Impact of Dobbs v. Jackson Women's Health Organization on Professional Decision-Making Among Urology Applicants.

MATERIALS AND METHODS: An Institutional Review Board-exempt REDCap survey was distributed through the Society of Academic Urologists to all 508 applicants registered for the 2023 Urology Match following the rank list submission deadline on January 10, 2023. The survey closed on February 1, 2023. Responses were anonymized, aggregated, and characterized using descriptive statistics. Thematic mapping of open text comments was performed by 2 reviewers. RESULTS: The response rate was 42% (215/508). Eighty-eight percent of respondents disapproved of the Dobbs ruling. Twenty percent of respondents (15% male/24% female) eliminated programs in states where abortion is illegal. Fifty-nine percent (51% male/70% female) would be concerned for their or their partner's health if they matched in a state where abortion was illegal, and 66% (55% male/82% female) would want their program to assist them or their partner if they required abortion care during residency. Due to the competitive nature of Urology, 68% of applicants reported feeling at least somewhat obligated to apply in states where abortion legislation conflicts with their beliefs. Of the 65 comments provided by respondents, 4 common themes emerged: (1) avoidance of states with restrictive abortion laws; (2) inability to limit applications because of the competitiveness of urology; (3) impacts on personal health care; and (4) desire for advocacy from professional urology organizations. CONCLUSION: The Dobbs ruling will impact the urology workforce by affecting urology applicants' decision-making regarding residency selection and ranking. Although the competitiveness of the Urology Match pressures applicants to apply broadly, many are taking reproductive health care access into consideration.

A provider survey assessing fetal impact of CFTR modulator use in males with CF during assisted and unassisted reproduction and partner pregnancy.

BACKGROUND: Most males with cystic fibrosis (mwCF) are infertile but with CF transmembrane conductance regulator (CFTR) modulator-conferred benefits, more are utilizing assisted reproductive technologies (ART). Administration of normal human doses of modulators in animal reproductive models caused no genotoxicity; no human data exists. Potential health decline following modulator discontinuation makes the decision to withhold therapy during reproduction challenging. METHODS: From August-October 2021, international CF clinicians completed an anonymous questionnaire regarding mwCF who used modulators during reproduction. RESULTS: We received 42 surveys for mwCF with partner pregnancies. Forty of 42 mwCF utilized ART; 35 continued modulators during sperm retrieval and 40/42 during partner pregnancy. One of four males who discontinued modulators experienced clinical deterioration. First trimester miscarriages occurred in 11.9 % of partner pregnancies. No congenital anomalies were reported. CONCLUSIONS: Use of CFTR modulators during reproduction and partner pregnancy in mwCF did not result in a higher-than-expected miscarriage rate nor congenital anomalies.

Prevalence of Low Testosterone in Men With Cystic Fibrosis and Congenital Bilateral Absence of the Vas Deferens: A Cross-sectional Study Using a Large, Multi-institutional Database.

OBJECTIVE: To investigate the prevalence and treatment rates of low testosterone (T) in men with cystic fibrosis (CF). CF is a genetic disease with highly variable presentation that results from a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Phenotypic manifestations of CF include alterations in function of the lungs, liver, pancreas, and reproductive system. Despite the well-described association between CF and infertility secondary to congenital bilateral absence of the vas deferens (CBAVD), men with CF report further sexual and reproductive health concerns, many of which are often associated with low testosterone. METHODS: We queried the TrinetX database for men over 18years old with CF or CBAVD to assess what percentage of men had a T level measured, and if hypogonadal (below 300 ng/dL), what percentage received T therapy (TT). We hypothesized that low T would be under-evaluated in the CF population. RESULTS: Serum T levels were measured in 10.1% of men with CF and 8.9% of men with CBAVD. Within each group, 464 men with CF (32.7%) and 132 with CBAVD (43.0%) demonstrated low T. The majority of men with T < 300 ng/dL went on to appropriately receive TT: 59.3% of men with CF and 78% with CBAVD. CONCLUSION: Our data suggests that hypogonadism is highly prevalent in men with CF and CBAVD. Investigation and appropriate treatment of testosterone deficiency may significantly improve quality of life.

Characteristics of Medical Schools in the United States Associated With Successful Match into Urology Residency Programs: Analysis of the 2016-2021 Urology Resident Cohort.

OBJECTIVE: To determine the characteristics of US medical schools associated with successful urology match applicants. MATERIALS AND METHODS: Using publicly available data, demographics and bibliometrics were collected for 1814 current urology residents who attend a US-based Accreditation Council for Graduate Medical Education (ACGME) Accredited program, reflecting matched applicants over a 6-year period from 2016-2021. A generated list of US feeder medical schools for urology was analyzed for correlative and predictive factors. Statistical analyses to characterize these factors included Pearson's Correlation Coefficient (PCC) and univariable and multivariable linear regression, respectively, as needed. RESULTS: There were 516 (28.45%) female residents and 58 (3.20%) international medical graduates. The mean number of published papers and abstracts ± SD pre-residency was 5.54 ± 7.20 with a mean h-index of 1.97 ± 2.24. The Cleveland Clinic Lerner College of Medicine had the highest percentage of successful matches into urology (n = 7, 3.65%), while the State University of New York Downstate Medical Center College of Medicine produced the highest absolute number (n = 41, 3.30%). The presence of a home urology program and pre-residency h-index had the strongest correlation with producing urology residents (PCC = 0.5769 and 0.3709, respectively, P<.0001). CONCLUSION: Understanding the characteristics of a successful urology match applicant and the medical schools that produce them will be vital as USMLE Step 1 exam becomes pass/fail. Further research into these schools' curricula is required to better understand the effect of early exposure to urology on matching into urology.

Medical therapies causing iatrogenic male infertility.

Primum non nocere. As physicians, our goal is to treat illnesses and alleviate suffering; however, in doing so, we can generate new problems in a game of medical whack-a-mole. For some patients, certain consequences or side effects are tolerable, while others may believe they have no alternative. For a male patient with infertility, a thorough history is imperative to elucidate whether the patient has been or is currently being exposed to medications that will harm libido, spermatogenesis, ejaculation, or the hypothalamic-pituitary-testosterone axis. This article will review the most common medications causing iatrogenic male infertility as well as options to minimize or even reverse their impact.

Pyospermia: background and controversies.

Pyospermia (or leukocytospermia) is suspected based on the presence of >1 × 106 round cells/mL of ejaculate and diagnosed using peroxidase stain revealing >1 × 106 white blood cells/mL. The presence of white blood cells is a concern for overt infections or excessive inflammation, both of which have been postulated to negatively impact bulk semen parameters and fertilization capability. The threshold for pyospermia has been debated upon in the literature, as has the optimal treatment method. In the absence of clinical infectious symptoms, it appears that antibiotics, anti-inflammatory agents, and/or frequent ejaculation may improve bulk semen parameters in men with pyospermia. Further research is needed to adequately assess the effect of these methods on pregnancy and live birth outcomes, especially among couples attempting natural conception compared to those attempting intrauterine insemination or in vitro fertilization.

Vasectomy: a guidelines-based approach to male surgical contraception.

Except for condom use, vasectomy is the only approved form of male contraception. The American Urological Association published guidelines on vasectomy in 2012, which clearly outlined patient counseling, vasectomy techniques to maximize successful occlusion, and postvasectomy care. However, there are certainly areas of further improvement to be addressed. Vasectomy is severely underutilized compared with tubal ligation for sterilization, likely due to lack of patient awareness. Although the majority of vasectomies are performed in the office with local anesthesia, some patients are still routinely prescribed narcotics for postprocedural pain, despite the well-described opioid pandemic. Finally, although patients are counseled on the necessity of a postvasectomy semen analysis to confirm sterility prior to the discontinuation of alternative contraceptives, more than 50% of men do not complete this test. Therefore, alternative strategies must be pursued to improve patient compliance.

Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce.

The number of practicing female urologists has increased from < 2% in 1980 to 9.2% in 2018. Despite this increase, urology trails far behind medical fields overall and surgical subspecialties, in achieving gender parity. Barriers, such as pervasive biases and institutional policies, exist at the medical student, resident, and practicing urologist levels. Once recognized as detrimental, action can be taken to combat these forces to allow for advancement of women in the field of urology. This will result in a richer workforce better able to serve its patient population and advance the field.

Gender Disparities in Industry Payments to Urologists.

OBJECTIVE: To analyze and compare industry payments to urologists in the Open Payments Database by gender. We hypothesized that industry payments might be greater to male vs women urologists. METHODS: The Open Payments Database was analyzed from 2013-2017 and gender determined for all urologists receiving payments in the following categories: (1) research (made in connection to a research program or protocol), (2) ownership (ownership or investment interests held by the physician or immediate family member), and (3) general. Payment form and amount was collected and average payment per category, by gender, was calculated. RESULTS: A total of 12,161 urologists received industry payments from 2013-2017, of which 90% were male. Over the study period, there was a greater proportional increase in female urologists participating in industry payments: 46.8% for female urologists, vs 12.3% for male urologists (P <.01). Male urologists earned twice as much as women in all categories except for Ownership. Average payment (USD) per urologist was $3,106 vs $1338, $34, 494 vs $16,020, and $39,062 vs $252,710 for General, Research, and Ownership, respectively. Although the number of female urologists receiving industry payment increased during the study period, the average payment amount increased by 14.6% for women, compared to 107.8% for men (P <.01). CONCLUSION: Analysis of the Open Payments Database shows that on average women urologists earned half as much as men in their industry reported payments.

Where will telemedicine go from here?

The COVID-19 pandemic accelerated the adoption of telemedicine internationally. The reproductive clinics that thrived in this tumultuous time had access to fully electronic medical records with user-friendly telehealth platforms and remote support staff for physicians. However, complete transition from in-person visits to telehealth uncovered many opportunities for innovation. At-home semen testing is not yet widely recognized, and patients still require an in-person visit for ultrasounds, procedures, and physical examinations. Although emergency policies and waivers have made it easier for providers to legally practice across state borders and receive payments from insurance companies, they vary from state to state and have not been cemented into law. Finally, clinical training for medical students, residents, and fellows has been affected by decreased clinical and surgical volume. However, trainees have also proven to be the most adaptable, quickly shifting to remote learning practices through social media, online surgical atlases, and wide distribution of "virtual visiting professor" lectures. As countries have eased physical distancing guidelines, patients ultimately benefit from having the option of a telehealth appointment. Although there is still much work to be done to improve telehealth, the COVID-19 pandemic has at least proven that it is a safe method of patient care and teaching.

Personalized Medicine for the Infertile Male.

Personalized medicine uses a patient's genotype, environment, and lifestyle choices to create a tailored diagnosis and therapy plan, with the goal of minimizing side effects, avoiding lost time with ineffective treatments, and guiding preventative strategies. Although most precision medicine strategies are still within the laboratory phase of development, this article reviews the promising technologies with the greatest potential to improve the diagnosis and treatment options for male infertility, including sperm cell transplantation, genomic editing, and new biomarker assays, based on the latest proteomic and epigenomic studies.

Indications for stent omission after ureteroscopic lithotripsy defined: A single-institution experience with cost analysis.

Objectives: To report on our experience with the use of an evidence-based algorithm defining specific indications for stent omission (SO) after ureteroscopic lithotripsy (URSL), as stent placement has been associated with increased cost and morbidity and indications for SO in the setting of uncomplicated ureteroscopy have been proposed but remain vague. Patients and methods: Indications for SO were defined as per the attached figure, data from URSL procedures performed from January 2016 to September 2017 were collected. For procedures eligible for SO, preoperative and intraoperative factors were recorded including: stone burden, presence of preoperative stent, procedure time, access sheath use, and whether SO was performed. Morbidity data were reviewed including: postoperative events, patient telephone calls for bothersome symptoms, unplanned return visits, and admissions within 30 days. Results: In all, 250 URSL procedures were performed during the study period, and 106 (42.4%) were eligible for SO. SO was performed in 60 (24.0%) cases reflecting a 56.7% compliance with the algorithm. There were no readmissions or re-operations within 30 days for the SO group. Lower postoperative event rates were noted in the SO group (16.7% vs 34.8%, P = 0.03), unplanned return visits (8.3% vs 17.4%, P = 0.16) and 30-day readmission rates (0.0% vs 6.5%, P = 0.08) were also lower in the SO group, although they did not reach statistical significance. Analysis also demonstrated a protective effect of SO on unplanned return visits (odds ratio 0.43, 95% confidence interval 0.13-1.42, P = 0.17), although this was not statistically significant. No statistically significant associations were noted between postoperative events and stone burden, procedure time, or presence of preoperative stent. Conclusions: We provide an algorithm defining indications for SO. SO is safe in a significant portion of URSL procedures, and SO appears to decrease postoperative events when performed judiciously. Abbreviations: IQR: interquartile range; LUTS: lower urinary tract symptoms; OR, odds ratio; SO: stent omission; URSL: ureteroscopic lithotripsy; YAG: yttrium-aluminium-garnet.

Intra-abdominal seminoma found incidentally during trauma workup in a man with bilateral cryptorchidism.

Bilateral cryptorchidism is a rare occurrence and seminoma is the most common germ cell tumor found in undescended testes when they occur. We present the case of a patient with bilateral cryptorchidism who presented to our trauma center after a motor vehicle collision and was found incidentally to have a 17-cm intra-abdominal mass. The mass was subsequently biopsied and proven to be seminoma. The patient completed three cycles of bleomycin/etoposide/cisplatin chemotherapy and successfully underwent a postchemo retroperitoneal lymph node dissection with no viable residual tumor or positive lymph nodes found in the surgical specimen. He also had an orchiopexy of the contralateral testicle. The patient recovered fully and has been found to be recurrence-free four months postoperatively. We highlight the importance of cisplatin-based chemotherapy and extensive tumor resection as the mainstay of initial cancer control.

Bullying has a potential role in pediatric lower urinary tract symptoms.

PURPOSE: National statistics estimate that a quarter of American school children are regularly bullied, making this issue the main parental concern and the leading form of school violence. To our knowledge no study in the literature has examined the association of bullying with lower urinary tract symptoms. We evaluated the relationship between being bullied and lower urinary tract symptoms in the pediatric population. MATERIALS AND METHODS: We accrued 100 patients from a pediatric urology practice in prospective case-control fashion. The degree of lower urinary tract symptoms was determined by the voiding severity score obtained by a single pediatric urologist. Using the Peer Relations Questionnaire and a thermometer scale we surveyed participants for evidence of victimization from bullying and school related anxiety. We then correlated voiding symptom severity with the degree of bullying. RESULTS: After applying our study exclusion criteria we examined and analyzed data on 38 control children without lower urinary tract symptoms and on 38 children with lower urinary tract symptoms. Mean age was similar in the 2 groups. There were more females in the group with lower urinary tract symptoms (22 vs 13). Mean case voiding severity score was 3.82 (range 2 to 5). As measured by Bullied Index Score the degree of being bullied was significantly higher in the case group (4.76 vs 1.95, p <0.001), as was the anxiety level estimated by the thermometer score (3.68 vs 0.97, p <0.001). We also found that physical forms of bullying accounted for worse voiding severity scores (4.56 vs 3.67, p <0.01). CONCLUSIONS: To our knowledge our study is the first to show that 1) bullying is significantly associated with pediatric lower urinary tract symptoms and 2) physical forms of bullying accompany worsened symptoms.