Urology Residency Applicant Selection: Program Directors' New Criteria.

OBJECTIVE: To evaluate the impact of the recent changes to the urology residency application process on the criteria utilized by residency program directors (PDs) for interview invitations and their perspectives concerning these changes. METHODS: One hundred thirty-seven urology residency PDs were invited to participate in an anonymous survey to explore interview selection criteria and the impact of the increase in preference signals (PS) per applicant. RESULTS: Fifty-eight PDs (42.8%) completed the survey. The highest-ranked criteria were letters of recommendation (LoR) and successful sub-internship (sub-I) at the PD's institution, without statistically significant differences between these 2. Gender, ethnicity, and medical school prestige were the lowest rated criteria, without significant differences between these 3. Compared to before the increase in the number of PS per applicant, 80.7% of PDs reported that not receiving a PS from an applicant this cycle would more negatively impact the chances of offering an interview to that applicant. Moreover, 12.2% stated they would not interview any applicants who did not send a PS. Finally, 62.1% of PDs believed recent changes worsened the process. CONCLUSION: Recent changes impacted PDs applicant evaluation, with the highest ranked criteria being LoRs and sub-I. Paradoxically, the increase in the number of PS per applicant has increased their importance as applicants are much less likely to receive interview offers from programs they have not signaled. Lastly, most PDs believe changes have worsened the evaluation process.

Posterior Urethral Reconstruction at the Time of Rectourethral Fistula Repair: Technique and Outcomes.

OBJECTIVE: To assess the impact of posterior urethral stenosis or defect on outcomes following rectourethral fistula (RUF) repair, we present a cohort of 23 men who underwent posterior urethroplasty concurrent with RUF repair. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003 and 2021. Of these, 23 (18%) underwent simultaneous posterior urethroplasty. Fifteen men received prior radiation for prostate cancer. Of the 8 men who were not radiated, 4 had a history of radical prostatectomy, 2 pelvic trauma, and 3 inflammatory bowel disease. All 23 men underwent fecal diversion prior to surgery (median, 6 months preoperatively), and 20 men suprapubic catheter placement (median, 5.5 months preoperatively). RESULTS: RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). Intraoperatively, 20 men (87%) had urethral stenosis, and 3 (13%) had significant urethral defects due to cavitation and tissue loss. There was stenosis/stricture involving the prostatomembranous urethra in 18 cases (78%) and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (78%) and using a buccal mucosal graft in 5 (22%). Gracilis flap interposition was performed in 21 cases (91%). At a median follow-up of 55.7 months (interquartile range (IQR), 23-82 months), 20 men (87%) had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. Fourteen men (61%) reported postoperative urinary incontinence, with 7 (30%) ultimately undergoing artificial urinary sphincter placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSION: Posterior urethral stenosis associated with RUF complicates an already challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis or defect.

Surgical Management and Oncologic Outcomes of Renal Cell Carcinoma and Inferior Vena Caval Thrombi With Aggressive Histologic Variants.

OBJECTIVE: To characterize the surgical management, perioperative, and cancer-specific outcomes, and the influence of aggressive histologic variants (AHV) on operative management among patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. RCC with rhabdoid and/or sarcomatoid differentiation, which we defined as AHV, portends a worse prognosis. AHV can be associated with a desmoplastic reaction which may complicate resection. METHODS: We reviewed patients undergoing radical nephrectomy and IVC thrombectomy between 1990 and 2020. Comparative statistics were employed as appropriate. Survival analysis was performed according to the Kaplan-Meier method, and intergroup analysis performed with log-rank statistics. Multivariable cox proportional hazards regression was used to assess the effect of AHV, age, thrombus level, vena cavectomy, metastases, and medical comorbidities on recurrence and overall survival (OS). RESULTS: Ninety-four of 403 (23.3%) patients had AHV, including 43 (46%) rhabdoid, 39 (41%) sarcomatoid, and 12 (13%) with both. AHV were more likely to present with advanced disease; however, increased perioperative complications or decreased OS were not observed. Median (IQR) survival was 16.7 (4.8-47) months without AHV and 12.6 (4-29) months with AHV (P = .157). Sarcomatoid differentiation was independently associated with worse OS (HR = 2.016, CI 1.38-2.95, P <.001), whereas rhabdoid alone or with sarcomatoid demonstrated similar OS (P = 0.063). CONCLUSION: RCC and IVC thrombus with AHV are more likely to present with metastatic disease, and sarcomatoid differentiation is associated with a worse OS. Resection of tumors with and without AHV have similar perioperative complications, suggesting that surgery can be safely accomplished in patients with RCC and IVC thrombus with AHV.

Impact of Virtual Care on Outpatient Urinary Tract Infection Management.

OBJECTIVE: To examine the effect of virtual care on urine testing, antibiotic prescription patterns, and outcomes of care in urinary tract infection (UTI) management. METHODS: We conducted retrospective analysis of adults treated for UTI in an ambulatory setting across a large health system from March 2020-2021. Outcomes included urine testing, antibiotic prescription, and retreatment or hospitalization, stratified by in-person vs virtual visit. Multivariable logistic regression was performed to examine factors contributing to outcomes. RESULTS: Significantly fewer patients seen virtually had urine testing as compared to those seen in-person (19% vs 69%, P <.001). On multivariable logistic regression analysis, virtual visit was the most significant predictor of urine testing, associated with an 86% reduction in the odds of urine testing (odds ratio (OR) 0.14, P <.001). Having a complicated UTI did not affect the likelihood of urine testing (OR 1.0, P = .95). Patients seen virtually were more likely to have a subsequent repeat ambulatory UTI visit (OR 1.16) or repeat antibiotic prescription (1.06) more than 2 weeks after the index encounter, though no more likely to be hospitalized for UTI (OR 1.00). CONCLUSION: Virtual care for UTI is associated with a significant reduction in urine testing and an increase in repeat UTI encounters and additional antibiotics among patients with complicated and uncomplicated UTIs.

Diversity Attracts Diversity: 2023 AUA Match Results.

OBJECTIVE: To assess the rationale behind the choice of programs for preference signaling (PS) and subinternships by urology applicants in the 2023 cycle. METHODS: We emailed an anonymous, multiple-choice survey to the 403 prospective candidates who applied to our institution for the 2023 Urology Residency Match. RESULTS: 121 applicants (30.0%) responded to the survey. 81.8% were in favor of the continuation of PS, with 4.1% against it. When choosing where to PS or subinternship, geographic location and perceived quality of clinical training were the highest-ranked criteria. Racial/ethnic diversity of the residents influenced PS or subinternship choice for 77.8% of Black, 72.7% of Asian, 57.1% of Latinos, and 46.5% of White respondents (P < .05 for Black and Asian vs White). Institutional statements on diversity influenced PS or subinternship choice for 88.9% of Black, 55% of Asian, 64.3% of Latino, and 25.4% of White respondents (P < .05 for Black, Asian and Latino vs White). Females had an increased likelihood of PS or choosing subinternship programs with gender diversity of residents (81.6% vs 33.8, P = .002). A program with PS was associated with a 2.74 increase in likelihood of obtaining an interview compared to programs that were not PS. Of 107 matched applicants, 47.5% matched at a program where they completed a subinternship, and 25.7% matched at a signaled program. CONCLUSION: PS plays a major role in the match process. When choosing where to PS, applicants prioritize geographic location and perceived quality of training. Diversity of residents plays a major role in recruiting diverse applicants.

Cancer risk in bladder diverticula: a large institutional analysis of risk and management.

PURPOSE: Bladder diverticula (BD) are usually asymptomatic, but may increase the risk of infections, stones, or malignancy, likely due to urinary stasis within the BD. We aim to characterize the risk of bladder cancer (BC) within diverticula. METHODS: Retrospective review was conducted of patients diagnosed with BD between 1994 and 2021 at a single institution. Cancer risk was characterized using descriptive statistics and multivariable logistic regression as appropriate. RESULTS: We identified 764 patients with mean age 68 years, the majority of whom were male (87%) and Caucasian (86%). Of this total, 13.3% (102/764) had a diagnosis of BC and 35.3% of this subset (36/102) had definitive cancer within the BD. Diverticulectomy or partial cystectomy was performed in 13.6% (104/764), 76% of whom were preoperatively presumed to have benign disease. Surgical patients were younger and had larger BD. Of the 79 patients who underwent diverticulectomy without preoperative suspicion for cancer, 5 were incidentally diagnosed with BC on final pathology. On multivariable logistic regression, male gender [odds ratio (OR) = 2.6, p = 0.03] and increasing age (OR = 1.02, p = 0.03) were independent risk factors for BC diagnosis. Indwelling catheter, recurrent urinary tract infections (UTIs), and bladder stones did not affect the risk of BC. CONCLUSIONS: The majority of patients with BD are not managed with surgery. BC is identified in a small but considerable proportion of patients with BD, with an even lower rate of incidentally diagnosed cancer among those undergoing BD surgery. Male gender and increasing age increased the risk of BC diagnosis.

Long-term Follow-up of Patients With Cerebral Palsy Undergoing Catheterizable Channel Creation Without Concurrent Bladder Augmentation.

OBJECTIVE: To characterize long-term outcomes for adults with cerebral palsy who have undergone catheterizable channel creation without concurrent bladder augmentation. METHODS: Retrospective review was conducted of patients who underwent catheterizable channel creation without augmentation by the senior author. Variables of interest included development of de novo neurogenic detrusor overactivity, change in continence, escalation in therapy, and upper tract changes. Descriptive statistics were conducted using t-tests and chi-squared tests as appropriate. RESULTS: Nine patients were followed for an average of 70 months. Prior to surgery two patients were on regular clean intermittent catheterization (CIC), six were not on CIC, and one was on occasional CIC. Patients not on CIC preoperatively were more likely to develop de novo neurogenic detrusor overactivity (83% vs 0%, P = .02), and have statistically significant decreases in average compliance (P = .04 vs P = .31). They were also more likely to require escalation in bladder therapy (83% vs 50%) and have worsening of incontinence (67% vs 0%), though these did not reach statistical significance (P = .34, 0.1). Five patients underwent repeat urodynamics an average of 46 months after initial postoperative study because of persistent urgency - 4 of 5 had stable urodynamic findings and one demonstrated >50% reduction in compliance and capacity. CONCLUSION: Adults with cerebral palsy who are not on CIC prior to creation of a catheterizable channel are at high risk for development of de novo neurogenic detrusor overactivity and decrease in bladder compliance. Prophylactic augmentation should be considered in this group.

Neurogenic Bladder:: Assessment and Operative Management.

We present a phenotype-based approach to neurogenic bladder (NGB) by describing prototypical patients with spinal cord injury (SCI), spina bifida (SB), cerebral palsy (CP), and multiple sclerosis (MS). Surgical management is categorized by failure to store and failure to empty, with a focus on catheterizable channels, bladder augmentation, and bladder outlet procedures. Mitigation and management of common complications are reviewed. Specific attention is paid to social support, body habitus, and extremity function, as we believe a holistic approach is necessary for appropriate surgical selection.

Stones and Moans: Higher Number of Nephrolithiasis Related Encounters Increases the Odds of Opioid Misuse.

OBJECTIVE: To evaluate the association between kidney stones and risk of subsequent opioid misuse. METHODS: The Healthcare Cost and Utilization Project's (HCUP) inpatient, ambulatory, and emergency department databases from 4 states were queried to identify associations with a primary diagnosis code related to kidney stones followed by a diagnosis of opioid abuse, dependence, or overdose between 2005, and 2015. Logistic regression was performed to determine the strength and significance of the relationship between number of primary kidney stone episodes and subsequent diagnosis of opioid misuse. RESULTS: The final cohort included 783,929 patients across 4 states. On multivariable analysis the number of primary stone encounters (PSE) was strongly associated with the risk of developing an opioid-related disorder (ORD) when adjusting for relevant covariates (odds ratio 1.3). Patients seen in the emergency department (OR 1.4) and those treated in Iowa (OR 2.9) were at higher risk for ORD than those seen in different contexts or states. Younger age increased the strength of this association. Higher income (OR 0.7) and non-white race (OR 0.7) reduced the risk of ORD, while a diagnosis of chronic pain (OR 3.5) increased risk. CONCLUSION: Risk of subsequent diagnosis of ORD is increased in patients who have multiple episodes of care related to kidney stones.

A Novel Metric for Hospital Quality in Kidney Cancer Surgery: A Veterans Affairs National Health System Validation of Concept.

INTRODUCTION: We aimed to develop and validate a Compound Quality Score (CQS) as a metric for hospital-level quality of surgical care in kidney cancer at the Veterans Affairs National Health System. METHODS: A retrospective review of 8,965 patients with kidney cancer treated at Veterans Affairs (2005-2015) was performed. Two previously validated process quality indicators (QIs) were explored: the proportion of patients with 1) T1a tumors undergoing partial nephrectomy and 2) T1-T2 tumors undergoing minimally invasive radical nephrectomy. Demographics/comorbidity/tumor characteristics/treatment year were used for case mix adjustments at hospital level. The predicted versus observed ratio of cases was calculated per hospital to generate QI scores using indirect standardization and multivariable regression models. CQS represents the sum of both scores. A total of 96 hospitals were grouped by CQS, and short-term patient-level outcomes were regressed on CQS levels to assess for length of stay (LOS), 30-day complications/readmission, 90-day mortality and total cost of surgical admission. RESULTS: CQS identified 25/33/38 hospitals with higher/lower/average performance, respectively. High performance hospitals had higher nephrectomy volumes (p <0.01). Total CQS independently associated with LOS (ß=-0.04, p <0.01, predicted LOS 0.84 days shorter for CQS=2 versus CQS=-2), 30-day surgical complications (OR=0.88, p <0.01) or 30-day medical complications (OR=0.93, p <0.01) and total cost of surgical admission (ß =-0.014, p <0.01, predicted 12% lower cost for CQS=2 versus CQS=-2). No association was found between CQS and 30-day readmissions or 90-day mortality (all p >0.05), although low event rates were observed (8.9% and 1.7%, respectively). CONCLUSIONS: Variability in quality of surgical care at hospital level can be captured with the CQS among patients with kidney cancer. CQS is associated with relevant short-term perioperative outcomes and surgical cost. QIs should be used to identify, audit and implement quality improvement strategies across health systems.

Role of Imaging in Renal Cell Carcinoma: A Multidisciplinary Perspective.

With the expansion in cross-sectional imaging over the past few decades, there has been an increase in the number of incidentally detected renal masses and an increase in the incidence of renal cell carcinomas (RCCs). The complete characterization of an indeterminate renal mass on CT or MR images is challenging, and the authors provide a critical review of the best imaging methods and essential, important, and optional reporting elements used to describe the indeterminate renal mass. While surgical staging remains the standard of care for RCC, the role of renal mass CT or MRI in staging RCC is reviewed, specifically with reference to areas that may be overlooked at imaging such as detection of invasion through the renal capsule or perirenal (Gerota) fascia. Treatment options for localized RCC are expanding, and a multidisciplinary group of experts presents an overview of the role of advanced medical imaging in surgery, percutaneous ablation, transarterial embolization, active surveillance, and stereotactic body radiation therapy. Finally, the arsenal of treatments for advanced renal cancer continues to grow to improve response to therapy while limiting treatment side effects. Imaging findings are important in deciding the best treatment options and to monitor response to therapy. However, evaluating response has increased in complexity. The unique imaging findings associated with antiangiogenic targeted therapy and immunotherapy are discussed. An invited commentary by Remer is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Infiltrative Renal Masses: Clinical Significance and Fidelity of Documentation.

BACKGROUND: The prevalence of infiltrative renal masses (IRMs) and fidelity of documentation of infiltrative features remain unclear. OBJECTIVE: To investigate the prevalence/significance of IRMs and assess whether infiltrative features were documented preoperatively. DESIGN, SETTING, AND PARTICIPANTS: A total of 522 patients with renal tumors managed with partial/radical nephrectomy (2012-2014) whose pathology demonstrated locally advanced and/or aggressive histology were analyzed. Preoperative computed tomography/magnetic resonance imaging was retrospectively/independently reviewed by two radiologists. IRMs were required to have a poorly defined interface with parenchyma and nonelliptical shape in one or more distinct/unequivocal areas. Infiltrative features were defined as extensive or focal. INTERVENTION: Partial/radical nephrectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cancer-specific mortality (CSM) was estimated using cumulative-incidence analysis. Significant and independent predictors of CSM were evaluated using Cox proportional hazard analysis. RESULTS AND LIMITATIONS: Median tumor size was 6.9cm; renal cell carcinomas (RCCs) predominated (92%). Image review confirmed 133 IRMs (25%), including 103 RCCs; 59 had sarcomatoid or poorly differentiated features. IRMs were larger and more often symptomatic compared than non-IRMs, and disseminated disease was also more common for IRMs (all p<0.001). Overall, 109 IRMs were imaged at our center; 42 were documented as IRMs in preoperative radiology reports, while infiltrative features were not documented in 67 (61%). Only four (6%) of these 67 were documented as infiltrative by the surgical team. Infiltrative features were more often focal in undocumented IRMs. On multivariable analysis, infiltrative features, disseminated disease, and non-RCC histology were independent predictors of CSM (hazard ratio or HR [95% confidence interval {CI}]=1.73 [1.21-2.47], 2.98 [2.10-4.23], and 2.79 [1.86-4.62], respectively). Among IRMs, extensive infiltrative features and disseminated disease were associated with CSM (HR [95% CI]=1.98 [1.27-3.07] and 2.35 [1.52-3.63], respectively), while documentation status failed to show an association. Excluding patients with disseminated disease or residual cancer after surgery, recurrence rates were 62% for IRMs versus 22% for non-IRMs (p<0.001), and there was again no significant difference between documented and undocumented IRMs (p=0.36). Limitations include a retrospective design. CONCLUSIONS: Twenty-five percent of locally advanced/histologically aggressive renal tumors exhibited infiltrative features, although many were not documented as IRMs. Among this high-risk surgical population, infiltrative features were independent predictors of CSM, irrespective of whether they were documented or not. Our data suggest that infiltrative features should be assessed and documented routinely during evaluation of renal masses. PATIENT SUMMARY: Infiltrative renal masses may be more common than previously appreciated, although many were not documented as infiltrative during preoperative evaluation. Our data suggest that infiltrative features have a strong impact on prognosis and should be assessed and documented routinely during radiologic and clinical evaluation of renal masses.

New Baseline Renal Function after Radical or Partial Nephrectomy: A Simple and Accurate Predictive Model.

PURPOSE: Preoperative estimation of new baseline glomerular filtration rate after partial nephrectomy or radical nephrectomy for renal cell carcinoma has important clinical implications. However, current predictive models are either complex or lack external validity. We aimed to develop and validate a simple equation to estimate postoperative new baseline glomerular filtration rate. MATERIALS AND METHODS: For development and internal validation of the equation, a cohort of 7,860 patients with renal cell carcinoma undergoing partial nephrectomy/radical nephrectomy (2005-2015) at the Veterans Affairs National Health System was analyzed. Based on preliminary analysis of 94,327 first-year postoperative glomerular filtration rate measurements, new baseline glomerular filtration rate was defined as the final glomerular filtration rate within 3 to 12 months after surgery. Multivariable linear regression analyses were applied to develop the equation using two-thirds of the renal cell carcinoma Veterans Administration cohort. The simplest model with the highest coefficient of determination (R2) was selected and tested. This model was then internally validated in the remaining third of the renal cell carcinoma Veterans Administration cohort. Correlation/bias/accuracy/precision of equation were examined. For external validation, a similar cohort of 3,012 patients with renal cell carcinoma from an outside tertiary care center (renal cell carcinoma-Cleveland Clinic) was independently analyzed. RESULTS: New baseline glomerular filtration rate (in ml/minute/1.73 m2) can be estimated with the following simplified equation: new baseline glomerular filtration rate = 35 + preoperative glomerular filtration rate (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). Correlation/bias/accuracy/precision were 0.82/0.00/83/-7.5-8.4 and 0.82/-0.52/82/-8.6-8.0 in the internal/external validation cohorts, respectively. Additionally, the area under the curve (95% confidence interval) to discriminate postoperative new baseline glomerular filtration rate ≥45 ml/minute/1.73 m2 from receiver operating characteristic analyses were 0.90 (0.88, 0.91) and 0.90 (0.89, 0.91) in the internal/external validation cohorts, respectively. CONCLUSIONS: Our study provides a validated equation to accurately predict postoperative new baseline glomerular filtration rate in patients being considered for radical nephrectomy or partial nephrectomy that can be easily implemented in daily clinical practice.