Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities.

PURPOSE: Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer. METHODS: Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations. RESULTS: We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05). CONCLUSION: Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

Development and Validation of Dynamic Multivariate Prediction Models of Sexual Function Recovery in Patients with Prostate Cancer Undergoing Radical Prostatectomy: Results from the MUSIC Statewide Collaborative.

Background: Radical prostatectomy (RP) is the most common definitive treatment for men with intermediate-risk prostate cancer and is frequently complicated by erectile dysfunction. Objective: To develop and validate models to predict 12- and 24-month post-RP sexual function. Design setting and participants: Using Michigan Urological Surgery Improvement Collaborative (MUSIC) registry data from 2016 to 2021, we developed dynamic, multivariate, random-forest models to predict sexual function recovery following RP. Model factors (established a priori) included baseline patient characteristics and repeated assessments of sexual satisfaction, and Expanded Prostate Cancer Index Composite 26 (EPIC-26) overall scores and sexual domain questions. Outcome measurements and statistical analysis: We evaluated three outcomes related to sexual function: (1) the EPIC-26 sexual domain score (range 0-100); (2) the EPIC-26 sexual domain score dichotomized at ≥73 for "good" function; and (3) a dichotomized variable for erection quality at 12 and 24 months after RP. A gradient-boosting decision tree was used for the prediction models, which combines many decision trees into a single model. We evaluated the performance of our model using the root mean squared error (RMSE) and mean absolute error (MAE) for the EPIC-26 score as a continuous variable, and the area under the receiver operating characteristic curve (AUC) for the dichotomized EPIC-26 sexual domain score (SDS) and erection quality. All analyses were conducted using R v3.6.3. Results and limitations: We identified 3983 patients at 12 months and 2494 patients at 24 months who were randomized to the derivation cohort at 12 and 24 months, respectively. Using baseline information only, our model predicted the 12-month EPIC-26 SDS with RMSE of 24 and MAE of 20. The AUC for predicting EPIC-26 SDS ≥73 (a previously published threshold) was 0.82. Our model predicted 24-month EPIC-26 SDS with RMSE of 26 and MAE of 21, and AUC for SDS ≥73 of 0.81. Inclusion of post-RP data improved the AUC to 0.91 and 0.94 at 12 and 24 months, respectively. A web tool has also been developed and is available at https://ml4lhs.shinyapps.io/askmusic_prostate_pro/. Conclusions: Our model provides a valid way to predict sexual function recovery at 12 and 24 months after RP. With this dynamic, multivariate (multiple outcomes) model, accurate predictions can be made for decision-making and during survivorship, which may reduce decision regret. Patient summary: Our prediction model allows patients considering prostate cancer surgery to understand their probability before and after surgery of recovering their erectile function and may reduce decision regret.

Patient reported outcomes in genital gender-affirming surgery: the time is now.

Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.

Patient- and Surgeon-Level Variation in Patient-Reported Sexual Function Outcomes Following Radical Prostatectomy Over 2 Years: Results From a Statewide Surgical Improvement Collaborative.

Importance: Of patient-reported outcomes for individuals undergoing radical prostatectomy, sexual function outcomes are among the most reported and the most detrimental to quality of life. Understanding variations at the patient and surgeon level may inform collaborative quality improvement. Objective: To describe patient- and surgeon-level sexual function outcomes for patients undergoing radical prostatectomy in the Michigan Urological Surgery Improvement Collaborative (MUSIC) and to examine the correlation between surgeon case volume and sexual function outcomes. Design, Setting, and Participants: This is a prospective cohort study using the MUSIC registry and patient-reported sexual function outcome data. Patient- and surgeon-level variation in sexual function outcomes were examined among patients undergoing radical prostatectomy from May 2014 to August 2019. Sexual function outcome data were collected using validated questionnaires, which were completed before surgery and at 3, 6, 12, and 24 months' follow-up following surgery. All participants were male. Race and ethnicity data were self-reported and were included to examine potential variation in outcomes by race and/or ethnicity. Data were analyzed from January 2021 to March 2021. Main Outcomes and Measures: There were 4 outcomes in this study, including the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) sexual function scores at 3, 6, 12, and 24 months' follow-up; patient-level sexual function recovery at 12- and 24-month follow-up; surgeon-level variation in sexual function outcomes at 12- and 24-month follow-up; and correlation between surgeon case volume and sexual function outcomes. Results: A total of 1426 male patients met inclusion criteria for this study. The median (IQR) age was 64 (58-68) years. A total of 115 participants (8%) were Black, 1197 (84%) were White, 25 (2%) were of another race or ethnicity (consolidated owing to low numbers), and 89 (6%) were of unknown race or ethnicity. Among patients undergoing bilateral nerve-sparing radical prostatectomy, mean (SD) EPIC-26 sexual function scores at 12- and 24-month follow-up (12 months, 39 [28]; 24 months, 63 [29]) did not return to baseline levels. There was wide variation in EPIC-26 sexual function scores at both 12-month follow-up (range, 23-69; P < .001) and 24-month follow-up (range, 27-64; P < .001). Similar variations were found in EPIC-26 sexual function scores and recovery of sexual function by surgeon. Recovery rates ranged from 0% to 40% of patients at 12-month follow-up (18 surgeons; P < .001) and 3% to 44% of patients at 24-month follow-up (12 surgeons; P < .001). Surgeon case volume and sexual function outcomes were not significantly correlated. On multivariable analysis, the following variables were associated with better recovery at 24-month follow-up: younger age (P < .001), lower baseline EPIC-26 sexual function score (P < .001), lower Gleason score (P = .05), and nonobesity (P = .03). Conclusions and Relevance: In this study, there was significant patient- and surgeon-level variation in sexual function recovery over 2 years following radical prostatectomy. Variation in surgeon-level sexual function outcomes presents an opportunity and model for surgical collaborative quality improvement.

Interest in Sex and Conversations About Sexual Health with Health Care Providers Among Older U.S. Adults.

Objectives: Sexual health is an important component of overall health and well-being for older adults. Despite this, little is known about the importance of sex to quality of life, as part of romantic relationships for older adults, and potential drivers of interactions between healthcare providers and older adults about sexual health. In this study using a nationally representative population, we describe perceptions and experiences of sex among older adults.Methods: A nationally representative, cross-sectional sample of community-dwelling U.S. adults aged 65-80 was surveyed about their sexual health and interaction with their health care providers about sexual health.Results: The survey completion rate was 75% (N = 1,002). Overall, 50.9% of men and 30.8% of women reported being sexually active. In all, 17.3% of adults aged 65-80 reported speaking to their health care provider about sexual health in the past two years and of those, 60.5% of patients initiated the conversation. Multivariable logistic regression demonstrated that sexual activity (yes/no), interest in sex, and satisfaction with sex life are major drivers of sexual health conversations between patients and healthcare providers.Conclusions: Many adults aged 65-80 are interested in and engage in sexual activity. While the majority of older adults reported a willingness to discuss their sexual health with their health care providers, few had done so, and most conversations were initiated by patients. Iterest in sex and satisfaction with sex life may be targets for intervention and offer a segue for providers as they begin the conversation to engage with older adults about their sexual health.Clinical Implications: Providers may have conversations with older adults about sexual health and may need sexual health training to have effective discussions; age nor chronic conditions should preclude this essential conversation. Clinical gerontologists may be helpful in this training and in encouraging patients to bring up sexual health concerns during their medical appointments.

Predictive Factor of Preresidency Publication on Career Academic Achievement in Urologists.

INTRODUCTION: Publications at any point in training can impact future academic interest and achievement. Implications of publishing scholarly work prior to residency on accomplishments during and after residency are understudied. METHODS: We obtained publication output before, during and after residency for urologists graduating between 2002 and 2008 from the 36 training programs affiliated with a top 50 urology hospital nationwide. Additional collected information included fellowship training, current appointment, total and R01 National Institutes of Health grants, and h-index. We compared urologists' preresidency scholarship with residency and career achievements. RESULTS: We retrieved data from 543 urologists, of whom 161 (29.7%) and 92 (16.9%) published 1 or more total and first author manuscripts before residency, respectively. A total of 269 (49.5%) urologists went on to pursue fellowship and 183 (33.7%) entered academic practice. Urologists with a first author publication before residency had increased odds of entering academics (OR 1.9, 95% CI 1.2-3.1), obtaining National Institutes of Health grants (OR 2.2, 95% CI 1.1-4.3) and acquiring National Institutes of Health R01 grants (OR 4.1, 95% CI 1.7-9.7). Those with more first author manuscripts prior to residency were also more likely to pursue fellowship (p=0.0002), have a higher h-index (p <0.0001) and publish more during (p <0.0001) and after residency (p=0.0002). However, those with more total publications before residency were only associated with greater h-index (p=0.002) and publications in residency (p=0.001). CONCLUSIONS: Preresidency scholarly endeavors, particularly first author publications, are associated with future scholarly achievement, which may inform both resident selection procedures and medical education curricular development.

Risk factors for orgasmic and concomitant erectile dysfunction in men with type 1 diabetes: a cross-sectional study.

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.

Clinical and Radiographic Factors Associated With Failed Renal Angioembolization: Results From the Multi-institutional Genitourinary Trauma Study (Mi-GUTS).

OBJECTIVE: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. MATERIAL AND METHODS: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. RESULTS: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. CONCLUSION: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.

Autonomic neuropathy and urologic complications in diabetes.

Diabetic autonomic neuropathy affects the entire autonomic nervous system and can lead to dysfunction of the cardiovascular, gastrointestinal, and genitourinary organ systems. Genitourinary dysfunction associated with diabetic autonomic neuropathy includes diabetic bladder dysfunction, sexual dysfunction, and recurrent urinary tract infections. Urological complications in diabetes mellitus are very common; in fact, genitourinary complications are more common than diabetic neuropathy or nephropathy. While several studies have reported on genitourinary dysfunction in individuals with diabetes, UroEDIC, an ancillary study to the Diabetes Control and Complications Trial (DCCT) and its observational follow up, the Epidemiology of Diabetes Interventions and Complications study (EDIC), comprehensively characterized the association between urologic complications and cardiovascular autonomic neuropathy. UroEDIC demonstrated significant associations between autonomic neuropathy and urologic complications in type 1 diabetes, specifically erectile dysfunction, female sexual dysfunction, and lower urinary tract symptoms. In this narrative review, we review the current literature on urological complications in diabetes.

Significant Management Variability of Urethral stricture Disease in United States: Data from the AUA Quality (AQUA) Registry.

OBJECTIVE: To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success. MATERIALS AND METHODS: The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census. RESULTS: We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64). CONCLUSIONS: Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.

Relationship of symptom severity and bother in individuals seeking care for lower urinary tract symptoms.

AIMS: Bother attributed to lower urinary tract symptoms (LUTS) drives care-seeking and treatment aggressiveness. The longitudinal relationship of LUTS severity and bother in a care-seeking cohort, however, is not well understood. We aim to conduct a longitudinal evaluation of LUTS severity and bother and identify characteristics of patients with discordant LUTS bother relative to severity. METHODS: Men and women with LUTS seeking care at six US tertiary care centers enrolled in the symptoms of lower urinary tract dysfunction research network study. Patients reporting at least one urinary symptom based on the LUTS Tool were prospectively enrolled from June 2015 to January 2017. Correlations were used to assess the relationship between LUTS severity and bother. Discordance scores (ie, the difference between bother and severity) were used to classify patients with high and low bother. Patients were classified as having high or low bother phenotypes if scores were one standard deviation above or below zero, respectively. Repeated measures multinomial logistic regression evaluated characteristics associated with high and low bother phenotypes. RESULTS: LUTS severity and bother were at least moderately correlated for all symptom items and highly correlated for 13 out of 21 items. Correlations were highest for urgency, and lowest for daytime frequency and urinary incontinence. Odds of being in high bother phenotype were lowest at 3 and 12 months (3 months vs baseline odds ratio [OR] = 0.71, 95% confidence ninterval [CI] = 0.54-0.94; 12 months vs baseline OR = 0.66, 95% CI = 0.48-0.91), and highest for those who endorsed all urgency questions (OR = 3.65, 95% CI = 2.17-6.13). Odds of being in the low bother phenotype were lowest for patients who endorsed all urgency items (OR = 0.33, 95% CI = 0.26-0.42), and all frequency items (OR = 0.68, 95% CI = 0.53-0.88). CONCLUSIONS: LUTS severity and bother correlate highly and measurement of both in clinical practice is likely redundant. There are patient factors associated with discordance which may justify additional evaluation.

The Top 100 Cited Articles in Urethral Reconstruction.

OBJECTIVE: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends. METHODS: The Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected. RESULTS: The mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques. CONCLUSION: In this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.

Female Urethral Strictures: Review of Diagnosis, Etiology, and Management.

PURPOSE OF REVIEW: In this review, we describe the incidence, diagnosis, and management of urethral strictures in women. RECENT FINDINGS: Definitive repair of urethral strictures in women traditionally utilizes vaginal and labial flaps. Oral mucosal buccal graft urethroplasty also has high success rates, with larger series demonstrating feasibility and durability. Urethral strictures in women are very rare. When they do occur, they are often difficult to diagnose, requiring a high index of suspicion. Women with urethral strictures often present with symptoms of obstructed urinary flow, such as incomplete emptying, straining, and elevated postvoid residual. First line, minimally invasive treatment consists of urethral dilation and urethrotomy, though urethrotomy is rarely performed. Repeat urethral dilation has low success rates compared with urethroplasty, which is a more definitive treatment.

Ethics in Global Surgery.

As the population increases in the world's poorest countries, the need for surgical interventions will increase. Short-term surgical missions can play an important role in increasing access to solve this disparity by providing much-needed surgical services to vulnerable populations in low-income and middle-income countries. As short-term surgical missions increase, it is important that basic ethical principles are a foundation in service delivery. By following ethical principles outlined in this article, abiding by common moral language, and establishing long-term relationships, a significant contribution can be made to global surgery to increase access and deliver high-quality surgery.

Strategies for Attracting Women and Underrepresented Minorities in Urology.

PURPOSE OF REVIEW: This article summarizes the current state of underrepresented minorities (URM) and women within urology. Specific strategies to promote the recruitment and retention of URM and women within urology are discussed. RECENT FINDINGS: Minorities and women remain underrepresented within urology, a disparity that has roots as early as medical school and persists throughout residency and practice. This is likely due to implicit and explicit bias, lack of role models, and persistent disparities in compensation and promotion. Strategies to improve recruitment and retention of these individuals should focus on increasing early exposure to urology, opportunities for mentorship, and support in professional development. Creation of a supportive institutional culture, consideration of alternative career advancement paths, and intentional diversity-focused recruitment efforts are also critical. Successful recruitment and retention of URM and women in urology requires specific, directed efforts to increase opportunities for exposure, mentorship, and career promotion at a programmatic, institutional, and national level.