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2.
J Healthc Qual ; 46(1): 12-21, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38166162

RESUMEN

ABSTRACT: No previous works have analyzed whether the order in which surgical teams see patients on morning rounds affects discharge efficiency at teaching hospitals. We obtained perioperative urologic surgery timing data at our academic institution from 2014 to 2019. We limited the analysis to routine postoperative day 1 discharges. Univariate and multivariate analyses were performed to determine whether various hospital and patient factors were associated with discharge timing. We analyzed 1,494 patients. Average discharge order time was 11:22 a.m. and hospital discharge 1:24 p.m. Univariate regression revealed earlier discharge order time for patients seen later in rounds by 4 minutes per sequential room cluster (p = .013) and by 12 minutes per cluster when excluding short-stay patients. Multivariate analysis revealed discharge order placement did not vary significantly by rounding order. However, time of hospital discharge did (p < .001), likely due to speed of discharge in the designated short-stay units. Attending physician was the most consistent predictor in variations of discharge timing, with statistical significance across all measured outcomes. Patients seen later in rounding progression received earlier discharge orders, but this relationship does not remain in multivariate modeling or translate to earlier discharge. These findings have helped guide quality improvement efforts focused on discharge efficiency.


Asunto(s)
Alta del Paciente , Urología , Humanos , Hospitales de Enseñanza , Factores de Tiempo , Eficiencia Organizacional
3.
Urology ; 184: 8-14, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-38065312

RESUMEN

OBJECTIVE: To assess the extent of formal point-of-care ultrasound (POCUS) training, current utilization of POCUS, and contemporary perceptions of POCUS amongst urologists. METHODS: A survey including questions regarding demographics, prior ultrasound education, current ultrasound utilization in practice/training, perceived optimal POCUS utilization, and the perception of formal ultrasound training was developed. The survey was disseminated to residency program directors (PDs) via the SAU and members of AUA subsection organizations. Data were collected via Redcap. RESULTS: A total of 40 PDs and 159 other respondents completed the survey with approximately half (51%) in an academic practice and two-thirds (68%) with more than 10years in practice. PD response rate was 28%, and general response rate was 2%. Among all respondents, 95% (186/196) and 82% (160/194) agreed/strongly agreed formal POCUS training would be worthwhile during and after residency. Among urology residency PDs, 93% (37/40) agreed/strongly agreed that formal POCUS training is worthwhile in residency. The majority of respondents used some form of ultrasound in practice (77%, 154/199). However, only 37% (72/199) of all respondents had prior formal POCUS training, and 19% (5/26) of PDs reported formal training in their programs. Of respondents without formal training, 63% (80/127) reported interest in pursuing formal training. CONCLUSION: POCUS is widely utilized in many practices. Yet, most urologists have not participated in formal POCUS training and most programs do not have curricula. Urologists have favorable opinions of the utility, safety, and efficacy of POCUS and desire training.


Asunto(s)
Internado y Residencia , Urología , Humanos , Sistemas de Atención de Punto , Escolaridad , Curriculum , Urólogos , Ultrasonografía
4.
Transl Androl Urol ; 12(10): 1518-1527, 2023 Oct 31.
Artículo en Inglés | MEDLINE | ID: mdl-37969765

RESUMEN

Background: Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. Methods: A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. Results: A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. Conclusions: The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

5.
Transl Androl Urol ; 12(8): 1229-1237, 2023 Aug 31.
Artículo en Inglés | MEDLINE | ID: mdl-37680222

RESUMEN

Background: Bladder recurrence after radical nephroureterectomy (RNU) is common and randomized data supports utilization of prophylactic intravesical mitomycin to reduce recurrence. Recently, gemcitabine has been shown to be safe and effective at reducing recurrence following transurethral resection of bladder tumors. We sought to evaluate the safety and efficacy of a single, intraoperative gemcitabine instillation immediately following bladder cuff closure during RNU, and to compare outcomes with non-gemcitabine intravesical chemotherapy agents. Methods: We retrospectively reviewed all patients from two high volume centers who underwent robotic-assisted RNU between 2016-2020 and received either 2 g intravesical gemcitabine immediately following bladder cuff closure or non-gemcitabine intravesical chemotherapies [40 mg mitomycin C (MMC) or 50 mg doxorubicin] at the beginning of the procedure. Clinicopathologic factors were compared between cohorts. Bladder recurrence rates were evaluated using the Kaplan-Meier method and log-rank test. Results: During RNU, 24 patients received gemcitabine and 31 patients received non-gemcitabine chemotherapy. In total, 35% (19/55) of patients experienced a bladder cancer recurrence. There was no significant difference in estimated bladder recurrence-free survival (bRFS) between gemcitabine and non-gemcitabine patient cohorts (P=0.64). By 12 months post-surgery, 25% of patients had experienced bladder recurrence. The estimated 1-year bladder RFS survival was 73% for gemcitabine and 76% for non-gemcitabine chemotherapy. Overall survival and cancer-specific survival did not differ between cohorts. No adverse events potentially attributable to the use of gemcitabine were noted within 30 days postoperatively. Conclusions: Gemcitabine instilled immediately following bladder cuff closure during RNU has similar bRFS rates compared to established chemotherapy agents instilled at the start of surgery.

6.
Urology ; 181: 29-30, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37770356
7.
Urology ; 181: 24-30, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37579855

RESUMEN

OBJECTIVE: To evaluate interviewer and interviewee perceptions of semiblinded interviews performed during 2021-2022 and 2022-2023 urology matches at our institution. Traditional interviews, where interviewers have access to the entire application, are open to significant bias. Blinded interviews are common in industry but under explored in resident selection. METHODS: Interviewers had access to a limited portion of the application (personal statement and letters of recommendation). Applicants were ranked by faculty based solely on their interview and these documents. Following the interview, a survey was given to applicants and faculty regarding their experience. RESULTS: A total of 67 applicants and 10 faculty responded to the questionnaire. Among applicants, 51% felt that blinding of interviewers offered a better assessment of fit into our program (39% neutral), while 37% felt they had improved eye contact with the interviewer (51% neutral) and that interviewers had improved (66%) or similar (19%) knowledge of their application in relation to nonblinded interviews. All but one faculty member felt able to accurately assess a candidate with the information provided, and 80% felt that the blinded interview allowed them to focus more on the applicant during the interview (20% neutral). CONCLUSION: Semiblinded interviews allow for accurate assessment of applicants and decrease bias in the interview process. Overall applicants and faculty were highly receptive to blinded interviews. Reducing the amount of information available to the interviewer allowed them to spend more time on the materials provided, leading to both improved eye contact and improved engagement between participants.


Asunto(s)
Docentes , Urología , Humanos , Emociones , Instituciones de Salud , Industrias
8.
J Urol ; 210(3): 480, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37340876
9.
J Endourol ; 37(9): 978-985, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37358403

RESUMEN

Introduction: T3a renal masses include a diverse group of tumors that invade the perirenal and/or sinus fat, pelvicaliceal system, or renal vein. The majority of cT3a renal masses represent renal cell carcinoma (RCC) and have historically been treated with radical nephrectomy (RN) given their aggressive nature. With the adoption of minimally invasive approaches to renal surgery, the combination of improved observation, pneumoperitoneum, and robotic articulation has allowed urologists to consider partial nephrectomy (PN) for more complex tumors. Herein, we review the existing literature regarding robot-assisted PN (RAPN) and robot-assisted RN (RARN) in the management of T3a renal masses. Methods: A literature search was performed using PubMed for articles evaluating the role of RARN and RAPN for T3a renal masses. Search parameters were limited to English language studies. Applicable studies were abstracted and included in this narrative review. Results: T3a RCC caused by renal sinus fat or venous involvement is associated with ∼50% lower cancer-specific survival than those with perinephric fat invasion alone. CT and MRI can both be used to stage cT3a tumors, however, MRI is more accurate when assessing venous involvement. Upstaging to pT3a RCC during RAPN does not confer a worse prognosis than pT3a tumors treated with RARN; however, patients who undergo RAPN for T3a RCC with venous involvement have relatively higher rates of recurrence and metastasis. Intraoperative tools including drop-in ultrasound, near-infrared fluorescence, and 3D virtual models improve the ability to perform RAPN for T3a tumors. In well-selected cases, warm ischemia times remain reasonable. Conclusions: cT3a renal masses represent a diverse group of tumors. Depending on substratification of cT3a, RARN or RAPN can be employed for treatment of such masses.


Asunto(s)
Carcinoma de Células Renales , Neoplasias Renales , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Resultado del Tratamiento , Nefrectomía , Estudios Retrospectivos
10.
Urology ; 2023 May 19.
Artículo en Inglés | MEDLINE | ID: mdl-37209881
11.
Urology ; 173: 47, 2023 03.
Artículo en Inglés | MEDLINE | ID: mdl-36958915
12.
Urology ; 175: 42-47, 2023 05.
Artículo en Inglés | MEDLINE | ID: mdl-36863598

RESUMEN

OBJECTIVES: To assess the difference in cranio-caudal renal position in both the supine and prone position, as well as the effect of arm position on renal location, using magnetic resonance imaging in subjects with BMI <30. METHODS: In a prospective IRB approved trial, healthy subjects underwent magnetic resonance imaging in the supine, prone position with arms at the side, and prone position with arms up using vertically placed towel bolsters. Images were obtained with end expiration breath holds. Distances between the kidney and other anatomical landmarks, including the diaphragm (KDD), top of the L1 vertebra (KVD) and lower edge of the 12th rib (KRD), were recorded. Nephrostomy tract length (NTL) and other measures for visceral injury were also assessed. Wilcoxon signed rank test was used for analysis (P < .05). RESULTS: Ten subjects (5 male, 5 female) with median age of 29 years and BMI of 24 kg/m2 were imaged. Right KDD was not significantly different between positions, but KRD and KVD noted significant cephalad movement when prone, as compared to supine. Left KDD noted caudal movement with prone positioning with no difference in KRD or KVD. Arm position did not affect any measurements. Right lower NTL was shorter when prone. CONCLUSIONS: In subjects with BMI < 30, prone positioning led to significant cephalad right renal movement, but not left renal movement. Arm position had no effect on anticipated renal position. Preoperative end expiration supine CT may reliably predict left kidney location and be used to improve preoperative counseling and/or surgical planning.


Asunto(s)
Riñón , Imagen por Resonancia Magnética , Masculino , Humanos , Femenino , Adulto , Estudios Prospectivos , Posición Supina , Posición Prona , Riñón/diagnóstico por imagen , Riñón/cirugía , Posicionamiento del Paciente/métodos , Espectroscopía de Resonancia Magnética
13.
Urology ; 173: 41-47, 2023 03.
Artículo en Inglés | MEDLINE | ID: mdl-36603653

RESUMEN

OBJECTIVE: To examine the Urology residency application process, particularly the interview. Historically, the residency interview has been vulnerable to bias and not determined to be a predictor of future residency performance. Our goal is to determine the relationship between pre-interview metrics and post-interview ranking using best practices for Urology resident selection including holistic review, blinded interviews, and structured behaviorally anchored questions. METHODS: Applications were assessed on cognitive (Alpha Omega Alpha, class rank, junior year clinical clerkship grades) and non-cognitive attributes (letters of recommendation [LOR], personal statement [PS], demographics, research, personal characteristics) by reviewers blinded to USMLE scores and photograph. Interviewers were blinded to the application other than PS and LORs. Interviews consisted of a structured behaviorally anchored question (SBI) and an unstructured interview (UI). Odds ratios were determined comparing pre-interview and interview impressions. RESULTS: Fifty-one applicants were included in the analysis. USMLE step 1 score (average 245) was associated with Alpha Omega Alpha, class rank, junior year clinical clerkship, and PS. The UI score was associated with the LOR (P = .04) whereas SBI scores were not (P = .5). Faculty rank was associated with SBI, UI, and overall interview (OI) scores (P < .001). Faculty rank was also associated with LOR. Resident impression of interviewees were associated with faculty interview scores (P = .001) and faculty rank (P < .001). CONCLUSION: Traditional interviews may be biased toward application materials and may be balanced with behavioral questions. While Step 1 score does not offer additional information over other PI metrics, blinded interviews may offer discriminant validity over a PI rubric.


Asunto(s)
Internado y Residencia , Humanos , Selección de Personal
14.
Urology ; 171: 55-56, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36610782
15.
Curr Urol Rep ; 23(11): 309-318, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-36255650

RESUMEN

PURPOSE OF REVIEW: Urology program directors are faced with increasing numbers of applications annually, making holistic review of each candidate progressively more difficult. Efforts to streamline evaluation using traditional cognitive metrics have fallen short as these do not predict overall resident performance. Situational judgment tests (SJTs) and personality assessment tools (PATs) have been used in business and industry for decades to evaluate candidates and measure non-cognitive attributes that better predict subsequent performance. The purpose of this review is to describe what these assessments are and the current literature on the use of these metrics in medical education. RECENT FINDINGS: SJTs relative to PATs have more original research. Data suggests that SJTs decrease bias, increase diversity, and may be predictive of performance in residency. PATs are also emerging with data to support use with ability to assess fit to program and certain traits identified more consistently among high-performing residents and correlation to performance on ACGME milestones. PATs may be more coachable than SJTs. SJTs and PATs are emerging as techniques to supplement the current resident application review process. Early evidence supports their use in undergraduate medical education as does some early preliminary results in graduate medical education.


Asunto(s)
Educación de Pregrado en Medicina , Internado y Residencia , Humanos , Educación de Postgrado en Medicina , Personalidad
16.
Urology ; 160: 215-216, 2022 02.
Artículo en Inglés | MEDLINE | ID: mdl-35216700
17.
Urology ; 160: 79-80, 2022 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-35216706
18.
J Endourol ; 36(6): 734-739, 2022 06.
Artículo en Inglés | MEDLINE | ID: mdl-35057636

RESUMEN

Objective: We wanted to evaluate two new treatment phases within our practice, including a nonopioid pathway, to determine the effect on opioid usage, health care utilization, and pain following ureteroscopy. Methods: Patients undergoing ureteroscopic lithotripsy were enrolled in a study utilizing text messaging to evaluate postoperative pain and opioid usage. Our historical postoperative pain regimen included #30 oxycodone. Patients in the N15 cohort were given improved counseling, preanesthesia acetaminophen, and #15 oxycodone. With further experience, narcotics were removed entirely from our postoperative care plan (N0) and replaced with a nonopioid multimodal regimen. Results: There were 61 and 58 patients in cohorts N15 and N0, respectively, with no difference in demographics, stone, or procedure details between each cohort. No difference in pain scores was detected between the N15 and N0 cohorts (p = 0.14). The median time to pain resolution was postoperative day (POD) 4 for cohort N15 and POD 3 for cohort N0 (p = 0.06). In the N0 cohort, nine patients required postoperative narcotics (15.5%; average of 2.4 pills/patient). There was no significant difference in emergency department visits, phone calls, or clinic visits (p = 0.17) between each cohort. Conclusions: Patients undergoing ureteroscopy have adequate postoperative pain control with a nonopioid treatment regimen, although some patients will still ultimately require narcotics.


Asunto(s)
Analgésicos no Narcóticos , Analgésicos Opioides , Analgésicos Opioides/uso terapéutico , Humanos , Narcóticos , Oxicodona , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Estudios Prospectivos , Ureteroscopía/efectos adversos
19.
Urol Oncol ; 40(1): 7.e19-7.e24, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-34187748

RESUMEN

INTRODUCTION: We hypothesized that the number of cores needed to detect prostate cancer would decrease with increasing MRI-targeted biopsy (TBx) experience. METHODS: All patients undergoing TBx at our institution from May 2017 to August 2019 were enrolled in a prospectively maintained database. Five biopsy cores were obtained from each lesion ≥3 on PI-RADS v2.0 followed by a systematic 12-core biopsy. To assess learning curve, the study population was divided into quartiles by sequential biopsies. Clinically significant prostate cancer (csPC) was defined as Gleason Grade Group 2 or higher. RESULTS: 377 patients underwent prostate biopsy (533 lesions); 233 lesions (44%) were positive for prostate cancer and 173 lesions (32%) were csPC. There was a significant decline in the number of cores required for diagnosing any cancer (P < 0.001) and csPC (P < 0.05) after the first quartile. There was no difference when stratifying by PI-RADS score or lesion volume. Within the first quartile, limiting the biopsy to 3 cores would miss 16.2% of csPC, decreasing to 6.6% after approximately 100 patients. CONCLUSION: MRI TBx is associated with a learning curve of approximately 100 cases. Four or 5 cores should be considered during the initial experience, but thereafter, 3 cores per lesion is sufficient to detect csPC.


Asunto(s)
Biopsia con Aguja Gruesa/métodos , Biopsia con Aguja Gruesa/estadística & datos numéricos , Biopsia Guiada por Imagen/métodos , Curva de Aprendizaje , Imagen por Resonancia Magnética Intervencional , Neoplasias de la Próstata/patología , Anciano , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
20.
Adv Radiat Oncol ; 6(6): 100778, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34934861

RESUMEN

PURPOSE: The cohort of patients with locally advanced prostate cancer (PC) and positive surgical margin(s) at radical prostatectomy (RP) who would benefit from salvage or adjuvant treatment is unclear. This study examines the risk of prostate-specific antigen (PSA) relapse in a large population of men with PC after margin-positive RP. METHODS AND MATERIALS: Using a multi-institutional database, patients with clinically localized PC who underwent RP between 2002 and 2010 with recorded follow-up PSA were retrospectively selected. Patients were excluded for pathologic seminal vesicle or lymph node involvement, metastatic disease, pre-RP PSA ≥ 30, or adjuvant (nonsalvage) radiation therapy or hormone therapy. The primary endpoint was biochemical relapse free survival (bRFS), where PSA failure was defined as PSA > 0.10 ng/mL and rising, or at salvage intervention. The Kaplan-Meier method was employed for bRFS estimates; recursive partitioning analysis using cumulative or single maximal margin extent (ME) and Gleason grade (GG) at RP was applied to identify variables associated with bRFS. RESULTS: At median follow-up of 105 months, 210 patients with positive margins at RP were eligible for analysis, and 89 had experienced PSA relapse. Median age was 61 years (range, 43-76), and median pre-RP PSA 5.8 ng/mL (1.6-26.0). Recursive partitioning analysis yielded 5 discrete risk groups, with the lowest risk group (GG1, ≤ 2 mm ME) demonstrating a bRFS of 92% at 8 years compared with the highest risk group (GG3-5, ≥ 3 mm ME) of 11%. CONCLUSIONS: This retrospective study suggests that it may be possible to risk-stratify patients undergoing margin-positive RP using commonly acquired clinical and pathologic variables. Patients with low-grade tumors and minimally involved margins have a very low recurrence risk and may be able to forego postprostatectomy radiation. Meanwhile, those with higher grade and greater involvement could benefit from adjuvant or early salvage radiation therapy.

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