While the enthusiasm for artificial intelligence (AI) to enhance surgical decision-making continues to grow, the preceding advance of risk prediction tools (RPTs) has had limited impact to date. To help inform the development of AI-powered tools, we evaluated the role of RPTs and prevailing attitudes among urologists. We conducted a national mixed methods study using a sequential explanatory design. Through the 2019 AUA Census, we surveyed urologists on RPT use, helpfulness, and trust. Based on responses, we interviewed 25 participants on RPTs, risk evaluation, and surgical decision-making. Coding-based thematic analysis was applied and integrated with survey findings. Among 2,081 urologic surgeons (weighted sample 12,366), 30.4% (95% CI 28.2-32.6%) routinely used RPTs and 34.3% (95% CI 31.9-36.6%) found them helpful while 47.0% (95% CI 44.6-49.5%) generally trusted their own assessment over RPT-generated estimates. More years in practice was negatively associated with RPT use, helpfulness, and trust (p<0.001). Qualitatively, participants described relying on their intuition for surgical risks and benefit and employing gist-based approximations rather than numerical information, which RPTs provide. RPT helpfulness centered on risk/benefit confirmation, calibration, and communication, but methodological (e.g., individual vs. group estimates, missing variables) and operational (e.g., ease of use, clinical workflow) challenges limit greater RPT use. Despite their wide availability, RPTs remain limited in their use and helpfulness. This reflects both the intuitive nature of surgical decision-making and implementation challenges. For AI to reach its promise and improve surgical care and outcomes, both types of barriers will need to be addressed.

Following the Dobbs decision overruling Roe vs. Wade, public interest in vasectomies increased. This ruling directly impacted urologic practice patterns, and warrants further investigation. To conduct a multi-institutional study quantifying the change in vasectomy practice volume between the pre-Dobbs (PD) and after-Dobbs (AD) eras. Multiple geographically distinct US academic medical centers participated in the study. Patients with an initial vasectomy consult between 1/1/2021 and 12/31/22 were included and categorized as pre- (1/1/21 - 6/24/22) or after-Dobbs (6/25/22 - 12/31/22). Dates of subsequent vasectomy procedure and patient demographic information were compared between the two groups. A total of 4326 initial vasectomy consults were analyzed. Among these, 3691 had subsequent vasectomies (2742 PD (152 cases per month) vs. 949 AD (158 cases per month)). Men in the AD group were more likely to be younger (median age 38 years vs. 39, P<0.001), non-Hispanic white (68% vs. 64%, P=0.009), English-speaking (94% vs. 91%, P=0.005), and privately insured (92% vs. 89%, P=0.008). The AD group also had fewer children (median number 2 [1-2] vs. 2[2-3], P<0.001) and longer median wait between vasectomy consult and procedure (56 days vs. 52, P<0.001). Married men in the AD group were more likely to be childless (11% vs. 5%, P<0.001), as were single men (40% vs. 23%, P<0.001). The Dobbs decision not only affected vasectomy volume nationwide but also the typical patient seeking a vasectomy. Urologists may need to adjust practice patterns to accommodate as well as to educate the evolving vasectomy demographic.

Promotion of professionalism/communication (P/C) is a strategic initiative within the American Board of Medical Specialties; however, reliable assessment of this competency in the certification process is lacking. In this article, we present the findings of the American Board of Urology's P/C objective structured clinical examination (OSCE), which was implemented on the 2023 and 2024 certifying examinations. The certifying examination was administered to 694 candidates (335 in 2023 and 359 in 2024). Each candidate was administered two 5-item OSCEs and four 10-item standard oral examinations (SOEs). One OSCE focused on P/C with simulated patient (SP) actors and one on diagnosis/imaging. SP actors interacted with examinees on the 10-minute P/C OSCE. A criterion-referenced standard was used for pass/fail decisions, and the Rasch model was used for scoring. The candidate's mean score and protocol difficulty did not differ significantly from 2023 to 2024. Reliability with the P/C and diagnostic OSCEs was similar both years. In 2023, the diagnostic OSCE had a higher average score than the P/C OSCE, with both OSCEs scoring higher than the SOEs. In 2024, the average diagnostic OSCE score was higher than that of the P/C OSCE and SOEs, which had similar scores. There was low correlation between the OSCEs and SOEs both years. The initial experience of P/C OSCEs on the American Board of Urology certification examination showed acceptable scoring, reliability, and low correlation with standard protocols. Initial data suggest that the P/C OSCE is a distinct construct from SOEs that specifically assesses P/C skills in the oral certification process.

In recent years, Medicare physician reimbursement has been a target for national healthcare spending adjustments, but detailed national and location-specific trends in urologic oncology are lacking. This study investigated reimbursement trends over the past two decades. The Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool was used to extract physician reimbursement data for urologic oncology procedures from 2002 to 2024. We analyzed 20 common or relevant urologic oncology CPT codes. Reimbursement data were recorded biennially and inflation-adjusted to 2024 United States Dollars. The compound annual growth rate (CAGR) over the study period was calculated for each procedure. Location-specific reimbursement trends were analyzed for robot-assisted radical prostatectomy (RARP, CPT 55866) in all available Medicare localities (n=89). Reimbursement data for the 20 procedures were retrieved with an average inflation-adjusted percent change of -41.08% from 2002-2024. For all procedures, the 2014-2024 CAGR indicated a faster rate of decline compared to the 2002-2014 CAGR. RARP showed the most significant inflation-adjusted decline. Kidney procedures experienced an average inflation-adjusted CAGR of -2.15%, bladder -2.49%, prostate -2.53%, and testicular -2.34%. Open surgeries averaged a CAGR of -2.32%, endoscopic -2.60% and laparoscopic/robotic -2.73%. Reimbursement for RARP declined across all 89 Medicare localities from 2014-2024, with slight variability in magnitude. Inflation-adjusted Medicare physician reimbursement has been declining for all urologic oncology procedures over the past two decades, with more substantial declines noted in recent years. As key stakeholders, urologists must remain active in policy decisions pertaining to physician reimbursement.

The ability to perform flexible ureteroscopy in children may be limited due to a smaller pediatric ureterovesical junction and ureteral diameter. Tamsulosin has been shown to improve success rates of ureteral instrumentation in adults. To date, the efficacy of this medication to facilitate pediatric ureteral access remains unclear. We conducted a multi-institutional retrospective review of patients aged 0-17 years who underwent ureteroscopy for the treatment of nephrolithiasis from 2013 to 2022. Patients were excluded if they had undergone ureteroscopy or ureteral stent placement within the prior year, underwent semi-rigid ureteroscopy, or had a known genitourinary abnormality. Study groups included patients prescribed 0.4 mg tamsulosin daily for at least one week preoperatively and patients who did not receive tamsulosin. There were 382 patients included, with 126 in the tamsulosin group and 256 in the no tamsulosin group. Although there were no differences in gender, race, and stone characteristics between the two groups, the tamsulosin group was significantly older and had a larger BMI. One week of preoperative tamsulosin was associated with a significantly increased success of flexible ureteroscopic access on first attempt ureteroscopy, with a 24% failure in the no tamsulosin group versus a 13% failure in the tamsulosin group (p=0.010). Our results expand on prior research and suggest that at least one week of preoperative tamsulosin facilitates flexible ureteroscopic access in the pediatric population. These results have significant clinical implications, with the potential to reduce multiple procedures and spare children from repeat anesthetic exposures.