The Ideal Neurogenic Bladder Management Team

This article discusses the ideal neurogenic bladder management team for patients who have neurogenic lower urinary tract dysfunction (NLUTD). It emphasizes the importance of a diverse team, including urologists, physiatrists, neurologist and others, working collaboratively to prevent complications and enhance patient outcomes. Owing to the unique nuances of the various neurologic conditions and patterns of NLUTD dysfunction, the roles of different specialists in the interdisciplinary team are outlined. This article describes 3 team models: multidisciplinary, interdisciplinary, and transdisciplinary, highlighting the benefits of collaborative approaches.

Urologist practice divestment from radiation vault ownership and treatment patterns for prostate cancer

BACKGROUND

Urologists practicing in single-specialty groups with ownership in radiation vaults are more likely to treat men with prostate cancer. The effect of divestment of vault ownership on treatment patterns is unclear.

METHODS

A 20% sample of national Medicare claims was used to perform a retrospective cohort study of men with prostate cancer diagnosed between 2010 and 2019. Urology practices were categorized by radiation vault ownership as nonowners, continuous owners, and divested owners. The primary outcome was use of local treatment, and the secondary outcome was use of intensity-modulated radiation therapy (IMRT). A difference-in-differences framework was used to measure the effect of divestment on outcomes compared to continuous owners. Subgroup analyses assessed outcomes by noncancer mortality risk (high [>50%] vs. low [≤50%]).

RESULTS

Among 72 urology practices that owned radiation vaults, six divested during the study. Divestment led to a decrease in treatment compared with those managed at continuously owning practices (difference-in-differences estimate, -13%; p = .03). The use of IMRT decreased, but this was not statistically significant (difference-in-differences estimate, -10%; p = .13). In men with a high noncancer mortality risk, treatment (difference-in-differences estimate, -28%; p < .001) and use of IMRT (difference-in-differences estimate, -27%; p < .001) decreased after divestment.

CONCLUSIONS

Urology group divestment from radiation vault ownership led to a decrease in prostate cancer treatment. This decrease was most pronounced in men who had a high noncancer mortality risk. This has important implications for health care reform by suggesting that payment programs that encourage constraints on utilization, when appropriate, may be effective in reducing overtreatment.

Complications of immuno-oncology care: what urologist should know

OBJECTIVES

To provide a practical review of immune-related adverse events (irAEs) that may be encountered in uro-oncology patients.

PATIENTS AND METHODS

We conducted a literature review of studies reporting irAEs including articles published through September 2023 for uro-oncology patients and the potential relevancy for the practicing urologist.

RESULTS

Immunotherapy has revolutionised cancer treatment, extending its impact to urological malignancies including for patients with urothelial, kidney, and prostate cancers. Immuno-oncology (IO) compounds have achieved measurable and durable responses in these cancers. Urologists, choosing to administer or co-manage IO patient care, should be prepared to understand, evaluate, and treat irAEs. This review discusses the spectrum of irAEs that can be encountered. Ongoing trials are exploring the use of immunotherapy at earlier stages of uro-oncological diseases, thus underscoring the evolving landscape of urological cancer treatment. Paradoxically, some data suggests that the occurrence of irAEs is associated with improved oncological outcomes.

CONCLUSIONS

Immune-related AEs, while manageable, may be life-threatening and require lifelong therapy. A thorough understanding of AEs and toxicity of a novel drug class is imperative.

Exploring the Demands of Urology: On-Call Compensation, Frequency, and Variability

INTRODUCTION

We investigate and analyze the available information regarding on-call patterns among urologists in the US.

METHODS

The AUA Workforce Workgroup collaborated with the AUA Data Team to analyze information from the 2022 AUA Census. Extracted data were analyzed to identify variability across gender, subspecialty, hours worked per week, AUA section, salary, and practice setting. We used χ2 tests to compare the groups with respect to each factor and defined statistical significance as a P value less than .05.

RESULTS

There were significant differences by gender and several other on-call factors including being required to take call to maintain hospital privileges (reported by 76% of female urologists vs 67% of male urologists; P = .026), getting paid for weekend call (28% of females vs 38% of males; P = .030), and making over $500 per day when taking weekend call (18% of females vs 32% of males; P < .001). Other differences existed between AUA sections in percentage of physicians receiving over $500 for weekday or weekend calls (P < .001). Lastly, practice setting differed in likelihood of being paid over $500 for weekday call (44% reported by private practice urologists, 7% reported by academic urologists, 14% reported by institutional urologists; P < .001).

CONCLUSIONS

These results underscore the substantial variability in on-call responsibilities and structure within the AUA workforce. Further research and regular participation in future censuses are recommended to continue to characterize these trends.

Online Tools to Decrease Out-of-Pocket Prescription Costs for Patients: A Practical Guide for Urologists

INTRODUCTION

Patients who seek urologic care have recently reported a high degree of financial toxicity from prescription medications, including management for nephrolithiasis, urinary incontinence, and urological oncology. Estimating out-of-pocket costs can be challenging for urologists in the US because of variable insurance coverage, local pharmacy distributions, and complicated prescription pricing schemes. This article discusses resources that urologists can adopt into their practice and share with patients to help lower out-of-pocket spending for prescription medications.

METHODS

We identify 4 online tools that are designed to direct patients toward more affordable prescription medication options: the Medicare Part D Plan Finder, GoodRx, Amazon, and the Mark Cuban Cost Plus Drug Company. A brief historical overview and summary for patients and clinicians are provided for each online resource. A patient-centered framework is provided to help navigate these 4 available tools in clinic.

RESULTS

Among the 4 tools we identify, there are multiples tradeoffs to consider as financial savings and features can vary. First, patients insured by Medicare should explore the Part D Plan Finder each year to compare drug plans. Second, patients who need to urgently refill a prescription at a local pharmacy should visit GoodRx. Third, patients who are prescribed recurrent generic prescriptions for chronic conditions can utilize the Mark Cuban Cost Plus Drug Company. Finally, patients who are prescribed 3 or more chronic medications can benefit from subscribing to Amazon RxPass.

CONCLUSIONS

Prescription medications for urologic conditions can be expensive. This article includes 4 online resources that can help patients access medications at their most affordable costs. Urologists can provide this framework to their patients to help support lowering out-of-pocket drug costs.

Surgical Force: Initial Study and Clinical Implications in the Assessment of Ureteral Access Sheath Induced Injury

Purpose: Ureteral access sheaths (UAS) pose the risk of severe ureteral injury. Our prior studies revealed forces ≤6 Newtons (N) prevent ureteral injury. Accordingly, we sought to define the force urologists and residents in training typically use when placing a UAS. Materials and Methods: Among urologists and urology residents attending two annual urological conferences in 2022, 121 individuals were recruited for the study. Participants inserted 12F, 14F, and 16F UAS into a male genitourinary model containing a concealed force sensor; they also provided demographic information. Analysis was completed using t-tests and Chi-square tests to identify group differences when passing a 16F sheath UAS. Participant traits associated with surpassing or remaining below a minimal force threshold were also explored through polychotomous logistic regression. Results: Participant force distributions were as follows: ≤4N (29%), >6N (45%), and >8N (32%). More years of practice were significantly associated with exerting >6N relative to forces between 4N and 6N; results for >8N relative to 4N and 8N were similar. Compared to high-volume ureteroscopists (those performing >20 ureteroscopies/month), physicians performing ≤20 ureteroscopies/month were significantly less likely to exert forces ≤4N (p = 0.017 and p = 0.041). Of those surpassing 6N and 8N, 15% and 18%, respectively, were high-volume ureteroscopists. Conclusions: Despite years of practice or volume of monthly ureteroscopic cases performed, most urologists failed to pass 16F access sheaths within the ideal range of 4N to 6N (74% of participants) or within a predefined safe range of 4N to 8N (61% of participants).

Laser Technology Advancements in the Treatment of Benign Prostatic Hypertrophy

PURPOSE OF REVIEW

Lasers have had a significant impact on the treatment of benign prostatic hypertrophy. This article attempts to distill the advancements in laser technology for the treatment of benign prostatic hypertrophy (BPH) into key and understandable points to help make this topic more accessible to urologists.

RECENT FINDINGS

The holmium:yttrium-aluminum-garnet (YAG) laser, one of the most significant lasers in the field of urology, has recently been improved with pulse modulating technology (Moses™ technology). New thulium:YAG technology allows both pulsed and continuous wave modes. The thulium fiber laser is one of the newer lasers to come to market and has been shown to have effective and safe outcomes. GreenLight™ lasers are predominantly used in photovaporization procedures and have also been studied extensively, although less in recent years. The modern urologist is fortunate to have many high-quality lasers and a wide variety of surgical techniques to choose from when treating BPH. Understanding the basic laser principles and applications will help urologists to select the best treatment options for their patients with BPH.

Adult Hypospadias Outcomes for the Pediatric Urologist

PURPOSE OF REVIEW

This review article will examine the current literature on hypospadias-related complications in adult patients.

RECENT FINDINGS

In this article, we will review the most recent studies evaluating hypospadias-related stricture disease, erectile function, fertility, and psychosexual outcomes in adult men with history of hypospadias repair in childhood. Managing hypospadias-related complications in adult patients is challenging to reconstructive urologists due to the compounded complexity of innate tissue deficiency and history of prior surgical repairs. In this review, we explore overall functional outcomes of adults with history of hypospadias repair as well as repair strategies of hypospadias-related urethral stricture disease. We will review erectile function, fertility and psychosexual outcomes as well as potential complications, which often do not surface until late adolescence and adulthood. Although it is challenging to characterize and quantify hypospadias-related complications, further longitudinal study is needed to better care for this complex patient population.

Long-term risks of childhood surgery

INTRODUCTION

Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery.

MATERIAL AND METHODS

Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery.

RESULTS

Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up.

CONCLUSION

Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.

Illumination matters Part III: Impact of light obstruction on illuminance from flexible ureteroscopes - a comparative PEARLS analysis

PURPOSE

Artifacts from poor ureteroscopes' light design with shadowing and dark areas in the field of view have been reported. The aim was to quantify effects of light obstruction in a kidney calyx model.

METHODS

We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using an enclosed 3D-printed pink in vitro kidney calyx model submerged in saline, where the field of light was intentionally partially obstructed alternatively at 12, 3, 6, and 9 o'clock. A color spectrometer was used for illuminance measurements at a 45° opening position in the background of the model.

RESULTS

Overall and mean background illuminance for each obstructive situation were significantly different between scopes for both 50% and 100% brightness settings (ANOVA p < 0.001). At 50% brightness setting, almost all scopes had their highest and lowest background illuminance with the 6 o'clock and 3 o'clock obstructive situation, respectively. At 100% brightness setting, these became 6 o'clock and 12 o'clock obstructive situations. Considering each obstructive situation individually, the Flex-Xc was consistently the scope with highest background illuminance and the Pusen 7.5F the lowest. Background illuminance for each obstructive situation varied significantly for each scope individually, with the greatest range of variability for Pusen 7.5F and V3.

CONCLUSIONS

Illuminance performance of ureteroscopes within an obstructed calyx model differ significantly for various obstructive situations. Urologists should be aware of this to help guide their choice of ureteroscope.

Patterns of treatment of high-risk BCG-unresponsive non-muscle invasive bladder cancer (NMIBC) patients among Arab urologists

PURPOSE

To understand the treatment plans suggested for BCG-unresponsive non-muscle invasive disease (NMIBC) patients in the Arab countries and therapeutic decisions applied for BCG-naive patients during BCG shortage time.

METHODS

A 10-minute online survey was distributed through the Arab Association of Urology (AAU) office to urologists in the Arab countries who treat patients with NMIBC.

RESULTS

One hundred six urologists responded to the survey. The majority of urologists had treated, in the past 6 months, > 10 patients with NMIBC who were considered BCG-unresponsive (55% of respondents). Radical cystectomy (RC) was the most popular treatment option (recommended by 50%) for these patients. This was followed by intravesical chemotherapy (30%), repeat BCG therapy (12%), resection with ongoing surveillance (8%). Clinical trials and intravenous checkpoint inhibitors were never selected. The most preferred intravesical chemotherapy was by ranking: 60% gemcitabine, 19% mitomycin C, 8% docetaxel, 8% gemcitabine/docetaxel, 4% sequential gemcitabine/mitomycin C, and 1% valrubicin. The use of intravesical chemotherapy appears limited by Arab urologists due to concerns regarding clinical efficacy (fear of progression) and the lack of clear recommendations by urology societies. Given the BCG shortage, which may vary per Arab country, Arab urologists have adjusted by prioritizing BCG for T1 and carcinoma in situ (CIS) patients over Ta, adapting intravesical chemotherapy, and reducing the dose/strength of BCG administered. Most physicians report an eagerness to utilize novel therapies to address the BCG deficit, especially to try intravesical chemotherapy.

CONCLUSIONS

Even though Arab urologists are in the majority of cases selecting RC for BCG-unresponsive cases, one-third of them are most recently initiating intravesical chemotherapy as an alternative option. To further assist Arab urologists in the appropriate selection of BCG unresponsive high risk NMIBC patient treatments, enhanced education and pathway protocols are needed.

The efficacy of artificial intelligence in urology: a detailed analysis of kidney stone-related queries

PURPOSE

The study aimed to assess the efficacy of OpenAI's advanced AI model, ChatGPT, in diagnosing urological conditions, focusing on kidney stones.

MATERIALS AND METHODS

A set of 90 structured questions, compliant with EAU Guidelines 2023, was curated by seasoned urologists for this investigation. We evaluated ChatGPT's performance based on the accuracy and completeness of its responses to two types of questions [binary (true/false) and descriptive (multiple-choice)], stratified into difficulty levels: easy, moderate, and complex. Furthermore, we analyzed the model's learning and adaptability capacity by reassessing the initially incorrect responses after a 2 week interval.

RESULTS

The model demonstrated commendable accuracy, correctly answering 80% of binary questions (n:45) and 93.3% of descriptive questions (n:45). The model's performance showed no significant variation across different question difficulty levels, with p-values of 0.548 for accuracy and 0.417 for completeness, respectively. Upon reassessment of initially 12 incorrect responses (9 binary to 3 descriptive) after two weeks, ChatGPT's accuracy showed substantial improvement. The mean accuracy score significantly increased from 1.58 ± 0.51 to 2.83 ± 0.93 (p = 0.004), underlining the model's ability to learn and adapt over time.

CONCLUSION

These findings highlight the potential of ChatGPT in urological diagnostics, but also underscore areas requiring enhancement, especially in the completeness of responses to complex queries. The study endorses AI's incorporation into healthcare, while advocating for prudence and professional supervision in its application.

ChatGPT in urology practice: revolutionizing efficiency and patient care with generative artificial intelligence

PURPOSE OF REVIEW

ChatGPT has emerged as a potentially useful tool for healthcare. Its role in urology is in its infancy and has much potential for research, clinical practice and for patient assistance. With this narrative review, we want to draw a picture of what is known about ChatGPT's integration in urology, alongside future promises and challenges.

RECENT FINDINGS

The use of ChatGPT can ease the administrative work, helping urologists with note-taking and clinical documentation such as discharge summaries and clinical notes. It can improve patient engagement through increasing awareness and facilitating communication, as it has especially been investigated for uro-oncological diseases. Its ability to understand human emotions makes ChatGPT an empathic and thoughtful interactive tool or source for urological patients and their relatives. Currently, its role in clinical diagnosis and treatment decisions is uncertain, as concerns have been raised about misinterpretation, hallucination and out-of-date information. Moreover, a mandatory regulatory process for ChatGPT in urology is yet to be established.

SUMMARY

ChatGPT has the potential to contribute to precision medicine and tailored practice by its quick, structured responses. However, this will depend on how well information can be obtained by seeking appropriate responses and asking the pertinent questions. The key lies in being able to validate the responses, regulating the information shared and avoiding misuse of the same to protect the data and patient privacy. Its successful integration into mainstream urology needs educational bodies to provide guidelines or best practice recommendations for the same.

Urologist Access for the Male Population: An 18-Year Study on Population Trends

INTRODUCTION

Our study examines the factors associated with urologist availability for younger and older men across the country over a period of 18 years from 2000 to 2018.

METHODS

The Area Health Resource Files and US Census Data were analyzed from 2000, 2010, and 2018. The younger male population was defined as men aged 20 to 49, and the older male population was defined as ages 50 to 79. Urologist availability was determined by county at all time points. Logistic regression analysis and geographically weighted regression was completed.

RESULTS

Over an 18-year period, overall urologist availability decreased for men by 19.6%. Access to urologist availability for men in metropolitan and rural counties decreased by 9.4% and 29.5%, respectively. Among the younger male cohort, urologist availability increased in metropolitan counties by 4%, but decreased by 16% in rural counties. There was an overall decrease in urologist availability of 28% and 43% in metropolitan and rural counties in the older male population. Multiple logistic regression analysis demonstrated that metropolitan status was the most significant factor associated with urologist availability for both male populations. The odds of each independent factor predicting urologist availability for the younger and older male population is dependent on geography.

CONCLUSIONS

The majority of the male population has seen a decline in urologist availability. This is especially true for the older male residing in a rural county. Predictors of urologist availability depend on geographical regions, and understanding these regional drivers may allow us to better address disparities in urological care.

Quality of information and appropriateness of ChatGPT outputs for urology patients

BACKGROUND

The proportion of health-related searches on the internet is continuously growing. ChatGPT, a natural language processing (NLP) tool created by OpenAI, has been gaining increasing user attention and can potentially be used as a source for obtaining information related to health concerns. This study aims to analyze the quality and appropriateness of ChatGPT's responses to Urology case studies compared to those of a urologist.

METHODS

Data from 100 patient case studies, comprising patient demographics, medical history, and urologic complaints, were sequentially inputted into ChatGPT, one by one. A question was posed to determine the most likely diagnosis, suggested examinations, and treatment options. The responses generated by ChatGPT were then compared to those provided by a board-certified urologist who was blinded to ChatGPT's responses and graded on a 5-point Likert scale based on accuracy, comprehensiveness, and clarity as criterias for appropriateness. The quality of information was graded based on the section 2 of the DISCERN tool and readability assessments were performed using the Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKGL) formulas.

RESULTS

52% of all responses were deemed appropriate. ChatGPT provided more appropriate responses for non-oncology conditions (58.5%) compared to oncology (52.6%) and emergency urology cases (11.1%) (p = 0.03). The median score of the DISCERN tool was 15 (IQR = 5.3) corresponding to a quality score of poor. The ChatGPT responses demonstrated a college graduate reading level, as indicated by the median FRE score of 18 (IQR = 21) and the median FKGL score of 15.8 (IQR = 3).

CONCLUSIONS

ChatGPT serves as an interactive tool for providing medical information online, offering the possibility of enhancing health outcomes and patient satisfaction. Nevertheless, the insufficient appropriateness and poor quality of the responses on Urology cases emphasizes the importance of thorough evaluation and use of NLP-generated outputs when addressing health-related concerns.

Urologist-level variation in the management of T1a renal cell carcinoma: A population-based cohort study

OBJECTIVES

Lack of strict indications in current guidelines have led to significant variation in management patterns of small renal masses. The impact of the urologist on the management approach for patients with small renal masses has not been explored previously.

MATERIALS AND METHODS

Using the linked Surveillance, Epidemiology, and End Results-Medicare database, patients aged ≥66 years diagnosed with small renal masses from January 1, 2004 to December 31, 2013 were identified and assigned to primary urologists. Mixed-effects logistic models were used to evaluate factors associated with different management approaches, estimate urologist-level probabilities of each approach, assess management variation, and determine urologist impact on choice of approach.

RESULTS

A total of 12,402 patients with 2,794 corresponding primary urologists were included in the study. At the individual urologist level, the estimated case-adjusted probability of different approaches varied markedly: nonsurgical management (mean, 12.8%; range, 4.9%-36.1%); thermal ablation (mean, 10.8%; range, 2.4%-66.3%); partial nephrectomy (mean, 30.1%; range, 10.1%-66.6%); and radical nephrectomy (mean, 40.4%; range, 17.7%-71.6%). Compared to patient and tumor characteristics, the primary urologist was a more influential measured factor, accounting for 13.6% (vs. 12.9%), 33.8% (vs. 2.1%), 15.1% (vs. 8.4%), and 13.5% (vs. 4.0%) of the variation in management choice for nonsurgical management, thermal ablation, partial nephrectomy, and radical nephrectomy, respectively.

CONCLUSIONS

Significant variation exists in the management of small renal masses and appears to be driven primarily by urologist preference and practice patterns. Our findings emphasize the need for unified guidance regarding management of these masses to reduce unwarranted variation in care.

Relationship Between Availability of Urologists and Primary Care Providers and Stage of Diagnosis for Invasive Urinary Bladder Cancer

INTRODUCTION

With no recommended screening approach, urinary bladder cancer patients rely on referral to urologists to ensure timely diagnosis of bladder cancer. This requires coordination between primary and specialty care. We provide estimates of the relative association between primary care physician and urologist density on stage of urinary bladder cancer diagnosis.

METHODS

We used 2010 to 2016 Pennsylvania Cancer Registry data to identify all adult patients diagnosed with bladder cancer. Our primary outcome was locoregional stage of diagnosis, since treatment modality changes and prognosis worsens beyond this stage. Based on patient's residential location at the time of diagnosis we defined both density of urologists and number of primary care providers (defined as providers per population) within the patient's county. We used univariate and multivariate logistic regression to estimate the association between provider density and likelihood of locoregional stage of diagnosis. We also controlled for age, sex, race/ethnicity, insurance type, and year.

RESULTS

Our sample included 11,771 urinary bladder cancer patients with 10,607 diagnosed at locoregional stage and 1164 at distant stage. Multivariate regression results show primary care density was associated with significantly higher odds of locoregional stage of diagnosis (odds ratio of 1.05 [95% CI: 1.02-1.08]) while urologist density was associated with significantly lower odds of locoregional stage (odds ratio of 0.65 [95% CI: 0.48-0.89]).

CONCLUSIONS

We found primary care density but not urologist density was associated with earlier stage of diagnosis, highlighting the importance of access to primary care and need for timely referral to urologic care.

Preference for diagnosing and treating renal colic during pregnancy: a survey among Chinese urologists

To explore the preference for diagnosing and treating renal colic during pregnancy among Chinese urologists. A questionnaire was designed using the Sojump® platform. WeChat, the largest social networking platform in China, was used to distribute the questionnaire to urologists at hospitals of all levels in China. In total, 110 responses were included. Of the respondents, 100.0% used ultrasound to diagnose renal colic during pregnancy, followed by magnetic resonance imaging (17.3%) and low-dose CT (3.6%). Phloroglucinol (80.9%) and progesterone (72.7%) were the most commonly used antispasmodics and analgesics. Opioid analgesics were not commonly used (12.7%). Most of the respondents (63.6%) indicated that no more than 20% of the patients needed surgical intervention. If surgery was unavoidable, 95.5% preferred temporary renal drainage, including ureteral stenting (92.7%) and percutaneous nephrostomy (2.7%). However, some respondents still preferred definitive stone treatment, such as ureteroscopy lithotripsy (3.6%) and percutaneous nephrolithotomy (0.9%). Moreover, there were no differences in the choices of urologists with different professional titles regarding diagnostic tools, most therapeutic medications, or surgical methods (p > 0.05). Ultrasound is the preferred tool for diagnosing renal colic during pregnancy. Low-dose CT is still not widely accepted. Pregnant patients with renal colic are initially treated conservatively. Urologists prefer ureteral stenting when there are clinical indications for intervention.

Surgical Artificial Intelligence: Endourology

Endourology is ripe with information that includes patient factors, laboratory tests, outcomes, and visual data, which is becoming increasingly complex to assess. Artificial intelligence (AI) has the potential to explore and define these relationships; however, humans might not be involved in the input, analysis, or even determining the methods of analysis. Herein, the authors present the current state of AI in endourology and highlight the need for urologists to share their proposed AI solutions for reproducibility outside of their institutions and prepare themselves to properly critique this new technology.

Growth in Newborn Circumcisions Performed by Pediatric Urologists and Advanced Practice Providers Between 2010 and 2021 in the United States

OBJECTIVE

To characterize changes in the proportion of newborn circumcisions performed by pediatric urologists and advanced practiced providers (APPs) in the United States over the last decade.

METHODS

The Merative MarketScan Commercial Database was queried for newborn circumcision private health insurance claims (Common Procedural Terminology 54150) between 2010 and 2021. Setting (inpatient/outpatient), US Census Bureau region, clinician specialty, and patient age (days) were determined for the full study time period, and by study year. Simple linear regression assessed growth in proportion of newborn circumcisions performed by pediatric urologists and APPs (nurse practitioner/physician assistant/midwife), over time.

RESULTS

In total, 1,006,748 newborn circumcisions (59% inpatient) were identified; while most were performed by obstetricians (45%) or pediatricians (33%); APPs performed 0.9%, and pediatric urologists performed 0.7%. From 2010-2021, the proportion of newborn circumcisions performed by pediatric urologists increased from 0.3% to 2.0% and by APPs in from 0.5% to 2.9% (P < .001 for both). Growth for both pediatric urologists and APPs occurred APPs predominantly from 2016 to 2021. Trends in proportion of newborn circumcision performed by pediatricians was stable [31.5% (2010) and 32.5% (2021)], but decreased for obstetricians [48.8% (2014) and 38.1% (2021)].

CONCLUSION

The proportion of newborn circumcisions performed by pediatric urologists and APPs increased more than 6-fold between 2010 and 2021, though both specialties still perform a minority of newborn circumcisions. These data provide important baseline information for newborn circumcision workforce planning, including evaluating collaborative care models where pediatric urologists train APPs to perform circumcision.

Grant funding among underrepresented minority and women urologists at academic institutions

INTRODUCTION

Grant funding to Urology has decreased over the last decade. Documented lack of gender and race diversity at the faculty level raises concerns for funding disparities. This study sought to characterize disparities based upon race and gender in National Institutes of Health (NIH) funding data to Urologic faculty.

METHODS AND MATERIALS

Data from 145 ACGME accredited Urology residency programs incorporating faculty gender and underrepresented in medicine (URiM) status was utilized. The NIH Research Portfolio Online Report Tool was queried between 1985 and 2023 for grants related to current Urology faculty. URiM status, gender, years of practice, academic rank, and Doximity residency program rank were factors in multivariable analysis.

RESULTS

A total of 2,131 faculty were included. Three hundred one Urologists received 793 urologic grants for a total of $993,919,052 in funding. By race, grants were awarded to: White 72.9%, Asian 21.8%, Hispanic 3.0%, Black 2.1%. Men received 708 grants (89.3%) worth $917,083,475 total. Women received 85 grants (10.7%) worth $76,835,577 total. Likelihood of being awarded a grant was significantly associated with non-URiM status (p < 0.001) and men (p < 0.0001). On multivariable analysis, Doximity rank (p < 0.001) and academic rank (p < 0.001) were significant predictors of receiving a grant; male gender, URiM status, and years of practice were not. Academic rank was also a significant predictor of number of grants received (p = 0.04) and total funding (p = 0.04); years of practice, Doximity rank, URiM status, and gender were not.

CONCLUSIONS

NIH grants were more likely awarded to higher ranked faculty from higher Doximity ranked institutions with no differences based on URiM status or gender.

Management of urachal anomalies in pediatric patients: A comparison of treatment strategies between pediatric urology and general surgery

INTRODUCTION

Persistence of embryonic urachal structures due to a failure of the urachus to involute into the median umbilical ligament is known as a urachal anomaly (UA). UAs may remain asymptomatic or lead to abdominal pain and recurrent infections. Management of UAs in pediatric patients has historically lacked a clear consensus between conservative and surgical management. While both urologists and general surgeons manage this pathology, a comparison of management style and outcomes between these specialties has not been published to our knowledge.

OBJECTIVE

To (1) evaluate trends in management of UAs among pediatric urologists and general surgeons across three tertiary care children's hospitals and (2) identify factors that place patients at higher risk for requiring surgery.

STUDY DESIGN

All patients diagnosed with a UA from 2016 to 2020 at our multi-site institution were identified by ICD-10 code Q64.4 "malformation of the urachus" and retrospectively reviewed. Patient demographics, treatment specialty, remnant subtype, and management strategy were recorded. Data was dichotomized between both urology and general surgery as well as between surgical and nonsurgical intervention to identify and compare management strategies.

RESULTS

Overall, 143 patients diagnosed with UAs were identified. Of these patients, 74 were treated by urology and 69 were treated by general surgery. Patients who were treated by urology were significantly more likely to receive conservative treatment (66.2% treated conservatively vs. 33.8% treated surgically), while patients treated by general surgery were significantly more likely to undergo surgery (84.1% treated surgically vs. 15.9% treated conservatively, p < .0001). Though, urology was more likely to treat patients who presented incidentally (p < .01), and general surgery was more likely to treat patients who presented with an infected remnant (p < .01). Patients of male sex were more likely overall to receive surgery compared to female patients (p < .01).

DISCUSSION

Management of UAs by urologists was more conservative than general surgeons. However, both specialties treat distinctly different patient presentations, with urology managing more incidental remnants and general surgery operating on more emergent, infected urachi. Limitations of the study included its retrospective nature and the insufficient reporting of urachal remnant subtypes and presence of infection among patients.

CONCLUSIONS

Management strategies of UAs differ among urology and general surgery, but surgical and conservative treatments are necessary to appropriately treat their distinct patient populations. This study provides valuable insight into current practices of UA management and may help to inform future treatment.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Current Utilization and Perceptions of Formal Education of Point-of-care Ultrasound in Urology

OBJECTIVE

To assess the extent of formal point-of-care ultrasound (POCUS) training, current utilization of POCUS, and contemporary perceptions of POCUS amongst urologists.

METHODS

A survey including questions regarding demographics, prior ultrasound education, current ultrasound utilization in practice/training, perceived optimal POCUS utilization, and the perception of formal ultrasound training was developed. The survey was disseminated to residency program directors (PDs) via the SAU and members of AUA subsection organizations. Data were collected via Redcap.

RESULTS

A total of 40 PDs and 159 other respondents completed the survey with approximately half (51%) in an academic practice and two-thirds (68%) with more than 10years in practice. PD response rate was 28%, and general response rate was 2%. Among all respondents, 95% (186/196) and 82% (160/194) agreed/strongly agreed formal POCUS training would be worthwhile during and after residency. Among urology residency PDs, 93% (37/40) agreed/strongly agreed that formal POCUS training is worthwhile in residency. The majority of respondents used some form of ultrasound in practice (77%, 154/199). However, only 37% (72/199) of all respondents had prior formal POCUS training, and 19% (5/26) of PDs reported formal training in their programs. Of respondents without formal training, 63% (80/127) reported interest in pursuing formal training.

CONCLUSION

POCUS is widely utilized in many practices. Yet, most urologists have not participated in formal POCUS training and most programs do not have curricula. Urologists have favorable opinions of the utility, safety, and efficacy of POCUS and desire training.

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 SUMMARY: The 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.

Evaluating the performance of ChatGPT in answering questions related to pediatric urology

INTRODUCTION

Artificial intelligence is advancing in various domains, including medicine, and its progress is expected to continue in the future.

OBJECTIVE

This research aimed to assess the precision and consistency of ChatGPT's responses to commonly asked inquiries related to pediatric urology.

MATERIALS AND METHODS

We examined commonly posed inquiries regarding pediatric urology found on urology association websites, hospitals, and social media platforms. Additionally, we referenced the recommendations tables in the European Urology Association's (EAU) 2022 Guidelines on Pediatric Urology, which contained robust data at the strong recommendation level. All questions were systematically presented to ChatGPT's May 23 Version, and two expert urologists independently assessed and assigned scores ranging from 1 to 4 to each response.

RESULTS

A hundred thirty seven questions about pediatric urology were included in the study. The answers to questions resulted in 92.0% completely correct. The completely correct rate in the questions prepared according to the strong recommendations of the EAU guideline was 93.6%. No question was answered completely wrong. The similarity rates of the answers to the repeated questions were between 93.8% and 100%.

CONCLUSION

ChatGPT has provided satisfactory responses to inquiries related to pediatric urology. Despite its limitations, it is foreseeable that this continuously evolving platform will occupy a crucial position in the healthcare industry.

Urologist validation of an artificial intelligence-based tool for automated estimation of penile curvature

INTRODUCTION

Severity of penile curvature (PC) is commonly used to select the optimal surgical intervention for hypospadias, either alone or in conjunction with other phenotypic characteristics. Despite this, current literature on the accuracy and precision of different PC measurement techniques in hypospadias patients remains limited.

PURPOSE

Assess the feasibility and validity of an artificial intelligence (AI)-based model for automatic measurement of PC.

MATERIAL AND METHODS

Seven 3D-printed penile models with variable degrees of ventral PC were used to evaluate and compare interobserver agreement in estimation of penile curvatures using various measurement techniques (including visual inspection, goniometer, manual estimation via a mobile application, and an AI-based angle estimation app. In addition, each participant was required to complete a questionnaire about their background and experience.

RESULTS

Thirty-five clinical practitioners participated in the study, including pediatric urologists, pediatric surgeons, and urologists. For each PC assessment method, time required, mean absolute error (MAE), and inter-rater agreement were assessed. For goniometer-based measurement, the lowest MAE achieved was derived from a model featuring 86° PC. When using either UVI (unaid visual inspection), mobile apps, or AI-based measurement, MAE was lowest when assessing a model with 88° PC, indicating that high-grade cases can be quantified more reliably. Indeed, MAE was highest when PC angle ranged between 40° and 58° for all the investigated measurement tools. In fact, among these methodologies, AI-based assessment achieved the lowest MAE and highest level of inter-class correlation, with an average measurement time of only 22 s.

CONCLUSION

AI-based PC measurement models are more practical and consistent than the alternative curvature assessment tools already available. The AI method described in this study could help surgeons and hypospadiology researchers to measure PC more accurately.

Ergonomics in Urology: Current Landscape and Future Directions

Optimal ergonomics are essential to improving clinical performance and longevity among urologists, as poor ergonomics can contribute to work-related injury and physician burnout. While a majority of urologists experience muscular injury throughout their career, women and trainees are disproportionately affected. These disparities are exacerbated by the lack of formal ergonomics education within urologic training programs. This review provides an overview of practical approaches to optimize ergonomics across working environments for urologists and trainees. We highlight intraoperative techniques and novel devices which have been shown to reduce work-related injury, and we identify knowledge gaps to guide future areas of ergonomic research.

Intrarenal pressures during flexible ureteroscopy: an insight into safer endourology

OBJECTIVES

To assess intrarenal pressures (IRPs) and complication rates after flexible ureteroscopy (fURS), and to assess factors that contribute to raised IRPs and postoperative complications.

PATIENTS AND METHODS

After informed consent patients underwent fURS under general anaesthesia. The transducer of a 0.3556 mm (0.014″) pressure guidewire was placed in the renal pelvis for live recording of IRPs. The fURS procedures were performed in a routine manner under antibiotic cover with the aim of dusting the calculus to completion. The operating surgeon was blinded to the live-recorded IRPs.

RESULTS

A total of 40 fURS procedures were performed in 37 patients (26 male and 11 female). The mean age was 50.5 years. As a cohort, the mean of average IRPs was 34.8 mmHg and the mean of maximal IRPs was 128.8 mmHg. Pearson's correlation showed a significant inverse correlation between the mean IRP and age (r[38]: -0.391, P = 0.013). Three cases experienced postoperative deviations from uncomplicated recovery, with two being hypotensive and one case being both hypotensive and hypoxic. Three cases returned to the emergency department within 30 days of surgery, with two cases of flank pain and one case of urosepsis with positive urine cultures. The patient presenting with urosepsis had exhibited IRPs exceeding the mean.

CONCLUSION

The IRPs changed significantly from normal baseline levels during routine fURS. The mean IRP during fURS correlates with patient age, but not with other factors. The IRP may be related to increased complication rates at fURS. Understanding factors that influence IRP will allow urologists to better manage this intraoperatively.

Gender disparities among publications within international sexual medicine urology journals and the impact of blinding in the review process

BACKGROUND

While female urologists are known to publish at less frequency than their male peers, The Journal of Sexual Medicine was reported to have among the highest growth in female authorship from 2002 to 2020 in urology journals.

AIM

We sought to assess the frequency of female authorship in sexual medicine journals worldwide and the factors that affect this, including the blinded/unblinded review process.

METHODS

Eleven sexual medicine journals were assessed for geographic location, peer review method, and SCImago Journal Rank citation index (a metric of citation frequency and prestige). Journals were grouped into top, middle, and bottom quartiles based on metric score. Web of Science was used to access the publications' first, second, last, and corresponding authors from the past 5 years. An internet search or Gender-API.com was used to determine the gender identities of authors. Univariate and multivariable logistic regression models were performed.

OUTCOMES

Outcomes included the likelihood of female authorship (first, second, last, and corresponding) based on journal location and ranking, the clustering of female authors, the journal's peer review process, and the frequency of female editorial board members.

RESULTS

Overall, 8938 publications were identified. Women represented 30.7%, 31.3%, 21.3%, and 18.7% of the first, second, last, and corresponding authors, respectively; gender was unable to be assessed for 2.6%, 17.2%, 7.3%, and 2.7%. On univariate analysis, journals from North America, in the top quartile, and with a double-blind review process were more likely to have female authors (P < .001). On multivariate analysis, articles were more likely to have a female first author if they had a double-blind peer review process (odds ratio [OR], 1.20; 95% CI, 1.02-1.40), a female second author (OR, 2.54; 95% CI, 2.26-2.85), or a female corresponding author (OR, 7.80; 95% CI, 6.69-9.10).

CLINICAL IMPLICATIONS

Gender-concordant mentoring and universal double-blind manuscript review processes may minimize the impact of gender bias and increase female authorship rates, in turn producing more diverse research.

STRENGTHS AND LIMITATIONS

This is the first study assessing female authorship in sexual medicine journals. Limitations include not assessing every author listed on articles and being unable to determine gender identities for some authors.

CONCLUSION

Female authorship rates are higher than reported rates of practicing female urologists but still lower than their male peers. Female authors were more likely to be published in journals with double-blind peer review processes and when publishing with additional female authors.

Advancements in stone classification: unveiling the beauty of urolithiasis

PURPOSE

Urolithiasis has become increasingly prevalent, leading to higher disability-adjusted life years and deaths. Various stone classification systems have been developed to enhance the understanding of lithogenesis, aid urologists in treatment decisions, and predict recurrence risk. The aim of this manuscript is to provide an overview of different stone classification criteria.

METHODS

Two authors conducted a review of literature on studies relating to the classification of urolithiasis. A narrative synthesis for analysis of the studies was used.

RESULTS

Stones can be categorized based on anatomical position, size, medical imaging features, risk of recurrence, etiology, composition, and morphoconstitutional analysis. The first three mentioned offer a straightforward approach to stone classification, directly influencing treatment recommendations. With the routine use of CT imaging before treatment, precise details like anatomical location, stone dimensions, and Hounsfield Units can be easily determined, aiding treatment planning. In contrast, classifying stones based on risk of recurrence and etiology is more complex due to dependencies on multiple variables, including stone composition and morphology. A classification system based on morphoconstitutional analysis, which combines morphological stone appearance and chemical composition, has demonstrated its value. It allows for the rapid identification of crystalline phase principles, the detection of crystalline conversion processes, the determination of etiopathogenesis, the recognition of lithogenic processes, the assessment of crystal formation speed, related recurrence rates, and guidance for selecting appropriate treatment modalities.

CONCLUSIONS

Recognizing that no single classification system can comprehensively cover all aspects, the integration of all classification approaches is essential for tailoring urolithiasis patient-specific management.

Development and validation of a novel home-made bench-top training model for retrograde intrarenal surgery

PURPOSE

To develop and validate a low-cost homemade bench-top training model to facilitate retrograde intrarenal surgery (RIRS) training.

METHODS

The RIRS training model (G-Model) was developed using a surgical glove and a recycled ureter access sheath. Fifteen participants including 10 residents and 5 urologists were enrolled. Designed training curriculum for residents was carried out. Face validity, content validity, construct validity and criterion validity evaluation of the G-Model were carried out.

RESULTS

The global score of face and content validity was 4.15 ± 0.53 and 4.65 ± 0.29, respectively. For construct validity, the overall modified global rating scale (mGRS) score was significantly improved [12.5 (5.25) vs. 24.0 (5.25), p = 0.004], and the total task time was significantly shortened (39.5 ± 4.48 min vs. 24.1 ± 3.81 min, p < 0.001) within residents after G-Model training. The baseline mGRS score and total task time of residents were poorer than those of urologists [12.5 (5.25) vs. 32.0 (1.00), p < 0.001; 39.5 ± 4.48 min vs. 16.0 ± 1.58 min, p < 0.001]. Spearman correlation analysis revealed strong correlations between residents' G-Model and real patient performance.

CONCLUSION

The current study presented a valid low-cost easily accessible RIRS bench-top training model which could facilitate skill acquisition and translate to real-life scenario.

Pathways to paediatric urology subspecialisation: a study of casemix, incumbent attitudes and opinions

OBJECTIVE

To identify any self-reported differences or attitudes towards certification, publication, or practice patterns between adult urology and paediatric general surgery-trained paediatric urology providers. There are no known published differences in clinical/operative/research outcomes in either group.

METHODS

An 18-item cross-sectional survey was compiled through the EAU Young Academic Urologists (YAU) office and disseminated to a trans-Atlantic convenience sample of current practising paediatric urologists. This was created using a mini-Delphi method to provide current semi-quantitative data relating to current opinions and attitudes of this cohort.

RESULTS

A total of 228 respondents completed the survey, with female respondents representing 37% and 34% for urology and paediatric general surgery, respectively. Nearly 90% overall respondents felt that a full 2-year paediatric fellowship program was very important and 94% endorsed a collaborative dedicated paediatric urology on call service, with 92% supporting the joint development of transitional care. Urology managed higher numbers of bedwetting (p = 0.04), bladder bowel dysfunction (p = 0.02), endourological procedures (p = 0.04), and robotics (p = 0.04). Paediatric general surgery managed higher numbers of laparoscopic reconstruction (p = 0.03), and posterior urethral valve ablation (p = 0.002).

CONCLUSION

This study represents the first time that a cross-sectional cohort of paediatric urologists from different training backgrounds were compared to assess their productivity, practice patterns and attitudes. Paediatric urology is in a unique position to have two contributing specialities, with the ability to provide optimal transitional and lifelong care. We believe that there should be a strong emphasis on collaboration and to remove any historically-created barriers under policies of equity, diversity and inclusivity.

Association Between Urologist Merit-Based Incentive Payment System Performance and Quality of Prostate Cancer Care

INTRODUCTION

We performed a study to evaluate the association between urologist performance in the Merit-Based Incentive Payment System (MIPS), and quality and spending for prostate cancer care.

METHODS

Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019 were assigned to their primary urologist. Associated MIPS scores were identified and categorized based on thresholds for payment adjustment as low (worst), moderate, and high (best). Multivariable mixed effects models were used to measure the association between MIPS performance and adherence to quality measures and price standardized spending for prostate cancer.

RESULTS

Adherence to quality measures did not vary across MIPS performance groups for pretreatment counselling by both a urologist and radiation oncologist (low-76%, [95% CI 73%-80%], moderate-77% [95% CI 74%-79%], and high-75% [95% CI 74%-76%]) and avoiding treatment in men with a high risk of noncancer mortality within 10 years of diagnosis (low-40% [95% CI 35%-45%], moderate-39% [95% CI 36%-43%], high-38% [95% CI 36%-39%]). Men on active surveillance managed by high performers more likely received a confirmatory test (44% [95% CI 43%-46%]) compared to those managed by moderate (38% [95% CI 33%-42%]) performers, but not low performers (36% [95% CI 29%-44%]). There was no difference in adjusted spending across MIPS performance groups.

CONCLUSIONS

Better performance in MIPS is associated with a higher rate of confirmatory testing in men initiating active surveillance for prostate cancer. However, performance was not associated with other dimensions of quality nor spending.

Greater Obstetric Barriers for Female Urologists Compared to Peer-Physicians

OBJECTIVE

To determine the prevalence of pregnancy complications, infertility, and maternal support for female urologists in comparison to the general population and other female physicians.

METHODS

An anonymous, voluntary survey was distributed to female physicians via private physician social media groups from June to August 2021. The survey queried pregnancy demographics and complications, infertility diagnosis and treatment, workplace environment, and prior education on these topics. Results were compared between urologists and the general population and other female physicians with Fisher exact test, chi-square with Yates's correction, or Student's t tests as indicated.

RESULTS

Four thousand six hundred twelve female physicians completed the survey including 241 (5%) urologists. Compared with the general population, urologists were more likely to have a miscarriage or preterm birth, have children later in life, and undergo infertility evaluation or infertility treatment (all P < .0001). 42% of urologists reported experiencing a pregnancy complication and only 9% of those surveyed received education on the risks of delaying pregnancy. Despite being educated more often regarding the risks of delaying pregnancy compared to other physicians, urologists were less likely to have children, had fewer children, and were more likely to be discouraged from starting a family during training and practice (all P < .0001). Additionally, urologists reported shorter parental leave, worked more hours per week while pregnant, and were less likely to receive lactation accommodations compared to other female physicians (all P < .001).

CONCLUSION

Education for trainees on family planning and fostering a culture of support are deficits identified in overcoming obstetric barriers in urologists.

Genitourinary Tuberculosis: A Brief Manual for Urologists on Diagnosis and Treatment from the European Association of Urology Urological Infections Panel

Although tuberculosis (TB) ranks among the most frequent infectious diseases worldwide, one of its extrapulmonary (EP) manifestations, genitourinary (GU) TB, is often underestimated by urologists, particularly in areas such as Europe where TB is not endemic. The aim of this review is to give urologists a concise overview of GUTB as a supplement to the more comprehensive European Association of Urology 2023 update on urological infections guidelines. EPTB can develop in 16% of TB cases. GUTB accounts for 4.6% of EPTB and is often asymptomatic or nonspecific, so it can be confused with other urogenital diseases. GUTB can be highly destructive, leading to failure of urogenital organs. Diagnosis is via microbiological, molecular, and histological testing for urine, genital secretions, or genitourinary tissue, supported by imaging. A 6-mo combinational medical regimen is the first-line treatment for GUTB. However, surgical interventions are also frequently required for the treatment of GUTB complications. Therefore, it is important to keep GUTB in mind for differential diagnosis. PATIENT SUMMARY: We reviewed scientific studies on the occurrence, diagnosis, and treatment of tuberculosis in the genitourinary tract. Our aim is to raise awareness among urologists from countries where this disease does not occur frequently, as urogenital tuberculosis can occur without any symptoms or with unspecific symptoms that can be confused with other diseases.

Risk stratification and management of non-muscle-invasive bladder cancer: A physician survey in six Asia-Pacific territories

OBJECTIVES

Multiple clinical practice guidelines, conflicting evidence, and physician perceptions result in variations in risk stratification among patients with non-muscle-invasive bladder cancer (NMIBC). This study aims to describe the extent of this variation and its impact on management approaches in the Asia-Pacific region.

METHODS

We conducted a cross-sectional survey involving 32 urologists and seven medical oncologists with ≥8 years of experience managing early-stage bladder cancer patients across Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. The physicians completed an anonymous questionnaire that assessed their risk stratification and respective management approaches, based on 19 NMIBC characteristics. For each NMIBC characteristic, they were required to select one risk group, and their most preferred management approach.

RESULTS

Our results demonstrated a higher consensus on risk classification versus management approaches. More than 50% of the respondents agreed on the risk classification of all NMIBC characteristics, but 42% or fewer chose the same treatment option as their preferred choice for all but two characteristics-existence of variant histology (55%) and persistent high-grade T1 disease on repeat resection (52%). Across territories, there was the greatest variation in preferred treatment options (i.e., no treatment, intravesical chemotherapy, or Bacillus Calmette-Guérin [BCG] treatment) for intermediate-risk patients and the highest consensus on the treatment of very high-risk patients, namely radical cystectomy.

CONCLUSIONS

Our study revealed considerable variation in risk stratification and management of NMIBC in the region. It is critical to develop practical algorithms to facilitate the recognition of NMIBC and standardize the treatment of NMIBC patients.

Artificial intelligence and urology: ethical considerations for urologists and patients

The use of artificial intelligence (AI) in medicine and in urology specifically has increased over the past few years, during which time it has enabled optimization of patient workflow, increased diagnostic accuracy and enhanced computer analysis of radiological and pathological images. However, before further use of AI is undertaken, possible ethical issues need to be evaluated to improve understanding of this technology and to protect patients and providers. Possible ethical issues that require consideration when applying AI in clinical practice include patient safety, cybersecurity, transparency and interpretability of the data, inclusivity and equity, fostering responsibility and accountability, and the preservation of providers' decision-making and autonomy. Ethical principles for the application of AI to health care and in urology are proposed to guide urologists, patients and regulators to improve use of AI technologies and guide policy-making.

["No discussions about discharge of semen!" : The wild life of the urologist Felix Schlagintweit (1868-1950)]

Felix Schlagintweit worked in a medical clinic, was co-owner of a sanatorium, had a private practice and wrote fictional books. He massively improved diagnostic methods (e.g., cystoscope) and was interested in psychoanalysis. He rejected the effectiveness of surgical treatment alone and also sole use of psychosomatics. In his view, conservative treatment options were often at least as effective. Because Schlagintweit refused to take part in national socialism, he was purged from professional discourse after 1933 and was only later were his contributions to the history of urology rediscovered.

Primary Care Physician and Urologist Perspectives on Optimizing Active Surveillance for Low-Risk Prostate Cancer

PURPOSE

We conducted a study to understand primary care physician (PCP) and urologist perspectives on determinants of active surveillance care delivery for men with low-risk prostate cancer.

METHODS

We conducted in-depth, semistructured, virtual interviews with a purposive sample of 19 PCPs and 15 urologists between June 2020 and March 2021. We used the behavioral theory-informed Theoretical Domains Framework to understand barriers to and facilitators of active surveillance care delivery. Interviews were recorded, transcribed, and deductively coded into framework domains and constructs by 3 independent coders. Participant recruitment continued until data saturation by group.

RESULTS

Our study included 19 PCPs (9 female; 4 in community practices, 15 in academic medical centers) and 15 urologists (3 female; 5 in private practice, 3 in academic medical centers). The most commonly reported Theoretical Domains Framework domains affecting active surveillance care were (1) knowledge and (2) environmental context and resources. Although urologists were knowledgeable about active surveillance, PCPs mentioned limitations in their understanding of active surveillance (eg, what follow-up entails). Both groups noted the importance of an informed patient, especially how a patient's understanding of active surveillance facilitates their receipt of recommended follow-up. Physicians viewed patient loss to follow-up as a barrier, but identified a favorable organizational culture/climate (eg, good communication between physicians) as a facilitator.

CONCLUSIONS

With patients increasingly involving their PCPs in their cancer care, our study presents factors both PCPs and urologists perceive (or identify) as affecting optimal active surveillance care delivery. We provide insights that can help inform multilevel supportive interventions for patients, physicians, and organizations to ensure the success of active surveillance as a management strategy for low-risk prostate cancer.

Perspectives on prostate cancer: advances and pending challenges for a multidisciplinary oncological approach in South America

Prostate cancer is one of the tumors with the highest incidence and mortality among men worldwide, and this situation is no different in South America. However, epidemiological data are highly variable for each country and even more so than in North America. These data may be influenced by the very low rate of early detection of disease, availability of diagnostic methods, proper data collection, and limited access to specialized multidisciplinary treatment. For many South American countries, academic referral centers can only offer state-of-the-art diagnostics and multidisciplinary cancer treatment for patients who live in or can travel to large cities, so most patients are cared for by non-expert urologists with limited resources, which can have a negative impact on their prognosis and worsen oncologic outcomes. We aimed to show the clinical management of prostate cancer patients, the current advances in management, limitations present in South America, and how a multidisciplinary approach in referral cancer centers conformed of specialized urologists, medical oncologists, and mental health professionals can maximize patient outcomes.

Prostate MRI and image quality: The urologist's perspective

The development of different imaging modalities of the prostate has significantly improved tumor detection, patient risk stratification, and quality of care.Among these, multiparametric magnetic resonance imaging (mp-MRI) has emerged as the most sensitive tool.It is useful in the diagnosis, localization, risk stratification, and staging of clinically significant prostate cancer, PCa. As a result, mp-MRI of the prostate is recommended as the initial diagnostic test for men with suspected PCa. A multidisciplinary approach is crucial in the diagnosis and management of prostate cancer and mp-MRI plays a fundamental role in this scenario.While many aspects of image quality certainly fall within the purview of radiology, it is important to recognize that urologists must also be attentive to imaging quality when utilizing mp-MRI to facilitate PCa management. We present our viewpoint as urologists on how image quality impacts the management of men diagnosed with PCa andattempt to identify the factors that impact mp-MRI image quality, consequences of poor image quality, and finally suggestions for improvements.