Urology Match: Important Factors Women Consider When Choosing a Residency Training Program.

OBJECTIVE: To determine factors that women urology resident physicians rate as most influential when selecting residency programs. METHODS: Surveys were emailed to female urology residents during the 2021-2022 academic year. Residents scored 19 factors influencing residency program choice from 1 "least" to 5 "most" important and ranked their top 5 most influential factors. Data were analyzed via descriptive statistics and quantile regression. RESULTS: One hundred thirty-six (37%) of 367 female urology residents who received the survey participated. Eighty-two percent had no children and 57% did not plan to have children during residency. The three highest scoring factors derived from Likert scale ratings were resident camaraderie (4.6 ±â€¯0.5 [mean ±â€¯SD]), resident happiness (4.6 ±â€¯0.6), and case variety/number (4.4 ±â€¯0.8). As a whole, the lowest scoring characteristics were attitudes toward maternity leave (2.6 ±â€¯1.2) and maternity leave policies (2.5 ±â€¯1.2). Married residents were more likely than those who were single and engaged/in a committed relationship to rank attitudes and policies toward maternity leave as more important (3 vs 2 vs 2, P <.0001). Residents with children were more likely than those without children to rank maternity leave policies as more important (3 vs 2, P <.0001). CONCLUSION: As a whole, women urology residents prioritized non-gender-related factors. However, gender-specific factors were rated highly by married residents and those with children or planning to have children. Urology training programs may use these results to highlight desirable characteristics to aid recruitment of female residents.

Impact of an inpatient advanced practice provider on hospital length of stay after major urologic oncology procedures.

INTRODUCTION: Although timely hospital discharge is a complex and multifactorial process, this metric is consistently a focus for hospitals and health care systems. It also has been a long practice that the American Urological Association (AUA) supports the use of advanced practice providers (APPs) as an integral member of the urological care team. MATERIALS AND METHODS: Here, we performed a preliminary evaluation of the effectiveness of an inpatient APP in reducing hospital length of stay (LOS) following major urologic oncology procedures. Surgical outcomes, surgeon data, and LOS for open and minimally invasive urologic oncology procedures, including radical prostatectomy, partial or radical nephrectomy, and radical cystectomy, were compiled over a 4-year period (pre-APP: 2014-2016 and post-APP: 2018-2020). Univariate descriptive statistics analyzed the association of an inpatient APP in with reducing hospital LOS over time. RESULTS: Average LOS decreased in all surgical procedures and for all surgeons in the post-APP setting, irrespective of surgical approach (P< 0.05). CONCLUSIONS: An inpatient APP was associated with a decrease of hospital LOS for urologic oncology patients over time. Such observations underscore the likely economic benefit to the health care system and potential improved coordination of care and satisfaction for patients undergoing major urologic oncology procedures.

Patient Perceptions Regarding Routine Oncologic Follow-Up for Urologic Malignancies.

INTRODUCTION: In colorectal, cervical, and breast cancers, oncologic follow-up can exacerbate or alleviate patient stress about disease recurrence. Such patient experiences are less well defined for urologic malignancies. We developed a cross-sectional prospective survey study to assess kidney (Kid), prostate (Pros), and bladder (Bld) cancer patient perceptions of oncologic follow-up following surgical treatment. PATIENTS AND METHODS: Patients with pTanyNanyM0 Kid, Pros, and Bld cancer presenting at least 60 days following primary surgical treatment of their cancer were eligible. Receipt of adjuvant therapy or disease recurrence were exclusion criteria. Questionnaires assessing attitudes towards follow-up and stress-reducing strategies were administered prior to revealing testing results. Analysis was performed according to cancer type and level of recurrence risk, with pathologic stage used a proxy for recurrence risk. RESULTS: Three hundred thirty-seven patients were prospectively surveyed from 2018 to 2020: 127 (38%) Kid, 134 (40%) Pros, and 76 (23%) Bld. Patients showed satisfaction with provided strategies to combat recurrence anxiety (Kid 86%, Pros 81%, Bld 85%). However, approximately 16% of patients reported wanting, but not receiving, strategies for fear reduction. Most patients reported diagnostic tests were "Not at All" burdensome (Kid 86%, Pros 94%, Bld 82%) and disagree that fewer tests would alleviate anxiety (Kid 89%, Pros 91%, Bld 84%). The majority reported an increased sense of worry if there were no cancer follow-ups (Kid 84%, Pros 80%, Kid 81%), and preferred their specialist to their family physician to direct such care (Kid 89%, Pros 91%, Bld 95%). When stratified by recurrence risk, no significant differences existed across cancers in patients' attitudes toward follow-up. However, Pros cancer patients showed a difference in fear of recurrence ("Not at All" worried about recurrence ≤T2 38%, ≥T3, 19%; P= .04). CONCLUSION: Urology patients appear satisfied with their oncologic follow-up. Sixteen percent of patients sought additional strategies to combat fear, indicating opportunity for improvement.

Perspectives on the Role of Biopsy for Management of T1 Renal Masses: Survey Results From Two Regional Quality Improvement Collaboratives.

OBJECTIVE: To understand perspectives on renal mass biopsy, a survey was distributed to urologists in the Michigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative. Renal mass biopsy (RMB) may reduce treatment of benign renal neoplasms; however, utilization varies widely. MATERIALS AND METHODS: Michigan Urological Surgery Improvement Collaborative and Pennsylvania Urologic Regional Collaborative are two quality improvement collaboratives that include a "real-world" collection of urologists from academic- and community-based settings. A 12-item survey assessing current RMB utilization, patient- and tumor-specific factors, adverse events, impact on management, and simulated patient scenarios was distributed. Responses are reported using descriptive statistics. RESULTS: Many responders (n = 54) indicated using RMB in less than 25% of cT1a (59%) and cT1b (85%) tumors. The most important patient-specific factors on the decision to recommend RMB were possible metastasis to the kidney (94%), patient comorbidity as a risk factor for active treatment (89%), and patient age (81%). The most important tumor-specific factors were the presence of bilateral tumors (81%), tumor size (70%) and perceived potential of performing nephron-sparing surgery (67%). Ten responders (19%) noted barriers to RMB in their practice, 23 (43%) recalled experiences with complications or poor outcomes, and 43 (80%) reported experiences where the results of RMB altered management. When presented with simulated patients, few urologists (9%-20%) recommended RMB in younger patients with any sized mass. Recommendations varied based on patient age, comorbidity, and tumor size. CONCLUSION: Understanding perspectives on RMB usage is essential prior to implementing quality improvement efforts. Most urologists participating in two statewide collaboratives infrequently recommend RMB. Optimizing RMB utilization may help reduce unnecessary treatments.

Potential Winners and Losers: Understanding How the Oncology Care Model May Differentially Affect Hospitals.

PURPOSE: With the introduction of the Oncology Care Model and plans for the transition to Oncology Care First, alternative payment models (APMs) are an increasingly important piece of the oncology care landscape. Evidence is mixed on the Oncology Care Model's impact on utilization and costs, but as policymakers consider expansion of similar models, it is critical to understand the characteristics of hospitals that may be differentially affected. METHODS: We used 2007-2016 SEER-Medicare data to identify patients with breast and prostate cancer receiving chemotherapy, endocrine therapy (breast), or androgen deprivation therapy (prostate). For each hospital, we calculated 6-month expected mortality, emergency department (ED) visits, inpatient admissions, and costs, all commonly collected APM outcomes. After calculating observed-to-expected rates for each outcome by hospital, we estimated the association between observed-to-expected rates and characteristics of each hospital to understand hospital characteristics that might be associated with higher- or lower-than-expected rates of each outcome. RESULTS: Hospitals with > 15% rural patients had significantly higher-than-expected mortality (0.31 points higher, P < .001) and ED visit rates (0.10 points higher, P = .029) as well as significantly lower costs (0.06 points lower, P = .004). Hospitals unaffiliated with a medical school also experienced significantly higher-than-expected mortality and ED visits. Hospitals eligible for disproportionate share hospital payment experienced significantly higher ED visits but lower costs. For-profit hospitals experienced higher-than-expected mortality. CONCLUSION: Rural hospitals and those unaffiliated with a medical school may require special consideration as APMs expand in oncology care. Designated cancer centers and larger hospitals may be advantaged.

Preventing Prostate Biopsy Complications: to Augment or to Swab?

OBJECTIVE: To use data from a large, prospectively- acquired regional collaborative database to compare the risk of infectious complications associated with three American Urologic Association- recommended antibiotic prophylaxis pathways, including culture-directed or augmented antibiotics, following prostate biopsy. METHODS: Data on prostate biopsies and outcomes were collected from the Pennsylvania Urologic Regional Collaborative, a regional quality collaborative working to improve the diagnosis and treatment of prostate cancer. Patients were categorized as receiving one of three prophylaxis pathways: culture-directed, augmented, or provider-discretion. Infectious complications included fever, urinary tract infections or sepsis within one month of biopsy. Odds ratios of infectious complication by pathway were determined, and univariate and multivariate analyses of patient and biopsy characteristics were performed. RESULTS: 11,940 biopsies were included, 120 of which resulted in infectious outcomes. Of the total biopsies, 3246 used "culture-directed", 1446 used "augmented" and 7207 used "provider-discretion" prophylaxis. Compared to provider-discretion, the culture-directed pathway had 84% less chance of any infectious outcome (OR= 0.159, 95% CI = [0.074, 0.344], P < 0.001). There was no difference in infectious complications between augmented and provider-discretion pathways. CONCLUSIONS: The culture-directed pathway for transrectal prostate biopsy resulted in significantly fewer infectious complications compared to other prophylaxis strategies. Tailoring antibiotics addresses antibiotic-resistant bacteria and reduces future risk of resistance. These findings make a strong case for incorporating culture-directed antibiotic prophylaxis into clinical practice guidelines to reduce infection following prostate biopsies.

Is pelvic MRI imaging sufficient cross-sectional imaging for staging intermediate and high-risk prostate cancer?

OBJECTIVES: The American Urological Association's (AUA) and National Comprehensive Cancer Network's (NCCN) provide highly recognized guidelines for staging prostate cancer (CaP). However, both are vague as to specific type of cross-sectional imaging (CT vs. MRI) and extent (abdominal vs. pelvis), thereby raising concern for overlapping imaging. We investigated if current AUA and NCCN CaP staging guidelines can become more specific yet maintain sufficient staging. METHODS: We identified 493 patients diagnosed with CaP between 2011 and 2017 and focused analysis on those with AUA and NCCN Intermediate risk (IR) and High risk (HR) groups. Type of staging imaging was recorded and frequency of overlapping (CT + MRI) and abdominal imaging determined. Significance of radiologist findings, for both overlapping and abdominal imaging, were classified as nonurologic, nonsignificant urologic, and CaP significant. RESULTS: Among IR and HR AUA and NCCN risk groups, 82 (35.7%) and 95 (37.3%) patients, respectively, experienced overlapping imaging, of which only 7 patients in AUA and 9 patients in NCCN risk groups had an abnormal CT with normal MRI. However, only 3 of these CTs had CaP significant findings, of which 2 identified bone metastases, which were subsequently detected on bone scan. In regard to the extent of imaging, a total of 157 (68.2%) AUA and 178 (69.8%) NCCN IR and HR patients received abdominal scans, of which only 46 (20.0%) and 49 (19.2%) were abnormal among AUA and NCCN risk groups, respectively. Among these abnormal abdominal scans, only 10 showed CaP significant findings, of which half were suspected bone metastases, and confirmed on recommended bone scan. CONCLUSIONS: Due to nonspecific staging guidelines in IR and HR CaP regarding type and extent of cross-sectional imaging, patients are frequently receiving imaging of overlapping locations. Based on low occurrences of unique CaP significant findings on CT and abdominal imaging, our exploratory analysis suggests that narrowing cross-sectional imaging recommendations to pelvic MRI may reduce imaging overlap while maintaining sufficient staging.

Prostate magnetic resonance imaging: The truth lies in the eye of the beholder.

PURPOSE: To determine the diagnostic accuracy and interobserver variability of radiologic interpretation of magnetic resonance imaging (MRI) performed for surgical planning before prostatectomy. PATIENTS AND METHODS: The records of 233 men undergoing prostatectomy with presurgical multiparametric 3T surface body coil MRI were reviewed. All initial films were read by a fellowship-trained body radiologist provided with relevant clinical information. A senior radiologist then reread all pelvic MRIs blinded to the initial interpretation with findings from both readings compared to final pathology. Kappa (κ) scores as well as sensitivity, specificity, positive predictive values (PPV), negative predictive value (NPV), and accuracy were determined. RESULTS: When considering extraprostatic extension (EPE), there was low concordance comparing the initial vs. repeat MRI interpretation (κ = 0.22). Additionally, when the senior radiologist reread his own initial interpretation (n = 93, blinded to initial result), concordance for EPE was greater (κ = 0.36) albeit similarly low. With regard to EPE, a comparison of initial MRI interpretation vs. reread by senior radiologist noted universal improvements in diagnostic characteristics including sensitivity (30.3% vs. 56.1%), specificity (80.2% vs. 88.6%), PPV (37.7% vs. 66.1%), NPV (74.4% vs. 83.6%), and accuracy (66.1% vs. 79.4%). In contrast, seminal vesicle invasion interpretation was more uniform whereby initial MRI interpretation vs. reread yielded similar sensitivity (18.2% vs. 27.3%), specificity (97.2% vs. 93.8%), PPV (40.0% vs. 31.6%), NPV (91.9% vs. 92.5%), and accuracy (89.7% vs. 87.6%). CONCLUSIONS: Even at a tertiary referral center, interobserver variability among radiologists regarding local extent of disease on prostate MRI is high. These observations underscore the importance of uniformity when defining criteria for EPE and seminal vesicle invasion to allow for optimal presurgical planning.

Is sarcopenia and sarcopenic obesity associated with clinical and pathological outcomes in patients undergoing radical nephroureterectomy?

PURPOSE: To investigate the association between sarcopenia and sarcopenic obesity on clinical, perioperative, and oncologic outcomes in patients with upper-tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). METHODS: Retrospective review of our institutional UTUC database was performed to identify all patients who underwent radical nephroureterectomy from 2002-2016. Skeletal Muscle Index (SMI) was measured at the L3 vertebral level and standardized according to patient height (cm2/m2). Sarcopenia was defined as<55cm2/m2 for men and<39cm2/m2 for women. Sarcopenic obesity was also assessed in patients with BMI>30kg/m2. Unadjusted logistic regression and Wilcoxon rank sum tests examined the relationship between sarcopenia and variables. RESULTS: A total of 100 patients (66 men and 34 women) with a mean age of 68 years, BMI of 30, Charlson comorbidity index of 4.0, tumor size of 3.5, and SMI of 50.8cm2/m2 were included. Furthermore, 42 patients (42%) were sarcopenic, and 18 patients (18%) had sarcopenic obesity. Median EBL was 150ml, OR duration was 322 minutes, and length of stay was 5.0 days. Sarcopenia was associated with several clinical factors including decreasing BMI, male sex, and coronary artery disease, albeit without association with any perioperative or oncologic outcomes. Sarcopenic obesity was similarly associated with several clinical variables including male sex, diabetes mellitus, hyperlipidemia, as well as increased EBL (P = 0.047) and non-bladder cancer disease relapse (P = 0.049). CONCLUSIONS: This contemporary cohort of patients undergoing RNU highlights the association of nonmodifiable risk factors with sarcopenia and disease relapse with sarcopenic obesity. Larger studies are necessary to further validate these observations.

Longitudinal Gender Disparity in Female Urology Resident Primary Authorship at an American Urological Association Sectional Meeting.

OBJECTIVE: To further evaluate the academic representation of female urology residents in the United States, we reviewed abstracts from the Mid-Atlantic American Urological Association (MA-AUA) sectional meetings to determine if the recent increase in the number of female urology residents mirrored an increase in this group's abstract authorship. MATERIALS AND METHODS: Full text abstracts from the MA-AUA meetings were analyzed from 2008 to 2014 excluding 1 joint section meeting. First-author gender was determined by querying publicly available institutional websites, social media platforms, and the U.S. News & World Report. First-author gender was indeterminable in 10 abstracts based on search criteria and these were excluded. Individual abstracts were broadly categorized based on keywords into 1 of several topics. Chi-square statistical tests examined the relationship between first-authorship gender, publication year, and abstract category. RESULTS: The number of female urology residents in the MA-AUA increased over the study period. A total of 484 abstracts were analyzed. Three hundred ninety-three abstracts (81%) included a male first-author, whereas 81 abstracts (17%) included a female first-author. Female first-authorship ranged from 13% to 25% annually. Comparison of male-to-female first-authorship was statistically significant in all years evaluated (P <.001). There was a statistically significant difference between male and female first-authorship in all topic categories (P <.01), except Education/Other (P = .56). CONCLUSION: Despite continued gains and increasing female representation in urology, these data highlight significantly fewer female first-authors at the regional Mid-Atlantic section meetings. Larger studies are necessary to identify contributing factors and further areas for improvement toward decreasing gender imbalances within the academic community.

Intravesical chemotherapy use after radical nephroureterectomy: A national survey of urologic oncologists.

To determine the use of prophylactic intravesical chemotherapy (pIVC) following radical nephroureterectomy (RNU) and barriers to utilization in a survey study of urologic oncologists. METHODS: A survey instrument was constructed, which queried respondents on professional experience, practice environment, pIVC use, and reasons for not recommending pIVC when applicable. The survey was electronically distributed to members of the Society of Urologic Oncology over an 8-week period. Survey software was used for analysis. RESULTS: The survey response rate was 22% (158 of 722). Half of the respondents were in practice for ≤10 years, while 90% performed ≤10 RNU cases annually. Of the 144 urologists regularly performing RNU, only 51% reported administering pIVC, including 22 exclusively in patients with a prior history of bladder cancer. One-third administered pIVC intraoperatively, whereas the remainder instilled pIVC at ≤3 (7%), 4 to 7 (37%), 8 to 14 (20%), and>14 (3%) days postoperatively. Almost all urologists noted giving a single instillation of pIVC. Agents included mitomycin-C (88%), thiotepa (7%), doxorubicin (3%), epirubicin (1%), and BCG (1%). Among respondents who did not administer pIVC, the most common reasons cited included lack of data supporting use (44%), personal preference (19%), and office infrastructure (17%). CONCLUSION: Only 51% of urologic oncologists report using pIVC in patients undergoing RNU. Reasons underlying this underutilization are multifactorial, thereby underscoring the need for continued dissemination of existing data and additional studies to support its benefits. Moreover, improving the logistics of pIVC administration may help to increase utilization rates.

Prognostic role of decreased E-cadherin expression in patients with upper tract urothelial carcinoma: a multi-institutional study.

PURPOSE: To assess the role of E-cadherin as prognostic biomarker in upper tract urothelial carcinoma (UTUC) in a large multi-institutional cohort of patients. METHODS: Immunohistochemistry technique was used to evaluate E-cadherin expression in 678 patients with unilateral, sporadic UTUC treated with RNU. E-cadherin expression was considered decreased if 10 % or more cells had decreased expression (<90 %). RESULTS: Decreased E-cadherin expression was observed in 353 patients (52.1 %) and was associated with advanced pathological stage (P < 0.001), higher grade (P < 0.001), lymph node metastasis (P = 0.006), lymphovascular invasion (P < 0.001), concomitant carcinoma in situ (P < 0.001), multifocality (P = 0.004), tumor necrosis (P = 0.020) and sessile architecture (P < 0.001). Within a median follow-up of 30 months (interquartile range 15-57), 171 patients (25.4 %) experienced disease recurrence and 150 (21.9 %) died from UTUC. In univariable analyses, decreased E-cadherin expression was significantly associated with worse recurrence-free survival (P < 0.001) and cancer-specific survival CSS (P = 0.006); however, in multivariable analyses, it was not (P = 0.74 and 0.84, respectively). The lack of independent prognostic value of E-cadherin remained true in all subgroup analyses. CONCLUSION: In UTUC patients treated with RNU, decreased E-cadherin expression is associated with features of biologically and clinically aggressive disease and worse outcome in univariable, but not multivariable, analyses. If E-cadherin's association with factors of advanced disease is confirmed on UTUC biopsy specimens, it could be used to help in the clinical decision-making regarding kidney-sparing approaches and/or neo-adjuvant chemotherapy.

Clinically localized type 1 and 2 papillary renal cell carcinomas have similar survival outcomes following surgery / Los carcinomas papilares de células renales tipo 1 y 2 localizados clínicamente tienen resultados de supervivencia similares después de la cirugía

Propósito Se intentó determinar la incidencia, hallazgos patológicos, factores pronósticos y resultados clínicos para pacientes con CCR papilar clínicamente localizado. Métodos Demográfico, Se recopilaron hallazgos clínicos y patológicos en todos los pacientes con CCRP sometidos a cirugía en cuatro centros médicos académicos. El punto final primario fue la supervivencia específica del cáncer (CSS). La supervivencia sin recaída (RFS) y la supervivencia general (OS) fueron puntos finales secundarios. Kaplan- Se obtuvieron estimaciones de Meier y se usaron modelos de regresión de riesgos proporcionales de Cox para evaluar predictores de mortalidad y recaída. Resultados Identificamos 626 CCPR, de los cuales 373 (60por ciento) fueron del tipo 1 y 253 (40 por ciento) fueron del tipo 2, con tres cuartas partes de todos los tumores siendo pT1. En comparación con los pacientes con tipo 1, aquellos con tipo 2 eran mayores (edad media: 63 frente a 61; (AU)

Purpose We aimed to determine incidence, pathologic fndings, prognostic factors and clinical outcomes for patients with clinically localized papillary RCC. Methods Demographic, clinical and pathologic fndings were collected on all patients with PRCC undergoing sur-gery at four academic medical centers. The primary end-point was cancer-specifc survival (CSS). Relapse-free survival (RFS) and overall survival (OS) were secondary endpoints. Kaplan­ Meier estimates were obtained, and Cox proportional hazard regression models were used to assess predictors of mortality and relapse. Results We identifed 626 PRCC, of which 373 (60 pertcent) were type 1 and 253 (40 pertcent) were type 2, with three-quar-ters of all tumors being pT1. Compared to patients with type 1, those with type 2 were older (mean age: 63 vs 61; (AU)

Altered Expression of the Transcription Factor Forkhead Box A1 (FOXA1) Is Associated With Poor Prognosis in Urothelial Carcinoma of the Upper Urinary Tract.

OBJECTIVE: To determine the prognostic significance of Forkhead Box A1 (FOXA1) expression in patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). MATERIALS AND METHODS: A retrospective analysis of 566 patients undergoing RNU at seven academic medical centers was performed. Tissue microarrays were subjected to immunohistochemistry using a commercially available polyclonal FOXA1 antibody. Logistic regression determined the association of FOXA1 expression with pathologic features and survival outcomes. RESULTS: Three hundred twenty-two men and 244 women were included. The pathologic distribution of specimens included 53% muscle-invasive or greater (≥pT2), 74% high-grade, 16% with flat architecture, 13% with necrosis, 21% with lymphovascular invasion, 18% with concomitant carcinoma in situ, and 8% with positive lymph nodes. The median FOXA1 score was 5.0 (range: 0-8). Lower FOXA1 expression was significantly correlated with advanced pathologic stage (≥pT3) (P = .02), concomitant carcinoma in situ (P = .006), and renal pelvis (vs ureter) location (P < .0001). At a median follow-up of 27.0 months (range: 3-196), 139 patients (25%) experienced disease recurrence and 121 (21%) died from the disease. In a multivariate model, lower FOXA1 expression was independently associated with disease recurrence (hazard ratio [HR]: 1.11, 95% confidence interval [CI]: 1.05-1.62, P = .04), cancer-specific mortality (HR: 1.17, 95% CI: 1.03-1.92, P = .04), and all-cause mortality (HR: 1.08, 95% CI: 1.02-1.18, P = .05). CONCLUSION: Lower FOXA1 expression is associated with adverse pathologic features and inferior survival outcomes for UTUC patients undergoing RNU. These data indicate lower FOXA1 expression may be a marker of aggressive disease in UTUC.