Complications and Surgeon Health: Resources for individuals and institutions.

The emotional impact of surgical complications on urologists is a significant yet historically under-addressed issue. Traditionally, surgeons have been expected to cope with complications and their psychological effects in silence, perpetuating a culture of perfectionism and 'silent suffering.' This has left many unprepared to handle the emotional toll of adverse events during their training and early careers. Recognizing the gap in structured education on this matter, there is a growing movement to openly address and educate on the emotional consequences of surgical complications. This article underscores the importance of such educational initiatives in the mid-career phase, proposing strategies to promote surgeon health, and psychological safety. It advocates for utilizing Morbidity and Mortality conferences as platforms for peer support, learning from 'near miss' events, and encourages at least annual department-wide discussions to raise awareness and normalize the emotional challenges faced by surgeons. Furthermore, it highlights the role of formal peer support programs, acceptance and commitment therapy, and resilience training as vital tools for promoting surgeon well-being. Resources from various organizations, including the American Urological Association and the American Medical Association, are now available to facilitate these critical conversations. By integrating these resources and encouraging a culture of openness and support, the article suggests that the surgical community can better manage the inevitable emotional ramifications of complications, thereby fostering resilience and reducing burnout among surgeons.

Patient Characteristics Associated with Sexual Interest and Activity Among Adults with Spina Bifida.

OBJECTIVE: To identify factors associated with sexual interest and activity among adults with spina bifida and to describe the sexual profile of those who were sexually active. Sexual health of adults with spina bifida is often neglected and current knowledge on the topic is limited. METHODS: An anonymous web-based survey was advertised and administered between March 2018 and September 2018 and participants 16 years and older with spina bifida were included in this study. Respondents were asked about sexual interest, activity, and function using the validated Patient-Reported Outcomes Measurement Information System Sexual Function Profile. Bivariate and multivariable models with ordinal logistic regression were fitted to evaluate predictors of sexual interest and sexual function. RESULTS: Of the 261 respondents with a self-reported diagnosis of spina bifida (mean age of 38.5 years), 73.2% noted at least a little bit of interest in sexual activity. In multivariate analysis, women were less likely to report higher sexual interest than men (odds ratio (OR) = 0.53, 95% CI 0.31-0.92, P = .03) whereas those with higher physical functioning were more likely to have higher sexual interest (OR = 1.04, confidence interval (CI) 1.01-1.07, P = .03). Just less than half of respondents (46.4%) were sexually active in the past 30 days, and those with a ventriculoperitoneal shunt were less likely to engage in sexual activity compared to those without (OR = 0.36, 95% CI 0.19-0.68; P <.01). CONCLUSION: The mismatch between sexual interest and sexual activity highlights the importance of exploring issues related to sexual health when counseling adult patients with spina bifida.

How older men live with stress urinary incontinence: Patient experience and navigation to treatment.

OBJECTIVES: To explore the context in which older men navigate treatment for stress urinary incontinence (SUI) following prostate surgery by characterizing lived experience of men with symptomatic SUI. SUBJECTS/PATIENTS AND METHODS: Mixed method study using surveys and semistructured interviews to examine a cohort of men who underwent evaluation for treatment of postprostatectomy SUI. RESULTS: Thirty-six men were interviewed after consultation for SUI and 31 had complete quantitative clinical data. Twenty-six underwent surgery and 10 chose no surgical intervention. In qualitative interviews, respondents experienced substantial decline in quality of life due to incontinence citing concerns associated with use of pads and worrying about incontinence. Most patients reported "workarounds"-efforts to mitigate or manage incontinence including Kegels, physical therapy, and garments. Participants also reported lifestyle changes including less strenuous physical activity, less sexual activity, and/or fewer social gatherings. Patients then described a "breaking point" where incontinence workarounds were no longer sufficient. After seeking evaluation, men described challenges in exploring treatment for SUI, including access to care and provider knowledge of treatment options. CONCLUSION: In a novel study of patients living with SUI a predictable lived experience was observed that culminated in a desire for change or "breaking point." In all men, this led to treatment-seeking behaviors and for many it led to SUI intervention. Despite effective treatments, patients continue to meet barriers gaining access to SUI evaluation and treatment.

Access and Utilization of Health Care by Adults with Spina Bifida.

OBJECTIVE: To contextualize the challenges that persons with congenital genitourinary conditions (CGC) may encounter in adulthood, we examined health care access, readiness for self-management, and health care utilization of adults with spina bifida (SB). METHODS: Through surveys distributed via social media, persons with SB were asked about access and barriers to care, readiness for self-management, and health care utilization (ie, medical visits, missed visits, emergency room [ER] visits, hospital admissions) within the past year. Multivariable models were fitted to examine determinants of utilization. RESULTS: Of the 270 eligible respondents (mean age 39), 24.5% had not received care from a urologist in the past year. The odds of missing any medical visits were increased among those with more prior urologic surgeries (odds ratio (OR) 1.35, 95%confidence interval (CI) 1.05-1.78) and those with ER visits for urologic condition within the past year (OR 2.65, 95%CI 1.22-6.01). Those with private insurance had lower odds of having ER visits for urologic condition (OR 0.46, 95%CI 0.22-0.84). The odds of hospital admission related to urologic condition were increased among female (OR 2.35, 95%CI 1.01-6.64), those with more prior urologic surgeries (OR 1.18, 95%CI 1.09-1.51), and those with a urologist (OR 2.98, 95%CI 1.15-14.47). CONCLUSION: A substantial proportion of adults with CGC lack routine urologic care. Considering the significant barriers to care and lapses in care, efforts to improve access and optimize health care services utilization for this population with high medical complexity are warranted.

Evaluation of urology trainee preferences in didactic education: a choice-based conjoint analysis.

Purpose: Didactic lectures are a commonly used educational tool during urology residency training. Recently, there has been a rapid introduction of online, collaborative didactics as a new model for resident teaching. The aim of this study is to determine which attributes of didactics education are most preferred by contemporary urology trainees. Methods: Urology trainees were invited to complete an online choice-based exercise assessing combinations of four attributes associated with didactics education: mode of communication, learning style, presenter credentials, and curriculum design. The survey was distributed via social media platforms and the Urology Collaborative Online Video Didactics (COViD) website. A choice-based conjoint analysis was used to identify how the trainees valued different combinations of didactic education. Results: Seventy-three trainees completed the conjoint analysis exercise. Mode of communication was rated as significantly more important than curriculum design (relative importance 28.6% vs. 19.9%). Overall, the majority preferred online/virtual presentations to in-person presentations. Respondents preferred national experts to faculty members from their local institutions, and preferred cased based lectures to didactics style lectures. A nationally standardized curriculum was also preferred over curriculum designed by local institutions. Finally, when segmented by level of training, there was increased preference for overall favored options as PGY year increased. Conclusion: This conjoint analysis shows clear preference by trainees for online, recorded didactics, nationally standardized with national experts, and preferably in a case-based format. Academic societies in urology and program directors should consider utilizing the shared experience of previously created collaborative online lectures in developing future didactic curriculum that can meet the needs of current trainees.

The relationship between frailty, incontinence severity, and treatment decisions for men with post-prostatectomy stress urinary incontinence: a mixed methods analysis.

Background: Frailty is common among urology patients in general as well as among men seeking evaluation for stress urinary incontinence (SUI), with 6.1% of men undergoing artificial urinary sphincter placement considered frail. It is unclear if and how patient views on frailty and incontinence severity impact decision-making with regards to SUI treatment. Methods: We undertook a mixed methods analysis to evaluate the intersection of frailty, incontinence severity, and treatment decision-making is presented. To do so, we utilized a previously published cohort of men undergoing evaluation for SUI at the University of California, San Francisco between 2015 and 2020, selecting those who had evaluation with timed up and go test (TUGT), objective measures of incontinence, and patient-reported outcome measures (PROMs). A subset of these participants had additionally undergone semi-structured interviews, and these interviews were re-examined to thematically code them with a focus on the impact of frailty and incontinence severity on SUI treatment decision-making. Results: Among the original cohort of 130 patients, 72 had an objective measure of frailty and were included in our analysis; 18 of these individuals had corresponding qualitative interviews. Common themes identified included (I) impact of incontinence severity on decision-making; (II) the interaction between frailty and incontinence; (III) the impact of comorbidity on treatment decision-making; and (IV) age as a construct of frailty and impact on surgical choice and/or recovery. Direct quotations regarding each theme provides insight into patients' views and drivers of SUI treatment decision-making. Conclusions: The impact of frailty on treatment decision-making for patients with SUI is complex. This mixed methods study highlights the variety of patient views on frailty with regards to surgical intervention for male SUI. Urologists should make a concerted effort to personalize patient counseling for SUI management and take time to understand each patient's perspective in order to individualize SUI treatment decision-making. More research is needed to help identify factors that influence decision-making for frail male patients with SUI.

Patient decision-making for surgical treatment of post-prostatectomy stress urinary incontinence: a mixed-methods exploratory pilot study.

Background: Male stress urinary incontinence (SUI) is a known complication following surgical intervention on the prostate, particularly following surgery for prostate cancer. Effective surgical treatments for SUI include artificial urinary sphincter (AUS) and male urethral sling. Prior data suggest that men may forego available treatment despite bothersome symptoms. The objective was to explore how men who underwent surgical correction for post-prostatectomy SUI navigated SUI treatment decisions. Methods: Mixed method study was employed. Semi-structured interviews, participant surveys and objective clinical assessment of SUI were performed among a group of men living with incontinence after prostate cancer surgery who underwent surgery for SUI at the University of California in 2017. Results: Eleven men were interviewed after consultation for SUI and all had complete quantitative clinical data. Surgery for SUI included AUS (n=8) and sling (n=3). There was a decrease in pads per day from 3.2 to 0.9 and no major complications. Most patients found that the impact on activities and their treating urologist were of great importance. Sexual and relationships played a variable role with some participants ranking these as "great deal of influence" and others "little or no influence". Participants who underwent AUS were more likely to cite a higher importance on "being very dry" in choosing that surgery while sling patients had more variable ranking of important factors. Participants found a variety of inputs helpful in hearing information about SUI treatment options. Conclusions: Among a group of 11 men who underwent surgical correction for post-prostatectomy SUI, there were identifiable themes on how men make decisions, evaluate quality of life (QoL) changes and approach treatment options. Men value more than being dry with measures of individual success that can include sexual and relationship health. Furthermore the role of the Urologist remains crucial as patients relied heavily on input and discussion with their Urologist to assist in treatment decisions. These findings can be used to inform future studies of the experience of men with SUI.

A Novel Standardized Morbidity and Mortality Process to Promote Discourse, Improve Education, and Facilitate Practice Change: The M-PROVE Model.

INTRODUCTION: The morbidity and mortality conference is essential to medical education and quality improvement. Ideally, the conference is inclusive, judgment-free, and focused on practice improvement. In reality, it may not meet these goals. We reimagined the process by standardizing presentations and creating an oversight committee to improve the perceived value of the conference and identify opportunities for improvement. This study evaluates the subjective impact of the redesigned process at our institution and provides a blueprint for our reproducible model. METHODS: We created a faculty and resident committee to review all submitted cases, implemented a standardized presentation template and moderating structure, and tracked quality improvement measures from proposed improvement initiatives. Attitudes toward the conference, including perceived quality/relevance, identification of potential systems changes, inclusiveness, and educational value, were assessed among faculty and trainees using pre- and postintervention Likert-style surveys. RESULTS: Of 45 eligible department members, 41 (91%) completed the preintervention and 36 (80%) completed the postintervention survey. We found a statistically significant improvement in all questions between pre- and postintervention surveys except on the question about the conference environment being nonthreatening, which also improved but was not statistically significant. The overall average answer improved on the postintervention survey compared to the preintervention survey (3.36 vs 4.20, P < .001). These trends were similar regardless of attendee role and gender. CONCLUSIONS: Redesigning and standardizing the morbidity and mortality conference with greater attention to education, inclusion, systems change, and quality improvement improves the attitudes of conference attendees and increases the perceived value of the conference.

Patient-identified Treatment Attributes Among Older Men With Stress Urinary Incontinence: A Qualitative Look at What Matters to Patients Making Treatment Decisions.

OBJECTIVE: To investigate which treatment attributes matter to patients with stress urinary incontinence (SUI), why and how they matter, and the context in which patients consider treatment attributes. Nearly a quarter of older men have decisional regret following SUI treatment. Knowledge of what matters to patients when making SUI treatment decisions is necessary to improve goal-concordant care. METHODS: We conducted semi-structured interviews with 36 men ≥65 years of age with SUI. Semi-structured interviews were conducted by telephone and transcribed. Four researchers (L.H., N.S., E.A., C.B.) coded the transcripts using both deductive and inductive codes to identify and describe treatment attributes. RESULTS: We identified 5 patient-derived treatment attributes of interest among older men with SUI who have faced treatment decisions: (1) dryness, (2) simplicity, (3) potential need for future intervention, (4) treatment regret/satisfaction, and (5) surgical avoidance. These themes reliably emerged in our patient-centered interviews from within various contexts, including prior negative healthcare experiences, the impact of incontinence on daily and quality of life, and the mental health burden of incontinence, among others. CONCLUSION: Men with SUI weigh a variety of treatment attributes in addition to dryness, a traditional clinical endpoint, and do so within the context of their individual experience. These additional attributes, such as simplicity, may run counter to the goal of dryness. This suggests that traditional clinical endpoints alone are not adequate for counseling patients. Contextualized patient-identified treatment attributes should be used to create decision-support materials to promote goal-concordant SUI treatment.

Kidney transplant access for children and young adults with congenital anomalies of the kidney and urinary tract.

PURPOSE: Although congenital anomalies of the kidney and urinary tract (CAKUT) are among the leading causes of end-stage kidney disease (ESKD) in children and young adults, kidney transplantation access for this population has not been well studied in the US. We compared transplantation access in the US based on whether the etiology of kidney disease was secondary to CAKUT, and additionally by CAKUT subgroups (anatomic vs. inherited causes of CAKUT). METHODS: Using the United States Renal Data System, we conducted a retrospective cohort study of 80,531 children and young adults who started dialysis between 1995 and 2015. We used adjusted Cox models to examine the association between etiology of kidney disease (CAKUT vs. non-CAKUT, anatomic vs. inherited) and receipt of kidney transplantation, and secondarily, receipt of a living vs. deceased donor kidney transplant. RESULTS: Overall, we found an increased likelihood of kidney transplantation access for participants with CAKUT compared to those without CAKUT (HR 1.23; 95% CI 1.20-1.27). Among the subset of individuals with CAKUT as the attributed cause of ESKD, we found a lower likelihood of kidney transplantation in those with anatomic causes of CAKUT compared to those with inherited causes of CAKUT (adjusted HR 0.85; 0.81-0.90). CONCLUSION: There are notable disparities in kidney transplantation rates among CAKUT subgroups. Those with anatomic causes of CAKUT started on dialysis have significantly reduced access to kidney transplantations compared to individuals with inherited causes of CAKUT who were initiated on dialysis. Further studies are needed to understand barriers to transplantation access in this population.

Repurposing an ACE Malone Channel for Continent Intermittent Catheterization During Re-augmentation Cecocystoplasty: The MACEtrofanoff Procedure.

OBJECTIVE: To describe a surgical alternative option in select patients with neurogenic bladder and a history of Malone antegrade continence enema (MACE) who now require revision augmentation of the bladder, and/or creation of a new continent catherizable urinary channel (CCC). METHODS: Herein, we describe a novel surgical approach for patients who have had prior MACE creation who subsequently require surgical revision and creation of a new CCC. Rather than the traditional approach of creating a new CCC utilizing bowel, we perform a cecocystoplasty and leave the previously created MACE intact. The prior MACE channel becomes repurposed as the new Mitrofanoff, which we have termed the MACEtrofanoff channel. Concomitant cecostomy tube placement for bowel management can be performed at the time of surgery. RESULTS: We have successfully performed this procedure in 2 patients with good outcomes to date. This technique does not require the sacrifice of the prior appendix channel, nor require the formation of a new stoma and channel. Patients are able to adapt easily to clean intermittent catheterization through a channel they are already familiar with for their prior antegrade enemas. CONCLUSION: In select patients, surgeons should consider the MACEtrofanoff procedure to avoid the added morbidity of further bowel mobilization.