Gender-based Disparity Exists in the Surgical Experience of Female and Male Urology Residents.

OBJECTIVE: To determine if a discrepancy exists in the number and type of cases logged between female and male urology residents. MATERIALS AND METHODS: ACGME case log data from 13 urology residency programs was collected from 2007 to 2020. The number and type of cases for each resident were recorded and correlated with resident gender and year of graduation. The median, 25th and 75th percentiles number of cases were calculated by gender, and then compared between female and male residents using Wilcoxon rank sum test. RESULTS: A total of 473 residents were included in the study, 100 (21%) were female. Female residents completed significantly fewer cases, 2174, compared to male residents, 2273 (P = .038). Analysis by case type revealed male residents completed significantly more general urology (526 vs 571, P = .011) and oncology cases (261 vs 280, P = .026). Additionally, female residents had a 1.3-fold increased odds of logging a case in the assistant role than male residents (95% confidence interval: 1.27-1.34, P < .001). CONCLUSION: Gender-based disparity exists within the urology training of female and male residents. Male residents logged nearly 100 more cases than female residents over 4years, with significant differences in certain case subtypes and resident roles. The ACGME works to provide an equal training environment for all residents. Addressing this finding within individual training programs is critical.

Longitudinal Changes in the Operative Experience for Junior Urology Residents.

OBJECTIVE: To evaluate longitudinal trends in surgical case volume among junior urology residents. There is growing perception that urology residents are not prepared for independent practice, which may be linked to decreased exposure to major cases early in residency. METHODS: Retrospective review of deidentified case logs from urology residency graduates from 12 academic medical centers in the United States from 2010 to 2017. The primary outcome was the change in major case volume for first-year urology (URO1) residents (after surgery internship), measured using negative binomial regression. RESULTS: A total of 391,399 total cases were logged by 244 residency graduates. Residents performed a median of 509 major cases, 487 minor cases, and 503 endoscopic cases. From 2010 to 2017, the median number of major cases performed by URO1 residents decreased from 64 to 49 (annual incidence rate ratio 0.90, P < .001). This trend was limited to oncology cases, with no change in reconstructive or pediatric cases. The number of major cases decreased more for URO1 residents than for residents at other levels (P-values for interaction <.05). The median number of endoscopic cases performed by URO1 residents increased from 85 to 194 (annual incidence rate ratio 1.09, P < .001), which was also disproportionate to other levels of residency (P-values for interaction <.05). CONCLUSION: There has been a shift in case distribution among URO1 residents, with progressively less exposure to major cases and an increased focus on endoscopic surgery. Further investigation is needed to determine if this trend has implications on the surgical proficiency of residency graduates.

FOXA1 repression drives lineage plasticity and immune heterogeneity in bladder cancers with squamous differentiation.

Cancers arising from the bladder urothelium often exhibit lineage plasticity with regions of urothelial carcinoma adjacent to or admixed with regions of divergent histomorphology, most commonly squamous differentiation. To define the biologic basis for and clinical significance of this morphologic heterogeneity, here we perform integrated genomic analyses of mixed histology bladder cancers with separable regions of urothelial and squamous differentiation. We find that squamous differentiation is a marker of intratumoral genomic and immunologic heterogeneity in patients with bladder cancer and a biomarker of intrinsic immunotherapy resistance. Phylogenetic analysis confirms that in all cases the urothelial and squamous regions are derived from a common shared precursor. Despite the presence of marked genomic heterogeneity between co-existent urothelial and squamous differentiated regions, no recurrent genomic alteration exclusive to the urothelial or squamous morphologies is identified. Rather, lineage plasticity in bladder cancers with squamous differentiation is associated with loss of expression of FOXA1, GATA3, and PPARG, transcription factors critical for maintenance of urothelial cell identity. Of clinical significance, lineage plasticity and PD-L1 expression is coordinately dysregulated via FOXA1, with patients exhibiting morphologic heterogeneity pre-treatment significantly less likely to respond to immune checkpoint inhibitors.

Impact of an inpatient advanced practice provider on hospital length of stay after major urologic oncology procedures.

INTRODUCTION: Although timely hospital discharge is a complex and multifactorial process, this metric is consistently a focus for hospitals and health care systems. It also has been a long practice that the American Urological Association (AUA) supports the use of advanced practice providers (APPs) as an integral member of the urological care team. MATERIALS AND METHODS: Here, we performed a preliminary evaluation of the effectiveness of an inpatient APP in reducing hospital length of stay (LOS) following major urologic oncology procedures. Surgical outcomes, surgeon data, and LOS for open and minimally invasive urologic oncology procedures, including radical prostatectomy, partial or radical nephrectomy, and radical cystectomy, were compiled over a 4-year period (pre-APP: 2014-2016 and post-APP: 2018-2020). Univariate descriptive statistics analyzed the association of an inpatient APP in with reducing hospital LOS over time. RESULTS: Average LOS decreased in all surgical procedures and for all surgeons in the post-APP setting, irrespective of surgical approach (P< 0.05). CONCLUSIONS: An inpatient APP was associated with a decrease of hospital LOS for urologic oncology patients over time. Such observations underscore the likely economic benefit to the health care system and potential improved coordination of care and satisfaction for patients undergoing major urologic oncology procedures.

Patient Perceptions Regarding Routine Oncologic Follow-Up for Urologic Malignancies.

INTRODUCTION: In colorectal, cervical, and breast cancers, oncologic follow-up can exacerbate or alleviate patient stress about disease recurrence. Such patient experiences are less well defined for urologic malignancies. We developed a cross-sectional prospective survey study to assess kidney (Kid), prostate (Pros), and bladder (Bld) cancer patient perceptions of oncologic follow-up following surgical treatment. PATIENTS AND METHODS: Patients with pTanyNanyM0 Kid, Pros, and Bld cancer presenting at least 60 days following primary surgical treatment of their cancer were eligible. Receipt of adjuvant therapy or disease recurrence were exclusion criteria. Questionnaires assessing attitudes towards follow-up and stress-reducing strategies were administered prior to revealing testing results. Analysis was performed according to cancer type and level of recurrence risk, with pathologic stage used a proxy for recurrence risk. RESULTS: Three hundred thirty-seven patients were prospectively surveyed from 2018 to 2020: 127 (38%) Kid, 134 (40%) Pros, and 76 (23%) Bld. Patients showed satisfaction with provided strategies to combat recurrence anxiety (Kid 86%, Pros 81%, Bld 85%). However, approximately 16% of patients reported wanting, but not receiving, strategies for fear reduction. Most patients reported diagnostic tests were "Not at All" burdensome (Kid 86%, Pros 94%, Bld 82%) and disagree that fewer tests would alleviate anxiety (Kid 89%, Pros 91%, Bld 84%). The majority reported an increased sense of worry if there were no cancer follow-ups (Kid 84%, Pros 80%, Kid 81%), and preferred their specialist to their family physician to direct such care (Kid 89%, Pros 91%, Bld 95%). When stratified by recurrence risk, no significant differences existed across cancers in patients' attitudes toward follow-up. However, Pros cancer patients showed a difference in fear of recurrence ("Not at All" worried about recurrence ≤T2 38%, ≥T3, 19%; P= .04). CONCLUSION: Urology patients appear satisfied with their oncologic follow-up. Sixteen percent of patients sought additional strategies to combat fear, indicating opportunity for improvement.

Diagnostic Imaging in Low-Risk Prostate Cancer: More Harm Than Good?

INTRODUCTION: Despite guidelines recommending that staging imaging is not needed in very low-risk (VLR) and low-risk (LR) prostate cancer (PCa), there is concern for overutilization in these risk groups. We investigate utilization of staging imaging and implications of findings in newly diagnosed VLR and LR PCa patients. METHODS: A total of 493 patients diagnosed with PCa between 2011 and 2017 were stratified according to American Urological Association and National Comprehensive Cancer Network® VLR and LR groups. Computerized tomography (CT), magnetic resonance imaging and bone scan performed at diagnosis was captured and guidelines compliance was evaluated. The significance of radiologist interpreted imaging findings, by imaging type, were classified as normal, nonurological, nonsignificant urological and PCa significant. RESULTS: Greater than 75% of patients in the VLR and LR groups underwent imaging at time of diagnosis. Bone scan was performed in 30% of patients, none of which noted PCa-significant findings, and the majority were normal. CT was utilized in 38% of patients, with only 3 showing PCa-significant findings. Ten CTs showed nonurological/nonsignificant urological findings causing further evaluation. Magnetic resonance imaging was the most utilized scan in low-risk groups, occurring in 70% of patients. Although the majority were normal, 25 scans showed nonsignificant urological findings while only 7 showed PCa-significant findings. CONCLUSIONS: Among VLR and LR PCa patients, there is high overutilization of imaging with most studies yielding minimal PCa-significant findings and further evaluation for incidental observations. This exploratory analysis gives awareness that staging imaging in VLR and LR PCa patients may do more harm than good.

Demographic and Practice Trends of Rural Urologists in the U.S.: Implications for Workforce Policy.

INTRODUCTION: There is a shortage in the number of urologists needed to satisfy the needs of an aging U.S. POPULATION: The urologist shortage may have a pronounced impact on aging rural communities. Our objective was to describe the demographic trends and scope of practice of rural urologists using data from the American Urological Association Census. METHODS: We conducted a retrospective analysis of American Urological Association Census survey data over a 5-year period (2016-2020), including all U.S.-based practicing urologists. Metropolitan (urban) and nonmetropolitan (rural) practice classifications were based on rural-urban commuting area codes for the primary practice location zip code. We conducted descriptive statistics of demographics, practice characteristics and specific rural-focused survey items. RESULTS: In 2020, rural urologists were older (60.9 years, 95% CI 58.5-63.3 vs 54.6 years, 95% CI 54.0-55.1) and were in practice longer (25.4 years, 95% CI 23.2-27.5 vs 21.2 years, 95% CI 20.8-21.5) than urban counterparts. Since 2016, mean age and years in practice increased for rural urologists but remained stable for urban urologists, suggesting an influx of younger urologists to urban areas. Compared with urban urologists, rural urologists had significantly less fellowship training and more frequently worked in solo practice, multispecialty groups and private hospitals. CONCLUSIONS: The urological workforce shortage will particularly impact rural communities and their access to urological care. We hope our findings will inform and empower policymakers to develop targeted interventions to expand the rural urologist workforce.

Integration of Robotics in Urology Residency Programs: an Unchecked Technological Revolution.

PURPOSE OF REVIEW: To review the integration of robotics in urology residency programs and evaluate how it has impacted a graduates' level of surgical competence. RECENT FINDINGS: Surgical technique training has shown a dramatic shift towards robotics with the most profound occurring in oncology. However, integration of robotics is not uniform across programs nor even among residents themselves. Robotics require graduates to garner a broader skill set within the same prescribed training time. Unfortunately, in this modern era, graduates are feeling more ill-equipped to start independent practice and show an increased need to pursue fellowship training to achieve technical proficiency. The dissemination of robotics in residency programs has gone unchecked. Modulating existing training structures through (1) development of procedure- and surgical technique-specific target metrics for graduation and (2) integration of a formalized robotic curriculum may improve the overall quality and outcome of the educational experience.

Is pelvic MRI imaging sufficient cross-sectional imaging for staging intermediate and high-risk prostate cancer?

OBJECTIVES: The American Urological Association's (AUA) and National Comprehensive Cancer Network's (NCCN) provide highly recognized guidelines for staging prostate cancer (CaP). However, both are vague as to specific type of cross-sectional imaging (CT vs. MRI) and extent (abdominal vs. pelvis), thereby raising concern for overlapping imaging. We investigated if current AUA and NCCN CaP staging guidelines can become more specific yet maintain sufficient staging. METHODS: We identified 493 patients diagnosed with CaP between 2011 and 2017 and focused analysis on those with AUA and NCCN Intermediate risk (IR) and High risk (HR) groups. Type of staging imaging was recorded and frequency of overlapping (CT + MRI) and abdominal imaging determined. Significance of radiologist findings, for both overlapping and abdominal imaging, were classified as nonurologic, nonsignificant urologic, and CaP significant. RESULTS: Among IR and HR AUA and NCCN risk groups, 82 (35.7%) and 95 (37.3%) patients, respectively, experienced overlapping imaging, of which only 7 patients in AUA and 9 patients in NCCN risk groups had an abnormal CT with normal MRI. However, only 3 of these CTs had CaP significant findings, of which 2 identified bone metastases, which were subsequently detected on bone scan. In regard to the extent of imaging, a total of 157 (68.2%) AUA and 178 (69.8%) NCCN IR and HR patients received abdominal scans, of which only 46 (20.0%) and 49 (19.2%) were abnormal among AUA and NCCN risk groups, respectively. Among these abnormal abdominal scans, only 10 showed CaP significant findings, of which half were suspected bone metastases, and confirmed on recommended bone scan. CONCLUSIONS: Due to nonspecific staging guidelines in IR and HR CaP regarding type and extent of cross-sectional imaging, patients are frequently receiving imaging of overlapping locations. Based on low occurrences of unique CaP significant findings on CT and abdominal imaging, our exploratory analysis suggests that narrowing cross-sectional imaging recommendations to pelvic MRI may reduce imaging overlap while maintaining sufficient staging.

Can preoperative imaging characteristics predict pT3 bladder cancer following cystectomy?

PURPOSE: Imaging characteristics in bladder cancer (BC), such as hydronephrosis, are predictive of ≥ pT3 disease at time of radical cystectomy (RC). The predictive capacity of other findings, such as perivesical stranding (PS), remains unclear. We investigated whether PS was associated with ≥ pT3 BC in patients who did not receive neoadjuvant chemotherapy (NAC). METHODS: We identified 433 patients with BC who underwent RC from 2003 to 2018 of which 128 did not receive NAC. Evidence of PS on pre-TURBT imaging was determined by radiologist review and a stranding grading system was created. Factors associated with PS and hydronephrosis were identified. Multivariable logistic regressions evaluated PS and hydronephrosis as predictors for ≥ pT3 BC. RESULTS: Of the 128 patients who did not receive NAC, 48 (38%) had pT3 and 12 (9%) had pT4 BC. 125 (98%) patients had CT and three (2%) had MRI. PS and hydronephrosis on imaging were identified in 19 (15%) and 45 (35%) patients. PS was not associated with imaging type (p = 0.38), BMI (p = 0.18), or pathologic T stage (p = 0.24). Hydronephrosis was more frequently associated with higher pathologic T stage (p = 0.034). Multivariable analysis demonstrated that PS was not predictive of ≥ pT3 BC (p = 0.457), while hydronephrosis was positively associated (p = 0.003). Stratification by grade of stranding did not improve the predictive capacity of PS (p = 0.667). CONCLUSION: While hydronephrosis is an indicator of higher stage BC, PS failed to be a reliable predictor of ≥ pT3 stage. These observations should give pause in using PS on imaging to guide decisions until further investigations can be explored.

Topical antiseptic at time of transrectal ultrasound prostate biopsy is associated with fewer severe clinical infections and improves antibiotic stewardship.

BACKGROUND: The 2017 AUA White Paper on prevention of prostate needle biopsy (PNB) complications highlights an algorithm for reducing procedural related infections. The incorporation of topical rectal antiseptic (TRS) at time of transrectal PNB is listed as one such modality. We present data on over 1000 transrectal PNB procedures to determine the impact of TRS on 1) infectious complications and 2) use of augmented procedural antibiotics. METHODS: The records of 1181 transrectal PNB procedures performed over a 10-year period were reviewed. In 2013, TRS with either 10% povidone iodine or 4% chlorhexidine was more regularly incorporated into PNB procedures. Clinical and procedural factors were analyzed for association with post-procedure infections. Infectious complications outcomes were compared in patients receiving TRS (n = 566) versus those who had not (n = 615). RESULTS: A total of 990 men underwent 1181 transrectal PNB procedures. Median age of the cohort was 63 years with a median PSA of 7 ng/dL. Of them, 86% of the men were Caucasian, 28% had undergone at least one prior biopsy, 14% were diabetic, and 6% had prior hospitalization within 6 months of the procedure. Five hundred sixty-six patients (48%) received TRS at time of biopsy. Perioperative IV adjunctive antibiotics were used less frequently in patients receiving TRS (13.4% vs. 28.6%, p < 0.001). Furthermore, patients receiving TRS experienced lower rates of clinical infections (1.2% vs. 2.4%, p = 0.14), as well as lower likelihood of severe infections evidenced by decreased rates of hospital admission (0.5% vs. 2.3%, p = 0.013). Rectal vault bacteriology obtained before and after TRS was available in 180 men noting a 98.1% decrease in colony counts after local treatment. CONCLUSIONS: TRS at time of transrectal PNB was associated with decreased use of IV procedural antibiotics as well as decreased severity of infections post-biopsy. This simple technique enhances antibiotic stewardship while simultaneously improving quality outcomes of the procedure.

Patterns of surveillance intensity in kidney cancer.

PURPOSE: Surveillance guidelines for kidney cancer following surgery are heterogeneous, making it unclear what factors influence surveillance intensity in practice. Thus, we assessed the patterns of surveillance intensity in kidney cancer after primary surgery among patients ≥ 66 years. METHODS: Non-metastatic kidney cancer patients after primary surgery (n = 2433) from 2007 to 2011 were identified in SEER-Medicare. Surveillance intensity was measured as the number of unique inpatient and outpatient claims made for kidney cancer starting 60 days after primary surgery. Multivariable linear regressions assessed relationships between patient factors and surveillance intensity (log-transformed). Parameters were reported using risk ratios (RRs). RESULTS: Patients diagnosed in contemporary years experienced 10% more surveillance visits/12 months (RR 1.10 for every 1-year increase, 95% CI 1.07-1.13, p < 0.001). Compared to pT1 stage, patients with pT2-4 disease experienced 108% more surveillance visits/12 months (RR 2.08, 95% CI 1.90-2.27, p < 0.001). Both older age and living in a metro/urban area, as compared to a big metropolitan location, were associated with significantly fewer follow-up visits (10-year increase in age: RR 0.89, 95% CI 0.83-0.95, p < 0.001; metro/urban: RR 0.86, 95% CI 0.79-0.93, p < 0.001). Surgery type (radical, partial or ablation), gender, race and Charlson comorbidity score were not significantly associated with surveillance intensity. CONCLUSIONS: Similar to guidelines, surveillance intensity in practice was associated with stage, but not with surgery type. Other factors such as diagnosis year, care location and patient age were associated with the amount of surveillance administered by the clinician. These additional influences are augmenting the heterogeneous delivery of kidney cancer surveillance care.

Histologic Heterogeneity of Extirpated Renal Cell Carcinoma Specimens: Implications for Renal Mass Biopsy.

Pathologic characteristics of extirpated renal cell carcinoma (RCC) specimens <7 cm were reviewed to get better information on technical nuances of renal mass biopsy (RMB). Specimens were stratified according to tumor stage, nuclear grade, size, histology, presence of lymphovascular invasion (LVI), necrosis, and sarcomatoid features. When considering pT1 (0-7 cm) tumors, pT1b (4-7 cm) RCC masses were more likely to have necrosis (43% vs 16%, P < 0.001), LVI (6% vs 2%, P = 0.024), high-grade nuclear elements (29% vs 17%, P < 0.001), and sarcomatoid features (2% vs 0%, P = 0.006) compared with pT1a (0-4 cm) tumors. Additionally, pT3a tumors were more highly associated with necrosis (P = 0.005), LVI, sarcomatoid features, and high-grade disease (P for all < 0.001) when compared to pT1 masses. For masses <4 cm, pT3a cancers were more likely to demonstrate necrosis (38% vs 16%, P < 0.001), LVI (22% vs 2%, P < 0.001), high-grade nuclear elements (45% vs 17%, P < 0.001), and sarcomatoid features (12% vs 0%, P < 0.001) compared to pT1a tumors. Similarly, for masses 4-7 cm, pathologic T3a tumors were significantly more likely to have sarcomatoid features (12% vs 2%, P = 0.006) and LVI (22% vs 6%, P = 0.003) compared to pT1b tumors. In summary, pT3a tumors and those RCC masses >4 cm exhibit considerable histologic heterogeneity and may harbor elements that are not easily appreciated with limited renal sampling. Therefore, if RMB is considered for renal masses greater than 4 cm or those that abut sinus fat, a multi-quadrant biopsy approach is necessary to ensure adequate sampling and characterization of the mass.

Patterns of Initial Metastatic Recurrence After Surgery for High-Risk Nonmetastatic Renal Cell Carcinoma.

OBJECTIVE: To evaluate postoperative recurrence patterns for high-risk nonmetastatic renal cell carcinoma (RCC) and to identify prognostic factors associated with site-specific metastatic recurrence using a multi-institutional contemporary cohort. METHODS: Data for nonmetastatic ≥pT3a RCC patients treated with surgery at 4 independent centers was analyzed. Initial recurrence locations were identified, and imaging templates were defined by anatomic landmarks using radiologic definitions. Prognostic factors for site specific recurrence were evaluated with univariate and multivariable analyses. RESULTS: A total of 1057 patients were treated surgically for ≥pT3a RCC. Initial recurrence location was in a single site for 160 (59.3%) patients and at multiple locations in 110 (41.7%) patients. The most common sites of metastatic recurrence were lung (144/270, 53.3%), liver (54/270, 20.0%), and bone (48/270, 17.8%). Recurrence was identified in 52 of 270 (19.3%) patients outside the chest/abdomen template, most commonly in the pelvis (25/270, 9.3%). Bone and brain metastases were the most common organs for metastases outside chest/abdomen. Patients with tumor diameter >10 cm and grade 4 were more likely to recur in the bone (HR 3.61, P <.001) and brain (HR 16.5, P <.001). CONCLUSION: Metastatic progression outside chest/abdomen imaging templates was present in 1 of 5 high risk patients at initial metastatic RCC diagnosis, most commonly in the pelvis. Patients with large (>10 cm) tumors and grade 4 histology are at highest risk for bone and brain metastases.

Hemostatic agent use during partial nephrectomy: trends, outcomes, and associated costs.

PURPOSE: To evaluate the ability of hemostatic agents (HA) to limit bleeding complications following partial nephrectomy (PN) and determine HA usage and costs as well as factors associated with post-operative bleeding complications. METHODS: The records of 429 PN performed for kidney cancers were reviewed for clinical, pathologic, and perioperative variables. Surgical approach, HA use, and HA expenditure were determined. Bleeding complications and management to 90 days after PN were annotated. Wilcoxon rank-sum and two-sample t tests identified factors associated with HA use. Univariate and limited multivariate logistic regression determined variables associated with bleeding complications. RESULTS: Use of HA was associated with longer OR duration, longer ischemia time, higher EBL, and method of PN (OPN and LPN > RPN) (all p values < 0.001). On bivariate analysis, while multiple factors were associated with bleeding complications, neither HA use (p = 0.924) nor the number of HA used (two agents vs one p = 0.712; three agents vs. one p = 0.606) were. A multivariable model noted that increasing RENAL score (p = 0.013) and surgical approach (OPN vs. RPN [p = 0.009] and LPN vs. RPN (p = 0.002]) were independently associated with bleeding complications, while HA use was not (p = 0.294). During the 16 years of analysis, a total of $77,687 USD was spent on HA. Average annual HA expenditure was $4855 USD with the peak being in 2010 where expense was $14,086. Mean annual costs for HA use were greater for OPN vs RAPN starting in 2013 (p = 0.02) CONCLUSIONS: The use of HA during PN was not associated with lower rates of bleeding complications. Therefore, judicious use in a case-specific manner is requisite to limit potentially unnecessary operative cost.

Evaluation of PD-L1 and other immune markers in bladder urothelial carcinoma stratified by histologic variants and molecular subtypes.

Although advanced bladder cancer overall has a poor prognosis, a subset of patients demonstrate durable response to immune checkpoint inhibitors. Evidence shows that the response to checkpoint inhibitors may be associated with type and degree of immune infiltration in the tumor microenvironment. Here, we evaluated immune markers stratified by molecular subtypes and histologic variants. The study utilized a series of urothelial carcinomas (UCs) by tissue microarray, on which histologic variants and molecular subtypes had previously been established. PD1, CD3, CD8 and CD68 expression was evaluated by immunohistochemistry in tumor infiltrating immune cells, while PD-L1 expression in the tumor microenvironment was assessed. Each marker was scored semi-quantitatively (score 0-3). Tumors were clustered by marker scores using agglomerative methods, and associations among markers, histologies, and molecular subtypes were analyzed. PD-L1 expression in the tumor microenvironment significantly correlated with presence of CD3, CD8 and chronic inflammation. Urothelial carcinoma may be classified as either immune high or low based on marker expression. The immune high group is enriched in higher CD3, PD-L1, and genomically-unstable molecular subtype, suggesting it may respond to checkpoint inhibitors. We also identified a degree of intratumoral heterogeneity in immune markers in bladder cancer.