A SWOT Analysis of Urology Residency.

PURPOSE OF REVIEW: Residency training is a pivotal educational step on the road to becoming a urologist. It combines both clinical and surgical instruction with the goal of producing proficient and compassionate surgeons and clinicians. In this review, we employ a SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) to investigate the current state of urologic residency training. RECENT FINDINGS: Urology remains an attractive and competitive residency with varied and complex surgical and medical training. Areas for improvement include standardization of evaluation and feedback, improving resident wellness, and expanding the use of surgical simulation. Workforce issues such as the predicted urologist supply deficit and poor readiness to enter the business of medicine can be addressed at the residency level. Failure to attract and retain underrepresented minorities, increasing burden of student debt, and resident burnout are serious threats to our field. Using a SWOT analysis we identify key areas for expansion, underscore valuable strengths, and provide a working roadmap for improvement of these formative years.

The role of perioperative medications in urinary retention following midurethral sling.

AIMS: Postoperative urinary retention (PUR) is a known complication of midurethral sling (MUS) placement. The use of certain perioperative medications may influence the risk of this complication. This study aimed to investigate the association of perioperative medications with urinary retention after MUS. METHODS: This was a retrospective study of women undergoing MUS placement for stress urinary incontinence by a fellowship-trained urologic surgeon between 2015 and 2018, under approval by the Institutional Review Board. Both retropubic and transobturator approaches were included. All patients underwent an active void trial following surgery. Intraoperative medications given by the anesthesia team were retrospectively noted. The Fisher's exact test was used to compare the association of PUR with categorical variables. RESULTS: A total of 82 patients were included, 17 (21%) of whom failed postoperative void trial due to urinary retention. Of 25 patients receiving perioperative scopolamine, 40% failed the postoperative void trial, compared to 12% of patients not receiving scopolamine (p = .048). Groups were then stratified based on scopolamine use due to the observed independent association with PUR. Subgroup analysis revealed a stronger association of postoperative retention with scopolamine in patients undergoing concomitant prolapse surgery. Notably, retention rate and scopolamine use were similar whether patients underwent sling placement alone or in combination with prolapse surgery. Rate of retention was also higher for retropubic versus transobturator slings (36% vs. 9%; p = .005). CONCLUSIONS: Perioperative scopolamine may be associated with an increased risk of postoperative urinary retention following MUS, especially in the setting of a concomitant prolapse surgery.

Nocturnal Enuresis in the Adult.

PURPOSE OF REVIEW: The goal of this paper is to describe the pathophysiology of adult nocturnal enuresis and develop a generalized approach for evaluation and treatment. RECENT FINDINGS: Although nocturnal enuresis (NE) impacts a significant proportion of the adult population, research on this topic remains lacking. In the few existing studies, the management strategy is extrapolated from research on pediatric nocturnal enuresis. Furthermore, treatment approaches highlight the importance of identifying risk factors and contributing pathologies. The modern urologist should understand the complexity of this problem and the variety of techniques to evaluate and treat the adult patient with NE. Adult nocturnal enuresis is multifactorial and may have multiple underlying pathologies. A comprehensive workup requires an understanding of the patient's history and symptomatology and the pathophysiologic processes that can occur. Treatment should first target identifiable etiologies, although a generalized algorithm can then be utilized with behavioral and lifestyle modifications, followed by medical therapy. Future studies will provide a better framework for treating this problem.

Implications of Opioid Prescriptions for Acute Renal Colic in the Emergency Setting on Return Visits and Long-Term Opioid Dependence.

Introduction: We sought to examine the practice patterns of pain management in the emergency room (ER) for renal colic and the impact of opioid prescriptions on return ER visits and persistent opioid use. Methods: TriNetX is a collaborative research enterprise that collects real-time data from multiple health care organizations within the United States. The Research Network obtains data from electronic medical records and the Diamond Network provides claims data. We queried the Research Network for adults who visited the ER for urolithiasis, stratified by receipt of oral opioid prescriptions, to calculate the risk ratio (RR) of patients returning to the ER within 14 days and persistent opioid use ≥6 months from the initial visit. Propensity score matching was performed to control for confounders. The analysis was repeated in the Diamond Network as a validation cohort. Results: There were 255,447 patients in the research network who visited the ER for urolithiasis, of whom 75,405 (29.5%) were prescribed oral opioids. Black patients were less likely to receive opioid prescriptions than other races (p < 0.001). After propensity score matching, patients who were prescribed opioids had an increased risk of a return ER visit (RR 1.25, confidence interval [95% CI] 1.22-1.29, p < 0.001) and persistent opioid use (RR 1.12, 95% CI 1.11-1.14, p < 0.001) compared with patients who were not prescribed opioids. These findings were confirmed in the validation cohort. Conclusions: A significant proportion of patients presenting to the ER for urolithiasis receive opioid prescriptions, which carries a markedly increased risk of return ER visits and long-term opioid use.

Pioglitazone Enhances Survival and Regeneration of Pelvic Ganglion Neurons After Cavernosal Nerve Injury.

OBJECTIVE: To investigate the effects of pioglitazone on pelvic ganglion neurons in a rat model of bilateral cavernosal nerve crush injury (BCNI), thereby elucidating the actions of pioglitazone in preventing post-prostatectomy neurogenic erectile dysfunction. METHODS: Sprague-Dawley rats aged 12 weeks were divided into four groups: (a) sham procedure, (b) BCNI, (c) BCNI + postsurgical pioglitazone, and (d) BCNI + pre and postsurgical pioglitazone (preventive therapy). Preoperative injection of Fluoro-Gold (FG) fluorescent tracer into the cavernosal tissue was performed for retrograde labeling of pelvic ganglion cells. Pelvic ganglia were resected at 2 weeks in all rats and processed for real-time polymerase chain reaction, immunohistochemistry, and Western blot to examine the expression of FG, neuronal nitric oxide synthase, ß-III tubulin, neurturin, and glial cell line-derived neurotrophic factor family receptor alpha-2 (GFRα2). RESULTS: Animals treated with pre- and postsurgical pioglitazone demonstrated increased staining for FG similar to sham levels. Gene expression of neuronal nitric oxide synthase, neurturin, GFRα2, and ß-III tubulin was also upregulated in the group receiving preventive therapy. CONCLUSION: Pioglitazone provides a protective effect on pelvic ganglion neurons after BCNI.

Avanafil for erectile dysfunction in elderly and younger adults: differential pharmacology and clinical utility.

The treatment modalities of erectile dysfunction range from oral pharmacotherapy to intracavernosal injections, intraurethral pellets, vacuum erectile devices, and the surgical option of penile prosthesis insertion. Oral phosphodiesterase 5 inhibitors still remain the preferred treatment for patients since they are the least invasive, not to mention that they can be prescribed by non-urologists. Due to these factors, there has been development of newer drugs with fewer side effects. This is a review of the second generation phosphodiesterase 5 inhibitor, avanafil, looking into its pharmacology as well as its clinical utility. Avanafil's faster onset and shorter duration of action has made it preferred as compared to other PDE5 inhibitors for patients with multiple comorbidities.