Academic Urologists Research Articles

P0750 - Survival outcomes after radical cystectomy versus conservative management for clinical T1 high grade non-muscle invasive micropapillary bladder cancer: A multicenter collaboration by the European Association of Urology–Young Academic Urologists

P0750 - Survival outcomes after radical cystectomy versus conservative management for clinical T1 high grade non-muscle invasive micropapillary bladder cancer: A multicenter collaboration by the European Association of Urology–Young Academic Urologists

IJU this issue

This issue of International Journal of Urology contains one Review Article, 11 Original Articles, two Urological Notes and 13 Editorial Comments. Taguchi et al (Tokyo, Japan) reviewed the evidence on the prognostic significance of tertiary Gleason pattern (TGP), and discussed how to deal with it in the context of the contemporary Gleason score and Gleason grade grouping. According to the 2019 International Society of Urological Pathology, a provisional definition of TGP is “<5% Gleason pattern 4 or 5 in radical prostatectomy specimens.” Although no objective and scientific data supporting this cut-off value have been reported, TGP should be routinely reported in radical prostatectomy specimens and further studies are required to assess the associations of TGP with prognostic significances. In the Original Articles, Kimura et al. (Tottori, Japan) reported the impact of penile rehabilitation on the recovery of erectile function after robot-assisted radical prostatectomy. Erectile dysfunction still remains an important complication after robot-assisted radical prostatectomy despite the preservation of neurovascular bundles with nerve-sparing (NS) surgery. This study presents novel findings regarding postoperative penile rehabilitation with phosphodiesterase-5 inhibitor, not only in cases of bilateral NS and/or unilateral NS, but also in other types of NS, such as partial NS or non-NS. Zhang et al. (Beijing, China) evaluated the outcomes and the learning curves of flexible ureteroscopy (FURS) and mini-percutaneous nephrolithotomy for pediatric kidney stones larger than 2 cm. FURS has already been shown to be a safe and feasible procedure alternative to percutaneous nephrolithotomy for children with upper urinary stones with a systematic review and meta-analysis (Urolithiasis 2019; 47: 189–99); however, this study showed an interesting finding, that a minimum of 20 cases of mini-percutaneous nephrolithotomy and 50 cases of FURS are necessary to achieve a high stone-free rate for pediatric kidney stones larger than 2 cm. Okada et al. (Chiba, Japan) reported the differences in the handling of forceps between the one-surgeon and two-surgeon techniques using an off-site simulator model. Nearly half of endourologists used only the dusting technique in their FURS practice, according to a recent worldwide survey of FURS practice from the European Association of Urology sections of young academic urologists (aged <40 years) and uro-technology groups (Cent. Eur. J. Urol. 2019; 72: 393–7). The European Association of Urology Guidelines on Urolithiasis has mentioned that “dust and go” strategies should be limited to the treatment of large (renal) stones and stones that can be extracted by endoscopic forceps or baskets. Therefore, the establishment of standards, safety requirements and acceptable procedures for basketing is essential. A large-scale study is required to confirm its usefulness as a new standard modality of stone retrieval in FURS. Shobeirian et al. (Rasht, Iran) evaluated the efficacy of intraprostatic injection of prophylactic antibiotics for the prevention of infections after transrectal ultrasonography-guided prostate biopsy. This unique concept of injecting antibiotics directly into the prostate was proposed in both animal and human studies, and its efficacy in the treatment of drug-resistant chronic prostatitis has already been reported. It will be necessary to carry out a randomized controlled trial. In the Urological Notes, Tully et al. (Boston, USA) analyzed bladder cancer incidence trends using the Surveillance, Epidemiology and End Results database, with a focus on distant stage among young individuals. They discussed possible explanations for the rising incidence of distant bladder cancer among young individuals. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are very interesting and informative. Please enjoy this issue of International Journal of Urology. None declared.

P0747 - Survival outcomes after radical cystectomy versus conservative management for clinical T1 high grade non-muscle invasive squamous bladder cancer: A multicenter collaboration by the European Association of Urology–Young Academic Urologists

P0747 - Survival outcomes after radical cystectomy versus conservative management for clinical T1 high grade non-muscle invasive squamous bladder cancer: A multicenter collaboration by the European Association of Urology–Young Academic Urologists

The best treatment approach for lower calyceal stones ≤20 mm in maximal diameter: mini percutaneous nephrolithotripsy, retrograde intrarenal surgery or shock wave lithotripsy. A systematic review and meta-analysis of the literature conducted by the European Section of Uro-Technology and Young Academic Urologists.

The highest in quality data in the literature which compared mini percutaneous nephrolithotripsy (mPCNL), retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) for the management of lower pole stone (LPS) with a maximal diameter ≤20 mm were investigated by means of systematic review (SR) and meta-analysis. A SR of the literature was conducted on PubMed, Cochrane, SCOPUS and EMBASE in January 2020. The study complied with the PRISMA statement and recommendations of the EAU Guidelines office. Only randomized controlled trials (RCTs) comparing retrograde intrarenal surgery (RIRS), shock wave lithotripsy (SWL) and mini-percutaneous nephrolithotripsy (mPCNL) were selected for the meta-analysis. The endpoints were the efficacy of each modality, measured by stone-free rate (SFR), operative time and retreatment rate and the safety of each method, based on hospitalization time and complications. Subgroup analyses for stones with a maximal diameter <10 mm and 10-20 mm were performed. Twenty-one RCTs were included in the meta-analysis. mPCNL had the highest SFR and the lowest retreatment rate among the three modalities, while SWL had the lowest SFR and the highest retreatment rate. The operative and hospitalization time were shorter in the case of SWL, whereas they were similar in the case of mPCNL and RIRS. The highest complication rate was observed in mPCNL group, which accounted for 8.3-22.4%, while RIRS and SWL had similar complication rates, which ranged between 1.3-31.4% and 0-48.5%, respectively. Further classification of the complications according to Clavien-Dindo system revealed that SWL had lower grade II complication rates compared to mPCNL and RIRS. Regarding stones <10 mm, SWL and RIRS had similar SFR, complication rate, operation and hospitalization time. SWL had higher retreatment rate. For LPSs ≤20 mm, mPCNL provides the highest SFR and the lowest retreatment rate. This modality has a higher complication rate and longer hospital stay in comparison to the other modalities. SWL provides the lowest SFR with the highest retreatment rate. RIRS has similar complication rate to SWL and could be preferred over SWL. For stones up to 10 mm, SWL may provide a valid alternative. Despite a higher retreatment rate, its SFR is similar to RIRS.

Perceived barriers to the adoption of active surveillance in low-risk prostate cancer: a qualitative analysis of community and academic urologists

BackgroundClinical practice guidelines recommend active surveillance as the preferred treatment option for low-risk prostate cancer, but only a minority of eligible men receive active surveillance, and practice variation is substantial. The aim of this study is to describe barriers to urologists’ recommendation of active surveillance in low-risk prostate cancer and explore variation of barriers by setting.MethodsWe conducted semi-structured interviews among 22 practicing urologists, evenly distributed between academic and community practice. We coded barriers to active surveillance according to a conceptual model of determinants of treatment quality to identify potential opportunities for intervention.ResultsCommunity and academic urologists were generally in agreement on factors influencing active surveillance. Urologists perceived patient-level factors to have the greatest influence on recommendations, particularly tumor pathology, patient age, and judgements about the patient’s ability to adhere to follow-up protocols. They also noted cross-cutting clinical barriers, including concerns about the adequacy of biopsy samples, inconsistent protocols to guide active surveillance, and side effects of biopsy procedures. Urologists had differing opinions on the impact of environmental factors, such as financial disincentives and fear of litigation.ConclusionsDespite national and international recommendations, both academic and community urologists note a variety of barriers to implementing active surveillance in low risk prostate cancer. These barriers will need to be specifically addressed in efforts to help urologists offer active surveillance more consistently.

Current Opinion Regarding Multidisciplinary Cancer Clinic Utilization for the Management of Prostate Cancer.

Objectives:Multidisciplinary cancer clinic (MDC) is an evaluation option for the management of prostate cancer (PCa). The purpose of MDC is to provide the patient with a comprehensive assessment and risk/benefit discussion of all pertinent treatment options. Our objective was to obtain a contemporary measure and analysis of urologists’ opinion regarding PCa MDC.Material and Methods:We created a 14-item questionnaire for respondent baseline characteristics, subjective and objective inquiries regarding MDC for PCa management. The survey was distributed through email to members of the Society of Urologic Oncology and the Endourological Society. Data were analyzed using R (R Core team, 2017).Results:One hundred and seven (51%) respondents reported participation in MDC; the majority of which were male (97.6%), academic (61.4%) urologists with urologic oncology fellowship training (50%), and >20 years in practice (40.3%). MDC patients were most commonly referrals (78.5%) and with high-risk disease (Gleason sum 8–10) (83.2%). A majority of the respondents felt that MDC was very or extremely beneficial for PCa research (45% and 19%, respectively) and treatment (35% and 20%, respectively). Responses dissuading the use of MDC included lack of infrastructure (41%) and time commitment (21%). On multivariate analysis, urologists with >10 years in practice were less likely to find MDC beneficial in the management of PCa (11–20 years, P = 0.028 and >20 years P = 0.009).Conclusion:A contemporary sampling of urologists’ opinion and practice patterns alludes to the benefits that advocate for and the resource demand that hinders routine use of MDC for PCa evaluation. Urologist training and practice environment can affect participation in PCa MDC.

Underdiagnosis of germline genetic prostate cancer: Are genetic testing guidelines an aid or an impediment?

10504 Background: Pathogenic/likely pathogenic (P/LP) germline genetic variants are estimated to occur in 10-15% of all prostate cancer (PCa) patients. However, genetic testing for PCa patients is underutilized, partially due to complicated and restrictive testing guidelines developed at a time when the cost of testing was high. We conducted a study based in community urology clinics to determine the incidence of P/LP variants in PCa patients who met and did not meet the NCCN 2019 PCa germline genetic testing criteria. Methods: An IRB-approved, multicenter, prospective registry was initiated with 15 community and academic urologists nationwide. Eligibility criteria included patients with a PCa diagnosis unselected for personal or family history, stage or histology who had not been previously tested. Consecutive patients ages 18-90 were consented and underwent an 84-gene germline panel test. HIPAA-compliant electronic case report forms distributed to clinician collected information on patient diagnoses, NCCN testing criteria, and results-based recommendations. Results: To date, 640 enrolled patients have genetic testing results available. Overall, 69 (10.8%) patients had 72 P/LP variants detected, 15% of which were in BRCA1/2. Of the 532 patients for whom we have clinician-reported data, 293 (55%) met NCCN criteria and 239 (45%) did not. Median age was 70 (range 44-90). Overall, 11.1% (59/532) of patients with clinician-reported data had a P/LP variant. 36 (12.3%) of patients who met NCCN criteria and 23 (9.6%) of patients who did not meet criteria had a P/LP variant. The difference in P/LP rate between the two groups was not statistically significant (p=0.33). If only a conservative 12-gene PCa panel was considered, P/LP yield was 5.5% (29/532), with 8 (28%) of these patients missed by guidelines. Stratification by self-reported ethnicity was: 76% White/Caucasian (52 patients w/ P/LP), 18% Black/African American (2 patients w/ P/LP), and &lt;5% each of Hispanic or Asian. Conclusions: There was no statistically significant difference in the yield of P/LP variants between patients who met and those who did not meet NCCN PCa guidelines, reinforcing that a significant number of P/LP variants are missed if NCCN guidelines are required for genetic testing. Expanded panel testing yields more medically actionable P/LP variants than testing BRCA1/2 alone or PCa panels with 12 genes. While 18% of the cohort was Black/African American, there was a lower P/LP rate (2%) relative to other groups, indicating that more research is needed to understand genetic variation in underrepresented populations with PCa.

The impact of an expert exchange-based educational initiative on urologist confidence and knowledge in implementing immunotherapy for bladder cancer.

e23001 Background: The rapid and robust emergence of the immunotherapy era in bladder cancer has prompted a paradigmatic shift in both early and late-stage bladder cancer management. Given this change, it is imperative that members of the bladder cancer care team, most notably urologists, medical oncologists, and urologic oncologists, be well-equipped to safely and effectively integrate immune checkpoint inhibitors into the treatment armamentarium. Methods: CEC Oncology delivered education at select meetings throughout 2019-2021 including ASCO GU, AUA, and SUO Annual Meetings; in addition to live presentations, the content was streamed live and on-demand on www.ceconceptslive.com and endured on myCME.com. Learning and knowledge was objectively assessed by analyzing pre- and post-test results before and after the educational activities. To determine retention of knowledge over time, follow-up assessments were sent to participants after each live activity. Assessment questions in the form of case studies were utilized to gauge whether participants translated knowledge into practice at follow-up. Statistical testing between pre- and post-tests and from pre-test to follow-up were conducted via chi square analysis with a priori significance set at 0.05. Results: Executed five live educational activities and a spin-off enduring component hosted on myCME.com. 765 total clinicians educated across the live elements of the curriculum. Across the curriculum, over 70% of attendees indicated at post-activity assessment that they would use systemic immunotherapy either primarily or exclusively in their practice compared to just 25% at pre-activity. Among urologists practicing at academic medical centers, confidence in appropriate implementation of immunotherapy increased for all participants, and more specifically, for clinicians practicing at academic medical centers (on a 4-point scale, All Participants demonstrated a confidence increase from 2.70 to 2.91; Academic Medical Center clinicians demonstrated an increase of 2.75 to 3.00); 97% said that the initiative increased their knowledge of ongoing ICI clinical trials in bladder cancer; Attendee ability to appropriately manage an irAE increased substantially from pre-test to post-test assessment (37% vs. 63%; P=.057). Clinicians practicing in community settings are the only attendees who did not exhibit an increase in mean confidence in appropriately implementing immunotherapy at post-activity assessment. Conclusions: Our Expert Exchange Bladder Cancer Curriculum precipitated substantive practice advances related to appropriate implementation of ICI therapy. Many of these advances, however, were specific to academic urologists and urologic oncologists; outcomes analyses have revealed tangible educational gaps among community-based urologists.

Changing the Status Quo: Developing a Virtual Sub-Internship in the Era of COVID-19

ProblemSubinternships are integral to medical education as tools for teaching and assessing fourth-year medical students. Social distancing due to COVID-19 has precluded the ability to offer in-person subinternships – negatively impacting medical education and creating uncertainty surrounding the residency match. With no precedent for the development and implementation of virtual subinternships, the Society of Academic Urologists (SAU) developed an innovative and standardized curriculum for the Virtual Subinternship in Urology (vSIU).MethodsThe vSIU committee's mandate was to create a standardized curriculum for teaching foundational urology and assessing student performance. Thirty-three members from 23 institutions were divided into working groups and given 3 weeks to develop 10 modules based on urologic subspecialties, Accreditation Council for Graduate Medical Education core competencies, technical skills training and student assessment. Working groups were encouraged to develop innovative learning approaches. The final curriculum was assembled into the “vSIU Guidebook.”ResultsThe vSIU Guidebook contains 212 pages – 64 pages core content and 2 appendices (patient cases and evaluations). It outlines a detailed 4-week curriculum with a sufficient volume of resources to offer a completely adaptable virtual course with the same rigor as a traditional subinternship. Modules contain curated teaching resources including journal articles, lectures, surgical videos and simulated clinical scenarios. Innovative learning tools include reflective writing, mentorship guidelines, videoconference-based didactics, surgical simulcasting and virtual technical skills training. The guidebook was disseminated to program directors nationally.Next StepsThe vSIU is the first virtual subinternship in any specialty to be standardized and offered nationally, and it was implemented by at least 19 urology programs. This curriculum serves as a template for other specialties looking to develop virtual programs and feedback from educators and students will allow the curriculum to evolve. As the pandemic continues to challenge our paradigm, this rapid and innovative response exemplifies that the medical community will continue to meet the needs of an ever-changing educational landscape.

Cross-sectional Survey-based Study of Underrepresented Minorities in Urology Academic Leadership Roles

ObjectiveTo define the current proportion of underrepresented minority (URM) academic urologists in leadership positions. MethodsA cross-sectional observational study of leadership positions in active United States Urology Residency Programs in 2020 was conducted. Academic urologists in leadership positions were electronically mailed a survey asking about personal and professional demographics. Self-reported variables including administrative position, race, and ethnicity were collected and analyzed. ResultsOver the study period, 133 urologists completed the survey out of a possible 320 academic urologists for a response rate of 41.6%. Overall, African-Americans represented 9.0%, Hispanics represented 3.8%, and American Indians/Alaska Natives made up 0.8% of leadership roles in the study sample. African-Americans comprised 8.5% (4 of 47) and Hispanics comprised 2.1% (1 of 47) of department chairs. African-Americans made up 7.4% (4 of 54) and Hispanics made up 1.9% (1 of 54) of program directors. The highest proportion of African-Americans in leadership positions was seen in oncology (18.2%), minimally invasive surgery (18.2%), and general urology (10%). The only subspecialties with Hispanics in leadership positions were in andrology/sexual medicine (16.7%) and female urology (15.4%). There were no reported URMs in leadership positions in endourology, neurourology, pediatrics, and reconstructive urology. ConclusionsTo our knowledge, this study is the first to quantify the representation of URM urologists in academic leadership. There are multiple subspecialties without URMs in leadership positions. This information is vital to understanding the presence and lack of racial representation of the leadership of our field.

Patient Satisfaction With Telemedicine Appointments in an Academic Andrology-focused Urology Practice During the COVID-19 Pandemic

To evaluate patient satisfaction with telemedicine appointments as an alternative to in-person appointments at an Andrology-focused academic urology practice during the coronavirus disease 2019 pandemic. Between March and June 2020, all appointments at the practice of a single Andrology-focused academic urologist were conducted by telephone. Consecutive patients were contacted by telephone following their appointment to complete a telephone questionnaire. Baseline demographic information was obtained, and perceptions regarding telephone appointments were assessed using a Likert scale. Ninety-six patients completed the telephone questionnaire. Median age was 48.5 years (interquartile range 37.3-62.8 years) with 55 of 96 (57.3%) of the appointments Andrology-focused. Mean distance of residence from the hospital was 8.4 km (interquartile range 4.7-25.2 km). Only 9 of 96 (9.3%) of the patients felt that the telephone format did not adequately address their needs. However, 26 of 96 (27.1%) of patients said they would prefer an in-person appointment. On multivariable analysis adjusting for age, gender, presenting complaint, type of appointment, education level, and employment status, no factors were associated with feeling that the telephone appointment adequately addressed needs or preference for an in-person appointment in the future. Patients were generally satisfied with telephone appointments as an alternative to in-person appointments during the coronavirus disease 2019 pandemic. Nonetheless, a substantial portion of patients said they would prefer in-person appointments in the future.

Remote consultations in paediatric urology–Not just for pandemics?

Although some centres have successfully integrated remote clinics into their paediatric urological practice, for many, remote clinics have developed due to the COVID-19 pandemic. One UK-based institution has integrated remote clinics in their practice for over two years and has developed guidelines considering which conditions may be suitable for remote consultations. These guidelines have been appraised by the European Association of Urology Young Academic Urologists paediatric working group. Through practical experience and anticipated difficulties, we have discussed considerations that paediatric urology departments should ponder when integrating remote clinics into their practice as we move forward from the pandemic.

Adherence to guidelines in the management of urolithiasis: are there differences among distinct patient care settings?

Urolithiasis is a common diagnosis in urology. New technologies offer a variety of diagnostic and therapy and consequently display a financial burden on healthcare systems. Hence, clinical practice guidelines (CPG) are essential to implement evidence-based medicine and assure a standard of care considering limited resources. To date, there is no evidence of the use and adherence to CPG on urolithiasis. Therefore, we performed a cross-sectional study to analyze the use of CPG on urolithiasis. Data collection was carried out by a questionnaire given to 400 German urologists. The survey included use and adherence to guidelines, evaluation of the clinical situation, therapy spectrum, and workplace. In total, 150 (37%) questionnaires were received and included in our survey. Statistics were performed by SPSS using Chi-quadrat test/Fisher's exact test. In our study, urologists were office based, hospital affiliated, non-academic, or academic centers in 53%, 32%, 16% and 5%, respectively. In 74% and 70%, urologists adhere to CPG in diagnostic and therapy. Interestingly, workplace and therapy spectrum determines the use of different CPG (p = 0.01; p = 0.022). Academic urologists were more likely to use international CPG of EAU (40%), while outpatient urologists significantly orientated on national CPG (46%). 86% of urologists with high volume of urolithiasis practice interventions in contrast to 53% in low volume (p = 0.001). More than 80% of urologists use short versions and app version of CPG. We firstly describe compliance and the use of CPG on urolithiasis. EAU and DGU present the most commonly used CPG. Short version and app version of CPG find frequent clinical utilization.

Resident involvement in the prostatic urethral lift: implementing innovative technology in an academic setting.

Adoption of the prostatic urethral lift (PUL) as a treatment for benign prostatic hyperplasia highlights the importance of training residents with novel technology without compromising patient care. This study examines the effect of resident involvement during PUL on patient and procedural outcomes. Retrospective chart review was conducted on all consecutive PUL cases performed by a single academic urologist between October 2017 and November 2019. Trainees in post-graduate year (PGY) 1–3 are considered junior residents, while those in PGY 4–6 are senior residents. The International Prostate Symptom Score (IPSS) and quality of life (QOL) scores were used to measure outcomes. Simple and mixed-effects linear regression models were used to compare differences. There were 110 patients with a median age of 66.4 years. Residents were involved in 73 cases (66.4%), and senior residents were involved in 31 of those cases. Resident involvement was not associated with adverse perioperative outcomes with respect to the number of implants fired, the percentage of implants successfully placed, or the postoperative catheterization rate. After adjustment for confounding factors, junior residents were associated with significantly longer case length compared to the attending alone (+12.6 min, P = 0.003) but senior residents were not (+2.4 min, P = 0.59). IPSS and QOL scores were not significantly affected by resident involvement (P = 0.12 and P = 0.21, respectively). The presence of surgeons-in-training, particularly those in the early stages, prolongs PUL case length but does not appear to have an adverse impact on patient outcomes.

Autonomous robots: a new reality in healthcare? A project by European Association of Urology-Young Academic Urologist group.

Artificial intelligence appears as a potential revolution in the general process of medical training, disease diagnosis and treatment. A novel disruptive technology of the 21st century will be 'learner' robots from artificial intelligence systems able to use all the combination of the available knowledge in medical repositories to give the best standard of care. The autonomy level of robots depends on three factors: the complexity of the task; the environment in which the robot operates, and the required level of human-robot interaction. Autonomous robots in healthcare may be classified in delivery, nurse, and surgical robots. The increasing capability of robots to perform independent actions and complex tasks raises responsibility and accountability issues in a wide variety of application domains. Ethical analyses of these issues are underway and are mostly oriented toward the development of ethical policies requiring a law frame on robotic autonomous behaviors. Autonomous robots have the potential to improve current medical practice offering a more secure, reliable, and reproducible medicine. Many advancements are required for these new technologies to be fully integrated. Furthermore, the ethical implications of these technologies are yet to be evaluated.

Postoperative Chemotherapy Bladder Instillation After Radical Nephroureterectomy: Results of a European Survey from the Young Academic Urologist Urothelial Cancer Group

BackgroundLevel 1 evidence supports the administration of single postoperative intravesical chemotherapy (pIVC) following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), in order to decrease intravesical recurrence risk. ObjectiveThe Young Academic Urologist Urothelial Cancer Group aimed to investigate the use of pIVC in daily practice among European colleagues. Design, setting, and participantsAn online survey was shared with European Association of Urology Section of Oncological Urology (ESOU) 2017 participants via e-mail. Submissions were accepted from April to June 2017. The topics for 15 questions of this survey included the habit of delivering pIVC, the choice of drug, its dosage, related doubts or concerns, reasons not to perform pIVC, knowledge of the evidence, and surgical preferences for RNU. Outcome measurements and statistical analysisSurvey software was used for analyses. Logistic regression analyses were used to investigate the association between surgeons’ experience and caseloads with pIVC utilization. Results and limitationsOverall, 127 responses were collected (11.6%). About half of the participants (47%) regularly administered pIVC following RNU. The drug most commonly utilized was mitomycin (85%); 82% adhered to the standard dosage of 40 mg. Different administration protocols were adopted: ≤48 h (39%), 7–10 postoperative days (35%), >10 d (11%), and intraoperatively (10%). The evidence was supported by prospective randomized clinical trials for only 65% of responders. Among interviewees who did not deliver pIVC, the most commonly reported reasons were lack of supporting data (55%), fear of potential side effects (18%), and organizational hurdles (15%). ConclusionsOur research highlights the limited use of pIVC following RNU for UTUC, raising the question of how the compliance with level 1 evidence in the urological community may be promoted. Patient summaryLevel 1 evidence supports the administration of single postoperative intravesical chemotherapy (pIVC) following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), in order to decrease intravesical recurrence risk. The Young Academic Urologist Urothelial Cancer Group aimed to investigate the use of pIVC in daily practice among European colleagues. Our research highlights the limited use of pIVC (47%) following RNU for UTUC, raising the question of how the compliance with level 1 evidence in the urological community may be promoted.

Trends in urologic oncology clinical practice and medical education under COVID-19 pandemic: An international survey of senior clinical and academic urologists

Objective: Ad-hoc guidelines for managing the COVID-19 pandemic are published worldwide. We investigated international applications of such policies in the urologic-oncology community. Methods: A 20-item survey was e-mailed via SurveyMonkey to 100 international senior urologic-oncology surgeons. Leaders’ policies regarding clinical/surgical management and medical education were surveyed probing demographics, affiliations, urologic-oncologic areas of interest, and current transportation restrictions. Data on COVID-19 burden were retrieved from the ECDC. Statistical analyses employed non-parametric tests (SPSS v.25.0, IBM). Results: Of 100 leaders from 17 countries, 63 responded to our survey, with 58 (92%) reporting university and/or cancer-center affiliations. Policies on new-patient visits remained mostly unchanged, while follow-up visits for low-risk diseases were mostly postponed, for example, 83.3% for small renal mass (SRM). Radical prostatectomy was delayed in 76.2% of cases, while maintaining scheduled timing for radical cystectomy (71.7%). Delays were longer in Europe than in the Americas for kidney cancer (SRM follow-up, P = 0.014), prostate cancer (new visits, P = 0.003), and intravesical therapy for intermediate-risk bladder cancer (P = 0.043). In Europe, COVID-19 burden correlated with policy adaptation, for example, nephrectomy delays for T2 disease (r = 0.5, P =0.005). Regarding education policies, trainees’ medical education was mainly unchanged, whereas senior urologists' planned attendance at professional meetings dropped from 6 (IQR 1−11) to 2 (IQR 0−5) (P < 0.0001). Conclusion: Under COVID-19, senior urologic-oncology surgeons worldwide apply risk-stratified approaches to timing of clinical and surgical schedules. Policies regarding trainee education were not significantly affected. We suggest establishment of an international consortium to create a directive for coping with such future challenges to global healthcare.

Reply by Authors.

You have accessJournal of UrologyLetters to the Editor/Errata1 Oct 2020Reply by Authorsis a reply to letterRe: COVID-19 and the Urology Match: Perspectives and a Call to Action A. T. Gabrielson, T. P. Kohn, and M. M. Clifton A. T. GabrielsonA. T. Gabrielson More articles by this author , T. P. KohnT. P. Kohn More articles by this author , and M. M. CliftonM. M. Clifton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001146AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail We thank Warren et al for their thoughtful comments. In addition to the uncertainty that the COVID-19 pandemic has caused, the cancelation of visiting student learning opportunities and in person interviews will certainly exacerbate the tendency for students to apply to an excessive number of residency programs during this cycle. An application cap would cut costs and may reduce the likelihood of applicants applying to geographic regions or programs they may not be truly interested in. To determine a reasonable cap (one that applicants and residency programs can agree on), a rational strategy could involve limiting urology applicants to the average number of applications submitted during this past cycle (72 per applicant), a number that more than 85% of students applying in this upcoming cycle may accept per a recent survey. While implementing a permissive application cap may address many of the aforementioned dilemmas, it is unlikely to be an all-encompassing solution. Just as medical students may feel pressured to apply to more programs, residency programs may similarly feel pressured to increase the number of applicants they interview in order to better assess the applicant class. These applicants may have less exposure to urology and fewer letters of recommendation compared to prior cohorts. If programs follow the recommendations of the Association of American Medical Colleges and use virtual platforms for interviews, applicants can attend, and residency programs can offer, a larger number of interviews than in the past. Thus, if student applications are capped and residency programs increase the number of interview offers, this may lead to a minority of students garnering and retaining a large number of interview positions. Therefore, if application caps are implemented, limits on the number of interviews that residency programs can offer must be put into place as well. Determining an appropriate interview limit for residency programs will be challenging to implement with a one-size-fits-all policy. Strategies could involve limiting the number of interviews based on the number of positions a program offers (eg 60 interviews for a program with 3 positions, 45 interviews for a program with 2 positions etc) or implementing a quota based on how many interviews a program offered the year before. This may require special considerations for smaller programs with 1 position per year. To ensure adherence, there would likely need to be a mandate or statement issued by the Society of Academic Urologists or the American Urological Association. So how does an applicant know which programs they should apply to this cycle? Ultimately there is a need for improved transparency among residency programs and improved access to data driven metrics for applicants to understand the characteristics of candidates that certain programs are matching. Helping students navigate the black box of “Will I be considered for an interview at this program?” will streamline efficiency of the self-selection process and improve future application cycles as well. Before the upcoming application deadline the Johns Hopkins Department of Urology intends to publish 15-year aggregated and anonymized application data (including test score ranges, research activities, number of clerkship honors etc) of applicants who were offered interviews at our institution. We hope this will allow applicants the opportunity to assess their fit with our program and initiate the transparency process for other programs. Lastly, just as residency programs will struggle to gauge student fit with their program, so too will medical students struggle to determine their fit with programs. We strongly recommend that urology departments bolster their virtual and online footprint (ie department websites, social media pages, town hall meetings, video content etc). Programs may consider offering virtual visiting student learning opportunities, allowing students an opportunity to interact with faculty and residents at their institution. Unlike in previous years, when the onus was on applicants to seek out program information and networking opportunities, residency programs must establish new mechanisms of seeking out applicants in the virtual setting. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology27 May 2020Re: COVID-19 and the Urology Match: Perspectives and a Call to Action Volume 204Issue 4October 2020Page: 851-852 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information A. T. Gabrielson More articles by this author T. P. Kohn More articles by this author M. M. Clifton More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Variations in Perioperative Antibiotic Prescriptions Among Academic Urologists After Ambulatory Endoscopic Urologic Surgery: Impact on Infection Rates and Validation of 2019 Best Practice Statement

ObjectiveTo evaluate adherence to the American Urologic Association (AUA) best practice statement guidelines regarding antibiotic duration in the perioperative setting for endoscopic urologic surgery. We assessed concordance to these guidelines among adult urologists at a single academic institution and its correlation with postoperative positive urine cultures as it relates to the revised 2019 best practice statement. MethodsWe performed a retrospective review of all adult endoscopic ambulatory urologic surgeries performed over an 18-month period by urologists at our institution. Patient demographics, pre- and postoperative urine cultures, operative details, stent or foley use, and antibiotic prescriptions were reviewed. Chi-squared and linear regression analyses were done. ResultsThree hundred thirty patients were included for analysis. Sixty-two percent of patients were prescribed postoperative antibiotics, for an average of 4 days. Trimethoprim/Sulfamethoxazole and fluroquinolones were most often prescribed (43% and 38%, respectively). Intraoperative stent placement, positive urine culture within 30 days prior to surgery, and a positive urine culture within 1 year prior to surgery predicted antibiotic prescription. No significant differences were seen in rates of positive postoperative urine culture rates between cohorts that received antibiotics postoperatively vs those who did not. ConclusionsAt our academic institution, we observed poor concordance with the AUA best practice statement for perioperative antibiotic prescription after ambulatory endoscopic urologic surgery. Rates of positive postoperative cultures were low and not associated with receipt or duration of antibiotic prescription at the time of surgery, supporting minimal use of antibiotics for most endoscopic cases.

875 - Setting the standards: Examining research productivity amongst academic urologists in the United States and Canada in 2019

875 - Setting the standards: Examining research productivity amongst academic urologists in the United States and Canada in 2019