Individual Urologist Research Articles

The initial results of MRI-TRUS fusion prostate biopsy in high volume tertiary center.

Multiparametric magnetic resonance imaging (mpMRI) is a prerequisite for targeted prostate biopsy. The aim of our study was to evaluate the performance and learning curve of the mpMRI-transrectal ultrasound (TRUS) software image fusion (MRI-TRUS fusion) biopsy (BX) process in the first year after its introduction in our urology department. MRI-TRUS fusion BX was performed in 293 patients with at least one Prostate Imaging-Reporting and Data System (PIRADS) ≥3 lesion. The proportion of patients and lesions with positive histopathologic result for prostate cancer (PCa) was analyzed. The learning curve for MRI-TRUS fusion BX was assessed at institutional and individual level. Positive BX lesions were further analyzed by PIRADS and Gleason scores. The proportion of patients with positive histopathologic results for targeted BX, systematic BX, and combined BX was 53.9%, 47.9%, and 63.5%, respectively. The chi-square test for the proportion of PCa positive patients showed no significant difference between the time-based patient groups at the institutional level and no significant difference between individual urologists. PIRADS score (p < 0.001), total PSA concentration (p = 0.05), prostate volume (p < 0.001) and number of cores per lesion (p = 0.034) were significant predictors of a positive histopathologic result in a lesion-based analysis. Clinically significant PCa (csPCa) was confirmed in 34.7% of the 412 BX lesions and 76.4% of the 187 positive PCa lesions. MRI-TRUS fusion targeted BX significantly improves the overall rate of PCa detection compared with systematic BX alone. No steep learning curve was observed in our urologists. The proportion of lesions with clinically insignificant PCa was low, limiting overdiagnosis of PCa.

Does Urologist-level Utilization of Active Surveillance for Low-risk Prostate Cancer Correspond with Utilization of Active Surveillance for Small Renal Masses?

Active surveillance (AS) for prostate cancer (CaP) or small renal masses (SRMs) helps in limiting the overtreatment of indolent malignancies. Implementation of AS for these conditions varies substantially across individual urologists. We examined the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry to assess for correlation of AS between patients with low-risk CaP and patients with SRM managed by individual urologists. We identified 27 urologists who treated at least ten patients with National Comprehensive Cancer Network low-risk CaP and ten patients with SRMs between 2017 and 2021. For surgeons in the lowest quartile of AS use for low-risk CaP (<74%), 21% of their patients with SRMs were managed with AS, in comparison to 74% of patients of surgeons in the highest quartile (>90%). There was a modest positive correlation between the surgeon-level risk-adjusted proportions of patients managed with AS for low-risk CaP and for SRMs (Pearson correlation coefficient 0.48). A surgeon’s tendency to use AS to manage one low-risk malignancy corresponds to their use of AS for a second low-risk condition. By identifying and correcting structural issues associated with underutilization of AS, interventions aimed at increasing AS use may have effects that influence clinical tendencies across a variety of urologic conditions. Patient summaryThe use of active surveillance (AS) for patients with low-risk prostate cancer or small kidney masses varies greatly among individual urologists. Urologists who use AS for low-risk prostate cancer were more likely to use AS for patients with small kidney masses, but there is room to improve the use of AS for both of these conditions.

Differences in the Urinary Microbiome of Patients with Overactive Bladder Syndrome with and without Detrusor Overactivity on Urodynamic Measurements.

It has been hypothesized that the urinary microbiome might play an important role in OAB. Studies have been conducted on the association between OAB symptoms and the microbiome, although a possible causality still has to be determined. In this study, 12 female patients, ≥18 years of age, with 'OAB DO+' and 9 female patients with 'OAB DO-' were included. Patients were excluded if they met one of the following exclusion criteria: bladder tumors and previous bladder operations; sacral neuromodulation; injection of Botox in the bladder; and TOT or TVT operations. Urine samples were collected and stored with patient informed consent and with the approval of the Hospital Ethical Review Board (Arnhem-Nijmegen). All OAB patients underwent urodynamics before collecting urine samples, and the diagnosis of detrusor overactivity was confirmed by two individual urologists. In addition, samples from 12 healthy controls who did not undergo urodynamic evaluation were analyzed. The 16S rRNA V1-V2 region amplification and gel electrophoresis were used to determine the microbiota. 12 of the OAB patients had DO shown on their urodynamic studies; the remaining 9 patients had a normoactive detrusor on their urodynamic measurements. Overall, there were no substantial differences among the demographic characteristics of the subjects. The samples were classified as the following: 180 phyla, 180 classes, 179 orders, 178 families, 175 genera, and 138 species. The least commonly observed phyla were Proteobacteria, with an average presence of 10%, followed by Bacteroidetes with 15%, Actinobacteria with 16%, and Firmicutes with 41%. Most of the sequences could be classified according to the genus level for each sample. Significant differences were observed in the urinary microbiome of patients with overactive bladder syndrome who have detrusor overactivity on urodynamics compared to OAB patients without detrusor overactivity and matched controls. OAB patients with detrusor overactivity have a significantly less diverse microbiome and show a higher proportion of Lactobacillus, particularly Lactobacillus iners. The results imply that the urinary microbiome could be involved in the pathogenesis of a specific phenotype of OAB. The urinary microbiome could be a new starting point to study the causes and treatments of OAB.

MP48-03 QUALITY MEASURES REPORTED BY UROLOGISTS IN THE MERIT-BASED INCENTIVE PAYMENT SYSTEM

You have accessJournal of UrologyCME1 Apr 2023MP48-03 QUALITY MEASURES REPORTED BY UROLOGISTS IN THE MERIT-BASED INCENTIVE PAYMENT SYSTEM Avinash Maganty, Noah Krampe, Anup Shah, and Vishnukamal Golla Avinash MagantyAvinash Maganty More articles by this author , Noah KrampeNoah Krampe More articles by this author , Anup ShahAnup Shah More articles by this author , and Vishnukamal GollaVishnukamal Golla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The majority of urologists are required to participate in merit-based incentive payment system (MIPS) –a Medicare-mandate reporting system in which physicians must track and report quality measures. Medicare adjusts physician reimbursement based on performance across these measures, with the intention to improve the quality of patient care. However, very few MIPS measures are relevant to urology patients and it is unclear what measures urologists are choosing to track and report. METHODS: We performed a cross-sectional analysis of MIPS measures reported by urologists for the most recent performance year. Urologists were categorized by their reporting affiliation (i.e., individual, group, or alternative payment model [APM]). We identified the measures which were most frequently reported by urologists. Among all measures reported, we identified those that were “topped out” (i.e., measures considered indiscriminate by Medicare because high performance is easily achieved) and those which were relevant for patients with urologic conditions (i.e., MIPS urology measures, qualified urologic registry measures, or those relevant to surgical care). RESULTS: 8,297 urologists reported in MIPS during the 2020 performance year, of whom 14% reported as an individual, 56% as a part of a group, and 30% as part of an APM. Among the top 10 most frequently reported measures, none were specific for urologic care (Table 1). 65% of individual urologists, 58% of those in groups, and 92% in APMs reported at least 1 or more “topped out” measures. Only 11% of urologists reported measures that were directly relevant to patients with urologic conditions. CONCLUSIONS: Most measures reported by urologists are not directly relevant to patients with urologic conditions and remain a poor indicator of the quality of urologic care provided. As Medicare transitions MIPS to condition specific quality measures, it will be important for the urology community to develop and submit measures that will be most impactful for patients. Source of Funding: Avinash Maganty is supported by funding from the National Cancer Institute Ruth L. Kirschstein Postdoctoral Award F32 Grant F32 CA275021-01 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e655 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avinash Maganty More articles by this author Noah Krampe More articles by this author Anup Shah More articles by this author Vishnukamal Golla More articles by this author Expand All Advertisement PDF downloadLoading ...

Merit-based Incentive Payment System Quality Reporting in Urology Practices.

Most urologists are required to participate in Merit-based Incentive Payment System-an alternative payment model in which physicians must track and report quality measures. However, Merit-based Incentive Payment System measures are urology-specific, and it remains unclear what measures urologists are choosing to track and report. We performed a cross-sectional analysis of Merit-based Incentive Payment System measures reported by urologists for the most recent performance year. Urologists were categorized by their reporting affiliation (ie, individual, group, or alternative payment model). We identified the measures most frequently reported by urologists. Among reported measures, we identified those that were specific to urological conditions and those that were "topped out" (ie, measures considered indiscriminate by Medicare because high performance is easily achieved). A total of 6,937 urologists reported in Merit-based Incentive Payment System during the 2020 performance year, of whom 14% reported as an individual, 56% as a group, and 30% as an alternative payment model. Among the top 10 most frequently reported measures, none were urology-specific. Eleven percent of urologists reported measures that were directly specific to urological conditions; 65% of individual urologists, 58% of those in groups, and 92% in alternative payment models reported at least 1 or more "topped out" measures. Most measures reported by urologists are not specific to urological conditions, and therefore performance within Merit-based Incentive Payment System may be a poor indicator of the quality of urological care provided. As Medicare transitions Merit-based Incentive Payment System to implement specific quality measures, the urological community will need to develop and submit measures that will be most impactful for urology patients.

Exploring Variation in the Receipt of Recommended Active Surveillance for Men with Favorable-Risk Prostate Cancer.

Men on active surveillance for favorable-risk prostate cancer do not receive all the recommended testing. Reasons for variation in receipt are unknown. We combined prospective registry data from the Michigan Urological Surgery Improvement Collaborative, a collaborative of 46 academic and community urology practices across Michigan, with insurance claims from 2014 to 2018 for men on active surveillance for favorable-risk prostate cancer. We defined receipt of recommended surveillance according to the collaborative's low-intensity criteria as: annual prostate specific antigen testing and either magnetic resonance imaging or prostate biopsy every 3 years. We assessed receipt of recommended surveillance among men with ≥36 months of followup (246). We conducted multilevel analyses to examine the influence of the urologist, urologist and primary care provider visits, and patient demographic and clinical factors on variation in receipt. During 3 years of active surveillance, just over half of men (56.5%) received all recommended surveillance testing (69.9% annual prostate specific antigen testing, 72.8% magnetic resonance imaging/biopsy). We found 19% of the variation in receipt was attributed to individual urologists. While increasing provider visits were not significantly associated with receipt, older men were less likely to receive magnetic resonance imaging/biopsy (≥75 vs <55 years, adjusted odds ratio 0.07; 95% confidence interval 0.01-0.81). Nearly half of men on active surveillance for favorable-risk prostate cancer did not receive all recommended surveillance. While urologists substantially influenced receipt of recommended testing, exploring how to leverage patients and their visits with their primary care providers to positively influence receipt appears warranted.

Urologist Scores in the Era of the Merit-Based Incentive Payment System (MIPS).

The shift from fee-for-service to value-based payment introduces a new set of challenges and opportunities for the practicing physician. It is unknown how urologists have been impacted by the recent implementation of the merit-based incentive payment system (MIPS). We describe the MIPS performance scores of urologists and investigate their association with practice patterns. Urologists were identified in the 2018 MIPS performance score database and classified by participation status: individual practice, group practice or alternative payment model (APM). The overall MIPS score is comprised of 4 categories: quality, promoting interoperability, cost and improvement activities. Comparative statistics were performed using Tukey's honest significance test and chi-square analysis. Multinomial logistic regression was performed to test associations. A total of 9,055 urologists were included with the following average scores: quality 82.5, promoting interoperability 88.9, cost 74.4, improvement activities 37.3 and overall 86.9. When stratified by participation status, urologists in group practices scored higher than individual urologists in each category except cost; urologists in APMs often scored even higher. Preference for group practice or APMs was more common among urologists who graduated medical school more recently. Geographic location also appears to be a contributing factor when evaluating practice type. Urologists who participated as a group practice or APM scored higher across most MIPS categories than those in an individual practice. Introduction of a new reimbursement schedule will likely result in further evolution of practice patterns in the future.

ПРОБЛЕМЫ НОРМАТИВНОГО И КАДРОВОГО ОБЕСПЕЧЕНИЯ УРОЛОГИЧЕСКОЙ ПОМОЩИ, ОКАЗЫВАЕМОЙ В АМБУЛАТОРНЫХ УСЛОВИЯХ ВЗРОСЛОМУ И ДЕТСКОМУ НАСЕЛЕНИЮ

Significance. The regulatory and staffing problems in urological care delivery to adults and children in outpatient settings, combined with the high social significance of diseases of the genitourinary system for the population of different age, potentially threaten successful implementation of the priorities of the state demographic policy. Purpose: to identify problems in regulation and staffing in urological care delivery to adults and children on the outpatient basis in the Russian Federation in 2015-2019. Material and methods. The study used data of the Fedral statistical observation Form No. 30 "Information about a medical organization" for the period 2015-2019. Statistical processing of the study materials was carried out by methods of descriptive statistics. Results. The analysis has identified contradictions in the orders of the Ministry of Health of the Russian Federation, which currently regulate staffing in urological care. The number of full-time and occupied positions of urologists in 2015-2019 decreased, which, coupled with the increased number of individuals, resulted in the increased number of urologists (+3.1%), increased level of staffing of individuals up to 62.9%. At the same time, the part-time coefficient among urologists remained high adding up to to 1.3. In 2015-2019, the number of full-time and occupied positions and individual pediatric urologists-andrologists increased, against the background of extremely low staffing level of individuals equalling to 26.7% in 2019 without any significant dynamics over a 5-year period. The function of the urologist position remained unchanged (4072 appointments per position in 20194 and 4181.3 in 2015), while the function of the pediatric urologist-andrologist position increased from 4215 appointments per position in 2015 to 5342 in 2019 (+ 26,7%). The integral staffing coefficient had a negative trend especially in relation to pediatric urologists-andrologists. Conclusions. The growth in the number of individual urologists and pediatric urologists-andrologists in 2015-2019 did not result in any significant changes in the staffing levels in the urological care delivery to adults and children on the outpatient basis. It is necessary to update the staffing standards, objectify statistical reporting and take urgent measures to bridge the shortage of doctors in outpatient settings. Scope of application. The study results can be used for timely updates of regulatory legal acts, staffing schedules of medical organizations in planning and implementing human resource programs aimed at eliminating personnel shortages and imbalances.

PD39-12 UROLOGIST-LEVEL UTILIZATION PATTERNS OF CYTOREDUCTIVE SURGERY FOR METASTATIC RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Advanced (including Drug Therapy) II (PD39)1 Apr 2020PD39-12 UROLOGIST-LEVEL UTILIZATION PATTERNS OF CYTOREDUCTIVE SURGERY FOR METASTATIC RENAL CELL CARCINOMA Joseph Cheaib*, Julia Wainger, Hiten Patel, Mitchell Huang, Meredith Metcalf, Michael Biles, Russell Becker, Joseph Canner, Michael Johnson, Mohamad Allaf, and Phillip Pierorazio Joseph Cheaib*Joseph Cheaib* More articles by this author , Julia WaingerJulia Wainger More articles by this author , Hiten PatelHiten Patel More articles by this author , Mitchell HuangMitchell Huang More articles by this author , Meredith MetcalfMeredith Metcalf More articles by this author , Michael BilesMichael Biles More articles by this author , Russell BeckerRussell Becker More articles by this author , Joseph CannerJoseph Canner More articles by this author , Michael JohnsonMichael Johnson More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , and Phillip PierorazioPhillip Pierorazio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000918.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cytoreductive surgery (CS) has been integral in the multimodal management of patients with metastatic renal cell carcinoma (mRCC) in the tyrosine kinase inhibitor (TKI) era. Its role, however, has recently come into question with the release of data from prospective trials. Accordingly, reporting current urologist-level patterns of utilization of CS would be important to evaluate the impact of such findings on future CS implementation. METHODS: We performed a population-based study of patients diagnosed with mRCC from 2004 to 2013 using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Patients were assigned to a specific primary urologist using Medicare physician specialty codes. A multivariable mixed-effects logistic model was fit to evaluate the association between the use of CS and select patient characteristics, assuming a urologist-level random intercept to account for correlation among urologists. From the model, the predicted probability of using CS was obtained for each urologist. RESULTS: A total of 4226 patients with mRCC and 1964 primary urologists were identified. On average, each urologist saw 3 patients (range: 1-35 patients). Overall, 1370 (32%) patients underwent CS for mRCC; CS included radical nephrectomy (N=1285, 94%), partial nephrectomy (N=55, 4%), and thermal ablation (N=30, 2%). Median age was 75 years (IQR: 70-81 years), and median tumor size was 7.3 cm (IQR: 5-10 cm). Table 1 shows the patient characteristics and predictors of CS. At the individual urologist level, the estimated probability of using CS varied from 26.9% to 38.7% (mean: 32.2%) (Figure 1). Of the 1964 urologists, 1077 (55%) never offered CS. CONCLUSIONS: Significant variation exists in the utilization of CS, with 27-39% of patients undergoing CS and 55% of urologists never offering CS to patients with mRCC in the TKI era. These data serve as a benchmark to measure continued changes in the use of CS in the contemporary era, with randomized clinical trials demonstrating little benefit to CS in patients with poor-risk mRCC. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e813-e814 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Cheaib* More articles by this author Julia Wainger More articles by this author Hiten Patel More articles by this author Mitchell Huang More articles by this author Meredith Metcalf More articles by this author Michael Biles More articles by this author Russell Becker More articles by this author Joseph Canner More articles by this author Michael Johnson More articles by this author Mohamad Allaf More articles by this author Phillip Pierorazio More articles by this author Expand All Advertisement PDF downloadLoading ...

PD28-07 ONLINE ACCESS TO PENILE PROSTHETIC SURGEONS: THE CHALLENGE OF FINDING A SPECIALIST

You have accessJournal of UrologySexual Function/Dysfunction: Evaluation I (PD28)1 Apr 2020PD28-07 ONLINE ACCESS TO PENILE PROSTHETIC SURGEONS: THE CHALLENGE OF FINDING A SPECIALIST Caleb Cooper*, Richard Fantus, Brian Helfand, Robert Brannigan, Nelson Bennet, and Joshua Halpern Caleb Cooper*Caleb Cooper* More articles by this author , Richard FantusRichard Fantus More articles by this author , Brian HelfandBrian Helfand More articles by this author , Robert BranniganRobert Brannigan More articles by this author , Nelson BennetNelson Bennet More articles by this author , and Joshua HalpernJoshua Halpern More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000892.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: When performed by experienced urologists, penile prosthesis implantation has lower infection and reoperation rates. Recent literature suggests that the Internet has become an increasingly popular source of information for patients regarding erectile dysfunction. We examined internet search results to understand the ease with which patients can identify a penile prosthetic specialist online. METHODS: An internet search was conducted using the term "penile prosthesis surgeon <state>" for all 50 states and Washington, DC. The first ten results (i.e. first page) of each search were evaluated for website type, practice type (individual or group-based), academic or private-practice affiliation, and Sexual Medicine Society of North America (SMSNA) affiliation. Descriptive statistics were used to summarize the findings. We examined search position rank (1-10) to determine the likelihood of finding a SMSNA-affiliated provider. RESULTS: A total of 510 search results were obtained, with 508 leading to active sites. Of these sites, 72 (14.1%) were links to individual urologists, 123 (24.2%) to group-based urologists, 46 (9.0%) to out-of-state providers, and 13 (2.8%) to non-urologist providers. An additional 25.7% led to directory sites, 9.8% to academic articles, 12.6% to non-academic and news articles, and 1.8% to industry-related websites. Of the results that linked to urologists, 20.6% had an academic-affiliation and 79.4% were non-academic or private-practice affiliated. A total of 39.3% of the individual and group-urologist results linked to a SMSNA member provider. The mean search position for SMSNA-affiliated results was 5.5 ±2.8. Of all search results in a top-3 position, only 28 (18%) of the results represented SMSNA member urologists. CONCLUSIONS: For many people, the search for goods & services begin online. In fact, 80% of Internet users have searched for health-related topics online. Interestingly, we found less than 50% of internet search results linked to a urologist specializing in penile prosthetics. Furthermore, less than a quarter of all top-3 search results led to an SMSNA-affiliated urologist. Our data show that there is a need for an online, centralized, search-optimized, continually updated database that will provide prospective patients with information & realistic expectations in the area of penile prosthetics. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e614-e614 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Caleb Cooper* More articles by this author Richard Fantus More articles by this author Brian Helfand More articles by this author Robert Brannigan More articles by this author Nelson Bennet More articles by this author Joshua Halpern More articles by this author Expand All Advertisement PDF downloadLoading ...

Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery: An Expert Panel Consensus

Opioids are frequently overprescribed after surgery. The 2018 AUA position statement on opioid use suggests using the lowest dose and potency to achieve pain control but the lack of procedure specific prescribing guidelines contributes to wide variation in prescribing patterns. To address this gap we aimed to develop opioid prescribing recommendations through an expert panel consensus. The 15-member multidisciplinary expert panel included representatives from 5 stakeholder groups. A 3-step modified Delphi method was used to develop recommendations for postoperative opioid prescribing. Recommendations were made for opioid naïve patients without chronic pain conditions. The panel used oxycodone 5 mg equivalents to define the number of prescribed tablets. Procedure specific recommendations were developed for 16 endourological and minimally invasive urological procedures. The panel agreed that not all patients desire or require opioids and, thus, the minimum recommended number of opioid tablets for all procedures was 0. Consensus ranges were identified to allow prescribed quantities to be aligned with expected needs. The maximum recommended quantity varied by procedure from 0 tablets (3 procedures) to 15 tablets (6 procedures) with a median of 10 tablets. Attending urologists typically voted for higher opioid quantities than nonattending panel members. The panel identified 8 overarching strategies for opioid stewardship, including contextualizing postoperative pain management with patient goals and preferences, and maximizing nonopioid therapies. Procedure specific guidelines for postoperative opioid prescribing may help align individual urologist prescribing habits with consensus recommendations. These guidelines can aid quality improvement efforts to reduce overprescribing in urology.

The "Acute" Stone Clinic Effect: Improving Healthcare Delivery by Reorganizing Clinical Resources.

To determine the time to specialist urologic consultation and definitive management after establishing a subspecialist administered acute stone clinic (ASC) for adults with symptomatic upper tract stones in a publically funded universal healthcare system. We retrospectively reviewed 337 adult referrals for stone management. Three distinct 9-week periods were assessed. Group 1 patients were seen/treated by their individual urologist before inception of a general urology emergency clinic (pre-EC). Group 2 patients were seen in a pooled EC and Group 3 patients were seen in the ASC. A total of 337 patients (75, pre-EC; 91, EC; 171, ASC) were reviewed. Mean time to consultation for pre-EC, EC, and ASC cohorts was 29, 7, and 7 days, respectively (p < 0.05), whereas loss to follow-up decreased from 13% to 5% (p < 0.05). On average, the number of patients seen per week increased from 9 to 20. Mean time to stone surgery from date of referral was 75 days pre-EC, 43 days EC, and 25 days ASC (p < 0.05). The percentage of patients undergoing surgery was between 59% and 63% per cohort; however, the number of patients increased from 5 to 11 per week. By reorganizing clinical resources, a dedicated ASC was able to increase patient capacity, reduce time to urologist consultation and reduce surgical wait times.

Urologist-Level Correlation in the Use of Observation for Low- and High-Risk Prostate Cancer

The reporting of individual urologist rates of observation for localized prostate cancer may be a valuable performance measure with important downstream implications for patient and payer stakeholder groups. However, few studies have examined the urologist-level variation in the use of observation across all risk strata of prostate cancer. To measure variation in the use of observation at the urologist level by disease risk strata and to evaluate the association between the urologist-level rates of observation for men with low-risk and high-risk prostate cancer. With the use of linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, a population-based study of men diagnosed with prostate cancer from January 1, 2004, to December 31, 2009, was performed in SEER catchment areas of the United States. A total of 57 639 men with prostate cancer with 1884 diagnosing urologists were identified. Data were analyzed from October 1 to December 31, 2015. The main outcome was observation, which is defined as the absence of definitive treatment within 1 year of diagnosis. In each risk stratum, a multivariable mixed-effects model was fit to characterize associations between observation and selected patient characteristics. From these models, the estimated probability of observation was calculated for each urologist within each risk stratum, and the association between the physician-level estimated rates of observation for low-risk and high-risk disease was assessed. Among the 57 639 men included in the study, the estimated probability of observation for low-risk disease varied impressively (mean, 27.8%; range, 5.1%-71.2%) at the individual urologist level. Considerably less urologist-level variation was seen in the use of observation for intermediate-risk disease (11.1%; range, 4.8%-31.5%) and high-risk disease (5.8%; range, 3.2%-16.5%). Furthermore, the estimated rates of observation for low- and high-risk disease were correlated at the urologist level (Spearman ρ = 0.17; P < .001). A comparable correlation was likewise observed among urologists with high-volume prostate cancer practices (Spearman ρ = 0.24; P < .001). Considerable urologist-level variation is seen in the use of observation for men with low-risk prostate cancer. More important, the use of observation for low-risk and high-risk patients with prostate cancer is correlated at the urologist level. This study reveals the strikingly variable use of observation among US urologists and establishes a framework for the use of urologist-level treatment signatures as a quality measure in the emerging value-based health care environment.

The Use of Neoadjuvant Chemotherapy in Patients With Urothelial Carcinoma of the Bladder: Current Practice Among Clinicians.

Guidelines recommend neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in patients with urothelial carcinoma of the bladder in clinical stages T2-T4a, cN0M0. We examined the frequency and current practice of NAC and sought to identify predictors for the use of NAC in a prospective contemporary cohort. We analyzed prospective data from 679 patients in the PROMETRICS (PROspective MulticEnTer RadIcal Cystectomy Series 2011) database. All patients underwent RC in 2011. Uni- and multivariable regression analyses identified predictors of NAC application. Furthermore, a questionnaire was used to evaluate the practice patterns of NAC at the PROMETRICS centers. A total of 235 patients (35%) were included in the analysis. Only 15 patients (2.2%) received NAC before RC. Younger age (< 70 years; P= .035), lower case volume of the center (< 30 RC/year; P< .001), and advanced tumor stage (≥ cT3; P= .038) were identified as predictors for NAC. Of the 200 urologists who replied to the questionnaire, 69% (n= 125) declared tumor stage cT3-4 a/o N1M0 to be the best indication for NAC application, although 45% of the urologists stated that they would not perform NAC despite recommendations. The decision for NAC was made by the individual urologist in 69% of cases, and only 29% reported that all cases were discussed in an interdisciplinary tumor board. NAC was rarely applied in the present cohort. We observed a discrepancy between guideline recommendations and practice patterns, despite medical indication and pre-therapeutic interdisciplinary discussion. The potential benefit of NAC within a multimodal approach seems to be neglected by many urologists.

Preparing for the Transition to ICD-10 by Chart Reviews of Four Urology Practice Types.

On October 1, 2015, coding for medical encounters in the United States will change to the International Classification of Diseases and Related Health Problems, 10th revision (ICD-10) code set, replacing the ICD-9 code set. Compared with ICD-9, ICD-10 has a novel structure that is greatly expanded in its specificity. In addition, ICD-10 contains new code types and new billing rules that must be understood for proper coding. This change may create great challenges for providers and billing staff. Providers will need to provide documentation to support the specific code chosen, based on the codes that are available. To evaluate how an individual urologist may be affected by this transition, a review of charts was undertaken. From a random date, 20 consecutive office charts were reviewed from a general urologist, a male health/infertility subspecialist, a pelvic floor/reconstruction subspecialist, and a pediatric subspecialist. The results and an analysis of the review can be used to give a practicing urologist a sense of the transition to ICD-10, and to highlight some challenges that may be expected.

Pad Weight Testing in the Evaluation of Urinary Incontinence

Aim To present the teaching module “Pad Weight Testing in the Evaluation of Urinary Incontinence.” This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations. Methods This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. Results The pad test is a non-invasive diagnostic tool for urinary incontinence. It is an easy to perform, inexpensive test with utilization in both the daily patient care and clinical research. Despite it is clear value in initial diagnosis, selection of treatment, and follow-up evaluation, only less than 10% of urologists perform the test routinely. A number of testing protocols with varying lengths of recording time exist, however, only a 1-hr pad test has been standardized. One-hour pad tests are most suitable in establishing initial diagnosis, the 24-hr test serves most often for evaluation of treatment outcomes, and longer pad tests are used in clinical studies. Conclusions The pad test is clearly underutilized. Well-designed studies providing level one evidence are lacking. Numerous variations in how the test is performed by individual urologists make the evaluation of published literature difficult. Future research goals should include randomized studies leading to establishment of optimal protocols of testing for clinical research and daily care. Neurourol. Urodynam. 33:507–510, 2014. © 2014 Wiley Periodicals, Inc.

Pad weight testing in the evaluation of urinary incontinence

To present the teaching module "Pad Weight Testing in the Evaluation of Urinary Incontinence." This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations. This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. The pad test is a non-invasive diagnostic tool for urinary incontinence. It is an easy to perform, inexpensive test with utilization in both the daily patient care and clinical research. Despite it is clear value in initial diagnosis, selection of treatment, and follow-up evaluation, only less than 10% of urologists perform the test routinely. A number of testing protocols with varying lengths of recording time exist, however, only a 1-hr pad test has been standardized. One-hour pad tests are most suitable in establishing initial diagnosis, the 24-hr test serves most often for evaluation of treatment outcomes, and longer pad tests are used in clinical studies. The pad test is clearly underutilized. Well-designed studies providing level one evidence are lacking. Numerous variations in how the test is performed by individual urologists make the evaluation of published literature difficult. Future research goals should include randomized studies leading to establishment of optimal protocols of testing for clinical research and daily care.

Narrow‐band imaging cystoscopy to evaluate bladder tumours – individual surgeon variability

Diagnosis (exploratory cohort) Level of Evidence 2b. To assess individual urologist variability using narrow-band imaging (NBI) cystoscopy to evaluate bladder tumours. In all, 50 patients underwent white-light and NBI cystoscopy to evaluate for recurrent bladder tumours. Endoscopic images in each patient were independently viewed by four urologists assessing presence or absence of tumour. Their findings were correlated with biopsy results. In all, 26 patients had recurrent tumour and 24 had benign histology. There were no significant differences among urologists detecting recurrent tumour or in determining final pathology. There does not appear to be a 'learning curve' for adapting to NBI-surveillance cystoscopy in patients with bladder cancer.

Should we train urologists in female urology? A European view

Training in female urology in Europe so far has been a national focus of individual European countries. Because of reasons like differentiation in pathology, activities of other specialisms like gynaecology and reimbursement issues, the way in which extra training in female urology is organized varies a lot. We have already encountered big changes in legislation of working hours and the way in which patients are more and better informed about diseases and treatments. This situation compels us to change and synchronize training in female urology on an international level. In Europe the answers to needs from individual urologists in a pluriform European setting comprise among others Residency Training Programmes in Urology, accredited by the European Board of Urology; a European Training Program for residents (EUREP) and a European Subspeciality Certification certified by the European Board of Urology (EBU). For training in Female Urology the lastest development is the organization of a Masterclass in Female and Functional Urology. This manuscript explains the European Situation and the European answer to the identified challenges.

Waiting time from initial urological consultation to nephrectomy for renal cell carcinoma—does it affect survival?: Stec AA, Coons BJ, Chang SS, Cookson MS, Herrell SD, Smith JA Jr, Clark PE, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

We report survival and recurrence outcomes in all patients undergoing radical or partial nephrectomy for renal cell carcinoma, as related to surgical waiting time. We retrospectively reviewed the records of 722 patients who underwent surgical resection for renal cell carcinoma. Patients were subdivided by waiting time from the initial urology visit until surgery. Surgical waiting time was evaluated as a continuous variable and by monthly subgroups. Univariate and multivariate analyses were performed to evaluate factors associated with overall, disease specific, and recurrence-free survival. Mean time from the first visit to surgery was 1.2 months, with 64.1% and 94.3% of patients undergoing surgery within 30 days and within 3 months, respectively. Overall and disease specific survival was not affected by surgical waiting time regardless of how time was analyzed. On univariate analysis, 5-year recurrence-free survival was poorer in patients undergoing surgery within 1 month vs. more than 1 month (75.7% vs. 88.4%, P = 0.02). On multivariate analysis T stage ( P < 0.0001), grade ( P = 0.009), lymph node involvement ( P = 0.0001), and histology ( P = 0.006) were independent predictors of recurrence-free survival, while surgical waiting time was not ( P = 0.18). Surgical waiting time less than 1 month was associated with higher stage and higher grade tumors ( P < 0.0001 and 0.0006, respectively). Surgical waiting time from initial urological consultation to operative intervention does not adversely affect the outcome of renal cell carcinoma within the time frames analyzed in this study, in which 94% of cases occurred within 3 months. Individual urologist judgment remains a critical factor in the appropriate and timely care of the patient with a suspicious renal mass.