Pediatric Urology Fellowship Research Articles

Assessment of the CDC hypospadias atlas for epidemiological research - A survey of experts

Hypospadias is a common congenital malformation. There are several classification systems for hypospadias. However, the phenotypic subtypes of hypospadias are inconsistently reported across databases due to the inherently subtle variability of the penile anatomy. Consistent classification of hypospadias would enable more accurate data regarding etiological correlates of specific subtypes as well as perioperative care and surgical outcomes. Existing classifications are designed for use by hypospadias surgeons, although there is a need for a system for epidemiologic data abstractors, who are generally not clinicians. The online Center for Disease Control (CDC) manual for birth defect surveillance includes a hypospadias atlas with photograph representation for different hypospadias phenotypic subtypes. However, this atlas is not widely known or used as a reference by pediatric urologists. We sought to evaluate the consistency amongst surgeons who specialize in managing this condition on the classification of hypospadias using the CDC atlas to determine whether this can be a tool in epidemiologic data collection. We developed a questionnaire using photographs taken directly from the CDC atlas for hypospadias. Demographic data regarding geographical location and years in practice also were obtained. The survey was distributed via email to members of the Society for Pediatric Urology and American Association of Pediatric Urologists. Responses were anonymously collected. 166 responses were received from 407 surveys request yielding a response rate of 40.8%. Agreement with the CDC atlas on the classification of hypospadias by responders was 93.4% for glanular hypospadias, 56.6% for subcoronal hypospadias, 3.6% for penile hypospadias, 54.2 for scrotal hypospadias, and 59% for perineal hypospadias. Our survey indicated that there is general disagreement in classification of hypospadias in the CDC atlas amongst members of pediatric urology societies. There exists a need for better standardization of a hypospadias classification system for epidemiologic research in hypospadias. Limitations of our study include a less than 50% of survey responses received and large proportion of responders were from the United States.

The integral co-management role of the medical pediatric urologist: Improving the care of children with urological conditions

The complexities of modern medicine prompt a re-evaluation of traditional patient care models to enhance safety and quality. We implemented a one-year pilot Medical Pediatric Urology fellowship, jointly developed by Urology and Pediatric Hospital Medicine, where a pediatrician received postgraduate training in both specialties. This innovative program aimed to augment knowledge and expertise in non-surgical aspects of pediatric urology. Upon completion of the fellowship, the trained pediatrician assumed the role of medical pediatric urologist (MPU), integrating into both Pediatrics and Urology faculties. Unlike the traditional specialist consultation model, the MPU became integral member of the Urology Division, working full-time and sharing responsibilities for both inpatient and outpatient pediatric urology care at a tertiary pediatric hospital in Canada. This study aims to delineate the training curriculum, role, clinical outcomes, and educational impact of the MPU over eight years. We retrospectively analyzed clinical outcomes, including patient volumes seen annually by MPU, urologists, and nurse practitioners from 2021 to 2023. Clinic wait times and patient satisfaction were compared between MPU's community and tertiary hospital pediatric urology clinics. Educational impact was assessed through pediatric residents' ratings for the MPU as a clinical teacher during urology rotations using a Likert scale. Integration of MPU led to the establishment of specialized clinics, including those for neurogenic bladder and posterior urethral valves. MPU accounted for approximately 34.7% of all outpatient clinic visits. Subjective feedback highlighted enhanced quality of care with MPU co-management in the inpatient setting. Additionally, in a community-based medical urology clinic (CUC) staffed by the MPU and a pediatric urology nurse practitioner, patients experienced shorter wait times and higher satisfaction (53±36 days and 194±108 days) (p<0.01), with 97% vs. 91% of families reported feeling highly satisfied with care (p<0.01) compared with hospital clinics, respectively. The MPU received ratings of 4/5 or 5/5 as a clinical teacher from 81.82% of pediatric residents. Our novel co-management approach in pediatric urology integrates medical and surgical expertise. However, limitations include the retrospective design and single-center setting. Nonetheless, this framework presents a potential model for other surgical specialties, offering a unique practice niche for trainees interested in the medical management of surgical conditions. The medical pediatric urologist plays a pivotal role as an educator, hospitalist, and director of the outpatient clinic, effectively integrating medical and surgical expertise. The MPU model is promising for optimizing safety and quality of care in pediatric urology.

DSD-related attitudes and beliefs held by pediatric endocrinologists and urologists: Insights from the North American disorders/differences of sex development (DSD) clinician survey

Disorders/Differences of Sex Development (DSD) encompass congenital conditions with atypical development of chromosomal, gonadal, or anatomical sex. Due to the rarity and complexity of these conditions, strong evidence for clinical practices is scarce, leading to controversies in management. This study, part of a broader project, examines changes over time in the attitudes and beliefs of DSD healthcare providers, focusing on factors contributing to patients' life satisfaction and the influence of medical specialty, gender, and age. Participants included active members of the Pediatric Endocrine Society (PES) and the Societies for Pediatric Urology (SPU) at three time points: 2003-2004 (T1), 2010-2011 (T2), and 2020 (T3). A survey covering predictors of patient life satisfaction, attitudes and beliefs regarding DSD care and outcomes, and participant characteristics was administered. Data were analyzed using descriptive statistics and Generalized Estimating Equations (GEE). Demographics: Participation rates were 56% (PES) and 64.7% (SPU) at T1, 41.1% (PES) and 52.3% (SPU) at T2, and 25.6% (PES) and 51.2% (SPU) at T3. Most participants were male (T1: 70.6%, T2: 61.7%, T3: 70.6%). Factors Affecting Life Satisfaction: Both endocrinologists and urologists ranked "gender identity consistent with assigned sex" as most important. Over time, the endorsement of some factors, such as performing genital surgery at Centers of Excellence, increased, while others, like the influence of prenatal androgen exposure determining gender identity, varied by specialty and gender. Attitudes and Beliefs: Across 18 statements, responses indicated three clusters with strong agreement, moderate agreement, and strong disagreement. Statements on the importance of family background and avoiding gender discordance were consistently endorsed, while those on delaying hypospadias repair until consent were least endorsed. The study highlights variability in beliefs about DSD management over time, influenced by specialty, gender, and age. Despite consensus on some care principles, discrepancies remain, particularly regarding the impact of prenatal androgens and the timing of surgical interventions. These findings underscore the need for regular interdisciplinary communication to align clinical practices with evidence-based guidelines and address subjective beliefs. The survey illustrates evolving perspectives among DSD healthcare providers, emphasizing the need for continued dialogue and education to bridge gaps between clinical evidence and practice. Collaborative efforts, such as the international I-DSD and the U.S. DSD Translational Research Network, are crucial for advancing patient-centered care in this field.

The development of surgical ability during pediatric urology fellowship and its evolution in the early years of practice

The development of surgical ability during pediatric urology fellowship and its evolution in the early years of practice

Recommendations for 46,XY Disorders/Differences of Sex Development Across Two Decades: Insights from North American Pediatric Endocrinologists and Urologists

Clinical decision-making for individuals with 46,XY disorders/differences of sex development (DSD) remains unsettled and controversial. The North American DSD Clinician Survey examines the recommendations of a large group of clinical specialists over the last two decades. Active members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology were invited to respond to a web-based survey at three different timepoints: 2003–2004 (T1), 2010–2011 (T2), and 2019–2020 (T3). Data from 429 participants in T1, 435 in T2, and 264 in T3 were included in this study. The participants were presented with three XY newborn clinical case scenarios—micropenis, partial androgen insensitivity syndrome, and iatrogenic penile ablation—and asked for clinical management recommendations. The main outcomes assessed included the recommended gender of rearing, surgical decision-maker (parent or patient), timing of genital surgery, and age at which to disclose medical details and surgical history to the patient. For all scenarios, the overwhelming majority recommended rearing as male, including a significant increase across timepoints in those recommending a male gender of rearing for the infant with penile ablation. The proportions recommending female gender of rearing declined significantly across timepoints. In general, most recommended parents (in consultation with the physician) serve as surgical decision-makers, but these proportions declined significantly across timepoints. Recommendations on the timing of surgery varied based on the patient’s gender and type of surgery. There has been a shift in recommendations away from the “optimal gender policy” regarding gender of rearing and surgical interventions for patients with XY DSD.

Pediatric Urologists' Views on the U.S. News & World Report Rankings.

Our goal was to understand the general attitudes of pediatric urologists regarding the U.S. News & World Report rankings for Best Children's Hospitals in Urology. We performed a cross-sectional survey study distributed via email to active and candidate members of the Societies for Pediatric Urology from October 2022 to December 2022. This anonymous survey was iteratively developed to contain multiple choice questions gathering information on demographics, personal interaction with the rankings system, and about attitudes toward the rankings across various domains. Of the 515 members surveyed, 264 pediatric urologists responded to the survey for a response rate of 51%. There was representation from all sections of the AUA and across all age categories and practice models. Overall, of the respondents, 71% disagreed that the rankings had led to improvements in care and 75% disagreed that programs were reporting their data honestly. Additionally, 71% believed the rankings are inaccurate in reflecting patient outcomes. The majority (86%) of respondents stated they would support organized efforts to withdraw from the rankings. This was significantly different by ranking cohort, with 78% from top 10 programs endorsing withdrawal vs 89% from those programs not in the top 10. Our survey found that most pediatric urologists would support efforts to withdraw from participating in the rankings and believe that programs are dishonest in reporting their data. The majority also do not believe a survey can adequately distinguish between programs. This highlights a clear need for a critical reevaluation of the rankings.

Recommendations for 46,XX Congenital Adrenal Hyperplasia Across Two Decades: Insights from the North American Differences of Sex Development Clinician Survey

Several aspects of clinical management of 46,XX congenital adrenal hyperplasia (CAH) remain unsettled and controversial. The North American Disorders/Differences of Sex Development (DSD) Clinician Survey investigated changes, over the last two decades, in clinical recommendations by specialists involved in the management of newborns with DSD. Members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology participated in a web-based survey at three timepoints: 2003–2004 (T1, n = 432), 2010–2011 (T2, n = 441), and 2020 (T3, n = 272). Participants were presented with two clinical case scenarios—newborns with 46,XX CAH and either mild-to-moderate or severe genital masculinization—and asked for clinical recommendations. Across timepoints, most participants recommended rearing the newborn as a girl, that parents (in consultation with physicians) should make surgical decisions, performing early genitoplasty, and disclosing surgical history at younger ages. Several trends were identified: a small, but significant shift toward recommending a gender other than girl; recommending that adolescent patients serve as the genital surgery decision maker; performing genital surgery at later ages; and disclosing surgical details at younger ages. This is the first study assessing physician recommendations across two decades. Despite variability in the recommendations, most experts followed CAH clinical practice guidelines. The observation that some of the emerging trends do not align with expert opinion or empirical evidence should serve as both a cautionary note and a call for prospective studies examining patient outcomes associated with these changes.

Putting the coach in the game: Current and future state of surgical coaching in pediatric urology

Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program. Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership. Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below). While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.

Prevalence of and factors associated with burnout in pediatric urology fellows

The 2016 AUA census found 39% of practicing urologists experienced burnout. Burnout is a syndrome of emotional exhaustion, depersonalization, and decreased feelings of personal accomplishment due to workplace stress. Despite the demands of training, little is known about the prevalence of burnout in pediatric urology fellows. To determine the prevalence of burnout in pediatric urology fellows and factors associated with higher levels of burnout. The Maslach Burnout Inventory (MBI) and an anonymous survey of personal and training characteristics were distributed electronically to pediatric urology fellows in April 2023. The MBI is a standardized and validated 22-item questionnaire used to quantify burnout and is comprised of three subscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). As per prior literature, higher scores in EE (>27) or DP (>10) were defined as high burnout. Demographic and training characteristics were compared between fellows with high and low to moderate levels of burnout with t tests and Fischer's exact tests. The survey response rate was 85% (29/34); 48% clinical fellows, 52% research fellows. Mean age of respondents was 31.4 years (SD 2.6), 59% female, 70% married, and 37% a parent. Mean scores for EE, DP, and PA were 15 (SD 10.2), 4 (SD 4.0), and 39 (SD 10.3), respectively, with no significant difference between year in fellowship. Nineteen percent of fellows met criteria for high burnout and 41% met criteria for moderate to high burnout based on EE or DP scores. Factors significantly associated with high burnout included number nights of call per month and number of projects required to complete in fellowship. Strategies fellows used most to combat burnout included quality time with family and friends, sleep, exercise, and watching TV/movies. Nearly 20% of pediatric urology fellows scored for high levels of burnout and over 40% scored for moderate to high levels of burnout. There appears to be an association with increased call and project workload requirements with increased levels of burnout, and efforts to combat burnout could specifically address these factors. Fellows with more children at home had lower levels of burnout, and many trainees described quality time with family and friends as their preferred strategy to prevent burnout. This survey-based study identifies risk factors for burnout in pediatric urology fellows. Fellows can use the information presented to consider personalized strategies to prevent burnout through training and into their careers.

Editorial comment to “Current state of inclusion and diversity in pediatric urology fellowship programs”

Editorial comment to “Current state of inclusion and diversity in pediatric urology fellowship programs”

Incidence and predictors of delays in starting fellowship training in urology.

The completion of residency and start of fellowship training marks a critical transition for urologists in the pursuit of subspeciality training. Most graduating urology residents are under contract until June 30, and most fellowships are scheduled to begin on July 1. There has been no investigation into the practical implications of fellowship delays in urology from a trainee perspective. Our research study aimed to investigate the incidence and predictors of delays in fellowship starts. Pediatric urology fellows that began their fellowship training between 2019 and 2023 and endourologic fellows that began their fellowship training between 2017 and 2022 were surveyed using SurveyMonkey®. A total of 250 endourology (EU) fellows and 90 pediatric urology (PU) fellows were contacted. A total of 26.0% and 14.3% of EU and PU fellows, respectively, experienced a delay in their training, despite many leaving their residency positions early (33.8% vs. 44.9%, p=0.2097); 11.7% and 8.2% of EU and PU fellows, respectively, experienced delays they reported to be "very stressful" and 9.1% and 4.1%, respectively, found them "somewhat stressful." Delays of 2-4 weeks were experienced by 5.2% and 6.1%, 4-6-week delays by 7.8% and 4.1%, and delays >6 weeks by 2.6% and 0% of EU and PU fellows, respectively (p=0.0007). Delays in fellowship training do occur at a notable rate, despite nearly half of urology fellows leaving their residency training positions early, with unclear impacts on patient care and resident colleague well-being. This research highlights the importance of fellowship programs considering delaying fellowship starts to mid-July or August, with support of the prior fellow cohorts.

The birth of pediatric urology in the United States: From pioneers to subcertification

Pediatric urology is a subspecialty of urology that emerged from a culture in which children with urological disorders were cared for by general urologists and general pediatric surgeons. The development of pediatric urology as a subspecialty was years in the making, highlighted by individuals who recognized that children with urological conditions were not just "small adults," but required special experience and training. Subspecialization was initiated by persistent visionaries who recognized the need for a trained cadre of experts to provide better care for children. It took the coordinated effort of all subgroups and leaderships in pediatric urology to push these efforts over the goal line. The focus of this review is to highlight certain individuals who played major roles in this vision and to document the efforts of many to coordinate the pathways to sub-specialization. The careers of Meredith F. Campbell and Frank B. Bicknell were researched to identify their rationale and roles in developing pediatric urology as a distinct medical specialty in the United States. In addition, the minutes of the meetings of the Pediatric Urology Advisory Council (PUAC) with the American Board of Urology (ABU) were reviewed. The origins of the Society for Pediatric Urology (SPU) and the American Academy of Pediatrics Section of Urology (AAP-SOU) were researched. The contributions of each to the certification of pediatric urology as a distinct subspecialty was delineated. Campbell was Chair of Urology at the New York University (NYU) School of Medicine and wrote prolifically about pediatric urology. He published one of the first practical textbooks in pediatric urology, almost completely self-written, in 1937. Bicknell, a general urologist in Michigan on the faculty at Wayne State University School of Medicine, led the initiative to create the Society for Pediatric Urology (SPU) that first met at the 1951 annual American Urological Association (AUA) meeting in Chicago and included nine attendees. Subsequently, John Lattimer (College of Physicians and Surgeons at Columbia University) organized a well-attended meeting of urologists interested in pediatrics at the 1964 annual AAP meeting in New York City. This led to the formation of the AAP Section on Urology. Integral to the justification for the development of a subspecialty was evidence of a published corpus of content. In addition to published textbooks devoted exclusively to pediatric urology, this was further fulfilled by the AAP Section on Urology Pediatric Supplement to the Journal of Urology, first published in 1986, and later with the Journal of Pediatric Urology in 2005. The SPU and the AAP Section on Urology came together to form the Pediatric Urology Advisory Council (PUAC) in 2000, which worked with the ABU to create subspecialty certification in pediatric urology with an independent exam, first administered in 2008 to 176 applicants. The metaphor "We have stood on the shoulders of giants" is apt for pediatric urology: Meredith Campbell, Frank Bicknell, David Innes Williams (Hospital for Sick Children, London), and J. Herbert Johnston (Alder Hay Hospital, Liverpool) come to mind among the first generation of pediatric urology pioneers, and others among their colleagues also had significant impact. Clearly this is a story of persistence and attention to detail on the part of those giants and those who followed. Pediatric urology became a distinct discipline after the SPU and AAP-SOU came together to create a robust cohort of pediatric urologists who through education and negotiation were able to help the ABU and the American Board of Medical Specialties (ABMS) recognize that subspecialization would lead to better care for children with urologic disorders. This benchmark set a high bar for future subspecialization in urology and other fields.

European Paediatric Surgeons' Association Survey on the Adherence to EAU/ESPU Guidelines in the Management of Undescended Testes.

The aim of this study was to assess the adherence to the European Association of Urology (EAU)/European Society for Pediatric Urology (ESPU) 2016 guidelines in the management of undescended testes (UDT). An online questionnaire was sent in 2023 to members of the European Paediatric Surgeons' Association (EUPSA). Among 157 members, 46 and 44% perform orchidopexy before 12 and 18 months, respectively. In total, 92% recommend conservative management of retractile testes and 58% offer close follow-up. In case of nonpalpable testes, 78% favor laparoscopy and 18% ultrasonography. If a peeping testicle is identified at laparoscopy, 76% perform a single-stage orchidopexy. In case of a high testicle, a staged procedure is preferred (84%). Management of blind-ending spermatic vessel is heterogenous with a majority ending the operation, followed by exploration of the inguinal canal and removal of the testicular nubbin with optional fixation of the contralateral testis. Only a minority recommends hormonal therapy to improve fertility potential in bilateral UDT. A majority (59%) discuss testis removal in UDT in postpubertal boys. In addition, 77% declare following the EAU/ESPU guidelines. Unawareness of guidelines was the most common reason cited for nonadherence. International guidelines were found to have the greatest influence on clinical practice; however, personal experience and institutional practice seem to play an important role. Most recommendations of the EAU/ESPU guidelines are being followed by EUPSA members; however, personal and institutional practice impact decision making. Hormonal therapy in bilateral UDT, management of vanishing testes, and UDT in postpubertal boys could be improved.

Current state of inclusion and diversity in pediatric urology fellowship programs

Increased racial/ethnic diversity of the physician workforce can improve health outcomes for marginalized populations. Currently, the pediatric urology workforce is less racially/ethnically diverse than the pediatric population it serves. We aimed to assess current recruitment efforts and barriers to recruitment of underrepresented in medicine (URM) fellows in pediatric urology fellowship programs. A 20-question REDCap survey was created and distributed to 27 pediatric urology fellowship program directors (PDs). The survey consisted of 4 sections of questions focused on PD demographics, program characteristics, recruitment efforts, and perceptions of barriers to recruitment. A total of 20 PDs responded to the survey (74%), including 3 incomplete responses. A majority of participants identified as Caucasian/white (79%), male (68%), over 40 years of age (89%), and had served as PD for 5 years or more (68%). Most PDs (70%) identified their program having 5-10 full-time pediatric urologists. Many PDs (75%, 15/20) identified their program as less diverse than the patient population served, and 53% (9/17) reported having no methods in place for diversity recruitment. Of those who reported a recruitment method, mentorship was the most common (35%, 6/17). When asked about recruitment barriers, 59% (10/17) reported that no barriers existed, while those who identified a barrier most commonly cited an overall limited applicant pool (18%, 3/17). Pediatric urology fellowship programs are less diverse than the patient populations served; while PDs value program diversity, most PDs report that there are no mechanisms in place to recruit racially/ethnically diverse trainees. To address this, we recommend active and intentional efforts to increase URM recruitment in pediatric urology. By taking an active role in existing recruitment efforts, pediatric urologists can increase their visibility, broadcast their commitment to diversity, form relationships with trainees earlier in training and increase opportunities for mentorship and early exposure to the field. Intentional recruitment efforts are needed to recruit URM trainees to pediatric urology fellowship programs and ensure the diversity of the pediatric urology workforce can better reflect patients served.

The diversity of hypospadias management in North America: a survey of pediatric urologists.

To determine trends in hypospadias management, including surgical techniques and perioperative care, by pediatric urologists in North America. An anonymous online survey was devised to assess approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. The survey was sent to all practicing members of the Societies for Pediatric Urology. The survey was completed by 133 (34.5%) respondents. Hypospadias repair was overwhelmingly recommended between ages 6-12months (89.5%). A local or regional anesthetic block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). The majority of surgeons perform distal repairs outpatient (70.7%), while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Nearly all respondents preferred either VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%) for urethroplasty. All but one respondent leaves a stent for midshaft to proximal repairs whereas stenting for glanular repairs was split with 53.4% leaving a stent. Most surgeons (60.9-70.9%) prescribe postoperative antibiotics regardless of severity and the majority (72.9%) prescribe narcotics for analgesia. Approaches to hypospadias repair are extremely varied such that there is a lack of consensus among pediatric urologists regarding most aspects of hypospadias management. Investigations comparing hypospadias practice patterns are necessary to develop a standard of care for this complex pediatric urologic entity.

Written surgical informed consent elements in pediatric differences of sex development: pediatric urologist and endocrinologist perspectives

IntroductionElective aspects of surgical management of pediatric differences of sex development (DSD) are associated with controversy. We examined North American pediatric urologist and endocrinologist perspectives regarding recommended and existing informed consent elements for written consent documents prior to pediatric genital surgery.MethodsFocus groups with pediatric urologist and endocrinologist members of the Societies for Pediatric Urology (SPU, n=8) or Pediatric Endocrine Society (PES, n=8) were held to identify elements of informed consent for DSD-related urogenital surgery. Elements were subsequently included in web-based surveys in 2003 and 2020 (SPU: n=121 and 143; PES: n=287 and 111, respectively). Participants rated their level of agreement with including each element in informed consent documents. In 2020, participants reported whether documents they use in clinical practice incorporate these elements.ResultsFocus groups identified four elements of informed consent: on-going debate over pediatric genital surgery; potential needs for multiple procedures; possible gender change and surgical reversal; and non-surgical alternatives. Across both years and both specialties, a majority (79% to 98%) endorsed the four elements, with significant between-group differences. Significantly more PES than SPU participants reported not knowing whether specific elements were included in current written informed consent; of those who knew, the majority (66% to 91%) reported inclusion.DiscussionSpecialists agree with including these four elements in written informed consent documents. Endocrinologists are not always familiar with the exact elements included. The degree to which non-surgeon members of the care team should be involved in the written informed consent process is an open question.

Gonadal tumors in a contemporary cohort of patients with differences in sex development undergoing surgery – A multi-site study from the Pediatric Urologic Oncology Working Group of the societies for pediatric urology

Disturbances in gonadal development lead to increased risk of gonadal malignancy in some but not all patients with differences in sex development (DSD). However, the natural history of these tumors is poorly described, and the literature remains sparse. The objective of this study was to describe the incidence of germ cell neoplasia in situ (GCNIS) and germ cell tumor (GCT) in a contemporary cohort of patients with DSD undergoing surgery and to provide long-term oncologic outcomes for these patients. Patients with DSD who have undergone gonadectomy or gonadal biopsy were identified at four institutions. Clinical characteristics, pathology, and treatment details were obtained retrospectively. Patients were stratified into risk categories based on DSD diagnosis. Oncologic treatment and outcomes were recorded. Descriptive statistics are reported using parametric methods. 83 patients were identified. Distribution of diagnoses is summarized in the summary table. 14 (16.9%) patients underwent gonadal biopsy, and 71 (85.5%) patients underwent gonadectomy (50/71 gonadectomies were bilateral). 8/83 (9.6%) patients had GCNIS or GCT (7 GCNIS, 1 GCT). Median age at surgery was 2.95 years (y) (interquartile range [IQR] 0.6-12.2) and 14y (IQR 0.85-16.9) in patients without and with GCNIS/GCT, respectively. All 8 patients with GCNIS/GCT had high or intermediate risk DSD diagnoses (4 mixed gonadal dysgenesis, 3 Turner with Y, 1 partial gonadal dysgenesis). Of the patients with high-risk diagnoses, 8/54 (15%) had GCNIS/GCT. No patient received adjuvant therapy, no patient had a recurrence, and all patients were living with mean follow up 6.4y. The risk of gonadal malignancy is heterogeneous in the DSD population and can vary based on DSD diagnosis as well as maturation, testicularization, and location of the gonads. The most recent consensus recommendations on gonadal management emphasize risk stratification and consideration of gonadal surveillance based on gender of rearing, but supporting literature remains sparse. In this contemporary cohort of DSD patients who underwent gonadal surgery, most patients did not have evidence of adverse pathology, all patients with malignant or premalignant pathology had a high/intermediate risk DSD diagnosis, and all patients with GCNIS/GCT were treated with surgery alone without recurrence. The distribution of patients with premalignant and malignant gonadal pathology and DSD in this cohort aligns with prior literature, and oncologic outcomes were excellent. These data add valuable information to the current literature and highlight the necessity to develop appropriate screening regimens for retained gonads.

PD23-11 CATHETER-FREE BLADDER PHANTOM PRESSURE MEASUREMENT-COMPARISON STUDY OF COMMERCIAL ULTRASOUND CONTRAST AGENTS

You have accessJournal of UrologyCME1 Apr 2023PD23-11 CATHETER-FREE BLADDER PHANTOM PRESSURE MEASUREMENT-COMPARISON STUDY OF COMMERCIAL ULTRASOUND CONTRAST AGENTS Kourosh Kalayeh, J. Brian Fowlkes, Amy Chen, Sophia Yeras, Mario L. Fabiilli, William W. Schultz, and Bryan S. Sack Kourosh KalayehKourosh Kalayeh More articles by this author , J. Brian FowlkesJ. Brian Fowlkes More articles by this author , Amy ChenAmy Chen More articles by this author , Sophia YerasSophia Yeras More articles by this author , Mario L. FabiilliMario L. Fabiilli More articles by this author , William W. SchultzWilliam W. Schultz More articles by this author , and Bryan S. SackBryan S. Sack More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003296.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Measuring voiding bladder pressure is a major challenge in urodynamic testing. The indwelling urethral catheter blocks flow of urine, causing elevated pressures and lower flow. We previously have shown that ultrasound contrast agents (UCAs) can reliably estimate bladder phantom pressures (BPP), through a technique called subharmonic-aided pressure estimation (SHAPE). We hypothesize that SHAPE performance in measuring BPP varies by UCA formulation. METHODS: Four different UCAs were considered (DEFINITY, Lumason, Sonazoid, and OPTISON). Each UCA was diluted in 0.9% normal saline and infused into the bladder phantom using cystometrogram (CMG) equipment (30 mL/min). For each UCA, simultaneous with pressurization, the UCA subharmonic (SH) signal was acquired with a GE LOGIQ E10 ultrasound scanner equipped with SHAPE. This was performed during infusion–filling event–and two post-filling events–PF1: immediately after infusion, and PF2: 5 min later. The change in BPP and SH signal were correlated and a linear regression model (lrm) was used to find the SHAPE sensitivity in dB/cmH2O. The UCA performances were compared in terms of i) SH signal longevity, ii) linear correlation of lrm, iii) sensitivity for BPP measurement, and iv) accuracy–root mean square error of lrm. RESULTS: SHAPE performance is summarized in Table 1. DEFINITY and Lumason show better performance, see examples of Figure 1. For every UCA (except OPTISON) SHAPE sensitivity showed time-dependent behavior. No statistically significant difference was found between SHAPE sensitivities of different CMG events for Lumason. For DEFINITY and Sonazoid SHAPE sensitivity for PF2 was significantly higher than the filling event. CONCLUSIONS: For every UCA and CMG event the SH signal decreases with increase in BPP. As hypothesized, SHAPE performance is dependent on the UCA. These findings will help in UCA selection for further evaluation of this method in human subjects and taking the next steps toward developing a catheter-free voiding bladder pressure measurement using SHAPE. Source of Funding: This research has been partially supported by grants from The Societies for Pediatric Urology (SPU), the University of Michigan Mcubed program, the Michigan Institute for Clinical and Health Research (MICHR), and the Departments of Urology and Radiology at the University of Michigan. The support for ultrasound scanner used in this study (GE LOGIQ E10) comes from General Electric Healthcare (Wauwatosa, WI, USA) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e676 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kourosh Kalayeh More articles by this author J. Brian Fowlkes More articles by this author Amy Chen More articles by this author Sophia Yeras More articles by this author Mario L. Fabiilli More articles by this author William W. Schultz More articles by this author Bryan S. Sack More articles by this author Expand All Advertisement PDF downloadLoading ...

MP18-11 DOES LEVEL OF TRAINEE INVOLVEMENT HAVE AN IMPACT ON HYPOSPADIAS TIP REPAIR OUTCOME?

You have accessJournal of UrologyCME1 Apr 2023MP18-11 DOES LEVEL OF TRAINEE INVOLVEMENT HAVE AN IMPACT ON HYPOSPADIAS TIP REPAIR OUTCOME? Vinaya Bhatia, Rocio Goodman, Maria Jabbour, and Walid Farhat Vinaya BhatiaVinaya Bhatia More articles by this author , Rocio GoodmanRocio Goodman More articles by this author , Maria JabbourMaria Jabbour More articles by this author , and Walid FarhatWalid Farhat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Teaching hypospadias repair to trainees is a major component of pediatric urology fellowship training but is not a focus of training junior residents. Herein, we reviewed outcomes of distal hypospadias repairs performed by a single surgeon in the proficiency stage of practice in a residency program and compared these outcomes to those for the same surgeon in the same stage in a fellowship program. METHODS: We reviewed all distal tubularized incised plate repairs performed by a single surgeon from 2019-2021. Data included age, meatal location, presence of curvature, operative time, occurrence of complications, and follow-up duration. Of note, resident involvement comprised mainly assisting in penile degloving urethroplasty and included skin closure under direct supervision. Our outcomes were compared to previously published data using descriptive statistics and Fisher’s exact tests, in which a p<0.05 was designated as statistically significant. RESULTS: A total of 52 patients met our inclusion criteria. A total of 5 patients had a megameatus, 6 had a glanular hypospadias, and 34 had a distal shaft hypospadias. The median age at surgery was 0.72 months (IQR 0.75 months). All patients did have an indwelling stent post-operatively. One patient (3.3%) was found to have complications, which were fistulae and meatal stenosis (Table 1). The time to complication for this patient was 6 months. When comparing previous data to the current data, the overall complication rates were lower (p=0.03), with overall complication rates of 15% (29/187) versus 3% (1/52). CONCLUSIONS: This is the first study directly comparing hypospadias surgical outcomes for the same surgeon in a different practice setting, specifically fellowship and residency programs. Though the detailed role of fellows in hypospadias repair might not be well delineated, it did entail autonomy and delegation, while residents only assisted or performed skin closure under supervision. Our data suggest that fellowship training programs might need to determine key steps for hypospadias repair they teach or delegate. This process should be delivered in a gradual manner gauged to the level of trainees to ensure that outcomes are improved. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e227 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vinaya Bhatia More articles by this author Rocio Goodman More articles by this author Maria Jabbour More articles by this author Walid Farhat More articles by this author Expand All Advertisement PDF downloadLoading ...

Residency graduates should not be expected to perform hypospadias repair without fellowship training: Results from a survey of SPU membership

Trainee autonomy has eroded over time as surgery has become more subspecialized and as attending oversight has increased, causing many trainees to seek additional fellowship training beyond residency. Less clear is whether there are cases that attendings view as "fellowship-level" or "privileged" cases in which resident-level trainees should not have high levels of autonomy due to complexity or high-stakes outcomes. We sought to better understand current attitudes and practices with regards to trainee autonomy in hypospadias repair as it represents a high complexity procedure within pediatric urology. We administered a RedCap survey to the SPU membership, asking respondents to describe the level of autonomy afforded to trainees in various types of hypospadias repair (distal, midshaft, proximal, perineal) as measured by the Zwisch scale. The Zwisch scale describes the role of the attending in the attending-trainee relationship in a low-to-high trainee autonomy fashion: show and tell; active help; passive help; supervision only. 177 of 761 (23%) unique recipients completed our survey and 174 of 177 (98%) of respondents felt that trainees should not perform hypospadias repair independently in practice without additional fellowship training. Among pediatric urologists who train residents, trainee autonomy as measured by the Zwisch scale decreased as the type of hypospadias repair moved from distal to proximal. There was near unanimous agreement among respondents that urology trainees should not perform hypospadias repair in practice without additional pediatric urology fellowship training, and that current practice affords little trainee autonomy in hypospadias repair at the resident level. These findings introduce a new wrinkle into the issue of trainee autonomy: cases in which trainees perhaps should not have autonomy. Concurrently, the concern with such findings is that this intentional lack of autonomy may extend to other urologic procedures that one would expect trainees to be able to perform independently. Urology trainees are not expected to be able to perform hypospadias in practice without additional training. This raises the question that there may be other such procedures in urology, and if so, should we as instructors, be forthcoming about the limitations of urology residency training to set appropriate trainee expectations?