Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology.

PURPOSE: The proportion of women in urology has increased from less than 0.5% in 1981 to 10% today. Furthermore, 33% of students matching in urology are now female. In this analysis we characterize the female workforce in urology compared to that of men with regard to income, workload and job satisfaction. MATERIALS AND METHODS: We collaborated with the American Urological Association to survey its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. A total of 6,511 survey invitations were sent via e-mail. The survey consisted of 26 questions and took approximately 13 minutes to complete. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction and compensation. RESULTS: A total of 848 responses (660 or 90% male, 73 or 10% female) were collected for a total response rate of 13%. On bivariable analysis female urologists were younger (p <0.0001), more likely to be fellowship trained (p=0.002), worked in academics (p=0.008), were less likely to be self-employed and worked fewer hours (p=0.03) compared to male urologists. On multivariable analysis female gender was a significant predictor of lower compensation (p=0.001) when controlling for work hours, call frequency, age, practice setting and type, fellowship training and advance practice provider employment. Adjusted salaries among female urologists were $76,321 less than those of men. Gender was not a predictor of job satisfaction. CONCLUSIONS: Female urologists are significantly less compensated compared to male urologists after adjusting for several factors likely contributing to compensation. There is no difference in job satisfaction between male and female urologists.

Treatment algorithm for the comprehensive management of severe lichen sclerosus in boys based on the pathophysiology of the disease.

INTRODUCTION: It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS. STUDY DESIGN: The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management. RESULTS: All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease. DISCUSSION: Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions. CONCLUSION: This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.

Mitigating Contaminant-Driven Risks for the Safe Expansion of the Agricultural-Sanitation Circular Economy in an Urbanizing World.

The widespread adoption of an agricultural circular economy requires the recovery of resources such as water, organic matter, and nutrients from livestock manure and sanitation. While this approach offers many benefits, we argue this is not without potential risks to human and environmental health that largely stem from the presence of contaminants in the recycled resources (e.g., pharmaceuticals, pathogens). We discuss context specific challenges and solutions across the three themes: (1) contaminant monitoring; (2) collection transport and treatment; and (3) regulation and policy. We advocate for the redesign of sanitary and agricultural management practices to enable safe resource reuse in a proportionate and effective way. In populous urban regions with access to sanitation provision, processes can be optimized using emergent technologies to maximize removal of contaminant from excreta prior to reuse. Comparatively, in regions with limited existing capacity for conveyance of excreta to centralized treatment facilities, we suggest efforts should focus on creation of collection facilities (e.g., pit latrines) and decentralized treatment options such as composting systems. Overall, circular economy approaches to sanitation and resource management offer a potential solution to a pressing challenge; however, to ensure this is done in a safe manner, contaminant risks must be mitigated.

Urethral mobilization for distal and mid shaft hypospadias with chordee.

PURPOSE: Many options are available for repairing mid shaft to distal hypospadias. Reported complications include poor cosmesis, persistent chordee, meatal stenosis and fistula. We hypothesized that advancing the intact native urethra would facilitate chordee correction and minimize complications. MATERIALS AND METHODS: We retrospectively reviewed our records of all 248 hypospadias repairs done from July 2003 to May 2009 and identified patients younger than 18 years with distal or mid shaft hypospadias who underwent repair by urethral mobilization. The outcomes recorded were patient satisfaction, bladder scan volume, and the rate of fistula, meatal stenosis or other complications. RESULTS: Of the patients 83 met study inclusion criteria, including 5 (6%) treated with previous failed hypospadias operations. The hypospadias site was the distal, mid shaft and megameatal intact prepuce variant in 69 (83.1%), 11 (13.3%) and 3 patients (3.6%), respectively. Chordee was present in 80 patients (96.4%). The mean degree of chordee was 61.5 degrees, mean age at operation was 35.7 months and mean followup was 18 months (range 0.25 to 79). Of parental responses 94% were pleased or very pleased. Mean bladder volume on bladder scan was 9.7 ml (range 0 to 81). Fistula developed in 1 patient (1.2%). There were no meatal stenosis cases. CONCLUSIONS: Urethral mobilization results in excellent cosmesis and a low complication rate. This technique is especially well suited to patients with prior operations or deficient preputial skin. Using the native urethra with its blood supply is our preferred method of repairing distal and mid shaft hypospadias with chordee.

Biofeedback therapy for dysfunctional voiding in children.

The past decade has seen a dramatic shift in the management of lower urinary tract dysfunction, including dysfunctional voiding, in children. Once treated primarily with medication, dysfunctional voiding now is managed successfully in most cases with noninvasive evaluations and biofeedback-based pelvic floor muscle retraining. Introduced in 1979, biofeedback initially was expensive and labor intensive, requiring inpatient treatment. The use of animated computer games has expedited results, allowing excellent resolution of dysfunctional voiding and coexisting conditions such as vesicoureteral reflux and constipation with outpatient treatment. Morbidity from medications and surgical procedures has been reduced at centers using biofeedback. Future goals of biofeedback therapy should include further refinements in technique and increasing access to care.

Maximum Covering Subtrees for Phylogenetic Networks.

Tree-based phylogenetic networks, which may be roughly defined as leaf-labeled networks built by adding arcs only between the original tree edges, have elegant properties for modeling evolutionary histories. We answer an open question of Francis, Semple, and Steel about the complexity of determining how far a phylogenetic network is from being tree-based, including non-binary phylogenetic networks. We show that finding a phylogenetic tree covering the maximum number of nodes in a phylogenetic network can be computed in polynomial time via an encoding into a minimum-cost flow problem.

Impact of Urology Trainee Debt Levels on Future Practice Choices and Expectations.

INTRODUCTION: Excessive trainee debt continues to be a problem. Little is known about how debt influences future practice decisions. We sought to examine the correlation between educational debt and anticipated practice choices and career expectations to better understand the impact of debt on urology trainees to inform urology workforce policy. METHODS: Data were collected from urology trainees who completed the AUA Annual Census between 2016 and 2018. We examined level of debt among urology trainees against their anticipated practice choices compensation expectation and various debt relief variables. RESULTS: Among 705 U.S. urology trainees who completed the survey, 22% had no debt, 23% had <$150,000 debt, 27% had $150,000 to $250,000 of debt, and the remaining 27% had >$250,000. Debt level did not appear to significantly affect anticipated future practice setting or the decision to pursue fellowship. Concerning how loan forgiveness influenced practice opportunity, 31% of trainees reported no effect, 42% some effect and 27% great effect. Those trainees with higher level of debt appeared to be more likely to accept a practice opportunity if loan forgiveness was offered (p ≤0.001). Those trainees with higher level of debt were more likely to anticipate higher annual compensation as compared to those with less debt (p=0.001). CONCLUSIONS: Nearly 70% of those trainees with debt had $150,000 of debt or higher. Our study showed carrying educational debt is statistically associated with trainees' choice of anticipated practice for better compensation and tuition forgiveness. Workforce policy should consider addressing the financial burden of urology trainees.

The management of dysfunctional voiding in children: a report from the Standardisation Committee of the International Children's Continence Society.

PURPOSE: We present a consensus view of members of the International Children's Continence Society on the management of dysfunctional voiding in children. MATERIALS AND METHODS: Discussions were held by the board of the International Children's Continence Society and a multi-disciplinary core group of authors was appointed. The draft document review process was open to all International Children's Continence Society members via the web site. Feedback was considered by the core authors and, by agreement, amendments were made as necessary. RESULTS: Guidelines on the assessment, and nonpharmacological and pharmacological management of dysfunctional voiding are presented. CONCLUSIONS: The final document is not a systematic literature review. It includes relevant research when available as well as expert opinion on the current understanding of dysfunctional voiding in children.

A Wii-related clay-shoveler's fracture.

A 38-year-old man presented to the accident and emergency department complaining of severe neck pain. This had started immediately after swinging his Wii game console control during a rather vigorous game. An X-ray demonstrated a clay-shoveler's fracture of C7. This had radiological features to suggest an acute injury. This is the first report of a clay-shoveler's fracture strongly suggestive of being related to the use of a Wii console.

Workforce Characteristics in Urology.

INTRODUCTION: In this study we holistically describe and characterize the current state of urology practice by evaluating compensation, workload and practice factors as they relate to our demographic makeup as a specialty. METHODS: We collaborated with the American Urological Association to query its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. The survey consisted of 26 questions and took approximately 13 minutes to complete. A total of 733 responders had complete data for the factors statistically analyzed in the study. RESULTS: Mean yearly compensation for urologists surveyed was $404,755 and median compensation was $380,000 (IQR $300,000-480,000). Female respondents had a significantly lower median yearly compensation vs males ($318,422 vs $400,000) on univariate and multivariate analysis. Respondents reported a median of 60 work hours per week (IQR 50-60) and the median number of call days per month was 7 (IQR 5-10). Of the respondents 62% indicated that they use advanced practice providers in their practice. In addition, 30% reported employed status, 49% reported self-employed status and 21% reported academic status. Overall 20% of respondents plan to retire within 5 years and 40% within 10 years. CONCLUSIONS: Higher income was associated with greater job satisfaction and hourly wage appeared to decrease at increased work hours per week. Several workplace and demographic factors drive compensation, number of hours worked per week, number of call days per month and job satisfaction.

Burnout in Urology: Findings from the 2016 AUA Annual Census.

INTRODUCTION: Physician burnout is linked to decreased job performance, increased medical errors, interpersonal conflicts and depression. Two recent multispecialty studies showed that urologists had the highest rate of burnout. However, these reports were limited by a low sample size of urologists (119). We aimed to establish the prevalence of urologist burnout and associated factors. METHODS: In the 2016 American Urological Association Census, Maslach Burnout Inventory questions were randomly assigned to half of the respondents. Using matrix sampling, the 1,126 practicing urologists who received and answered the Maslach Burnout Inventory questions represented the entire 2,301 who completed the census. Burnout was defined as scoring high on the scales of emotional exhaustion or depersonalization. Demographic and practice variables were assessed to establish factors correlating to burnout. RESULTS: Overall 38.8% of urologists met the criteria for burnout, with 17.2% scoring high for emotional exhaustion and 37.1% scoring high for depersonalization. Multivariate analysis revealed that urologist burnout is associated with more patient visits per week, younger age, being in a subspecialty area other than pediatric or oncology, in solo or multispecialty practice, practice size greater than 2 and greater number of work hours per week. CONCLUSIONS: These results suggest that the burnout rate for urologists is lower than previously reported, and are consistent with rates reported in other medical and surgical specialties. However, burnout continues to be an important issue. Greater workload correlated with increased burnout while other practice patterns appeared to be protective. It is critical to keep urologists in the workforce to help lessen projected shortages.

Laparoscopic cryotherapy for pediatric angiomyolipoma: the first report.

BACKGROUND AND PURPOSE: Renal cryotherapy for pediatric angiomyolipoma has never been reported in the literature. We present the first experience with this procedure, describing techniques and short-term outcome. CASE REPORT: A 14-year-old girl was being followed for a 2-cm left renal angiomyolipoma. Growth was demonstrated by ultrasonography and CT imaging over a 2-year period, and the family desired intervention. A transperitoneal approach employing three 5-mm laparoscopic ports was used. Tumor size was measured by intraoperative ultrasonography as 25 x 28 mm. Intraoperative biopsy was done with a biopsy gun through the lateral port. An 8-mm cryoprobe was utilized. Two freeze-thaw cycles were performed with cooling to -160 degrees C. Hemostasis was accomplished with thrombin (FloSeal) and oxidized cellulose (Surgicel). RESULTS: The operative time was 92 minutes, and the blood loss was minimal. No perioperative complications occurred. There was mild perioperative hematuria that resolved within 20 hours without stenting. The hospital stay was 46 hours. There were no complications or hematuria at 1-week postoperative follow-up. CONCLUSION: Laparoscopic cryotherapy can be performed in the pediatric population. To our knowledge, this is the first case of pediatric renal angiomyolipoma managed with laparoscopic cryotherapy.

Focusing on organ preservation and function: paradigm shifts in the treatment of pediatric genitourinary rhabdomyosarcoma.

OBJECTIVE: Pediatric genitourinary rhabdomyosarcoma (RMS) accounts for 25 % of all pediatric soft tissue sarcomas. The treatment of these tumors has shifted over time from debilitating radical exenteration to organ-sparing techniques using multimodal therapy. Our review aims to summarize recent relevant literature regarding the current treatment practices of pediatric genitourinary RMS and how these practices have shifted over time. METHODS: PubMed database search was utilized to identify relevant literature from 1997 to 2015 relating to the treatment of pediatric genitourinary RMS with emphasis on organ preservation and maintaining organ function. RESULTS: A total of 31 articles from 1997 through 2015 were identified relating to current management concepts in pediatric genitourinary sarcomas. Relevant articles were reviewed in detail and discussed. CONCLUSION: The treatment of pediatric genitourinary RMS has shifted from debilitating pelvic exenteration to a multimodal treatment approach involving surgery, chemotherapy, and radiation therapy in an effort to preserve genitourinary organs and reduce treatment morbidity. Continued research is required to improve post-treatment organ function. Further studies utilizing objective urodynamic evaluation are necessary to better characterize bladder function after treatment for RMS. Exciting recent developments in RMS research of fusion proteins that induce cell transformation and inhibit apoptosis and myogenic differentiation may result in future management changes to treatment protocols.

Urinary tract infections in children with prenatal hydronephrosis: A risk assessment from the Society for Fetal Urology Hydronephrosis Registry.

INTRODUCTION: Risk factors for urinary tract infection (UTI) in children with prenatal hydronephrosis (PNH) are not clearly defined. Our study aim was to describe incidence and identify factors associated with UTI among a cohort of children diagnosed with PNH. MATERIAL AND METHODS: Patients with confirmed PNH from four medical centers were prospectively enrolled in the Society for Fetal Urology (SFU) hydronephrosis registry between 9/2008 and 10/2015. Exclusion criteria included enrollment because of UTI, associated congenital anomalies, and less than 1-month follow-up. Univariate analysis was performed using Fisher's Exact test or Mann-Whitney U. Probability for UTI was determined by Kaplan-Meier curve. RESULTS: Median follow-up was 12 (IQR 4-20) months in 213 patients prenatally diagnosed with hydronephrosis. The majority of the cohort was male (72%), Caucasian (77%), and 26% had high grade (SFU 3 or 4) hydronephrosis. Circumcision was performed in 116/147 (79%) with known status, 19% had vesicoureteral reflux (VUR), and 11% had ureteral dilatation. UTI developed in 8% (n = 18), 89% during their first year of life. Univariate analysis found UTI developed more frequently in females (p < 0.001), uncircumcised males (p < 0.01), and the presence of parenchymal renal cyst (p < 0.05). Logistic regression found renal cyst to no longer be significant, but female gender a significant risk factor for development of UTI (p < 0.001). Regression analysis stratified by gender found neither hydronephrosis grade nor parenchymal renal cyst to be significant risk factors for UTI development among females. However, hydronephrosis grade and circumcision status were significant risk factors for development of UTI among males (p < 0.05 and p < 0.01, respectively). CONCLUSION: Identification of factors associated with UTI in patients with PNH is still progressing; however, several observational studies have identified groups that may be at increased risk of UTI. Use of prophylactic antibiotics (PA), degree of kidney dilation, gender, and circumcision status all have been reported to have some degree of impact on UTI. A previous study identified risk factors for UTI as female gender, uncircumcised status, hydroureteronephrosis, and VUR, and reported that prophylaxis provided a protective effect on prevention of UTI. Our data mirror those in some respect, identifying an association of UTI with female gender and, among males, uncircumcised status, and high grade hydronephrosis. However, we were unable to demonstrate an association between UTI and the use of PA, presence of VUR, dilated ureter, or renal duplication in this observational registry.