Outcomes of Orchiectomy for Gender-affirming Surgery: A National Surgical Quality Improvement Program Study.

OBJECTIVE: To identify perioperative outcomes of transgender orchiectomy (TGO) and to broadly compare outcomes of TGO to cisgender orchiectomy (CGO) for nononcologic indications. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2020, a retrospective study was performed on patients with ICD-9/10 codes for gender dysphoria, testicular torsion, and testicular pain who underwent simple orchiectomy. Demographics and surgical outcomes were summarized. Welch two-sample t test and chi-square test were used for group analysis. A trend analysis was performed for temporal trends of these surgeries. RESULTS: 246 patients underwent TGO and 997 patients underwent CGO (607 testicular torsion, 390 testicular pain). Overall complication rates between TGO and CGO did not differ for testicular torsion (3.7% vs 4.4%, P = .6) or testicular pain (3.7% vs 5.9%, P = .2). No differences in patient characteristics were seen within the TGO group when comparing those who experienced complications to those who didn't. From 2015 to 2020, TGO cases significantly increased by, on average, 9.5 cases per year (95% CI: 6.3-12.7, P = .001), while CGO had showed no significant temporal change. CONCLUSION: Standalone TGO can be performed safely in an outpatient setting with an acceptable complication profile in medically diverse patients.

Glans Adipodermal Augmentation for Management of Neophallus Fat Atrophy After Penile Implant Insertion: Surgical Technique and Outcomes.

OBJECTIVE: To describe our surgical technique and outcomes of glans augmentation with autologous adipodermal or acellular dermal matrix (ADM) interposition grafts for fat atrophy of the neophallus following penile implant insertion. METHODS: We retrospectively reviewed the outcomes of glans augmentation in phalloplasty patients presenting with fat atrophy following penile prosthesis insertion. Glans augmentation is performed by making a small posterior coronal incision to preserve the shaft-to-glans dermal blood supply. A plane is made between the glans skin and the capsule of the distal penile implant cylinder. An adipodermal graft or ADM sheet graft is then sized to the glans dissection space and inserted, covering the implant capsule and filling the glans. The graft harvest site and posterior coronal incisions are then closed. The primary postoperative outcome was the recurrence of implant glans skin impingement or erosion. RESULTS: From October 2017 through January 2023, 15 patients underwent glans augmentation after penile prosthesis insertion. The mean follow-up was 20 months. Adipodermal grafts were placed in 12 (80%) patients and ADM grafts in 3 (20%) patients. Two patients developed complications requiring surgical revision and 3 patients are considering a secondary glans augmentation, for a potential surgical revision rate of 33% (5/15). There were no wound infections, implant infections, or erosions. CONCLUSION: Glans augmentation with adipodermal or ADM graft interposition between the glans skin and implant capsule improves the neophallus appearance and may help prevent future implant erosion in phalloplasty patients who develop fat atrophy after penile implant insertion.

Abdominal vs Sub-Inguinal Placement of Pressure Regulating Balloon for Artificial Urinary Sphincter.

OBJECTIVES: To compare peri- and postoperative outcomes following artificial urinary sphincter (AUS) insertion using an abdominal versus a sub-inguinal counterincision for pressure regulating balloon (PRB) placement. METHODS: This was a retrospective review of all AUS placements by a single surgeon from 2010-2020. Demographic, clinical, and surgical details were obtained from chart review. The cohorts were divided by PRB placement technique (sub-inguinal, abdominal, and attempted sub-inguinal converted intra-operatively to abdominal ["conversion group"]). RESULTS: There were 182 AUS devices placed. The sub-inguinal approach was successfully completed in 132/144 (92%) and converted to abdominal PRB placement in 12/144 (8.3%). The risk of conversion was not increased by prior laparoscopically-assisted robotic prostatectomy (LRP) or radiotherapy (RT). Median operative time was 62, 75, and 77 minutes for sub-inguinal, abdominal, and conversion groups, respectively ( P = 0.30). Time to device activation was 25.0, 32.0, and 37.5 days for abdominal, sub-inguinal, and conversion groups, respectively (P<0.01). There were no bowel or bladder injuries and no PRB herniation in any group; however, there were five instances of pump migration superiorly, all in the sub-inguinal or conversion groups (P = 0.05). CONCLUSIONS: The sub-inguinal approach to PRB placement during AUS is safe and can be successfully completed over 90% of the time. However, it is not faster than the abdominal approach to PRB placement and it is associated with an increased risk of pump migration, though the latter may be confounded by the sub-dartos pouch for pump placement that was used in all sub-inguinal cases.

The "Fragile" Urethra as a Predictor of Early Artificial Urinary Sphincter Erosion.

OBJECTIVES: To identify predictors of early artificial sphincter (AUS) erosion among a cohort of men with erosion, who underwent AUS placement by either university or community-based surgeons. METHODS: The records of all patients with AUS erosions, including men who underwent AUS placement at outside facilities, were retrospectively reviewed. A Cox proportional-hazards model for time to erosion was performed with the predictors being the components of a fragile urethra (history of radiation, prior AUS, prior urethroplasty), androgen deprivation therapy (ADT), trans-corporal (TC), and 3.5 cm cuff, controlling for other risk factors. Kaplan-Meier survival curves and log-rank test compared "fragile" urethras with "not fragile" urethras. All statistical analysis was done using R version 3.5.2. RESULTS: Of the 156 men included, 36% had undergone AUS placement in the community. Median time to erosion was 16.0 months (1.0-240.0 months), and 122 (78%) met at least one fragility criteria. Radiation (HR 2.36, 95% CI 1.52-3.64) and prior urethroplasty (HR 2.12, 95% CI 1.18-3.80) were independently associated with earlier time to erosion. The Kaplan-Meier estimates demonstrate 1- and 5-year survival rates of 76.5% and 50.0%, respectively, for "non-fragile" and 44.1% and 14.8% for "fragile" urethras (P < .0001). CONCLUSION: In a diverse cohort of men with AUS erosion, men with "fragile" urethras eroded sooner. Radiation and prior urethroplasty were independent risk factors for earlier time to erosion, but prior AUS, ADT, TC and 3.5 cm cuff were not.

Multi-institutional review of non-hypospadiac penile urethral stricture management and outcomes.

OBJECTIVES: Penile urethral stricture disease not associated with hypospadias is rare, and there is a wide range of commonly used surgical repair techniques for this disease. We sought to compile a multi-institutional database of patients who had surgical correction of strictures in the penile urethra not limited to the meatus, and who had no history of hypospadias, for analysis using the Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology classification system. METHODS: A retrospective database from 13 institutions was compiled of patients who had undergone surgical correction of Trauma and Urologic Reconstructive Network of Surgeons length, urethral segment and etiology urethral stricture segments S2b/S2c and excluding E5, with a minimum follow-up time of 4 months. Failure was defined as cystoscopically confirmed recurrence of a stricture measuring less than 16-Fr. RESULTS: We analyzed 222 patients with a median age of 57 years and a follow-up of 49 months. The overall surgical success rate was 80.2%. On multivariate analysis, the two variables identified that were predictive of surgical success were stricture length ≤2 cm as well as use of a buccal mucosa graft as compared to use of a fasciocutaneous flap, which had success rates of 83% and 52%, respectively (P = 0.0004). No statistically significant differences were found based on incisional approach or surgical technique, nor were outcomes different based on etiology or preoperative patient demographics. CONCLUSIONS: Surgical repair of penile urethral strictures of non-hypospadiac origin have a favorable overall success rate, at 80.2%. Regardless of incisional approach or surgical technique, all operations appear to have similar outcomes other than repairs using fasciocutaneous flap, which were statistically less successful than those using buccal mucosa graft.

Association of stone surgery with patient-reported complications after spinal cord injury.

AIMS: To determine if a history of urinary stone surgery in individuals with spinal cord injury (SCI) is associated with an increased incidence of SCI-related complications and lower quality of life (QOL). METHODS: The Neurogenic Bladder Research Group (NBRG) registry is a multicenter, prospective, observational study which measures QOL after acquired SCI. Over 1.5 years, 1479 participants were enrolled and grouped according to history of stone surgery. We evaluated SCI-related complications, QOL, and associations between patient factors and prior stone surgery using multivariable regression. RESULTS: Participants were a median of 11 years post-SCI and 189 (12.8%) reported prior bladder or kidney stone surgery; 95.8% of these occurred after the SCI. Median time between SCI and first stone was 5.6 years (IQR: 1.8-12.8). Hospitalizations were higher for those with prior stone surgery, with common reasons including UTIs, blood clots, pressure ulcers, and pneumonia (p < 0.001). During the year of observation, the incidence of stone surgery was 17% in those with a prior history of stone surgery and 2% per year in those without prior stone surgery (p < 0.001). Controlling for covariates, bladder management strategy, age, BMI, and years since SCI were associated with history of stone surgery. CONCLUSIONS: People with SCI and a history of surgical stone disease are at high risk for episodes of recurrent stones and increased hospitalizations, particularly those with kidney stones and indwelling catheter use. Identification of high-risk patients may guide tailored surveillance for complications and stone prevention strategies.

Illeal conduit associated parastomal hernias: A novel laparoscopic top hat repair.

Parastomal hernias (PH) are a well-known complication following ileal conduit urinary diversion. We present a case report of a woman in her mid-nineties with a symptomatic parastomal hernia at the site of her ileal conduit which was repaired laparoscopically by an inverted top-hat technique. The "top hat" is constructed by assembling a transected ring of synthetic mesh with a secondary mesh cylinder and laparoscopically securing this mesh construct in an underlay fashion. At eighteen months follow-up, the patient remains pain free and without evidence of hernia recurrence.

The Management of Complications of Feminizing Gender Affirming Genital Surgery.

Penile inversion vaginoplasty is the most common technique used for gender affirming genital surgery in the treatment of gender dysphoria among transwomen. As vaginoplasty becomes more widely available, the management of associated complications has become its own field. There is a relative dearth of literature on surgery for complications following vaginoplasty. This review illustrates surgical technique and management options for patient reported complaints and complications following vaginoplasty. The goal of this manuscript is 2-fold (1) to introduce community surgeons to common postoperative issues they may encounter and (2) provide a systematic operative approach to complications for reconstructive surgeons who see transgender patients regularly.

A Laparoscopic Approach to Parastomal Hernia Repair With Re-Siting of Urinary Stoma.

BACKGROUND: Parastomal and ventral hernias are common complications in patients with continent catheterizable channels or incontinent urinary diversions. Patients with neurogenic bladder are at particularly high risk due to weak abdominal wall musculature, and hernia repair often requires resiting of their stoma. While parastomal hernia repair with urinary stoma resiting has acceptable long-term success rates, it often necessitates a laparotomy which is associated with significant morbidity. OBJECTIVE: To describe a novel approach to combined laparoscopic parastomal hernia repair with resiting of the urinary stoma in patients with neurogenic bladder. The video will outline the surgical steps and pitfalls. MATERIALS AND METHODS: The case begins laparoscopically or robotically with adhesiolysis to dissect out the subfascial portion of the channel and the parastomal hernia. The subfascial portion of the channel is dissected out to the anterior abdominal wall, ensuring to preserve its mesentery. The abdomen is then desufflated and the suprafascial portion of the channel is dissected and the channel dropped into the abdomen. The hernia is then repaired laparoscopically using mesh and the channel is brought out through one of the laparoscopic port sites and matured to the skin. RESULTS: In our series of 4 patients, this technique was performed for 2 continent catheterizable channels and 2 incontinent diversions. One patient developed a hernia recurrence 7 months later which was repaired laparoscopically. In another, the stoma was successfully resited but the hernia was unable to be repaired laparoscopically due to dense adhesions. Continent and patency outcomes of the urinary stomas were 100% at a mean follow-up of 2 years. CONCLUSION: Laparoscopic parastomal hernia repair with resiting of the urinary stoma has similar long-term success rates compared to that of an open repair and avoids the morbidity of a laparotomy. This repair can be performed for catheterizable channels or incontinent diversions.

Neurofibroma originating from a urachal mass.

Urachal anomalies are rare in the adult population and when diagnosed, are typically malignant. Herein, we report a case of a 61-year-old male who underwent an excision of a urachal mass for a presumed malignancy. Pathologic evaluation demonstrated a neurofibroma. Neurofibromas are benign peripheral nerve sheath tumors that mostly appear as localized skin tumors and rarely involve the genitourinary system. Neoplastic transformation of neurofibromas is rare but not unheard. To our knowledge, this is the first description of a neurofibroma originating from the urachus.

A live porcine model for robotic sacrocolpopexy training.

INTRODUCTION AND HYPOTHESIS: Robotic sacrocolpopexy is an effective and durable technique for pelvic organ prolapse repair. However, the learning curve for this procedure has underscored the need for an effective surgical training module. Given the cost, infection risk, poor tissue compliance, and scarcity of human cadavers, the live porcine model represents a realistic, available, and cost-effective alternative. This article describes a live porcine model for teaching robotic sacrocolpopexy to determine whether it teaches key aspects of live human robotic sacrocolpopexy to the learner. METHODS: This robotic sacrocolpopexy model was created using the Da Vinci Xi or Si robotic system on domestic pigs under general anesthesia. The main steps of the model include: (1) creating the porcine "cervix" and (2) performing robotic sacrocolpopexy. The model was evaluated with a survey given to 18 board-certified surgeons who attended the training course between December 2016 and April 2018. RESULTS: All of the participants reported improvements in their economy of motion, tissue handling ability, suturing efficiency, and overall performance of robotic sacrocolpopexy. Furthermore, a majority of participants were likely to incorporate aspects of the model into their practice (88.8%) and recommend the model to colleagues (94.2%). CONCLUSIONS: The porcine model provides a feasible tool for teaching robotic sacrocolpopexy to physicians.

The Learning Curve for Magnetic Resonance Imaging/Ultrasound Fusion-guided Prostate Biopsy.

BACKGROUND: Magnetic resonance imaging/ultrasound-guided fusion biopsy (FBx) is more accurate at detecting clinically significant prostate cancer than conventional transrectal ultrasound-guided systematic biopsy. However, learning curves for attaining accuracy may limit the generalizability of published outcomes. OBJECTIVE: To delineate and quantify the learning curve for FBx by assessing the targeted biopsy accuracy and pathological quality of systematic biopsy over time. DESIGN, SETTING, AND PARTICIPANTS: We carried out a retrospective analysis of 173 consecutive men who underwent Artemis FBx with computer-template systematic sampling between July 2015 and May 2017. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The accuracy of targeted biopsy was determined by calculating the distance between planned and actual core trajectories stored on Artemis. Systematic sampling proficiency was assessed via pathological analysis of fibromuscular tissue in all cores and then comparing pathology elements from individual cores from men in the first and last tertiles. Polynomial linear regression models, change-point analysis, and piecewise linear regression were used to quantify the learning curve. RESULTS AND LIMITATION: A significant improvement in targeted biopsy accuracy occurred up to 98 cases (p<0.01). There was a significant decrease in fibromuscular tissue in the systematic biopsy cores up to 84 cases (p<0.01) and an improvement in pathological quality when comparing systematic cores from the first and third tertiles. Use of a different fusion platform may limit the generalizability of our results. CONCLUSIONS: There is a significant learning curve for targeted and systemic biopsy using the Artemis platform. Improvements in accuracy of targeted biopsy and better sampling for systematic biopsy can be achieved with greater experience. PATIENT SUMMARY: We define the learning curve for magnetic resonance imaging/ultrasound-guided fusion biopsy (FBx) using targeted biopsy accuracy and systematic core sampling quality as measures. Our findings underscore the importance of overcoming learning curves inherent to FBx to minimize patient discomfort and biopsy risk and improve the quality of care for accurate risk stratification, active surveillance, and treatment selection.

Understanding Your Online Ratings: A Methodological Analysis Using Urogynecologists in the United States.

OBJECTIVE: The influence of online physician ratings is growing, yet their interpretation remains difficult. Our aim was to analyze the online content of urogynecologists on 1 website to transform these ratings into practical tools for care improvement. METHODS: This cross-sectional analysis studied the ratings and reviews of every board-certified urogynecologist listed on Healthgrades.com. The ratio of 5:1 ratings was compared between various physician characteristics and practice qualities. Four investigators classified narrative reviews into one or more of the following themes: about the (1) physician, (2) clinical outcomes, (3) and/or staff. The content of the narrative reviews was analyzed, and word clouds were created to understand the primary motivators behind ratings. RESULTS: In February 2018, the Healthgrades pages for 689 urogynecologists were evaluated, and 523 physicians were included in the study. Higher 5:1 ratios were found among men versus women (4.0 vs 3.0; P < 0.01), and OB-GYN-trained versus urology-trained (4.0 vs 2.2; P < 0.01) physicians. A benchmarking rubric was developed to illustrate the 5:1 ratio distribution for all physicians stratified by number of ratings. A total of 3300 narrative reviews were assigned themes with strong inter- and intrarater reliability (Table 3). Physician qualities most influenced extreme scores (1 or 5 stars), whereas average reviews were more influenced by staff. Commonly discussed physician qualities included professionalism, time with patient, and counseling. CONCLUSIONS: Using the 5:1 rating ratio and simplified review themes as tools, physicians can understand what their ratings signify both as an indicator of their online reputation compared with their peers and as a means for improving the patient experience.

Composite health behaviour classifier as the basis for targeted interventions and global comparisons in men's health.

INTRODUCTION: Lifestyle-related diseases are the leading cause of death among North American men. We evaluated health behaviours and their predictors that contribute to morbidity and mortality among Canadian men as a means to making recommendations for targeted interventions. METHODS: A cross-sectional analysis of Canadian men drawn from 5362 visitors to our online survey page was conducted. The current study sample of 2000 men (inclusion: male and >18 years; exclusion: incomplete surveys) were stratified to the 2016 Canadian census. The primary outcome was the number of unhealthy men classified using our Canadian Composite Classification of Health Behaviour (CCCHB) score. Secondary outcomes included the number of men with unhealthy exercise, diet, smoking, sleep, and alcohol intake, as well as socioeconomic and demographic factors associated with unhealthy behaviours to be used for targeting future interventions. RESULTS: Only 118/2000 (5.9%) men demonstrated 5/5 healthy behaviours, and 829 (41.5%) had 3/5 unhealthy behaviours; 391 (19.6%) men currently smoked, 773 (38.7%) demonstrated alcohol overuse, 1077 (53.9%) did not get optimal sleep (<7 or >9 hours per night), 977 (48.9%) failed to exercise >150 minutes/week, and 1235 (61.8%) had an unhealthy diet. Multivariate analysis indicated that men with high school education were at increased risk of unhealthy behaviours (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.15-2.18; p=0.005), as were men living with relatives (OR 2.10; 95% CI1.04-4.26; p=0.039), or with their partner and children (OR 1.34; 95% CI 1.02-1.76; p=0.034). CONCLUSIONS: An overwhelming 41.5% of Canadian men had 3/5 unhealthy behaviours, affirming the need for targeted lifestyle interventions. Significant health inequities within vulnerable subgroups of Canadian men were identified and may guide the content and delivery of future interventions.

Varicella-zoster virus and urologic practice: a case-based review.

INTRODUCTION: Each year, varicella-zoster virus (VZV) affects nearly one million people in the United States, often in the form of herpes zoster, or shingles. The urologic system is a rare but often debilitating target. This paper reviews the epidemiology, symptomatology, diagnosis, and management of VZV as it relates to urologic practice. MATERIALS AND METHODS: We performed a PubMed search using the query "herpes zoster" and "varicella-zoster virus" combined with multiple urological terms. RESULTS: Infection caused by VZV, specifically the resurgent clinical infection herpes zoster (HZ), is prevalent and increasing. It often affects older men and women and those in immunocompromised states and usually manifests as a painful cutaneous rash. However, urological conditions such as voiding dysfunction, erectile issues, and flank pain have also been noted in conjunction with an HZ infection. Additionally, urological procedures and treatments may incite an HZ outbreak. Awareness and prompt treatment can ameliorate the intensity and duration of this infection. CONCLUSIONS: An understanding of the atypical manifestations of HZ and disseminated VZV infection may aid urologic practitioners in avoiding misdiagnosis and delay of treatment.

Multiple Regions of Interest on Multiparametric Magnetic Resonance Imaging are Not Associated with Increased Detection of Clinically Significant Prostate Cancer on Fusion Biopsy.

PURPOSE: We sought to determine the association between multiple regions of interest on prebiopsy magnetic resonance imaging and the detection of clinically significant prostate cancer in men undergoing magnetic resonance imaging-ultrasound fusion biopsy. MATERIALS AND METHODS: We performed a retrospective, single institution analysis of men who underwent fusion biopsy. Men with prior positive biopsies, magnetic resonance imaging performed elsewhere and/or magnetic resonance imaging prior to release of the PI-RADS™ (Prostate Imaging Reporting and Data System) version 2 were excluded from study, resulting in 381 participants. Modeled independent variables included patient age, number of regions of interest with a PI-RADS categorization of 3 or greater, body mass index, prostate specific antigen, prostate volume and PI-RADS categorization. Multivariable logistic regression was performed to determine factors associated with finding clinically significant prostate cancer (Gleason 7 or greater) on biopsy. RESULTS: Median age was 67.2 years (IQR (61.6-73.0) and median prostate specific antigen was 6.6 ng/ml (5.0-10.0). Adjusted analysis demonstrated that age (OR 1.10, 95% CI 1.06-1.15, p ≤0.001), body mass index (OR 1.08, 95% CI 1.01-1.16, p = 0.038) and prostate specific antigen (OR 1.06, 95% CI 1.01-1.10, p = 0.015) were associated with detection of clinically significant prostate cancer. PI-RADS categories 4 (OR 4.62, 95% CI 2.23-9.33) and 5 (OR 6.75, 95% CI 2.72-16.71, each p <0.001) were associated with greater odds of clinically significant prostate cancer. Multiple regions of interest were not associated with the detection of clinically significant prostate cancer (OR 1.05, 95% CI 0.60-1.84, p = 0.857). CONCLUSIONS: Multiple regions of interest do not portend a greater likelihood of finding clinically significant prostate cancer. Physicians should recognize that multiple regions of interest should not influence the decision to perform fusion biopsy. Our findings may ease patient anxiety concerning these findings.

Review of optimal techniques for robotic-assisted radical prostatectomy.

PURPOSE OF REVIEW: Robotic-assisted radical prostatectomy has been rapidly adopted and is now the standard of care in the surgical management of prostate cancer. Since the initial description in 2001, the technique has evolved to optimize oncological functional outcomes. Herein, we review key techniques for the robotic-assisted radical prostatectomy. RECENT FINDINGS: With the current influx of new technology such as focal therapy, stereotactic body radiation therapy and prostate-sparing treatments, there is greater emphasis on maximizing outcomes of robotic-assisted radical prostatectomy. The evidence-based techniques of optimizing oncological outcomes including the lymph node dissection and improving cancer control through minimizing positive surgical margins are reviewed. Improvements in functional recovery has also been seen with technical modifications such as nerve sparing, preservation of the urethral support structures and the bladder neck and the urethra-vesical reconstruction. SUMMARY: Robotic prostatectomy has demonstrated adequate long-term oncologic success and satisfactory functional recovery. As technology and techniques in robotic-assisted surgery evolve, surgeons will continue to optimize techniques to maximize functional outcome recovery and cancer control. Further studies are actively being conducted to provide level one evidence in multiple aspects of the robotic-assisted radical prostatectomy.

Factors influencing scholarly impact: does urology fellowship training affect research output?

PURPOSE: Residents seek postresidency fellowship training to increase competency with novel surgical techniques and augment their fund of knowledge. Research productivity is a vital component of advancement in academic urology. Our objectives were to use the h-index (an objective and readily available bibliometric that has been repeatedly shown to correlate with scholarly impact, funding procurement, and academic promotion in urology as well as other specialties) to determine whether any relationship exists between fellowship training and scholarly impact among academic urologists. Additional examination was performed to determine whether any differences in scholarly influence are present among practitioners in the major urologic subspecialties. MATERIALS AND METHODS: Overall, 851 faculty members from 101 academic urology departments were organized by academic rank and fellowship completed. Research productivity was calculated using the h-index, calculated from the Scopus database. RESULTS: There was no statistical difference in h-index found between fellowship-trained and nonfellowship-trained academic urologists. The highest h-indices were seen among urologic oncologists (18.1 ± 0.95) and nonfellowship-trained urologists (14.62 ± 0.80). Nearly 70% of department chairs included in this analysis were urologic oncologists or general urologists. CONCLUSIONS: No difference in h-index existed between fellowship-trained and nonfellowship-trained urologists, although practitioners in the subspecialty cohorts with the highest research productivity (nonfellowship-trained and urologic oncologists) comprised 70% of department chairpersons. This relationship suggests that a strong research profile is highly valued during selection for academic promotion. Differences existed on further comparison by subspecialty. Fellowship training may represent another potential opportunity to introduce structured research experiences for trainees.

Circumcision as a strategy to minimize HIV transmission.

The newest data related to the Human Immunodeficiency Virus (HIV) / Acquired Immune Disease Syndrome (AIDS) epidemic is primarily positive, but many areas of the world, especially Sub-Saharan Africa, remain disproportionately affected. Between 2005 and 2007, three large randomized trials evaluating circumcision for prevention of HIV acquisition in heterosexual African males showed a reduction in the rate of acquisition of HIV by up to 66 % over 24 months. Since the results of these studies were published, global health organizations have ramped up efforts to help target countries to provide male circumcision delivery services in sub-Saharan Africa. Male circumcision (MC) is cost-effective and efficacious, especially when used in combination with other prevention strategies. Available data shows good acceptability amongst target populations. Neonatal circumcision is well tolerated and more cost effective than adult male circumcision and should be included as part of MC initiatives in the future. Behavioral disinhibition and risk compensation are important factors that may mitigate the rate of risk reduction conferred by male circumcision and should be further investigated. As delivery of male circumcision services is expanded, the issues affecting the female sexual partners of the target population must be outlined and addressed. Whether or not the results of the African trials can be extrapolated to warrant expansion of MC programs to other populations is a critical area for further study.