Incidence and predictors of delays in commencing fellowship training in urology.

INTRODUCTION: The completion of residency and start of fellowship training marks a critical transition for urologists in the pursuit of subspeciality training. Most graduating urology residents are under contract until June 30, and the majority of fellowships are scheduled to begin on July 1. There has been no investigation into the practical implications of fellowship delays in urology from a trainee perspective. Our research study aims to investigate the incidence and predictors of delays in fellowship starts. METHODS: Pediatric urology fellows that began their fellowship training from 2019-2023 and endourologic fellows that began their fellowship training from 2017-2022 were surveyed using SurveyMonkey®. A total of 250 endourology (EU) fellows and 90 pediatric urology (PU) fellows were contacted. RESULTS: A total of 26.0% and 14.3% of EU and PU fellows, respectively, experienced a delay in their training, despite many leaving their residency positions early (33.8% vs. 44.9%, p=0.2097); 11.7% and 8.2% of EU and PU fellows, respectively, experienced delays they reported to be "very stressful" and 9.1% and 4.1%, respectively, found them "somewhat stressful. Delays of 2- 4 weeks were experienced by 5.2% and 6.1%, 4-6-week delays by 7.8% and 4.1%, and delays >6 weeks by 2.6% and 0% of EU and PU fellows, respectively (p=0.0007). CONCLUSIONS: Delays in fellowship training do occur at a notable rate, despite nearly half of urology fellows leaving their residency training positions early, with unclear impacts on patient care and resident colleague well-being. This research highlights the importance of fellowship programs considering delaying fellowship starts to mid-July or August, with support of the prior fellow cohorts.

Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate Outcomes? A Prospective Randomized Controlled Trial.

Introduction: Holmium laser enucleation of the prostate (HoLEP) is routinely performed with a 24F, 26F, or a 28F scope. Proponents of the larger scopes propose that a bigger sheath size allows for superior flow and visibility leading to a more efficient operation and better hemostasis. Those utilizing the smaller scopes suggest that the smaller sheath is less traumatic, resulting in lower stricture rates and temporary incontinence. We sought to compare outcomes of ambulatory HoLEP using the 24F and 28F laser scope. Materials and Methods: From May 2022 to March 2023, we randomized patients undergoing HoLEP (<200 cm3 in size) 1:1 to either a 24F or 28F scope. The primary outcome was differences in surgical duration between groups (minutes). Secondary outcomes included surgeon scope evaluation and postoperative patient results. Results: There was no difference in patient characteristics in those randomized to 28F (n = 76) vs 24F (n = 76) (p > 0.05) scopes. Procedural duration and efficiencies were not different between groups (all p > 0.05). The 28F scope was associated with improved surgeon-graded irrigation flow and visibility (p < 0.001). Patients treated with the 28F scope were more likely to achieve effective same-day trial of void (SDTOV) (28F 94.3% vs 24F 82.1%, p = 0.048) and have a shorter length of stay (LOS) (28F 7.0 vs 24F 11.9 hours, p = 0.014), however, rates of same-day discharge (SDD) were not statistically different (28F 87.8% vs 24F 78.4%, p = 0.126). There was no difference between the cohorts in rates of 90-day emergency room presentations, re-admissions, complications, or functional ouctomes (p > 0.05). Conclusions: We identified no clear advantage of scope size with regard to intraoperative or postoperative outcomes at 3-month follow-up due to scope size. However, if SDD is part of your postoperative pathway, the 28F scope may shorten LOS and increase rates of effective SDTOV. Clinicaltrials.gov: NCT05308017.

Beyond Efficiency: Surface Electromyography Enables Further Insights into the Surgical Movements of Urologists.

Introduction: Surgical skill evaluation while performing minimally invasive surgeries is a highly complex task. It is important to objectively assess an individual's technical skills throughout surgical training to monitor progress and to intervene when skills are not commensurate with the year of training. The miniaturization of wireless wearable platforms integrated with sensor technology has made it possible to noninvasively assess muscle activations and movement variability during performance of minimally invasive surgical tasks. Our objective was to use electromyography (EMG) to deconstruct the motions of a surgeon during robotic suturing (RS) and distinguish quantifiable movements that characterize the skill of an experienced expert urologic surgeon from trainees. Methods: Three skill groups of participants, novice (n = 11), intermediate (n = 12), and expert (n = 3), were enrolled in the study. A total of 12 wireless wearable sensors consisting of surface EMGs and accelerometers were placed along upper extremity muscles to assess muscle activations and movement variability, respectively. Participants then performed a RS task. Results: EMG-based parameters, total time, dominant frequency, and cumulative muscular workload, were significantly different across the three skill groups. We also found nonlinear movement variability parameters such as correlation dimension, Lyapunov exponent trended differently across the three skill groups. Conclusions: These findings suggest that economy of motion variables and nonlinear movement variabilities are affected by surgical experience level. Wearable sensor signal analysis could make it possible to objectively evaluate surgical skill level periodically throughout the residency training experience. Clinical Trial Registration Number: HS# 2018-4407.

Multidisciplinary Approach and Outcomes of Pretreatment Small (cT1a) Renal Mass Biopsy: Single-Center Experience.

Purpose: We evaluated our experience of a multidisciplinary approach to renal mass biopsy (RMB) for small renal masses (SRMs) employing in-office ultrasound (US)-guided biopsy by urology (24%), CT, or US biopsy by interventional radiology (IR) (79%), and endoscopic ultrasound (EUS)-guided biopsy by gastroenterology (GI) (4%). Materials and Methods: A single-institution retrospective review of patients who underwent RMB for SRM from May 2013 to August 2019 was conducted. Data regarding patient demographics, tumor characteristics, biopsy technique, histopathology, and management were collected. Diagnostic rates, concordance with final pathology, complications, and outcomes were analyzed. Results: Of the 192 biopsies reviewed, 63% biopsies were malignant, 20% were benign, and 17% were nondiagnostic. Based on biopsy results, 71 patients (37%) elected active surveillance. Thirty-eight (20%) patients underwent cryoablation, 56 (29%) underwent partial nephrectomy, 14 (7%) underwent radical nephrectomy, and the remaining patients were treated elsewhere. The rate of surgery for benign pathology after pretreatment RMB was 3%. The concordance rate between biopsy and final pathology was 99% for malignancy, 96% for specific pathology subtype, and 85% for renal cell carcinoma grade. Median time from diagnosis to definitive treatment was 97 days (urology: 76, IR: 110 and GI: 54, p = 0.002). Three (1.6%) Clavien I complications were reported. Conclusion: Our multidisciplinary approach to RMB for clinical stage T1a demonstrated favorable safety and diagnostic rates, which effectively directed management strategies and minimized surgery for benign disease. Urologist-performed office biopsies significantly shortened the time from diagnosis to definitive treatment. Our experience with GI EUS biopsy has demonstrated feasibility and safety for tumors that were otherwise not accessible percutaneously.

Comparison of Outcomes for Hypogonadal Men Treated with Intramuscular Testosterone Cypionate versus Subcutaneous Testosterone Enanthate.

PURPOSE: Intramuscular testosterone cypionate (IM-TC) is known to cause significant rises in estradiol (E2), hematocrit (HCT), and prostate specific antigen (PSA) due to its supraphysiological testosterone peaks, whereas a novel subcutaneous testosterone enanthate autoinjector (SCTE-AI) was designed with a lower testosterone peak-to-trough ratio to mitigate these reactions. We compare the total testosterone (TT), E2, HCT and PSA response to treatment with IM-TC versus SCTE-AI. MATERIALS AND METHODS: A total of 234 hypogonadal men were treated with testosterone replacement therapy (TRT) via IM-TC 100 mg weekly or SCTE-AI 100 mg weekly. TT, E2, HCT and PSA levels were obtained at baseline and 12 weeks post-treatment. Significant differences in baseline and post-treatment levels were identified by univariate analysis. Linear regression models determined whether treatment modality was independently associated with post-TRT levels of TT, E2, HCT and PSA. RESULTS: Post-TRT, both cohorts had significant increases in trough TT compared to their baseline levels (IM-TC: 313.6 ng/dL to 536.4 ng/dL, p <0.001; SCTE-AI: 246.6 ng/dL to 552.8 ng/dL, p <0.001). After linear regression, type of TRT modality was not found to be associated with TT levels (p=0.057). SCTE-AI was independently associated with lower post-therapy E2 (p <0.001) and HCT (p <0.001). Neither TRT modality was associated with significant post-therapy elevation of PSA (p=0.965). CONCLUSIONS: While IM-TC and SCTE-AI provide a significant increase in TT levels, SCTE-AI is associated with lower levels of post-therapy HCT and E2 compared to IM-TC after adjusting for significant covariates. SCTE-AI is an effective testosterone delivery system with a potentially preferable safety profile over IM-TC.

Post-market safety and efficacy profile of subcutaneous testosterone enanthate-autoinjector: a cohort analysis.

A subcutaneous testosterone enanthate-autoinjector (SCTE-AI) was recently approved by the Food and Drug Administration for patient-administered weekly testosterone replacement therapy (TRT). From January 2019 to October 2019, 110 hypogonadal men were treated with SCTE-AI at two institutions. Patients were assessed in a pretherapy visit prior to receiving SCTE-AI and re-assessed 6 weeks after treatment initiation. Patients with a history of prostate cancer were excluded. Trough serum total testosterone (TT), estradiol (E2), prostate-specific antigen (PSA), and hematocrit (HCT) levels were collected at clinic visits. Therapeutic phlebotomy was recommended for HCT > 54%, and treatment was discontinued for significant increases in PSA as well as for significant treatment-related adverse events. Values from each visit were compared with univariate analysis. 110 patients completed the 6 weeks of observation with a mean age of 40.3 (SD: 10.5). TT significantly rose from 246.6 ng/dL (SD:113.3) pretherapy to 538.4 ng/dL (SD: 209.3) at 6 weeks (p < 0.001). Post-therapy, 101/110 (91.8%) of patients had TT > 300 ng/dL. No patients had HCT > 54%. 74 patients (70.5%) had PSA increase with only 3 (2.9%) experiencing an increase >1.0 ng/dL. There was a significant increase in mean PSA from 1.07 ng/dL (SD: 0.8) pretherapy to 1.18 ng/dL (SD: 0.9) at 6 weeks (p = 0.01). One patient had immediate treatment cessation following diagnosis of prostate cancer. This is the largest non-industry sponsored safety and efficacy profile of SCTE-AI application in urology clinics. After 6 weeks of observation, TT levels increased significantly without any reports of adverse events. SCTE-AI is a safe and effective alternative delivery system of TRT.

Screening Laboratory Testing in Asymptomatic Minor Pediatric Blunt Trauma Leads to Unnecessary Needle Sticks.

OBJECTIVE: Screening blood work after minor injuries is common in pediatric trauma. The risk of missed injuries versus diagnostic necessity in an asymptomatic patient remains an ongoing debate. We evaluated the clinical utility of screening blood work in carefully selected asymptomatic children after minor trauma. METHODS: Patients seen at a level 1 pediatric center with "minor trauma" for blunt trauma between 2010 and 2015 were retrospectively reviewed. Exclusion criteria were age <4 of >18 years, a Glasgow Coma Scale score of <15, penetrating trauma, nonaccidental trauma, hemodynamic instability, abdominal findings (pain, distension, bruising, tenderness), hematuria, pelvic/femur fracture, multiple fractures, and operative intervention. Data abstraction included demographics, blood work, interventions, and disposition. RESULT: A total of 1308 patients were treated during the study period. Four hundred thirty-three (33%) met inclusion criteria. Mean ± SD age was 12.7 ± 4 years (range, 4-18 years), and 59% were male. Seventy-eight percent were discharged home from the emergency department. All patients had blood work. Twenty-eight percent had at least one abnormal laboratory value. The most common abnormal blood work was leukocytosis (16%). Thirty percent had an intervention, and none prompted by abnormal blood work. One patient had an intra-abdominal finding (psoas hematoma). CONCLUSION: When appropriately selected, screening laboratory testing in asymptomatic minor pediatric blunt trauma patients leads to unnecessary needle sticks without significant advantage.

Intralesional Injection Therapy and Atypical Peyronie's Disease: A Systematic Review.

INTRODUCTION: Peyronie's disease (PD) is an inflammatory disorder of the tunica albuginea causing fibrotic changes including abnormal penile curvature, pain, and erectile dysfunction. Approximately 10% of PD patients will have atypical features including ventral plaques, hourglass deformities, unilateral indentations, severely shortened penile length, and multiplanar curvatures. Currently, the only intralesional treatment approved by the United States Food and Drug Administration is considered off-label for atypical PD. Furthermore, treatment of atypical PD, especially ventral plaques, is met with hesitation, in part due to potential urethral injury. OBJECTIVES: To systematically review the available literature for the safety and efficacy of intralesional injections for atypical PD. METHODS: A thorough literature search of the PubMed database was performed on manuscripts published between 1982 and 2020. Keywords included atypical Peyronie's disease, ventral plaque, hourglass deformity, and injection. RESULTS: 15 articles met the criteria for evaluation. Overall, 1,357 patients with PD were treated with intralesional therapy, of which 250 patients were considered to have an atypical presentation. 162 (648%) of the patients were treated with intralesional collagenase Clostridium histolyticum, 49 (19.6%) with verapamil, 29 (11.6%) with interferon alfa-2b, 5 (2.0%) with hyaluronic acid, and another 5 (2.0%) with onabotulinumtoxinA. There was only 1 reported severe adverse event (penile fracture), which was surgically repaired. There were no reports of urethral injury. CONCLUSION: Intralesional injection treatment may be a safe alternative option for atypical PD. There is a great need for future research to closely monitor the role of intralesional therapy in this cohort. Choi EJ, Xu P, El-Khatib FM, et al. Intralesional Injection Therapy and Atypical Peyronie's Disease: A Systematic Review. Sex Med Rev 2021;9:434-444.

Low Testosterone in Male Cancer Patients and Survivors.

INTRODUCTION: Hypogonadism (HG) is prevalent among patients with ongoing advanced cancer and cancer survivors. The etiology of HG in these patients is multifactorial and can be examined from cancer-related and cancer-treatment perspectives. There is evidence that HG contributes to increased morbidity in male cancer patients. Testosterone replacement therapy (TRT) for cancer survivors and advanced cancer patients is not well studied outside of prostate cancer. Here, we evaluate and summarize the current literature on HG in male cancer patients, including the role of TRT in nonprostate cancer patients. OBJECTIVE: To summarize and present the literature for the background, etiology, clinical consequences, and treatment for HG in male cancer patients and survivors. METHODS: A literature review was performed in MEDLINE between 1980 and 2020 using the terms hypogonadism, advanced cancer, testosterone replacement therapy, quality of life, and cancer survivors. Studies including only prostate cancer patients were excluded. RESULTS: The main outcome measure was to complete a review of peer-reviewed literature. HG is not only prevalent among male cancer patients and survivors but also clinically reduces quality of life and increases morbidity. The etiology of HG in male cancer patients and survivors is multifactorial. There are few studies examining the benefit of TRT in these patient populations. The results of randomized controlled trials show potential benefit for TRT in hypogonadal male cancer survivors and those with advanced cancer. CONCLUSION: HG affects many male cancer patients and survivors because of a multifactorial etiology. HG in these patients contributes to increased morbidity and reduced quality of life. Treatment of HG in male cancer patients is not well studied, and further studies are needed to elucidate the role of TRT. Xu P, Choi E, White K, et al. Low Testosterone in Male Cancer Patients and Survivors. Sex Med 2021;9:133-142.

Hypogonadism and its treatment among prostate cancer survivors.

Adult-onset hypogonadism (AOH) is associated with sexual dysfunction, poor bone mineralization, decreased muscle mass, metabolic syndrome disorder, and cognitive suppression. Historically, testosterone has been contraindicated in men with a history of prostate cancer. However, there has been a modern resurgence in re-evaluating this belief. Not only can testosterone be safely utilized to alleviate AOH symptoms in prostate cancer survivors, it has been also touted as a treatment option for aggressive prostatic cancer. While much work remains in understanding the relationship between testosterone and prostate cancer, those who survive this disease should not be automatically turned away from an opportunity to be treated and restored.

Variability of Retail Pricing of Generic Urologic Medications in a Major US Metropolitan Area.

OBJECTIVE: To investigate retail pricing for generic urologic medications in the St. Louis area as a function of pharmacy type, zip-code, and median income. MATERIALS AND METHODS: Pharmacies spanning 51 zip-codes were identified. From May-June 2017, pharmacies were inquired regarding cost, without insurance, for 30- and 90-tablet prices for finasteride 5 mg, tamsulosin 0.4 mg, oxybutynin 5 mg, and oxybutynin extended release (ER) 5 mg and 10 mg. Median income was determined using US census data. K-means clustering defined groupings based on zip-code, median income, and a combination of the two. Pricing between groups and pharmacy type was compared using Kruskal-Wallis and Wilcoxon rank-sum tests. Associations between pricing and median income were tested using Spearman's rho. RESULTS: 152 chain and 16 independent pharmacies provided data. Retail pricing for generic urologic medications did not vary as a function of zip-code, median income, or a combination of the two. There was a significant difference in the pricing of tamsulosin 0.4 mg, and oxybutynin ER 5 mg and 10 mg based on pharmacy type, where independent pharmacies have significantly lower prices compared to chain (P = .00-.00003). CONCLUSION: Pricing for generic urologic medications demonstrated wide variability at the retail pharmacy level. Compared to chain, independent pharmacies have significantly lower pricing for tamsulosin 0.4 mg, and oxybutynin ER 5 mg and 10 mg. Pharmacy zip-code, median income, and a combination of the two did not correlate with pricing.

Outcomes of renal salvage for penetrating renal trauma: a single institution experience.

INTRODUCTION: Conservative management of penetrating renal trauma is emerging, with data originating from centers with variable level of trauma care. This study reviews the outcomes of renal salvage after penetrating trauma at a level I trauma center. MATERIALS AND METHODS: An institutional review board approved trauma registry at Saint Louis University Hospital was retrospectively analyzed, for patients with penetrating renal trauma from 2009 to 2014. Patients were divided into nephrectomy group (NG) or non-nephrectomy group (non-NG), and compared. A multi-variable analysis was performed to determine predictors of nephrectomy, with cross validation to evaluate the performance of the multi-variable model. Data was analyzed using R version 3.3.2. A p value of < 0.05 was considered as significant. RESULTS: A total of 121 patients were identified with penetrating renal trauma. Gunshot injury was the leading cause of injury (87%). Eighteen (15%) patients required nephrectomy. The overall mean injury severity score (ISS). was 20. High grade (grade 4-5) renal injuries were noted in 41 patients (34%). Among these, 14 patients (34%) underwent a nephrectomy, while 27 patients (66%) were managed conservatively to salvage renal units. CT grade of renal injury was the only predictor of nephrectomy, on multi-variable analysis (OR 17.09 CI 2.75-105.99, p = 0.002). CT grade of injury and injury severity score were predictors of endoscopic intervention on a sub group analysis of non-NG. CONCLUSIONS: CT grade of injury predicts nephrectomy after penetrating renal trauma. Conservative management is a feasible option in penetrating renal trauma even with a higher grade of injury.

Imaging for acute appendicitis at nonpediatric centers exposes children to excess radiation.

BACKGROUND: Radiation exposure is the reason for the decreased utilization of computed tomography (CT) in pediatric centers (PCs). We sought to compare the radiation dose exposure of CT imaging performed at outside hospitals (OH) versus PC in pediatric patients with acute appendicitis (AA). MATERIAL AND METHODS: A retrospective review of all patients managed at our PC for AA from January 2011 to March 2016 was performed. Patients who had CT imaging for AA at OH were compared to those who underwent CT for appendicitis at our PC. Radiation dosing was compared using the dose index (CTDI [mGY]) and dose length product (DLP [mGYcm]). Independent t-test samples were used to compare means for radiation dose. RESULTS: 379 patients met inclusion criteria. There were 59.4% (225) patients imaged at our PC and 40.6% (154) patients were transferred from an OH. When performed at OH, 6.5% of CTs were considered inadequate as they were done without intravenous contrast compared to 1.3% in our PC. Mean CTDI was 6.9 at our PC and 11.8 at OH (P < 0.0001). Mean DLP at PC was 296.2 versus 456.8 at OH (P < 0.0001). An excess radiation dose of 4.9 mGY and 160.5 mGYcm was noted when CT scan was performed at OH versus PC. CONCLUSIONS: Using DLP as a gauge of radiation exposure, CT imaging performed at OH has a 44% higher radiation rate relative to the exposure at PC. In cases of suspected AA at a facility without pediatric surgeons, early transfer to PC prior to imaging is advocated.