A Gender Transformation in Urology

Abstract

BJU InternationalVolume 105, Issue 12 p. ii-v Free Access A Gender Transformation in Urology Women find the specialty family-friendly and full of opportunities First published: 24 May 2010 https://doi.org/10.1111/j.1464-410X.2010.09426.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Elisabeth Pauline Pickett, MD, was an avid mountain climber who scaled most of the Alps with relish. Perhaps this passion was a logical pursuit, given her adeptness at conquering other heights in the medical field. Dr Pickett, who died earlier this year on February 14—just four days shy of her 91st birthday—was the first board certified female urologist in the United States. Despite being a pioneer in a male-dominated surgical specialty, Dr Pickett would not have traded in any moment of her career, which included academic positions at Memorial Sloan–Kettering Cancer Center and Cornell University Medical School, both in New York, USA. “I enjoyed every bit of my life”, she said. “It was exciting and crazy”. Although women are not entering urology in droves, they are coming to realize the advantages of the surgical specialty. Currently, there are 465 board-certified women urologists in the US, around 5% of the total. Since 1996, the number of female urology residents in the US has more than doubled, from 9.4% to around 21%. Women often cite urology mentors—both male and female—as one of the reasons that they eventually enter the field. Lori Lerner, MD, a urologist at the Veterans Administration Boston Healthcare System in the US, studies women in the specialty. She has found that women urologists believe female medical students should have female surgical role models. In her recent survey of women urologists, Dr Lerner found that 89% of respondents agreed or strongly agreed with the statement “women medical students need role models of successful women faculty members”. (See “Commentary” on page TK of this issue of BJUI for more on this survey.) According to Dr Lerner, “all residents should have a mentor during their training and feel supported by their attending staff”. Further Reading • Birenbaum R. Growing number of female physicians changing the face of Canadian medicine. Can Med Assoc 1995;153:1164–1166 • Harnisch BA, Stolzmann KL, Lerner LB. Mentoring, fellowship training and academic careers of women urologists. BJU Int 2010;105:TK • Hill C. On becoming the first woman urologist in Canada. Can Med Assoc 1980;122:356 • Lerner BH. Urology field slowly altered, by women. NY Times 2008; September 9 • Lerner LB, Baltrushes RJ, Stolzmann KL, Garshick E. Satisfaction of women urologists with maternity leave and childbirth timing. J Urol 2010;183:282–286 • Lerner LB, Stolzmann KL, Gulla VD. Birth trends and pregnancy complications among women urologists. J Am Coll Surg 2009;208:293–297 • Yang JH, Donat SM. Elisabeth Pauline Pickett (1918-): opening the door for women in urological oncology. J Urol 2007; 78:1875–1877 NO ONE STEREOTYPE Serving as a mentor to both female and male urology registrars in Perth, Australia, is Jessica Yin, MBBS, who chairs the Western Australian Regional Committee of the Royal Australasian College of Surgeons. “I've often joked that once they see me work, they say ‘geez, if she can do that, anyone can!’” she says. “Actually, it is quite nice to think that you can be a role model for people. If you can find someone who is remotely or vaguely like you, it is a confidence builder”. Throughout her long training and career as a urologic surgeon, Dr Yin has discovered there is one thing perfectly clear about women in urology. “To say there is the stereotype of a female urologist is so wrong”, she points out. “Every woman urologist I've ever met is completely individual in their situation”. She has seen both married and unmarried women in urology, those with big families and others with no kids. “Some are attached to their career and cats—and that's about it”, she says. “You’ll find others, however, who have a wide range of community interests. Whenever I hear people talking about women in urology, I think, ‘Hmmm, how are they going to pigeonhole that one!’” In her studies of female urologists, Dr Lerner has uncovered some interesting findings, particularly when it comes to childbirth. For example, women urologists have children later in life and opt for smaller families. “We found they have a much higher incidence of complications with their pregnancy than the general population”, Dr Lerner notes. “The use of assisted reproduction techniques is nearly 10 times higher”. Dr Lerner also found that 69% of women urologists reported feeling dissatisfied with their maternity leave due to work- or residency-related issues. Most (70%) took only eight weeks or less of leave as a result of strong stressors at work, which also interfered with breast-feeding satisfaction. Dr Lerner would like to see more programs in place during residency and later in practice to support women urologists in their desire to have children. Dr Lerner sees these issues of childbearing, maternity leave and childrearing as unchangeable constants that will always prevent true equality between men and women. “The playing field in urology is much more level than it has ever been”, she says. “Clearly, there are many who champion women in urology. Obstacles that once existed are no longer par for the course and are likely more specific to certain individuals and institutions”. Although not true across the board, women are more likely to be responsible for the daily running of the home and for childcare issues, according to Dr Lerner. She is quick to cite the support she has received from her colleagues, institution and the American Urological Association (AUA). However, Dr Lerner has found it extremely challenging to work full time, be a full-time mother and produce meaningful published research in the field of academic urology that will ultimately lead to her promotion as associate professor. “This is just the way it is”, she explains. “I don't think there is much that really will—or can—change in this regard”. Dr Lerner finds that having male colleagues who are aware of these issues certainly helps, while at the same time fostering respect for the accomplishments of all women urologists, regardless of their family life situation. Most women were satisfied with their choice of urology. If they had the option to do it again, they would. [ Lori Lerner, MD ] A MOTHER's TOUCH Women entering urology must also deal with the fact that a good portion of the specialty deals with male sexual anatomy and related issues. Men may be reluctant to share important clinical information with a female physician or undergo a physical examination. There are still stories women urologists being mistaken for nurses or being called ‘sweetheart’ and ‘honey’. However, many of these situations are faced by female physicians in other specialties, and pelvic examinations by male gynecologists are commonplace. Dr Yin sees many male patients who very much enjoy the ‘mothering’ they receive from women urologists. “We speak to them more and explore other issues”, she says. “When they turn around and say something about what's happening at home, instead of shutting them down and going on to the next patient, we ask them to tell us about that”. Specializing in benign prostatic hyperplasia, Dr Lerner agrees with Dr Yin, finding that the mostly male population she sees appreciates the time she takes with them. “I clearly spend more time with my patients than my male colleagues do”, she admits. Men with prostate cancer may find that once the surgery is over, male urologists gloss over their new concerns about potency and sexual confidence. “They find their complaints and concerns fall on deaf ears with male urologists”, says Dr Yin. “These men really do appreciate having that extra help, time and attention. Women urologists explore a lot more about the patient than just their urological problems”. However, some ethnic populations, particularly Muslims, still have difficulties with seeing female urologists due to religious reasons. The late Christina Hill, MD, the first woman urologist in Canada, once commented that, “women physicians have no inborn talent for explanation, but they are more likely than men to take time to discuss things with patients”. She believed that patients of female physicians were “much more likely to be compliant. Compliance depends on how well the patient understands what he or she needs to do. Women physicians are more likely to explain what has to be done and why”. ENDLESS CHOICES AND OPPORTUNITIES Most women urologists see the field as family-friendly, a specialty for those looking for a balanced life. Unlike other surgical specialties such as trauma and orthopedic surgery, urology rarely has emergencies that cannot be handled until the next day. “Depending on the environment you work in, most of the time you don't have to go in during the middle of the night”, says Dr Lerner. But, perhaps the real reason why more women are selecting urology is one that men have known for years: it has an infinite variety of options. “The field is so broad”, says Dr Yin, “that in some ways it is really like a general surgery specialty. If you want to do plastic surgery, you can reconstruct urethras. If you want to do big surgeries, you can remove kidneys, bladders and prostates. Plus, there is endoscopic, laparoscopic and robotic work. You can really find your niche”. Dr Hill felt the same way about the field at a time when kidney transplants were dramatic events and endoscopy was just emerging. By chance, she was assigned to two weeks of urology training during her fourth year in medical school. “I fell madly in love with the field”, she recounted in a story about her career. “It was exciting. I was fascinated”. Like every surgical specialty, urology is a hard job. “You have to like it and get something out of it”, cautions Dr Yin. “For all of us, it is the operating that keeps us excited”. In her studies, Dr Lerner found satisfaction rates with the field to be very high among women urologists. “Most women were satisfied with their choice of urology”, says Dr Lerner. “If they had the option to do it again, they would”. Dr Yin tells women considering urology to be realistic about why they are going into the field. Urology has been wonderful and very humbling for her. “It brings back your humanity in many ways. It is such an honor to do what we do. If you can get that kind of love out of it, they you’ve got it made”. DRUG AND TECHNOLOGY NEWS MORE DATA SUPPORT PCA3 TEST At the recent 2010 Genitourinary Cancer Symposium (GUCS) in San Francisco, California, USA, data were released on Progensa, the prostate cancer gene 3 (PCA3) assay used to measure post–digital rectal examination (three strokes per lobe) PCA3 messenger RNA in the urine (Abstract 5). The latest findings come from 1072 men participating in the Reduction by Duasteride of Prostate Cancer Events (REDUCE) trial. Men with higher PCA3 scores were found to be more likely to have a positive biopsy result. Such higher PCA3 scores were also associated with a higher biopsy Gleason score of >7, suggesting the possible usefulness of Progensa in identifying more aggressive prostate cancers. All of the 1072 men were taken from the placebo arm of REDUCE, where participants undergo 10-core biopsies at two and four years. All had previous negative biopsy results. Serum prostate-specific antigen (PSA) levels were between 2.5 and 10 ng/mL. After urine specimens were collected and stored prior to the year two and four biopsies, they were later tested with Progensa. At year two, 18% of the men had positive biopsies. Cancer was diagnosed in 6% of the men with a PCA3 score of <5. This percentage increased to 57% in men with PCA3 scores of more than 100. The PCA3 test predicted the likelihood of prostate cancer after four years in men with negative biopsies at year two. Those men who had PCA3 scores of >35 and negative biopsies after two years were twice as likely as men with lower PCA3 scores to have cancer show up when biopsies were taken at year four. No correlations were observed between PSA levels at two and four years (serum PSA and percentage of free PSA) and future biopsy outcomes. Currently, Progensa is approved in Europe but not in the United States. IMPORTANT PAPERS YOU MAY HAVE MISSED JOURNAL WATCH • Mahmud SM, Franco EL, Aprikian AG. Use of nonsteroidal anti-inflammatory drugs and prostate cancer risk: A meta-analysis. Int J Cancer 2010; January 20. [Epub ahead of print] • Leungwattanakij S, Watanachote D, Noppakulsatit P et al. Sexuality and management of benign prostatic hyperplasia with alfuzosin: SAMBA Thailand. J Sex Med 2010; March 8. [Epub ahead of print] • Weyers S, Lambein K, Sturtewagen Y et al. Cytology of the ‘penile’ neovagina in transsexual women. Cytopathology 2010; 21: 111–115 • Jensen TK, Swan SH, Skakkebæk NE et al. Caffeine intake and semen quality in a population of 2,554 young Danish men. Am J Epidemiol 2010; 171:883–891 • Hadid A. Double Y glanuloplasty for glanular hypospadias. J Pediatr Surg 2010; 45: 655–660 PRESURGICAL TREATMENT WITH SORAFENIB SHRINKS RENAL TUMOURS Treating primary kidney tumours with sorafenib (Nexavar) prior to surgery produces shrinkage rates up to 40%, according to a new study.1 Preoperative therapy is well tolerated by patients and poses no increase in complications after surgery. Tumour shrinkage reduced the extent of surgery needed and improved recovery. The study included 30 patients with clinical stage II or higher renal masses (17 localized, 13 metastatic). Sorafenib therapy was given for a median duration of 33 days. There was a median decrease in primary tumour size of 9.6%. Radiographic evidence showed the loss of intratumoural enhancement (median, 13%). Out of 28 patients evaluated for response (based on Response Evaluation Criteria in Solid Tumours), two patients had a partial response and 26 had stable disease. GENETIC MARKERS PREDICT KIDNEY DISEASE RISK Highly-informative DNA markers in the MYH9 gene have been identified that can predict who will develop end-stage kidney disease (ESKD).2 The markers are linked to a variant of the cellular nano-motor protein encoded by the gene. Their discovery may help explain why there is a high incidence of ESKD requiring dialysis or transplant in patients with African ancestry. Markers in the MYH9 gene were analyzed in a group of 1425 African Americans and Hispanic Americans that included dialysis patients and healthy subjects. Researchers used 42 single nucleotide polymorphisms (SNPs) within the MYH9 gene and 40 genome-wide and 38 chromosome 22 ancestry informative markers. Three of the E-1 haplotype SNPs were found to be associated with ESKD in the new sample set of African Americans, with an even stronger association for Hispanic Americans. The researchers also identified MYH9 SNPs that are more powerfully associated with the ESKD phenotype compared with the E-1 SNPs. The high-risk markers are found in up to 60% of people originating from western and southern African regions. They increase the risk of ESKD as much as three- to four-fold when an individual carries them at both parental copies of chromosome 22. REFERENCES 1 Cowey CL, Amin C, Pruthi RS, et al. Neoadjuvant clinical trial with sorafenib for patients with stage II or higher renal cell carcinoma. J Clin Oncol 2010; 28: 1502– 1507 CrossrefCASPubMedWeb of Science®Google Scholar 2 Behar DM, Rosset S, Tzur S, et al. African ancestry allelic variation at the MYH9 gene contributes to increased susceptibility to non-diabetic end-stage kidney disease in Hispanic Americans. Hum Mol Genet 2010; 19: 1816– 1827 CrossrefCASPubMedWeb of Science®Google Scholar In this issue… Urological Oncology THE FEASIBILITY OF SALVAGE HIFU FOR LOCAL RECURRENCE AFTER RP P1642 Standard treatment for local recurrence of prostate cancer after radical prostatectomy (RP) involves salvage radiotherapy (RT). Not only is this course of treatment lengthy and time-consuming, but it is also physically demanding for elderly patients. Murota-Kawano et al. present their experience with using high-intensity focused ultrasound (HIFU) as salvage therapy for biopsy-confirmed local recurrence at the vesico-urthral anastomosis. They have found HIFU to be a feasible approach in these patients, even if the patients have already undergone salvage radiotherapy. The authors treated four patients with prostate cancer recurrence after RP using HIFU. Three of the patients had received external beam radiotherapy as salvage therapy after RP. Following their RP, two patients were staged T3N0M0, one patient was staged T2aN0M0, and one had unknown staging. After HIFU, patients were followed for 24 months. At the end of 24 months, two of the four patients were biochemically disease free. One of these patients had a prostate-specific antigen (PSA) level of 0.02 ng/mL at 31 months of follow-up. The second patient had a PSA of <0.01 ng/mL at 15 months of follow-up. All three patients who were biopsied after HIFU showed no presence of prostate malignancy. HIFU safely caused coagulation necrosis and fibrosis at the anastomotic lesion. Mini-Review MOVING TOWARD CHRONIC PDE5-I TREATMENT OF ED P1634 The treatment of erectile dysfunction (ED) has undergone an evolution over the years, not only in the comfort level of patients inquiring about therapies, but also in the number of agents currently available. With a proven efficacy and safety record, ‘on-demand’ prescribing has become the standard care for ED. However, there is a subset of patients who respond poorly to this type of therapy for various reasons. Ultimately, ‘as necessary’ regimens of phosphodiesterase type 5 inhibitors (PDE5-i) fail to restore ‘normal’ sexual life in 40–50% of patients with ED at some point. In their review, Fusco et al. present the current state of affairs regarding chronic dosing of PDE5-i and identify a subset of patients with ED mostly likely to benefit from this novel therapeutic approach. Chronic therapy with these agents is designed to correct the underlying pathophysiology in both psychogenic and organic ED rather than compensating for a symptom. A prolonged half-life plus lengthy responsiveness periods create an ideal pharmacokinetic profile for chronic dosing strategies. This article also reviews studies evaluating chronic PDE5-i administration in difficult-to-treat populations, including men with diabetes and ED and non-responders to treatment. The data do not permit the identification of any one group of men more likely to benefit from chronic rather than on-demand treatment. However, 10 years of experience with using PDE5-i suggests that chronic treatment may be a viable option for men with either organic or psychogenic ED. At present, tadalafil (5 mg daily) is the only drug currently approved by the European Commission for chronic therapy of ED. Lower Urinary Tract NO EXTRA BENEFIT SEEN WITH ADDING BEHAVIOURAL INTERVENTIONS TO DRUG THERAPY IN TREATING OAB P1680 Anticholinergic medication remains the main drug therapy for the treatment of overactive bladder (OAB) and the symptom of urinary urge incontinence (UUI). In addition, fluid management may be employed to manage the condition, because women with UUI may try to control their fluid intake on their own. While keeping daily diaries of fluid intake and voiding volumes may improve OAB, compliance with specific instructions can be challenging. Zimmern et al. shed light on the effect of fluid management on fluid intake and UUI in women taking tolterodine. In their 10-week trial, 307 women with UUI for three or more months were randomized to daily treatment with tolterodine or tolterodine combined with behavioural therapies. Both groups received general fluid management instructions. Those in the drug plus behaviour arm also received additional strategies if they experienced excessive urine output of >2.1 L/day. There was an equally significant reduction from baseline in the number of leakage episodes and urgency severity in both groups as recorded in the women's seven-day diaries. Such episodes decreased by 74%. The number of leakage episodes with urgency rated as severe decreased from 22% to 7%. These decreases occurred despite no significant change in intake and output variables recorded in the women's diaries. Behavioural training did not affect any of the voiding diary measures. Also, such strategies did not change fluid intake in any significant manner. This was the case even in women with excessive fluid consumption of >2.1 L/24 h. These results may be due to the fact that both groups of women received basic fluid instruction. The findings do support the view that UUI has a strong sensory component that is addressed by anticholinergic medications. Fig 3: Pathological findings of the vesico-urethral anastomotic site before HIFU (A) and after HIFU (B) in patient two. Gleason 3 + 3 adenocarcinoma was present before HIFU (A), but the follow-up biopsy at six months after HIFU (B) showed fibrosis. Volume105, Issue12June 2010Pages ii-v ReferencesRelatedInformation