Burnout in Urological Education: An In-Depth Study of Residents and Fellows in the 2021 AUA Census.

PURPOSE: Our goal was to explore the current trends in burnout, career choice regret, and well-being needs among urology residents and fellows, with specific emphasis on identifying key factors associated with burnout. MATERIALS AND METHODS: The AUA Workforce Workgroup collaborated with the AUA Data Team to analyze data from the 2021 AUA Census, comprising a total of 243 residents and fellows. Key demographics, benefits and resources, career choice and debt, and burnout levels were analyzed, focusing on variables like gender, PGY (postgraduate year) level, debt burden, and personal health appointments. RESULTS: Overall, 48% of residents and 33% of fellows met criteria for professional burnout, with a higher incidence among PGY-2 residents (70%). Depersonalization was particularly notable, with 74% of residents reporting medium to high levels. Burnout was significantly associated with difficulty attending personal health appointments (52% vs 34%) and lack of access to on-call rooms (54% vs 36%). In contrast, having children during residency was associated with lower burnout levels (30.8% vs 49.1%). Meal plans were ranked as the most desired benefit (32%), followed by ability to attend health appointments during work hours (17%) and paid family leave (16%). Educational debt over $150,000 was carried by 53% of residents and 48% of fellows. Interestingly, burnout rates showed no statistically significant difference in response rates across genders, relationship status, amount of educational debt, presence of paid maternity or paternity leave, and type of childcare arrangements. CONCLUSIONS: Burnout remains a significant issue among urology trainees, with a complex interplay of factors like lack of personal time and provision of call rooms. The alarming rates of depersonalization and exhaustion highlight the urgency of implementing targeted interventions. Enhanced support systems, improved access to health care appointments, provision of call rooms, and debt management programs are recommended to alleviate the growing problem of professional burnout in the field of urology.

Burnout: A Call to Action From the AUA Workforce Workgroup.

PURPOSE: We hypothesize burnout has failed to improve and certain demographics may be disproportionately affected. MATERIALS AND METHODS: The AUA Workforce Workgroup examined work from the annual AUA Census over the past several years. Particular to this study, relevant burnout-related data were examined from the past 5 years. RESULTS: In 2021, 36.7% of urologists reported burnout compared to 36.2% in 2016. Burnout in men decreased from 36.3% to 35.2%, but increased in women from 35.3% to 49.2%. When examined by age, the largest increases in burnout were seen in those <45 years old, increasing from 37.9% to 44.8%, followed by 45-54 years old, increasing from 43.4% to 44.6%. When asked about the effect of COVID-19 on burnout, 54% of urologists didn't feel COVID-19 impacted burnout. Beyond burnout, only 25.0% of men and 4.6% of women reported no conflict between work and personal responsibilities, while 25.7% of men and 44.7% of women resolved these conflicts in favor of work or were unable to resolve them. Of respondents, 22.5% of men and 37.1% of women were "dissatisfied" with work-life balance. Similarly, 33.6% of men reported their work schedule does not leave enough time for personal/family life, compared to 57.5% of women. CONCLUSIONS: Overall, urologists have higher burnout now when compared to 2016. The gender discrepancy has vastly widened with women experiencing burnout at an increased rate of 14% compared to 2016, while burnout in men decreased by 1%. Burnout has increased the most in those <45 years old. Further action is needed to substantiate the causes of burnout.

Clinical challenges of scrotal lymphangioma in an adult: a rare case of scrotal swelling.

Scrotal lymphangiomas represent an extremely rare cause of scrotal swelling. We report a case of scrotal lymphangioma in an 18-year-old male who presented with painful scrotal swelling. Scrotal ultrasound revealed a complex multicystic structure in the left hemiscrotum. The patient underwent successful surgical excision of the mass. Postoperatively, he developed a hydrocele which eventually spontaneously regressed. Histopathology confirmed the diagnosis. We outline the unusual presentation, characteristic imaging and histology findings, and surgical management of scrotal lymphangiomas. With this information, urologists may exercise a heightened level of awareness for this rare cause of scrotal swelling.

Does total testicular volume predict testicular volume difference in adolescent males with varicocele?

INTRODUCTION: We evaluated the relationship between total testicular volume (TTV) and testicular volume differential (TVD) in adolescent males with varicocele. Both low TTV and high TVD have been independently associated with higher incidences of infertility later in life, but a predictive relationship between TTV and TVD directly has yet to be described. MATERIALS AND METHODS: We retrospectively analyzed a database of Tanner 5 boys ages 16-21 who presented with varicocele at a single institution between 2009 and 2017. All patients had a scrotal sonogram prior to surgical intervention. TTV and TVD were calculated for each individual and four non-exclusive groupings of patients were created for statistical analysis. We chose 30 cc as a cut off value for low TTV based on prior studies. RESULTS: 209 patients met our inclusion criteria. Mean age was 18.3 years (16-21, SD 1.7) with a mean total testicular volume of 36 cc (13.5-78.2, SD 11.1). Cut off points of TVD of 20% and TTV of 30 cc were used to separate patients. There were 65 boys (31%) with TTV < 30 cc and 58 boys (28%) with TVD ≥ 20%. Among males with TTV < 30 cc, 23 (35%) had a TVD ≥ 20%. Among males with TTV ≥ 30 cc, 35 (24%) had a TVD ≥ 20%. The relationship between TVD and TTV was found to be non-significant (p > 0.05). DISCUSSION: Adolescent varicoceles continue to pose a challenge to pediatric urologists. The dilemma of over-aggressive treatment has proven difficult to balance with the risk of infertility. We hoped that elucidating the relationship between TTV and TVD could be useful in identifying patients who are at greater risk for infertility while decreasing the need for more intrusive testing, such as semen analysis, in an adolescent population. We looked at the direct relationship between low TTV and high TVD. In our population, there was a non-significant relationship between TTV < 30 cc and TVD ≥ 20% (p > 0.05) indicating that in adolescents with varicocele, TTV and TVD are independent variables. Our study limitations include the inherent user dependent bias of ultrasound measurements and data collection at a single institution with high ethnic diversity, possibly not comparable to all patient populations. CONCLUSIONS: Low TTV (< 30 cc) itself is not predictive of high TVD (≥ 20%) in adolescent boys with varicocele, despite their reported independent associations with impaired fertility in other studies.

Exploring the Demands of Urology: On-Call Compensation, Frequency, and Variability.

INTRODUCTION: We investigate and analyze the available information regarding on-call patterns among urologists in the US. METHODS: The AUA Workforce Workgroup collaborated with the AUA Data Team to analyze information from the 2022 AUA Census. Extracted data were analyzed to identify variability across gender, subspecialty, hours worked per week, AUA section, salary, and practice setting. We used χ2 tests to compare the groups with respect to each factor and defined statistical significance as a P value less than .05. RESULTS: There were significant differences by gender and several other on-call factors including being required to take call to maintain hospital privileges (reported by 76% of female urologists vs 67% of male urologists; P = .026), getting paid for weekend call (28% of females vs 38% of males; P = .030), and making over $500 per day when taking weekend call (18% of females vs 32% of males; P < .001). Other differences existed between AUA sections in percentage of physicians receiving over $500 for weekday or weekend calls (P < .001). Lastly, practice setting differed in likelihood of being paid over $500 for weekday call (44% reported by private practice urologists, 7% reported by academic urologists, 14% reported by institutional urologists; P < .001). CONCLUSIONS: These results underscore the substantial variability in on-call responsibilities and structure within the AUA workforce. Further research and regular participation in future censuses are recommended to continue to characterize these trends.

An Analysis of American Urological Association Census Trends: Earlier Planned Retirement and Practice Pattern Changes May Exacerbate the Urology Workforce Shortage.

OBJECTIVE: To explore how changes in planned retirement age, practice setting, and physician productivity may impact the workforce shortage in urology. METHODS: We compared data between the 2015 and 2022 American Urological Association census, a specialty-wide annual survey which collects data on demographics, practice patterns, and procedures from a representative sample of U.S. urologists. Workforce productivity was measured by the self-reported number of hours worked per week and patients seen per week. A novel formula was developed to demonstrate how planned retirement age and productivity impact the workforce's production capacity. RESULTS: The total number of practicing urologists increased during the period from 2015 to 2022 (11,990 to 13,976), while the mean age of practicing urologists decreased slightly (55.0 to 54.5years; P < .002). During this period, the mean planned age of retirement for all urologists decreased from 68.9years to 67.7 (P < .001). Urologists in solo practice had a significantly higher planned age of retirement at 71.9years (P < .001) as compared to all other practice models. The number of patients seen per week for all urologists decreased from 78.7 to 72.9 (P < .001). The amount of hours worked per week remained relatively constant between the study periods. The maximum possible number of patients seen by the workforce prior to retirement increased by only 2.4% during the study interval. CONCLUSION: Though the U.S. urology workforce is growing and the mean age is decreasing, decreases in planned retirement age and productivity may offset these gains and intensify the physician shortage for U.S. urologists.

Factors Influencing Medical Students' Pursuit of Urology: Results From the AUA Census (2019-2021).

INTRODUCTION: Growing interest in urology among medical students highlights the need to understand factors influencing their specialty choice in today's context. We also investigate COVID-19's impact on these factors and any disparities among female and underrepresented in medicine (URiM) students. METHODS: From 2019 to 2021, the AUA Annual Census survey included medical student-focused questions on demographics, career interests, and decision factors. Responses were analyzed. RESULTS: One hundred ninety-two medical students participated. Thirty-six (24%) identified as female and 19 (13%) as URiM. Common reasons students would choose urology included surgical procedures (93%) and "good lifestyle" among surgical careers (85%), with no differences across gender or URiM status. Compared to pre-COVID (2019), during COVID (2020-2021), a greater proportion of students cited cutting-edge technology (90.1% vs 73.1%, P = .008) and surgical procedures (98.6% vs 87.2%, P = .008) as reasons to choose urology. Reasons for not choosing urology included competitiveness (48%) and poor lifestyle (26%). Female and URiM students expressed concern related to the combined "male dominated/gender discrimination/lack of diversity" aspect (female 33% vs male 3%, P < .001; URiM 25% vs non-URiM 7%, P = .04). CONCLUSIONS: The AUA Census survey highlights factors influencing medical students' decisions regarding urology. Interest in procedural and technological aspects grew during COVID. Students expressed concern over the field's competitiveness and poor lifestyle, while also acknowledging that urology offers a favorable lifestyle compared to other surgical careers. Female and URiM students expressed ongoing concerns over the combined aspect of gender discrimination and/or the lack of existing diversity in the field.

Factors Related to Differential Treatment and Practice Limitations Amongst Urologists: A Report of American Urological Association 2021 Census Data.

OBJECTIVE: To assess rates of urologist-reported differential treatment in practice and practice limitations based on characteristics of urologists... identity. MATERIALS AND METHODS: The 2021 AUA Census samples were linked with the United States (US) practicing urologist population file and assigned proper sample weighting to adjust for non-response bias. Responses to 2 questions of the Census related to (1) (negative) differential treatment experienced in practice and (2) limitations in patients/diagnoses seen in practice due to different aspects of respondent...s identity were evaluated. Responses were stratified based on self-reported gender (female vs male) and race (White vs non-White); results were compared using a chi-squared test. RESULTS: A total of 1742 urologists, representing 13,790 practicing US urologists through post-stratified weighting, responded to the Census. Overall, amongst those who answered the relevant questions, 16.3% reported having experienced differential treatment in practice due to their identity and 6.1% reported being limited in patients/diagnoses seen in practice due to their identity. Women were more likely than men to have experienced differential treatment (75.0% vs.ß10.2%, P.ß<.ß.001) and to be limited in patients/diagnoses seen in practice (27.0% vs.ß3.7%, P.ß<.ß.001). Similarly, non-White respondents were more likely than White urologists to both have experienced differential treatment (30.4% vs.ß14.1%, P.ß<.ß.001) and to be limited in patients/diagnoses seen in practice (12.8% vs.ß5.0%, P.ß<.ß.001). CONCLUSION: Female and non-White urologists are more likely to experience differential treatment in their practice and limitations in the scope of their practice. Further studies are needed to characterize these experiences and explore the etiologies of these differences.

Professional Burnout of Advanced Practice Providers Based on 2019 American Urological Association Census Data.

INTRODUCTION: Burnout has been recognized as an occupational hazard among health care professionals. The objective of this study was to assess the extent and pattern of burnout in advanced practice providers (APPs) in urology by analyzing American Urological Association Census data. METHODS: The American Urological Association conducts an annual census survey to all providers in the urological care community, including APPs. In the 2019 Census, the Maslach Burnout Inventory questionnaire was included to measure burnout among APPs. Demographic and practice variables were assessed to establish correlating factors to burnout. RESULTS: A total of 199 APPs (83 physician assistants and 116 nurse practitioners) completed the 2019 Census. Slightly more than 1 in 4 APPs experienced professional burnout (25.3% in physician assistants and 26.7% in nurse practitioners). Observed higher burnout rates were seen in APPs who were aged 45 to 54 (34.3%), women (29.6% vs 10.8% in men, p value <0.05), non-White (33.3% vs 24.9% in White), those who had 4-9 years of practice (32.4%) and those who practiced in academic medical centers (31.7%). Except for gender, none of the above observed differences were statistically significant. Using a multivariate logistic regression model, gender remained the only significant factor associated with burnout (women vs men with an odds ratio of 3.2 [95% confidence interval: 1.1-9.6]). CONCLUSIONS: Overall, APPs in urological care reported lower levels of burnout than urologists; however, there was a higher chance of female APPs experiencing higher professional burnout in comparison to their male counterparts. Future studies are needed to investigate possible reasons for this finding.

An Updated Review on Physician Burnout in Urology.

Physician burnout is an issue having an impact on all of medicine but having a significant impact on the field of urology. Burnout begins in medical school and worsens in residency. Increased workload leads to increased burnout both in residency and in practice. Issues with work-life balance, electronic medical record usage, decreasing reimbursements, and increased Centers for Medicare & Medicaid Services burden all have an impact on physician satisfaction with their practices. Burnout should be acknowledged, and measures for prevention should be taken by hospitals and residency programs to decrease and prevent physician burnout.

Professional Burnout, Career Choice Regret, and Unmet Needs for Well-Being Among Urology Residents.

OBJECTIVE: To measure burnout and career choice regret from the American Urological Association Census, a national sample of urology residents, and to identify unmet needs for well-being. METHODS: This is a cross-sectional study describing U.S. urology residents' responses to the 22-item Maslach Burnout Inventory and questions about career and specialty choice regret from the 2019 AUA Census. Respondents reported and prioritized unmet needs for resident well-being. RESULTS: Among 415 respondents (31% response), the prevalence of professional burnout was 47%. Burnout symptoms were significantly higher among second-year residents (65%) compared to other training levels (P = .02). Seventeen and 9% of respondents reported regretting their overall career and specialty choices, respectively. Among the 53% of respondents who had ever reconsidered career and specialty choice, a majority (54%) experienced this most frequently during the second year of residency, significantly more than other training levels (P = .04). Regarding unmet needs, 62% of respondents prioritized the ability to attend personal health appointments; the majority experienced difficulty attending such appointments during work hours, more so among women than men (70% vs 53%, P < .01). CONCLUSION: In the largest study of urology resident burnout to date, 47% of residents, including 65% of second-year residents, met criteria for professional burnout. One in 6 residents reported career choice regret. Targeting interventions to early-career residents and enabling access to medical and mental health care should be priorities for reform.

The Current State of Educational Debt among Practicing Urologists.

INTRODUCTION: Previous studies have shown urology trainees to carry large amounts of educational debt. However, little is known about the educational debt metrics in the urology workforce. Therefore, we set out to characterize educational debt among practicing urologists. METHODS: The American Urological Association (AUA) Workforce Workgroup examined the 2019 AUA Census data. Domains pertaining to demographics and educational debt were examined. RESULTS: Of respondents 31.6% never had educational debt, 47.6% have paid off all their debt, 9.9% had ≤$150,000 debt, and 11% had >$150,000. Of the respondents practicing urology for 11-15 years since completing residency 20.2% had ≤$150,000 debt and 6.5% reported >$150,000 compared to 29% and 17.4%, respectively, for those practicing urology 6-10 years since completing residency. Of female urologists 18.6% had ≤$150,000 and 18.4% carried over >$150,000 compared to 9.0% and 10.1%, respectively, among male urologists (p <0.001). Concerning race, 21% of Black respondents carried ≤$150,000 and 30.4% carried >$150,000 compared to 9.4% and 10.9% in whites and 12.5% and 4.2% in Asian respondents. Furthermore, those in academic settings were more likely to have educational debt compared to those in private groups, 13.5% vs 10.7% vs 10.1% ≤$150,000 and 12.5% vs 10.9% vs 10.3% >$150,000, respectively (p=0.01); 23.6% felt their educational debt contributed to burnoutConclusions:A large percentage of practicing urologists carry educational debt for several years after residency. A higher percentage of respondents with Black race and female gender have debt compared to white and Asian race, and male gender. A substantial proportion of those with debt feel the debt contributes to burnout.

The Gender Pay Gap in Urology.

INTRODUCTION: Female physicians earn less than males in every medical specialty. We sought to determine whether a pay gap existed in urology and explore potential associated factors. METHODS: We used 2,323 responses to the 2017 American Urological Association census to represent all 12,517 U.S. urologists. We limited analysis to ages 34 to 65 and matched on years in practice. We explored the association between self-reported salary (more than $350,000 vs less than $350,000) and gender using multivariable logistic regression adjusted for age and practice. RESULTS: On bivariate analysis males were more likely to make more than $350,000 (56.9% vs 39.7%, p=0.01). There were no gender differences in weekly clinical (43.1 female vs 46.9 male, p=0.13) or nonclinical hours (7.9 female vs 9.1 male, p=0.23). Men do more inpatient procedures per month (7.8 vs 5.6, p=0.02) and more patient visits per week (78.4 vs. 68.4, p=0.04). Women spent more time with each patient (17.6 vs 14.9 minutes, p <0.01). On unadjusted logistic regression men were more likely to earn more than $350,000 (OR 2.01, p=0.02). On multivariable regression, gender was no longer significant (OR 1.59, p=0.11). Factors associated with earning more than $350,000 include more clinical/fewer nonclinical hours, shorter/more office visits, more inpatient surgeries, private practice, subspecialty training, Northeast location and nonWhite race. CONCLUSIONS: This analysis suggests a gender pay gap. While men and women work equal hours, women urologists are more likely to work in less profitable settings, perform fewer inpatient procedures and see fewer patients. Future research needs to understand whether women choose these practices or whether external factors compel them to do so.

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.

Promotion Disparities in Academic Urology.

OBJECTIVE: To better understand promotion timelines across gender and race/ethnicity and how academic output impacts promotion in urology. METHODS: We examined the 2017 census. An academic subset was asked questions regarding their promotion timeline. We obtained demographic, academic output, and family responsibility data. RESULTS: Of 2926 academic urologists who identified a position of Assistant, Associate, or Full professor, 11.2% were women, 75% were White, and 94% were non-Hispanic. Men authored more papers and achieved principal investigator status more often than women. Non-Hispanics authored more papers than Hispanics. On average, women took 1.2 years longer than men to advance from Assistant to Associate Professor (7.3 years [95% CI: 6.8-7.8] vs 6.1 years, [95% CI: 5.8-6.6, P <.001]). Advancement from Associate to Full Professor was similar between women and men (6.0 years [95% CI: 5.1-6.9] vs 6.6 [95% CI: 6.1-7.1, P = .25]). Compared to women, men were more likely to experience rapid promotion (≤4 years) to Associate Professor (odds ratio 3 [95% CI: 1.8-5.1]). There was no statistical difference across race/ethnicity for promotion from Assistant to Associate, Associate to Full Professor, or rapid promotion. CONCLUSION: We identified disparities in promotion times based on gender but not race and ethnicity. The number of under-represented minority faculty in urology is low. Understanding the causes of disparities should be a priority in order to support fair promotion practices and retention of diverse faculty.

Economic impact of failed or delayed primary repair of bladder exstrophy: differences in cost of hospitalization.

PURPOSE: Patients with bladder exstrophy and failed primary newborn closure or who undergo delayed primary repair have suboptimal functional outcomes. We sought to determine whether these patients also have costlier, more resource intensive hospitalizations compared to patients who undergo neonatal primary closure. MATERIALS AND METHODS: We reviewed hospital coding records to identify patients who underwent surgical repair of classic bladder exstrophy at The Johns Hopkins Hospital between 1997 and 2006, and obtained charge records for each hospitalization. Total hospital charges (excluding professional fees) were inflation adjusted to year 2005 dollars. Cases were identified as newborn primary repair, delayed primary repair or reclosure of failed prior repair. RESULTS: Results of classic exstrophy repair were analyzed in 80 patients. A total of 34 procedures were newborn primary repairs, 15 were delayed primary repairs and 31 were reclosures of failed prior repair. All of the patients undergoing delayed primary repairs and reclosures underwent osteotomy, compared to only 21% of those undergoing newborn primary repair. Overall mean inflation adjusted hospitalization charge was $66,348 +/- $26,625 (range $29,689 to $179,403). Newborn closures were significantly less costly (mean charge $53,188 +/- $15,086) than either reclosure ($71,621 +/- $19,366) or delayed primary closure ($85,278 +/- $42,354, p <0.0001). Controlling for multiple variables in a regression model showed that the primary factors associated with charges were operative time, days in intensive care unit and length of stay. Length of stay and operative times were significantly shorter in the newborn surgical group, likely accounting for the lower costs in this group (despite higher intensive care unit use). Mean hospital charges and mean length of stay increased during the study period. CONCLUSIONS: Primary newborn exstrophy repair is associated with lower surgical hospitalization costs compared to delayed primary repair and reclosure. Combined with previous data on clinical outcomes, these data reiterate the paramount importance of achieving a successful initial newborn closure whenever possible.

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.

Malignancy associated with the use of intestinal segments in the urinary tract.

Use of intestinal segments for urinary tract reconstruction has become widespread. In these patients, urologists are increasingly encountering malignancies that may be a direct result of this altered milieu. This review attempts to summarize the current literature on cancer in patients with intestinal segments in their urinary tracts. Although the exact etiology for this increased risk of malignancy is still unclear, several theories have been proposed. Many investigators now recommend annual screening in patients who have intestinal segments in contact with urine beginning 10 years after the initial surgery.