Functional and oncologic outcomes of prostate capsule-sparing radical cystectomy: A systematic review and meta-analysis.

Radical cystectomy (RC) is the gold standard treatment for patients with organ-confined bladder cancer. However, despite the success of this treatment, many men who undergo orthotopic neobladder substitution develop significant erectile dysfunction and urinary symptoms, including daytime and nighttime urinary incontinence. Prostate-capsule-sparing radical cystectomy (PCS-RC) with orthotopic neobladder (ONB) has been described in the literature as a surgical technique to improve functional outcomes in appropriately selected patients. We performed a systematic review and meta-analysis of manuscripts on PCS-RC with ONB published after 2000. We included retrospective and prospective studies with more than 25 patients and compared PCS-RC with nerve-sparing or conventional RC. Studies in which the entire prostate was spared (including the transitional zone) were excluded. Comparative studies were analyzed to assess rates of daytime continence, nighttime continence, and satisfactory erectile function in patients undergoing PCS-RC compared with those undergoing conventional RC. Fourteen reports were included in the final review. Our data identify high rates of daytime (83%-97%) and nighttime continence (60%-80%) in patients undergoing PCS-RC with ONB. In comparative studies, meta-analysis results demonstrate no difference in daytime continence (RR:1.12; 95% CI: 0.72-1.73) in those undergoing PCS-RC compared to those undergoing conventional RC. Similarly, nighttime continence was similar between the 2 groups (RR:1.85; 95% CI: 0.57-6.00. Erectile function was improved in those undergoing PCS-RC (RR 5.35; 95% CI: 1.82-15.74) in the PCS-RC series. Bladder cancer margin positivity and recurrence rates were similar to those reported in the literature with conventional RC with an average weighted follow-up of 52.2 months. While several studies utilized different prostate cancer (CaP) screening techniques, the rates of CaP were low (incidence 0.02; 95% CI:0.01-0.04), and oncologic outcomes were similar to standard RC. PCS-RC is associated with improved nighttime continence and erectile function compared to conventional RC techniques. Further work is needed to standardize CaP screening before surgery, but the data suggest low rates of CaP with similar oncologic outcomes when compared to RC.

A Multinational Study of The Impact of Covid-19 On Urologic Surgery Residency and Wellbeing.

OBJECTIVE: To assess changes to the experiences and wellbeing of urology trainees in the United States (US) and European Union (EU) during the COVID-19 pandemic. METHODS: A 72-item anonymous online survey was distributed September 2020 to urology residents of Italy, France, Portugal, and the US. The survey assessed burnout, professional fulfillment, loneliness, depression and anxiety as well as 38 COVID specific questions. RESULTS: Two hundred twenty-three urology residents responded to the survey. Surgical exposure was the main educational concern for 81% of US and 48% of EU residents. E-learning was utilized by 100% of US and 57% of EU residents with two-thirds finding it equally or more useful than traditional didactics. No significant differences were seen comparing burnout, professional fulfillment, depression, anxiety, or loneliness among US or EU residents, 73% of US and 71% of EU residents reported good to excellent quality of life during the pandemic. In the US and EU, significantly less time was spent in the hospital, clinic, and operating room (P <.001) and residents spent more time using telehealth and working from home during the pandemic and on research projects, didactic lectures, non-medical hobbies and reading. The majority of residents reported benefit from more schedule flexibility, improved work life balance, and increased time for family, hobbies, education, and research. CONCLUSION: The COVID-19 pandemic has resulted in significant restructuring of residents' educational experience around the globe. Preservation of beneficial changes such as reduction of work hours and online learning should be pursued within this pandemic and beyond it.

Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients.

INTRODUCTION: Lower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy. METHODS: We performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient. RESULTS: The lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months. CONCLUSION: This early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.

Impact of leadership behaviour on physician well-being, burnout, professional fulfilment and intent to leave: a multicentre cross-sectional survey study.

OBJECTIVE: To examine how perceived leadership behaviours affect burnout, professional fulfilment and intent to leave the organisation among physicians. DESIGN: Anonymous cross-sectional survey study from November 2016 to October 2018. SETTING: 12 036 attending and resident physicians at 11 healthcare organisations participating in the Physician Wellness Academic Consortium (PWAC) were surveyed to assess burnout and professional fulfilment and their drivers. PARTICIPANTS: A sample of 5416 attending physicians with complete data on gender, specialty, leadership, burnout and professional fulfilment. MAIN OUTCOMES AND MEASURES: The leadership behaviour of each physician's supervisor was assessed using the Mayo Clinic Participatory Management Leadership Index and categorised in tertiles. Multivariable logistic regression analyses examined the effect of leadership behaviour rating of each physician's supervisor on burnout, professional fulfilment and intent to leave controlling for gender and specialty. RESULTS: The response rate was 45% across 11 institutions. Half of the respondents were female. Professional fulfilment increased with increasing tertiles of leadership behaviour rating (19%, 34%, 47%, p<0.001). The odds of professional fulfilment were 5.8 times higher (OR=5.8, 95% CI: 5.1 to 6.59) for physicians in the top tertile compared with those in the lowest tertile. Physicians in the top tertile were also 48% less likely to be burned out (OR=0.52, 95% CI: 0.45 to 0.61) and reported 66% lower intent to leave (OR=0.34, 95% CI: 0.26 to 0.44). Individuals who rated their supervisor's leadership in upper tertiles relative to lower tertiles exhibited lower levels of burnout (18% vs 35% vs 47%, p<0.001), and intent to leave (16% vs 24% vs 50% p<0.001). CONCLUSION: Perceived leadership behaviours have a strong relationship with burnout, professional fulfilment and intent to leave among physicians. Organisations should consider leadership development as a potential vehicle to improve physician wellness and prevent costly physician departures.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings.

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Complex space of Retzius lymphocele resulting in iliac compression and submassive pulmonary embolism after robotic Retzius sparing prostatectomy.

Lymphoceles are common following prostatectomy with lymph node dissection, but the vast majority are asymptomatic. We present a unique case of a large complex lymphocele tracking into the anterior space of Retzius following Retzius sparing prostatectomy and bilateral pelvic lymphadenectomy. The patient initially presented with shortness of breath and subsequent diagnosis of a submassive pulmonary embolism. Further evaluation revealed compression of the iliac vessels by the fluid collection. Following multiple failed attempts of drainage percutaneously, the patient required return to the operating room for peritoneal marsupialization, drainage of fluid collection, and evacuation of large amounts of clot within the collection.

The impact of gender and institutional factors on depression and suicidality in urology residents.

INTRODUCTION Surgical trainees experience high rates of depression and suicidal ideation (SI). However, there remain a gap in knowledge on the drivers of depression and SI in trainees, especially within the field of urology. MATERIALS AND METHODS: We conducted a national study of urology trainees using a 50-item questionnaire in May 2018. The survey included demographic, depression (Patient Health Questionnaire-9 (PHQ-9)), burnout (Maslach Burnout Inventory (MBI)), and quality of life (QoL) questions. RESULTS: Overall, 37 (17.6%) endorsed depression; 24 residents endorsed SI (11%). SI was higher in those with depression (p < 0.001). Burnout was also higher among depressed residents (97.3% versus 61.8%, p < 0.001) and those endorsing SI (16.1% versus 1.5%, p < 0.001). Depression was associated with female gender (29.2% versus 12.4%, p = 0.005), fatigue (29.5% versus 7.8%, p < 0.001), and lack of structured mentorship (23.7% versus 9.8%, p = 0.010). Access to mental health services was protective (p = 0.016). Older age, low QoL, dissatisfaction with work-life-balance (WLB), and fatigue were associated with SI. On adjusted analysis, gender (OR 3.1 [95%CI 1.4-6.9], p = 0.006), fatigue (OR 3.8[95%CI 1.6-9.0], p = 0.002), and burnout (OR 16.7 [95%CI 2.2-127.5], p = 0.007) increased the odds of depression. On exploratory analysis, self-reported burnout alone was predictive of SI (OR 7.6 [95%CI 2.5-23]), and performed similarly to an adjusted model (AUC Area 0.718 [95%CI 0.634-0.802] versus 0.825 [0.753-0.897]). CONCLUSIONS: Urology trainees experience high rates of depression and SI. Female residents have significantly higher risk of depression. A single-item appears useful to screen for SI. Further investigation is needed to understand and promote urology resident wellness.

Resident burnout in USA and European urology residents: an international concern.

OBJECTIVE: To describe the prevalence and predictors of burnout in USA and European urology residents, as although the rate of burnout in urologists is high and associated with severe negative sequelae, the extent and predictors of burnout in urology trainees remains poorly understood. SUBJECTS AND METHODS: An anonymous 32-question survey of urology trainees across the USA and four European countries, analysing personal, programme, and institutional factors, was conducted. Burnout was assessed using the validated abridged Maslach Burnout Inventory. Univariate analysis and multivariable logistic regression models assessed drivers of burnout in the two cohorts. RESULTS: Overall, 40% of participants met the criteria for burnout as follows: Portugal (68%), Italy (49%), USA (38%), Belgium (36%), and France (26%). Response rates were: USA, 20.9%; Italy, 45.2%; Portugal, 30.5%; France, 12.5%; and Belgium, 9.4%. Burnout was not associated with gender or level of training. In both cohorts, work-life balance (WLB) dissatisfaction was associated with increased burnout (odds ratio [OR] 4.5, P < 0.001), whilst non-medical reading (OR 0.6, P = 0.001) and structured mentorship (OR 0.4, P = 0.002) were associated with decreased burnout risk. Lack of access to mental health services was associated with burnout in the USA only (OR 3.5, P = 0.006), whilst more weekends on-call was associated with burnout in Europe only (OR 8.3, P = 0.033). In both cohorts, burned out residents were more likely to not choose a career in urology again (USA 54% vs 19%, P < 0.001; Europe 43% vs 25%, P = 0.047). CONCLUSION: In this study of USA and European urology residents, we found high rates of burnout on both continents. Despite regional differences in the predictors of burnout, awareness of the unique institutional drivers may help inform directions of future interventions.