of an Indiana pouch (1 pt), 33% (3/9) were managed with eventual cystectomy and an enteric urinary conduit. In the nine patients with no concurrent bladder neck injury all were managed with a suprapubic tube placement and consideration for a delayed urethral reconstruction. Delayed end to end urethroplasties were performed in 67% (6/9). Eighty-three percent (5/6) are continent, 50% (3/6) are voiding per urethra without sequale, 33% (2/6) developed recurrent urethral strictures, one was treated with a single DVIU and has retrained urethral patency, at four years post treatment, one is on daily intermittent catheterization to maintain patency. Stress incontinence is noted in 17% (1/6). Due to concurrent neurologic injuries 33% (3/9) of these pts did not undergo further attempt at repair and have been managed with a long-term suprapubic tube. CONCLUSIONS: PFUI with simultaneous rectal lacerations have significant comorbid injuries, especially, concurrent bladder neck lacerations and neurologic injuries that affect the urologic prognosis. In patients with a concurrent BNL we recommend initial intervention include primary lower urinary tract reconstruction with simultaneous proximal urinary diversion to help prevent the complication of persistent urinary extravasation with resultant pelvic sepsis.

Neurogenic bladder: management of the severely impaired patient with complete urethral destruction: ileovesicostomy, suprapubic tube drainage or urinary diversion-is one treatment modality better than another?

BACKGROUND: Management of the severely impaired patient (pt) with a neurogenic bladder (NGB) and complete urethral destruction employs three therapeutic options; bladder neck closure (BNC) with ileovesicostomy, BNC with suprapubic tube (SPT) placement or in pts with an end-stage bladder, cystectomy with enteric conduit diversion. This paper was performed to test the hypothesis that pts managed with an ileovesicostomy would have the best long-term prognosis. METHODS: Patients with a NGB and complete urethral destruction managed between 1986-2018 were reviewed. Three treatment populations were assessed, pts treated with BNC with ileovesicostomy, BNC with SPT placement or cystectomy with enteric conduit diversion. A minimal follow-up interval of 2 years was necessary to be entered into the study. The number of uroseptic episodes, development of urolithiasis, the onset of new renal scars, ≥ stage 3 chronic renal failure, or need for additional surgery were recorded. Statistical evaluations used either chi-squared contingency table analysis, Fisher's exact 2-tailed tests, or Kaplan-Meier curve analysis where indicated. P values of <0.05 were considered significant. RESULTS: Ten pts were managed by cystectomy, and enteric conduit, 17 by BNC and ileovesicostomy and 21 by BNC and SPT placement, median follow up of 8 yrs (range, 2-30 yrs). No significant differences between the three groups regarding the development of urolithiasis (30%, 3/10 pts; 53%, 9/17 pts; 52%, 11/21 pts; respectively), new onset of renal scarring (30%, 6/20 kidneys; 41%, 14/34 kidneys; 45%, 19/42 kidneys; respectively) or stage 3 chronic renal failure (40%, 4/10 pts; 47%, 8/17 pts; 24%, 5/21 pts; respectively. However, the number of hospitalizations for uroseptic episodes significantly increased in patients managed with an ileal conduit (60%, 6/10 pts) and ileovesicostomy (82%; 14/17 pts) compared to those maintained with a SPT (29%, 6/21 pts) P=0.025 and 0.006, respectively. When evaluating the need for delayed surgical intervention due to either urolithiasis or other complications, a total of 50% (5/10 pts) of the patients managed by an ileal conduit, 88% (15/17 pts) of the ileovesicostomy and 52% (11/21 pts) of the patients with a SPT required additional operations. In essence, significantly more pts undergoing BNC and ileovesicostomy required delayed surgical interventions for complications arising from the surgery compared to patients managed with either a cystectomy and ileal conduit (P=0.0285) or BNC and SPT placement (P=0.0180). CONCLUSIONS: In severely impaired pts with a NGB and urinary outlet destruction, BNC and ileovesicostomy are associated with a significantly increased incidence of urosepsis and late surgical complications that required operative intervention compared to alternative treatments. This finding has resulted in the abandonment of the ileovesicostomy from our surgical armamentarium.