Experiences and Outcomes of the Society of Genitourinary Reconstructive Surgeons Fellowship Training: Growth in Fellowships Mirrors the Evolution of the Discipline.

OBJECTIVE: To describe experiences and outcomes of the Society of Genitourinary Reconstructive Surgeons (GURS) fellowship match. In 2012, GURS developed a centralized fellowship match which has grown from 13 to 30 programs. METHODS: GURS match statistics and case logs were reviewed from 2013-2024. Additionally, a 37-question survey evaluating satisfaction, procedural competency, fellowship experience, and employment opportunities were sent to graduates. Linear regression was performed to examine trends over time. RESULTS: Over the study period, program match success remained stable (94.7%; P = .50) while applicant success (63.3%) increased over time (P = .04). North American and female applicants experienced higher match success (72.8% and 73.6%) compared to their international (35.5%; P <.0001) and male counterparts (60.0%; P = .02). On case log analysis, mean surgical volumes per year increased in urethral reconstruction (mean=88.1; P = .02), male sexual health (n = 32.7; P = .03), genital reconstruction (mean=16.4; P <.01) and abdominal reconstruction (mean=24.5; P = .03). Male incontinence surgeries remained stable (mean=30.5; P = .21) while female reconstruction declined (mean=23.2; P = .01). With a survey response rate of 54.5% (97/178), training satisfaction was 95.9% which did not differ by gender (P = .54) or year of training (P = .22). Around 97.9% felt competent to enter unsupervised reconstructive practice, 94.8% reported an understanding of the relevant literature and 96.9% were satisfied with their job as a reconstructive urologist. Around 49.5% identified a different case mix in practice compared to fellowship, most commonly related to abdominal (44.9%) or genital reconstruction (16.3%). CONCLUSION: GURS fellowships have grown organically over the last decade and mirror the growth and evolution of the discipline with sustained high levels of graduate satisfaction, surgical experience, competence, scholarly inquiry and employment.

Single Dilation in Primary Inflatable Penile Prosthesis Placement Is Associated With Fewer Corporal Complications Than Sequential Dilation.

OBJECTIVE: To assess the difference in outcomes between single dilation (SingD) and sequential dilation (SeqD) in primary penile implantation, hypothesizing that patients who undergo SeqD had higher rates of noninfectious complications. METHODS: We performed a multicenter, retrospective study of men undergoing primary inflatable penile prosthesis placement. Intraoperative complications and postoperative noninfectious outcomes were assessed between the two groups. Multivariable analysis was performed to identify predictors of complications. RESULTS: A total of 3293 patients met inclusion criteria. After matching, there were 379 patients who underwent SingD and 379 patients who underwent SeqD. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length (20 cm with interquartile range [IQR] 18-21 cm vs 20 cm with IQR 18-20 cm respectively, P = .4). On multivariable analysis, SeqD (OR 5.23 with IQR 2.74-10, P < .001) and older age (OR 1.04 with IQR 1.01-1.06, P = .007) were predictive of postoperative noninfectious complications. There was no significant difference in intraoperative complications between patients who underwent SingD vs SeqD, nor was there any difference in cylinder length. SeqD and older age were predictive of postoperative noninfectious complications. CONCLUSION: During inflatable penile prosthesis placement in the uncomplicated patient without fibrosis, SingD is a safe technique to utilize during implantation that will minimize postoperative adverse events, and promote device longevity without loss of cylinder length.

Prescribing Trends in Post-operative Pain Management After Urologic Surgery: A Quality Care Investigation for Healthcare Providers.

OBJECTIVE: To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge. METHODS: All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline. RESULTS: 817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill. CONCLUSION: Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills.

Optimal Modeling: an Updated Method for Safely and Effectively Eliminating Curvature During Penile Prosthesis Implantation.

OBJECTIVES: To assess outcomes of a variant of traditional modeling ("optimal modeling," OM) in patients with residual curvature following prosthesis implantation. METHODS: We performed a retrospective review of all patients who underwent penile implant insertion. Patients with >30° of residual curvature after cylinder placement and inflation underwent OM and were compared 1:1 to a demographically-matched cohort who received implantation without ancillary straightening. Optimal modeling was performed by forcibly bending the erect penis in the direction opposite the point of maximal curvature while maintaining glanular pressure to prevent urethral injury. This was performed for 90-second intervals for as many cycles as necessary to achieve <15° curvature. RESULTS: Eighty patients were included in the final analysis; 40 (50.0%) underwent optimal modeling while 40 (50.0%) did not need additional straightening following surgery. The mean premodeling curvature was 47.8° (range 30°-90°) while post-modeling curvature improved to a mean of 10.6° (range 0°-30°, P < .001); 87.5% of patients had <15° of residual curvature. Patients in the OM cohort experienced longer operative times (82.7 vs 75.8 min, P = .15). No patient in either group experienced an intraoperative or postoperative complication at a mean follow-up of 29.9 months. CONCLUSION: Although many prosthetic urologists forego manual modeling in cases of moderate-severe penile curvature, our contemporary series shows it to be both safe and effective. OM may preclude the need for more time-consuming and complex surgical procedures.

Unexpected High Rates of Angiography and Angioembolization for Isolated Low-grade Renal Trauma: Results From a Large, Statewide, Trauma Database.

OBJECTIVE: To evaluate usage of diagnostic angiography (DA) and renal angioembolization (RAE) for isolated renal injuries while assessing differences in utilization based on trauma-level designation. METHODS: Isolated renal injuries from 2000 to 2013 were identified in the prospectively maintained Pennsylvania Trauma Outcome Study database and stratified by the American Association for the Surgery of Trauma kidney injury grade. Therapeutic intervention and International Classification of Diseases-9 codes identified DA and/or RAE performance, whereas renal injury was designated through Abbreviated Injury Scale codes. Univariate and multivariate models identified factors associated with utilization of DA or RAE. RESULTS: Of 449,422 patients entered into the Pennsylvania Trauma Outcome Study from 2000 to 2013, 1628 (0.4%) isolated kidney injuries were identified. The majority of patients (1190/1628, 73.1%) experienced low-grade (American Association for the Surgery of Trauma I-III) renal trauma. Although isolated grade IV (41/350, 11.7%) or grade V (10/88, 11.4%) renal trauma patients underwent DA or RAE at a greater rate (P < .001), low-grade patients still underwent DA or RAE 4.3% (51/1190) of the time. Patients with grade I injuries were significantly more likely to undergo DA or RAE at level 1 trauma centers (odds ratio 5.4, 95% confidence interval 1.2-23.8, P = .03). CONCLUSION: Despite overwhelming evidence supporting conservative management for patients with isolated, low-grade traumatic renal injuries, contemporary utilization of DA and RAE in such patients treated at trauma centers is surprisingly high. Factors accounting for a significant increase in utilization at Level 1 trauma centers need to be further elucidated.

Trends in Urology Residents' Exposure to Operative Urotrauma: A Survey of Residency Program Directors.

OBJECTIVE: To determine longitudinal trends in resident exposure to urotrauma and to assess whether presence of Genitourinary Reconstructive Surgeon (GURS) faculty has impacted exposure and career choice. METHODS: An identical, 31-question multiple-choice survey was sent to program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited urology residency programs in 2006 and 2013. The areas of focus included program demographics, extent of urotrauma exposure, program director perceptions regarding educational value of urotrauma, and impact of GURS fellowship trained faculty. Responses were de-identified, compiled, and compared for differences. RESULTS: Response rates were 57% (64/112) and 43% (53/123) for the 2006 and 2013 survey, respectively (P = .03). Trauma Level 1 designation (56/64 [89%] vs 44/53 [88%], P = .84) and presence of GURS faculty (22/64 [34%] vs 22/53 [43%], P = .43) were similar between survey periods. Although survey respondents felt urotrauma volume had remained constant (34/64 [53%] vs 30/53 [56%], P = .71), more recent respondents reported that conservative management strategies negatively impacted resident exposure (14/64 [22%] vs 23/53 [43%], P = .01). Residencies with GURS faculty in 2013 (22/53, 42%) were positively associated with residents publishing urotrauma literature (9/22 [41%] vs 4/31 [13%], P = .02), the presence of multidisciplinary trauma and urology conferences (3/22 [14%] vs 0/31 [0%], P = .03), and residents matriculating to GURS fellowships (15/22 [68%] vs 10/31 [32%], P = .009). CONCLUSION: Many contemporary urology residencies report poor resident exposure to urotrauma during training. Although presence of GURS faculty may influence resident career choice, additional strategies may be warranted to expose residents to urotrauma during training.

Racial differences in hypogonadal improvement and prostate-specific antigen levels in hypogonadal men treated with testosterone replacement therapy.

PURPOSE: To observe hypogonadal men undergoing testosterone replacement therapy (TRT) and assess racial differences in hypogonadal improvement and prostate-specific antigen (PSA) levels. MATERIALS AND METHODS: In a retrospective analysis, 75 hypogonadal men were followed for an average 34 months after initiating TRT. Total testosterone and PSA levels were assessed every 6 months, and patients diagnosed with prostatitis or prostate cancer during treatment were excluded. RESULTS: For 16 African American men, the average age at diagnosis of hypogonadism was 53.5 years, compared with 57.8 years in 59 Caucasian men (p=NS). Pre- and post-treatment testosterone was 219 ng/dL and 310 ng/dL in African American men, and 247 ng/dL and 497 ng/dL in Caucasian men (p=NS). Symptomatic response was 81% in African American men and 93% in Caucasian men (p=NS). Baseline PSA level was 1.32 ng/mL in African American men and 1.27 ng/mL in Caucasian men, and there was no significant difference in PSA between racial groups at 6-month intervals, although there was a small decreasing trend in the PSA of African Americans compared with Caucasians. CONCLUSIONS: Hypogonadal African American men have a similar normalization of testosterone and symptomatic response as hypogonadal Caucasian men, and PSA levels remain stable over time in both groups. In this hypogonadal cohort, in contrast to studies of eugonadal men, higher PSA levels in African Americans were not observed.

Racial differences in hypogonadal improvement and prostate-specific antigen levels in hypogonadal men treated with testosterone replacement therapy

PURPOSE: To observe hypogonadal men undergoing testosterone replacement therapy (TRT) and assess racial differences in hypogonadal improvement and prostate-specific antigen (PSA) levels. MATERIALS AND METHODS: In a retrospective analysis, 75 hypogonadal men were followed for an average 34 months after initiating TRT. Total testosterone and PSA levels were assessed every 6 months, and patients diagnosed with prostatitis or prostate cancer during treatment were excluded. RESULTS: For 16 African American men, the average age at diagnosis of hypogonadism was 53.5 years, compared with 57.8 years in 59 Caucasian men (p = NS). Pre- and post-treatment testosterone was 219 ng/dL and 310 ng/dL in African American men, and 247 ng/dL and 497 ng/dL in Caucasian men (p = NS). Symptomatic response was 81 percent in African American men and 93 percent in Caucasian men (p = NS). Baseline PSA level was 1.32 ng/mL in African American men and 1.27 ng/mL in Caucasian men, and there was no significant difference in PSA between racial groups at 6-month intervals, although there was a small decreasing trend in the PSA of African Americans compared with Caucasians. CONCLUSIONS: Hypogonadal African American men have a similar normalization of testosterone and symptomatic response as hypogonadal Caucasian men, and PSA levels remain stable over time in both groups. In this hypogonadal cohort, in contrast to studies of eugonadal men, higher PSA levels in African Americans were not observed.