Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study.

BACKGROUND: Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures. METHODS: We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications. RESULTS: A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age. CONCLUSION: The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.

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.

"Postoperative Outcomes Following Buried Penis Reconstruction: A Single-Institution Experience Using the Wisconsin Classification System".

BACKGROUND: Adult acquired buried penis (AABP) is a complex condition often necessitating surgical intervention. This study seeks to examine the validity of the Wisconsin Classification System (WCS) in guiding the surgical management of AABP. Additionally, we aimed to identify which factors contribute to postoperative complications and persistent symptoms following AABP repair. METHODS: We retrospectively reviewed all patients who underwent surgical repair of AABP from 2015-2021 by the senior author at our institution. Patients were categorized according to anatomic characteristics using the WCS. Preoperative symptoms, postoperative symptoms, and postoperative complications were evaluated. RESULTS: Fifty-two patients underwent AABP repair. The mean age was 56.5±14.8 years, and the mean duration of follow-up was 350.0±517.4 days. The assigned preoperative WCS score was congruent with operative management in most patients (86.0%). Morbid obesity (BMI>40.0kg/m2) and postoperative complications were associated with persistent symptoms following AABP repair (p=0.026 and p=0.021, respectively). Increased WCS score was not associated with persistent postoperative symptoms (p=0.314). Morbid obesity (p=0.003), diabetes (p=0.029) and having a panniculectomy during AABP repair (p=0.046) increased the odds for developing postoperative complications. Patients with Type I AABP had significantly fewer complications than those with Type II, III, or IV (p=0.032). CONCLUSIONS: The Wisconsin Classification System serves as a preoperative guide, an educational tool for patients, and provides a framework for the discussion of intraoperative maneuvers and the likelihood of complications. It is imperative to counsel patients on the surgical management of AABP and the postoperative course, as this may permit realistic patient expectations and optimize outcomes.

Functional penile replantation after traumatic avulsion amputation below the pubis: A case report.

Penile amputation is a rare injury with significant posttraumatic ramifications. We present a case of successful immediate replantation after traumatic penile avulsion in a 52-year-old male patient. The patient reported his penis was caught in machinery during a boating accident, and avulsed at the level of the pubis. Immediate replantation of this proximal avulsion injury with no suitable proximal arterial stumps required transfer of the superficial inferior epigastric artery for arterial inflow. One artery and two veins were repaired. The urethral injury was found to be immediately distal to the urethral sphincter in the membranous portion, and repaired primarily. Urinary diversion was performed with a suprapubic catheter until the repair had healed. The postoperative course was complicated by less than 10% skin necrosis requiring skin grafting. At three years follow up, the patient has a penis with normal urinary function and is able to obtain erections with pharmacologic aids. Avulsion should not preclude penile replantation, which may have acceptable functional and esthetic results.

The Balance between Open and Robotic Training among Graduating Urology Residents-Does Surgical Technique Need Monitoring?

PURPOSE: A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation. MATERIALS AND METHODS: Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests. RESULTS: A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p <0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution. CONCLUSIONS: Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

Renal autotransplantation results in pain resolution after left renal vein transposition.

Left renal vein transposition is often the preferred treatment of nutcracker syndrome. However, pain returns in some patients despite surgery. One solution to this problem is renal autotransplantation. Here we report our initial results of renal autotransplantation in patients with persistent flank pain despite a previous left renal vein transposition. We used the University of Wisconsin loin pain hematuria syndrome test as a diagnostic maneuver to determine who may benefit from renal autotransplantation; this procedure subsequently resulted in complete pain resolution in all three patients. All patients underwent successful renal autotransplantation and remain pain free. These cases support the test as a diagnostic maneuver to determine which patients may benefit from renal autotransplantation.

Is Your Career Hurting You? The Ergonomic Consequences of Surgery in 701 Urologists Worldwide.

Purpose: Our objective was to seek correlations between the type, volume, and duration of surgical work performed, surgeon habits and characteristics, and the prevalence of neck and back musculoskeletal complaint and intervention across career from training to retirement. Materials and Methods: An anonymous web-based multinational survey of urologists was conducted. The primary outcome measured was pain. Secondary outcomes included pain requiring intervention and surgery. Responses were subgrouped according to geography, practice patterns, and demographics. Student t test, Fisher's exact test, and chi-square test were used for analysis. Results: A total of 701 complete responses were received from this multinational survey. Gender, pain distribution, and private or academic practice did not correlate with pain, whereas exercise, lower weight, and body mass index (BMI) were protective. Dose-response of surgical type was assessed with high- and low-volume density quartiles and frequency of each pain severity; no correlation was found. Secondary analysis showed that female practitioners seek invasive therapy less than male counterparts, and practitioners of direct optical cystoscopy report no more neck trouble than others. Length of career since residency shows little relationship to pain or pain-free rates. Conclusions: In this, the largest surgical ergonomic study to date: surgical type, duration, volume, setting, and physician gender were unrelated to surgeon pain throughout career. Exercise was associated with lower prevalence of pain in a dose-related manner; increasing weight and BMI were positively associated with pain. Although 47% of urologists with spinal pain blame their career, we are unable to identify any dose-response relationship that supports that assumption.

The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System.

BACKGROUND: Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. OBJECTIVES: The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. METHODS: The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. RESULTS: Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. CONCLUSIONS: Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being.

Commentary: Loin Pain Hematuria Syndrome.

Loin Pain Hematuria Syndrome (LPHS) remains a rare disease but has a significant impact on those affected by it. Patients diagnosed with LPHS experience severe, constant or intermittent flank pain that radiates to the groin and may be exacerbated even by a gentle touch. These patients often require significant narcotic regimens for pain control and are unable to maintain a functional lifestyle. Previously, diagnosis has been made based on clinical presentation. One treatment for this syndrome is renal autotransplant; however, success rates are varied. Therefore, patient selection for this procedure is important. We have developed the UW-LPHS test as a diagnostic maneuver in order to determine which patients with LPHS would benefit from renal autotransplant. To perform this diagnostic test, bupivacaine is instilled into the ureter on the affected side and left to dwell. Patients who experience pain relief following this test are deemed to benefit from renal autotransplant. Here we describe this novel diagnostic test and initial success rates following renal autotransplant.

When to operate: online patient-reported outcome measures (PROMs) can help decide.

We present a report on use of a web-based electronic patient-reported outcome measures (ePROMs) system to support decision-making for a patient with an osteoarthritic knee. After being placed on a waiting list for knee arthroplasty, the use of preoperative PROMs allowed the patient and surgical team to review ongoing disability, and, as a result, alter the management plan by deferring surgery. Ongoing clinical review and symptom management has been centred on ePROMs and has been tailored to the specific needs of the individual. PROMs data are increasingly becoming a necessary component of outcome measurement in many surgical areas. Often, these data are available to neither patient nor clinician in a way that prospectively allows meaningful management. This case highlights how ePROMs can directly influence patient care in real time.

An acute knee injury: tracking a two-year recovery online.

Current government policy aims to deliver high quality healthcare by recording accurate data at the point of giving care, storing it efficiently and displaying it in a format, which is easily interpreted by healthcare professionals and patients. Few published reports describe the benefits of collecting and reporting such data from the point of view of the patient. We report the case of a 62-year-old lorry driver who used a web-based system to track patient reported outcome measures (PROMs) following an acute knee injury to full recovery over a 24-month period. The system reports clinical outcome scores in real-time to the patient and their medical team, clearly illustrating and enhancing recovery from injury. This case reveals how local software meets the needs of the individual patient linking and integrating such local systems must be the future focus of eHealth within the NHS to release the benefits presented by the information revolution.

Fertility preservation in the male with cancer.

This article reviews the current concepts, recommendations, and principles of fertility preservation in men with cancer. Obstacles to sperm banking are addressed, as well as future directions for fertility-preserving technologies. All cancer therapies--chemotherapy, radiation, and surgery--are potential threats to a man's reproductive potential. Additionally, cancer itself can impair spermatogenesis. Thus, sperm cryopreservation prior to initiating life-saving cancer treatment offers men and their families the best chances to father biologically-related children and should be offered to all men with cancer before treatment. Better patient and provider education, as well as deliberate, coordinated strategies at comprehensive cancer care centers, are necessary to make fertility preservation for male cancer patients a priority during pre-treatment planning.

Online follow-up after total hip replacement: a first case.

With the current challenging financial climate in the NHS there is an increasing drive to reduce the number of postoperative follow-up appointments. We report on a patient who has successfully used a new online platform, www.myclinicaloutcomes.co.uk, to record condition-specific and generic wellbeing scores following total hip replacement. This case highlights the potential for remote follow-up of routine postoperative patients.

Predictors of participation in sports after hip and knee arthroplasty.

BACKGROUND: While the primary objective of joint arthroplasty is to improve patient quality of life, pain, and function, younger active patients often demand a return to higher function that includes sporting activity. Knowledge of rates and predictors of return to sports will help inform expectations in patients anticipating return to sports after joint arthroplasty. QUESTIONS/PURPOSES: We measured the rate of sports participation at 1 year using the UCLA activity score and explored 11 variables, including choice of procedure/prosthesis, that might predict return to a high level of sporting activity, when controlling for potential confounding variables. METHODS: We retrospectively evaluated 736 patients who underwent primary metal-on-polyethylene THA, metal-on-metal THA, hip resurfacing arthroplasty, revision THA, primary TKA, unicompartmental knee arthroplasty, and revision TKA between May 2005 and June 2007. We obtained UCLA activity scores on all patients; we defined high activity as a UCLA score of 7 or more. We evaluated patient demographics (age, sex, BMI, comorbidity), quality of life (WOMAC score, Oxford Hip Score, SF-12 score), and surgeon- and procedural/implant-specific variables to identify factors associated with postoperative activity score. Minimum followup was 11 months (mean, 12.1 months; range, 11-13 months). RESULTS: Preoperative UCLA activity score, age, male sex, and BMI predicted high activity scores. The type of operation and implant characteristics did not predict return to high activity sports. CONCLUSIONS: Our data suggest patient-specific factors predict postoperative activity rather than factors specific to type of surgery, implant, or surgeon factors. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty.

BACKGROUND: The cause of recently reported pseudotumor formation in patients with metal-on-metal hip replacements is unknown. It has been postulated that there is an association between elevated levels of serum metal ions and pseudotumor formation. The primary purpose of this study was to assess the prevalence of pseudotumor formation in asymptomatic patients with a metal-on-metal total hip replacement after a minimum duration of follow-up of two years. A secondary purpose was to assess whether a correlation exists between elevated serum metal ion levels and pseudotumor formation. METHODS: In the present study, the prevalence of pseudotumor formation, as detected with ultrasound, was evaluated for thirty-one asymptomatic patients with a metal-on-metal total hip arthroplasty, twenty-four asymptomatic patients with a metal-on-polyethylene total hip arthroplasty, and twenty asymptomatic patients with a metal-on-metal hip resurfacing arthroplasty. Serum levels of cobalt and chromium were measured in the metal-on-metal total hip arthroplasty and hip resurfacing arthroplasty groups. RESULTS: Ten patients (32%) in the metal-on-metal total hip arthroplasty group had a solid or cystic mass, with another three patients (10%) having a substantial fluid collection. Five patients (25%) in the hip resurfacing arthroplasty group had a solid or cystic mass, with another patient (5%) having a fluid collection. Pseudotumor formation was significantly more frequent in the metal-on-metal total hip arthroplasty group compared with the metal-on-polyethylene total hip arthroplasty group (p = 0.015). We did not detect a significant correlation between the serum metal ion levels and the size of pseudotumor abnormality. The median serum metal ion level was greater in patients with pseudotumor formation than it was in those without pseudotumor formation, but the difference was not significant. CONCLUSIONS: We recommend high-resolution ultrasound surveillance of all asymptomatic patients with a metal-on-metal implant that is known to result in high serum metal ion levels. Once a metal-on-metal implant is known to be associated with high serum metal ions, the measurement of ion levels does not helpfully contribute to surveillance.

Improving surgical access: the Vancouver experience.

The University of British Columbia Hospital program was designed to augment existing provincial capacity for hip and knee replacement. The patient-surgeon relationship was maintained throughout the entire care pathway and "ring-fenced" capacity (i.e., designated hospital ward bed and operating room capacity that is geographically remote from the emergency intake of patients) minimized the risk of cancellations. Analysis of the results revealed a mean patient satisfaction score of 4.7 out of 5, a complication rate of 4.4%, a mean operating room time of 1 hour and 45 minutes and a mean postoperative length of stay in hospital of 3.4 days. More than 1600 joint replacements -- an additional 16% provincial capacity -- were performed within budget during each of the first 2 years of operation. A high standard of care was maintained, with high rates of patient satisfaction and a low complication rate.

Chromosomal abnormalities in 2 cases of testicular failure.

This study investigated the underlying chromosomal abnormalities of testicular failure using molecular cytogenetic analysis. We report 2 cases of rare genetic anomalies that resulted in hypogonadism. The first patient presented with severe hypogonadism. Chromosome analysis revealed a mosaic 46,X,r(Y) (p11.3q11.23)/45,X karyotype, with a ring Y chromosome. A Y chromosome microdeletion assay showed a deletion in the azoospermia factor a region. The second patient presented with infertility and nonobstructive azoospermia. Cytogenetic and fluorescent in situ hybridization analysis revealed a 47,XY,+mar.ish i(15) (D15Z1++,SNRPN2,PML2) karyotype, with a small supernumerary chromosome derived from chromosome 15. These results emphasize the need for molecular cytogenetic evaluation in patients with testicular failure before using advanced reproductive techniques.