A Comparative Review of Oral Board Delivery Across Procedural Disciplines.

OBJECTIVE: Despite its ubiquity in the certification process among surgical specialties, there is little data regarding oral board delivery across various procedural fields. In this study we sought to determine the specifics of oral board exam administration across surgical disciplines with the goal of highlighting common practices, differences, and areas of innovation. This comparative analysis might further serve to identify unifying principles that undergird the oral board examination process across specialties. DESIGN: A standardized questionnaire was developed that included domains of exam structure/administration, content development, exam prerequisites, information about examiners, scoring, pass/failure rates, and emerging technologies. Between December 2022 and February 2023 structured interviews were conducted to discuss specifics of various oral board exams. Interview answers were compared between various specialties to extrapolate themes and to highlight innovative or emerging techniques among individual boards. SETTING: Interviews were conducted virtually. PARTICIPANTS: Executive members of 9 procedural medical boards including anesthesiology, neurosurgery, obstetrics, and gynecology, ophthalmology, orthopaedic surgery, otolaryngology-head and neck surgery, plastic surgery, general surgery, and urology RESULTS: Common themes include assessment of pre-, intra- and postoperative care; all testing involved candidate examination by multiple examiners and psychometricians were used by all organizations. Important differences included virtual versus in person administration (3 out of 9), inclusion and discussion of candidates' case logs as part of the exam (4 out of 9), formal assessment of professionalism (4 out of 9), and inclusion of an objective structured clinical examination (2 out of 9). CONCLUSIONS: While there are common themes and practices in the oral board delivery process between various surgical fields, and important differences continue to exist. Ongoing efforts to standardize exam administration and determine best practices are needed to ensure oral board exams continue to effectively establish that candidates meet the qualifications required for board certification.

Perceived Barriers Among Underrepresented and Historically Marginalized Medical Students Pursuing a Career in Urology.

OBJECTIVE: To assess perceived barriers to pursuing urology among medical students and to determine if marginalized groups identified greater challenges to entry. METHODS: The Deans of all New York medical schools were asked to disseminate a survey to their students. The survey collected demographic information to identify underrepresented minorities, students of low socioeconomic background, and lesbian, gay, bisexual, transgender, queer, intersex, and asexual individuals. Students were asked to rate various survey items on a five-point Likert scale to determine which factors were perceived as barriers to applying to urology residency. Student t tests and ANOVA were used to compare mean Likert ratings between groups. RESULTS: A total of 256 students responded to the survey from 47% of medical institutions. Underrepresented minorities students cited lack of evident diversity within the field as a more significant barrier than counterparts (3.2 vs 2.7, P= .025). Lesbian, gay, bisexual, transgender, queer, intersex, and asexual students perceived the lack of evident diversity within urology (3.1 vs 2.65, P = .01), exclusivity of the field (3.73 vs 3.29, P = .04), and fear that residency programs would have negative perceptions of them as students (3.0 vs 2.1, P < .0001) as substantial obstacles compared to peers. Students with childhood household incomes less than $40,000 cited socioeconomic concerns as a higher barrier compared to students with household incomes greater than $40,000 (3.2 vs 2.3, P = .001). CONCLUSION: Underrepresented and historically marginalized students perceive more significant barriers to pursuing urology than their peers. Urology training programs must continue to foster an inclusive environment to recruit prospective students from already marginalized groups.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

The relationship between vascular calcifications and urolithiasis in a large, multiethnic patient population.

Several studies have reported associations between vascular calcifications and urinary stone disease (USD). However, results have been inconsistent and the majority of studies did not report on race/ethnicity. We examined the association between vascular calcifications and USD in a large, racially/ethnically diverse patient population. We identified 672 USD cases and 672 controls (i.e., patients without a history of USD) from patients who underwent non-contrast CT imaging at Montefiore Medical Center in Bronx, New York between 2004 and 2013. Controls were matched to cases on age, sex and race/ethnicity. The non-contrast CT imaging was used to measure abdominal aortic calcification (AAC) and calculate the AAC severity score. Logistic regression models were used to examine associations of AAC presence and severity score with risks of USD and stone types. Cases and controls had similar AAC prevalence (45.2% vs. 44.8%, p = 0.87), and AAC severity score (median 10 vs. 9.3, p = 0.47). The presence of AAC (OR = 0.98, 95% CI 0.78-1.23; p = 0.86) or AAC severity score were not associated with risk of USD: ORs of 0.96, 0.87, 1.07 and 1.03 for increasing AAC quartiles (p-trend = 0.54). There were also no associations in the stratified analyses by race/ethnicity or by sex. However, when USD patients were stratified by stone type, brushite/apatite stone formers had an inverse association with the lowest quartile of AAC severity score (OR = 0.35, 95% CI 0.11-0.84, p = 0.04) in comparison to patients without AAC. Overall, we found no association between vascular calcifications and risk of urinary stone disease in this large, hospital-based, case-control study.

Disparities in care among patients presenting to the emergency department for urinary stone disease.

To determine whether patients with ureteral stones received different standard of care in the emergency department (ED) according to various sociodemographic factors. We conducted a retrospective study of patients presenting to EDs in a large tertiary-care hospital in the Bronx, New York with a diagnosis of ureteral stones. Electronic chart review was used to assess each patient's ED course and to gather socio-demographic information. The primary outcomes of interest were administration of pain medication, prescription of alpha-1 antagonists to facilitate stone passage, and whether or not patients received CT scan or ultrasound. Associations of these outcomes with age categories, sex, race/ethnicity, BMI category, socioeconomic status and insurance status were examined using multivariate logistic regression models. 1200 patients were included in this analysis of which 616 (51%) were women. A large proportion of patients were minorities: 40% Hispanic, 15% non-Hispanic Black, and 20% other/multiracial. Patients aged 55-64 years and those 65 or older were less likely to receive pain medication compared to patients < 35 years (OR = 0.48, 95% CI 0.27-0.86, p = 0.01 and OR = 0.46, 95% CI 0.21-1.00, p = 0.05, respectively). Women were less likely than men to undergo any form of diagnostic imaging (OR = 0.52, 95% CI 0.35-0.76, p = 0.001). Similarly, patients in the lowest quintile of SES received less imaging than patients in the highest SES group (OR = 0.50, 95% CI 0.27-0.90, p = 0.02). Finally, women were less likely to receive alpha blockade compared to men (OR = 0.68, 95% CI 0.49-0.92, p = 0.014). Multiple disparities exist among patients presenting to the emergency department for ureteral stones.

Baseline chronic kidney disease does not predict long-term renal functional decline after percutaneous nephrolithotomy.

To compare renal functional outcomes in patients with and without chronic kidney disease (CKD) to identify predictors of change in renal function after percutaneous nephrolithotomy (PCNL). We reviewed patients who underwent PCNL by a single surgeon over 3.5 years. Patients' pre- and post-operative Glomerular Filtration Rate (GFR) was calculated. Baseline GFR < 60 ml/min/1.73 m2 (stage ≥ 3 CKD) defined our CKD cohort. Patients' baseline renal function, comorbidities, stone parameters, and intra-operative variables were analyzed to determine the relationship with post-operative renal function after PCNL by multivariate analysis. 202 patients were analyzed. Mean follow-up time was 16 months. At baseline, 163 (80.7%) patients were free of CKD and 39 (19.3%) had CKD. Patients without CKD had an overall decrease in GFR from 105.6 to 103.3 ml/min/1.73 m2 (p = 0.494). 14/163 (8.6%) non-CKD patients experienced a significant decline in renal function after PCNL; 7/163 (4.3%) developed de novo CKD and 7 had a ≥ 30% decline in GFR. Patients with CKD had an overall increase in mean GFR post-operatively, from 47.3 to 54.0 ml/min/m2 (p = 0.067). Two in this cohort (5.1%) experienced a > 30% decline in renal function post-operatively. Age, gender, African American race, presence of comorbidities and pre-operative CKD were not significant predictors of renal function post-operatively on multivariate analysis. PCNL in this cohort appears GFR neutral in the setting of baseline CKD. CKD was not predictive of renal functional decline after PCNL. Given that stone disease carries a high recurrence rate and that CKD is associated with stone formers, further investigation into predictors of renal function change after PCNL is warranted.

Fecal transplant modifies urine chemistry risk factors for urinary stone disease.

Urinary stone disease (USD) is a major health concern. There is a need for new treatment modalities. Recently, our group provided evidence for an association between the GMB composition and USD. The accessibility of the Gut Microbiome (GMB) makes it an attractive target for investigation and therefore, in these studies we have evaluated the extent to which the whole gut microbial community in fecal transplants can affect urinary stone risk parameters in an animal model. Fresh fecal pellets were collected from Zucker lean rats, homogenized in PBS (100 mg/mL), filtered through a 70 µm strainer and then orally gavaged into C57BL/6NTac germ-free mice. Twenty-four hours urine collections and GMB analysis were performed over time for 1 month. Kidney and gut tissue were harvested from transplanted mice for western blot analysis of expression levels of the Slc26a6 transporter involved in oxalate balance. Urinary calcium decreased after fecal transplant by 55% (P < 0.001). Urinary oxalate levels were on average 24% lower than baseline levels (P < 0.001). Clostridiaceae family was negatively correlated with urinary oxalate at 4 weeks after transplant (r = -0.83, P < 0.01). There was a 0.6 unit average increase in urinary pH from a baseline of 5.85 (SE ± 0.028) to 6.49 (SE ± 0.04) (P < 0.001) after transplant. There was a concomitant 29% increase in gastrointestinal alkali absorption (P < 0.001) 4-weeks after fecal transplant. Slc26a6 expression increased by 90% in the cecum after transplant. Our results suggest that the gut microbiome may impact metabolism, alters urinary chemistry, and thereby may influence USD; the accessibility of the GMB can potentially be leveraged for therapeutic interventions.

Outcomes for Patients Undergoing Ambulatory Percutaneous Nephrolithotomy.

INTRODUCTION: Multiple studies have concluded that ambulatory percutaneous nephrolithotomy (aPCNL) is safe. However, selection criteria remain vague and no investigators have assessed the practicality of using various post-procedural drainage strategies in the ambulatory setting. In this study we establish a set of inclusion and exclusion criteria for aPCNL, compare outcomes between aPCNL patients and those admitted following PCNL, and incorporate a variety of "exit" strategies including Double-J stent, ureteropelvic junction (UPJ) stent and totally tubeless techniques. METHODS: We developed inclusion and exclusion criteria to determine patient eligibility for aPCNL. Between January 2014 and December 2016, 52 out of 145 patients met criteria for aPCNL and 47 of these patients were ultimately discharged on the same day. Forty-seven of the remaining 98 patients who were admitted following PCNL were randomly selected as a control group. Primary outcomes included stone-free status, emergency department (ED) visits and hospital readmissions within the 6-week post-operative period. Statistical analysis was performed using Student's t-tests, chi square tests, and Fischer's exact tests. RESULTS: Both groups had similar age (P = 0.91), sex (P = 0.68), body mass index (P = 0.91), and stone burden (P = 0.12). Patients in the ambulatory group had a lower Charlson Comorbidity score (aPCNL CCS = 0.11, inpatient PCNL CCS = 0.62, P = 0.002). Seventy three percent of ambulatory patients and 62% of standard PCNL patients had no residual stone burden 6 weeks following PCNL (P = 0.33). The average residual stone fragment in our ambulatory and standard PCNL group was 3.5 and 3.2 mm, respectively. Five patients (11%) from the aPCNL group and 4 (9%) from the standard PCNL group presented to the ED (P = 0.76). One aPCNL (2%) and three standard PCNL (6%) patients were re-admitted to the hospital (P = 0.62). CONCLUSIONS: In this study we establish specific inclusion and exclusion criteria for aPCNL. Using these criteria we then demonstrated the practicality of using various exit strategies to facilitate aPCNL. Future randomized control trials would be beneficial in confirming the safety and efficacy of aPCNL in select patients.

Elevated fetal haemoglobin levels are associated with decreased incidence of retinopathy in adults with sickle cell disease.

Among the many vascular complications of sickle cell disease (SCD), retinopathy is the most prevalent and represents a leading cause of blindness. Hydroxycarbamide therapy ameliorates many symptoms of SCD, and high fetal haemoglobin (HbF) levels have been shown to protect against the development of retinopathy in children with HbSS. Its effect on adults with SCD, who are at a much higher risk of developing retinopathy, has not been studied. We aimed to investigate the effect of hydroxycarbamide use and HbF level on sickle cell retinopathy development in adults. We performed a retrospective cross-sectional study and collected demographics, comorbidities, and ocular and haematological data from 300 adult sickle cell subjects examined at the Henkind Eye Institute at Montefiore Medical Center during a 5-year period, from October 2012 to November 2017. The cohort was comprised mainly of Black and Hispanic subjects with all SCD genotypes, aged 18-71 years. Results show that in HbSS patients treated with hydroxycarbamide, those with retinopathy had significantly lower HbF levels compared to patients without retinopathy (P = 0·018). Our study identified the optimal HbF cut-off point for retinopathy protection to be 14·87%. Thus, a HbF level of 15% appears to be the threshold above which the odds for developing retinopathy in SS patients are reduced by 50%.