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OBJECTIVE:To better understand promotion timelines across gender and race/ethnicity and how academic output impacts promotion in urology. METHODS:We examined the 2017 census. An academic subset was asked questions regarding their promotion timeline. We obtained demographic, academic output, and family responsibility data. RESULTS:Of 2926 academic urologists who identified a position of Assistant, Associate, or Full professor, 11.2% were women, 75% were White, and 94% were non-Hispanic. Men authored more papers and achieved principal investigator status more often than women. Non-Hispanics authored more papers than Hispanics. On average, women took 1.2 years longer than men to advance from Assistant to Associate Professor (7.3 years [95% CI: 6.8-7.8] vs 6.1 years, [95% CI: 5.8-6.6, P

Many urology papers describe the development of statistical prediction models, what are often described as “nomograms”. Indeed, a simple search of Medline for urology prediction models retrieves close to 1000 papers. These studies come from investigators across the globe, including those researching both malignant and benign disease in organs from the kidney on down. In short, everyone is doing it. This can make asking questions about prediction modeling a bit embarrassing (if everyone is doing it, shouldn’t I know all about it?). As such, we present a short list of “Everything you always wanted to know about evaluating prediction models (but were too afraid to ask)”. This is a personal take on some well-known statistical principles; we have not added citations to the text, but a list of further reading is given at the end.

To determine factors and barriers associated with scholarly activity among faculty members at urology residency programs in the United States.An online survey was sent to all 134 urology residency program directors. The survey assessed program characteristics including size, location and definition of scholarly activity. It assessed available support for and barriers to resident scholarly activity, faculty participation in scholarly activity and mentorship of residents. Linear regression analysis was used.We had a 40% response rate (N = 40). Faculty attitudes toward conducting scholarly activity (P.001) and lack of a research curriculum (P = .05) were barriers to the outcome 'participation in scholarly activity'. Faculty attitudes toward conducting scholarly activity was also a barrier to the outcomes 'mentorship of residents' (P = .004) and 'publication of at least 1 paper' (P = .004). Available statistician was positively associated with the outcomes 'publications' (P = .062) and 'presentations' (P = .032). A minimum requirement of a local presentation (P=0.04) and chairman support (P = .015) were positively associated with the outcome 'presentation at a conference.'Training residents in research matters for the resident, the institution and future generations of surgeon scientists. Higher levels of faculty scholarly activity were associated with a minimum requirement for residents to submit a manuscript for publication, strong chairman support for resident research, and the availability of a statistician. A common barrier to faculty scholarly activity, publications, and resident mentorship was faculty attitudes toward resident scholarly activity. Urology residency programs seeking to prioritize scholarly activity among faculty should consider these factors.

Author(s): Lee, Austin W; Ramstein, Joris; Cohen, Andrew J; Agochukwu-Mmonu, Nnenaya; Patino, German; Breyer, Benjamin N | Abstract: ObjectiveTo examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends.MethodsThe Web of Sciences Sci-Expanded Index was used to conduct a search for urethral reconstruction. References were assessed for relevance to urethral reconstruction by 2 independent reviewers and a final list of the top 100 articles ranked by citation count was obtained. For each article, citation count, publication date, corresponding author, origin institution, origin country, topic area, study design, level of evidence, and origin journal were collected.ResultsThe mean citation count per publication was 108 (median = 94.5; range = 69-366, SD = 43) with a total of 10,874 citations for all papers since 1970. The top 100 articles were published between 1973 and 2011, came from 19 different countries and 16 different journals. Nearly half were case series and most studies were Level III evidence or lower. The United States was the largest contributor to the top 100 with 56 publications, followed by Italy (14), England (12), and Egypt (7). "Outcomes of surgical treatment for urethral stricture disease" was the most prevalent topic area comprising 55 articles in the top 100, with most articles including descriptions or outcomes of novel surgical techniques.ConclusionIn this study, we discovered that the most cited literature in the field of urethral reconstruction is singularly focused and lacking in high levels of evidence. The top 100 cited articles originate primarily from the United States, focus on short-term outcomes after surgical treatment for urethral stricture disease, and are predominantly case series.

Alberto Contador won the 2010 Tour de France riding a Specialized SL3 racing bike. The US rider Chris Horner, who came in 12 minutes behind, rode a Trek Madone. The top rookie Daniel Lloyd, rode a Cervelo S3, but was pretty far down the field, over 4 hours behind the leaders. We presume that no self-respecting urologist would use this information to claim that the Trek is a faster bike than the Cervelo, or that Daniel Lloyd could have won, if only he had ridden a Specialized. About radical prostatectomy claims, however, it seems that urologists are considerably less discriminating. A good number of studies have recently purported to address the question of whether the open, pure laparoscopic or robotic approach to radical prostatectomy leads to superior results. In a typical paper, that of Ficarra et al.1, urinary and erectile outcomes were documented for patients treated by one of six surgeons, four open and two robotic. The authors reported a 9% absolute higher probability of continence at one year for robotic surgery, and concluded that the robotic approach leads to improved urinary function. To know whether this conclusion is reasonable, we have to consider what sort of variation we might expect between individual surgeons. For example, if all surgeons had continence rates within a few percent of one another, it would be difficult to explain the 9% difference in terms of the four open surgeons, just by chance, being less skilled than the two robotic surgeons. There is now overwhelming evidence that the results of individual surgeons vary by a good deal more than a few percentage points. Begg and colleagues reported that complication rates among high volume surgeons ranged from less than 5% to greater than 50%2. With respect to functional outcomes, our group found 30 – 40% absolute differences in erectile and urinary function between a small number of surgeons at a single tertiary care center3. Differences between surgeons therefore dwarf differences between surgical approaches. Accordingly, just as an analysis of Tour de France results tells us more about the riders than the bicycles, a study of a handful of surgeons concluding that one approach is better than another most likely reflects the relative skill of the surgeons practicing each approach. That said, at least patients in the Ficarra paper were part of the same cohort. Several papers have compared results reported for open and robotic case series published in the literature4, 5. Alternatively, authors have reported their results for robotic or laparoscopic surgery and compared these to published open series6. It is just about impossible to tell whether patients and outcomes are comparable in these sorts of studies: pathologists may grade and score surgical margins differently; patients may differ in terms of baseline function; assessments of function and surgical complications are unlikely to be identical. These studies are the equivalent of asking Contador, Lloyd and Horner to leave home for a 100 mile ride and then announcing that the best bike is the one ridden by the first cyclist home, ignoring any differences in terrain or weather. One of the reasons why we would want to avoid concluding that one bike is better than another on the basis of finishing places is that some riders are more experienced than others: Contador was a prior Tour winner, whereas Lloyd was a rookie. Few urologists would deny that radical prostatectomy is similarly associated with a learning curve. Indeed, our group has documented dramatic learning curves for two independent groups of surgeons, open7 and laparoscopic working without robotic assistance8. A comparison of the two learning curves is shown in the figure. There are extremely large reductions in recurrence rates as a surgeon gains experience with radical prostatectomy. Figure 1 Learning curves for open (grey) and laparoscopic (black) radical prostatectomy This has obvious implications for the question of whether the open, pure laparoscopic or robotic approach is better. When we ask this question, are we referring to the recently trained surgeon, the highly experienced surgeon or some kind of “average” surgeon? The figure shows that both highly experienced surgeons, as well as those who are just starting their career, likely have similar results on open and non-robotic laparoscopic surgery. However, the latter is harder to learn. There are currently few comparable data on the learning curve for robotic radical prostatectomy. My guess is that robotic surgery does have a learning curve and that, when practiced by high volume surgeons, this compares favorably with the learning curves for open and laparoscopic. Either way, it should be obvious that “what is better, open, robotic or pure laparoscopic?” is meaningless outside the context of the learning curve. The presence of surgeon heterogeneity raises further questions about the “average” effect of different procedures. As a simple example, imagine that we compared two groups of 10 orthopedic surgeons, one of which used what we will call the “dependable” technique and the other a novel, but “difficult” approach for refractory back pain. Assume that all 10 surgeons in the “dependable” group reported close to 35% of their patients experiencing good pain relief. Further assume that, in the “difficult” group, success rates amongst 9 of the surgeons varied widely between 5% and 50%, with an average of 30%. However, the 10th surgeon had managed to master the approach with 95% of patients reporting less pain, giving an overall success rate of 36.5%. On average, the “difficult” technique led to a higher chance of pain relief than the “dependable” technique, but we would likely prefer all surgeons to get reasonable results than there to be huge variation, with a limited number of experts obtaining remarkable results. This is particularly because the proportion of surgeons who would be able to master the “difficult” technique would likely not be well estimated. If results of different surgeons differ dramatically, then it seems more meaningful to ask about how results vary within a particular approach than about average results. Lance Armstrong famously stated that “It’s not about the bike”; some urologists seem to say, “No, but it is all about the robot”. I work with robotic surgeons and have observed several perform a radical prostatectomy. I have been impressed by their skill and I am confident that their results are better than many open and pure laparoscopic surgeons. But we need to get beyond our obsession with technology and do the hard work of figuring out why it is that some surgeons have so much better results than others, a question largely irrespective of surgical approach. Empirical studies of surgeon technique will require a far greater investment of time, resources and scientific ingenuity than retrospective analyses of surgical databases, but they are far more likely to produce discoveries that will lead to surgical progress.

OBJECTIVE To evaluate the association between SpaceOAR and radiation dosing, toxicity and quality-of-life vs no spacer across all radiotherapy modalities for prostate cancer. METHODS A systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase was performed from database inception through May 2020. Two reviewers independently screened titles/abstracts and full papers. Data extraction was performed, and quality assessed by 1 reviewer and checked by a second, using a third reviewer as required. The synthesis was narrative. RESULTS 19 studies (3,622 patients) were included (only 1 randomized controlled trial, in image-guided intensity-modulated radiotherapy (IG-IMRT), 18 comparatives non-randomized controlled trials in external-beam radiotherapy (EBRT), brachytherapy, and combinations thereof). No hypofractionation studies were found. Regardless of radiotherapy type, SpaceOAR significantly reduced rectal radiation dose (eg, V40 average difference -6.1% in high dose-rate brachytherapy plus IG-IMRT to -9.1% in IG-IMRT) and reduced gastrointestinal and genitourinary toxicities (eg, late gastrointestinal toxicity 1% vs 6% (P = .01), late genitourinary toxicity of 15% vs 32% (P < .001) in stereotactic body radiotherapy). Improvements were observed in most Expanded Prostate Cancer Index Composite quality-of-life domains (eg, bowel function score decrease at 3 and 6 months: Average change of zero vs -6.25 and -3.57 respectively in low dose-rate brachytherapy plus EBRT). CONCLUSION The randomized controlled trial in IG-IMRT demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel, and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types. Further research is required in hypofractionation.

Objective To study the impact of genomic testing in shared decision making for men with clinically low-risk prostate cancer (PCa). Materials and Methods Patients with clinically low-risk PCa were enrolled in a prospective, multi-institutional study of a validated 17-gene tissue-based reverse transcription polymerase chain reaction assay (Genomic Prostate Score [GPS]). In this paper we report on outcomes in the first 297 patients enrolled in the study with valid 17-gene assay results and decision-change data. The primary end points were shared decision on initial management and persistence on active surveillance (AS) at 1 year post diagnosis. AS utilization and persistence were compared with similar end points in a group of patients who did not have genomic testing (baseline cohort). Secondary end points included perceived utility of the assay and patient decisional conflict before and after testing. Results One-year results were available on 258 patients. Shift between initial recommendation and shared decision occurred in 23% of patients. Utilization of AS was higher in the GPS-tested cohort than in the untested baseline cohort (62% vs 40%). The proportion of men who selected and persisted on AS at 1 year was 55% and 34% in the GPS and baseline cohorts, respectively. Physicians reported that GPS was useful in 90% of cases. Mean decisional conflict scores declined in patients after GPS testing. Conclusion Patients who received GPS testing were more likely to select and persist on AS for initial management compared with a matched baseline group. These data indicate that GPS help guide shared decisions in clinically low-risk PCa.

Tkachenko А. I., Chetverikov S. G., Chaika A. M., Lysachenko V. V. Echinococcosis at urology. Pelvic parasitic cyst. Case report. Journal of Education, Health and Sport. 2019;9(3):296-300. eISNN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.2596630 http://ojs.ukw.edu.pl/index.php/johs/article/view/6707 The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part B item 1223 (26/01/2017). 1223 Journal of Education, Health and Sport eISSN 2391-8306 7 © The Authors 2019; This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 20.02.2019. Revised: 28.02.2019. Accepted: 15.03.2019. ECHINOCOCCOSIS AT UROLOGY. PELVIC PARASITIC CYST. CASE REPORT А. I. Tkachenko, S. G. Chetverikov, A. M. Chaika, V. V. Lysachenko Reconstructive Center (University Clinic) of Odessa National Medical University, Odessa, Ukraine Abstract Introduction. Echinococcosis is a serious chronic parasitic disease. Early diagnostics and patients` treatment with echinococcal lesions is an up-to-date problem. Objective. The aim of the article is to present the clinical case of diagnostics and treatment of the patient with urological complications caused by parasitic echinococcal pelvic cyst. Clinical case. The article highlights the features of diagnostics and treatment of urological complications of pelvic echinococcal lesions. The patient was operated in volume: "Laparotomy. Resection of parasitic cyst of small pelvic cavity. Echinococcectomy of the liver, abdominal cavity, retroperitoneal space." The peculiarities of operation was highlighted. The postoperative period lasted without complications. Conclusions. The demonstrated clinical case points out the necessity of the dispanserisation, early diagnostics and special helminth treatment of the patients living in the endemic regions. It allows to prevent the appearance of the echonococcosis advanced cases that lead to the reoperations and frequent patients` disability. Keywords: echinococcosis, parasitic pelvic cyst, surgical treatment.

The paper presents the results of statistical analysis of the official reporting forms during a 5 year period (2011–2015 years), concerning the number of nephrectomies, their causes, institutions in which they are performed, as well as the index of postoperative mortality that reflects the quality of medical care. The material is presented in a comparative mannerbetween different Ukrainian regions. In addition, the last two years have been taken into account in connection with the well-known events that have changed the territorial integrity of the country.

Clinical results investigations of the Ukrainian uroflowmeter “Flow-KM” for a home urofloumetry monitoring of patients with lower urinary tract symptoms are presented in this paper. The apparatus has been developed A.E. Kvyatkovsky (2014). Thirty two patients with benign prostatic hyperplasia, prostate sclerosis, prostatitis, urethral stricture have been examined. The home urofloumetry monitoring eliminates the office stress impact during the uroflowmetry and allows to get the data as close as possible to real ones. The home monitoring is an evidence-based medicine diagnostic method of lower urinary tract urodynamics evaluation for several days and can detect hidden or circadian violations of urodynamics. Its application for the pharmacological tests conducting permits to evaluate the intensity and duration of drugs action. It helps to develop a drug therapy plan and to evaluate its effectiveness after treatment. The uroflowmeter “Flow-KM” is an accurate and reliable apparatus which permits urofloumetry monitoring.

The paper presents the results of the study of basic indicators of urological service for the adult population of Ukraine and the results of activities of the service during 2017 compared with the past. It is proved that the developed network, which has a high personnel potential, is stored in the country and works efficiently enough. However, there is a deterioration of health of population due to the accumulation of patients with the most common diseases ("kidney infection" chronic pyelonephritis, cystitis, urolithiasis, benign prostatic hyperplasia), increases cancer incidence (RC, prostate cancer) and prevalence of RC, RSM. Also increases the mortality level at all cancer diseases, and the reduction of indices in urolithiasis and benign prostatic hyperplasia is accompanied by high growth rates among men in the first and among the rural population with urolithiasis, benign prostatic hyperplasia, prostate cancer, malignancies of other organs and systems. Traceability of the regional variability of indicators related to the organization and the quality of provision of specialized assistance is of high socio-economic importance.

Diapevtic is a sequential transition of diagnostic stages of the development of urology into effective instrumental and therapeutic intervention. Diapevtic operating aids in urology take leading positions in many diseases, including those with urolithiasis. To date, we have experience of more than 7,500 diagastrotic operations in the last 10 years. In our clinic, the complex “Modularis Uro Pro (Simens)” Germany, complete with endoscopes and consumables from Karl Storz Richard Wolf, is used to perform diagenetic interventions. Our accumulated experience has given us the opportunity to create and develop methodological recommendations for practitioners of Ukraine, taking into account the economic situation. The paper highlights possible complications and ways to eliminate them. Our experience allows us to evaluate diabetic treatments as the main method of treating urolithiasis, and to oppose remote therapies. We have worked out indications and contraindications for the management of anesthesia in diagentative interventions. The article outlines possible complications and ways to combat them. On the basis of our clinic formed elective courses for urologists on “urological diagnostics”. The course program is designed for a cycle of 78 hours, with the issuance of a certificate. For the successful and safe operation of urologists who solve the problems of modern interventions for urolithiasis, a gradual formation of “modular operating” ones is necessary, which allow removal of stones at any level of the urinary system by a non-invasive method. In our opinion, modern surgical intervention should be carried out with the help of combined ultrasound, X-ray and endoscopic guidance.

The cardiac chamber's involvement with neoplastic embolism has been rarely reported; it is mostly associated with gastric, breast, lung, liver, and prostate cancers, and usually affects the pulmonary arteries. This paper reports a case of a 31-year-old man with a malignant testicular germ cell tumor who presented with multiple episodes of pulmonary thromboembolism and died of sudden respiratory failure 1 year after the initial diagnosis. Death was attributed to massive pulmonary embolism and pulmonary infarction associated with a neoplastic thrombus that extended from the gonadal veins to pulmonary arteries. A postmortem computerized tomographic angiography and autopsy confirmed this finding.

Chronic kidney disease (CKD) is common. According to several analyses of the National Health and Nutrition Examination Surveys (NHANES), as much as 13% of the non-institutionalized US adult population belongs to CKD stages 1 to 4. This includes 3.2% with stage 2 (GFR 60–89 mL/min/1.73m2) and 7.7% with stage 3 (GFR 30–59 ml/min/1.73 m2) (1). This high prevalence of renal impairment affects the analysis of blood biomarkers that are cleared by renal elimination. The low molecular mass of free PSA (fPSA) is compatible with clearance by glomerular filtration; this has been confirmed in several investigations. The half-life of fPSA after successful renal transplantation is 17 h, similar to that of creatinine (23 h) (2). Patients with terminal renal failure show significantly increased levels of fPSA and %fPSA (3,4). Percent fPSA was 39.5% in hemodialysis patients and 39.6% in patients on continuous ambulatory peritoneal dialysis, compared to 28.1% in controls (4). Among 101 patients with moderate renal failure with median GFR of 23 mL/min/1.73m2 (range 8–83 mL/min/1.73m2), Bruun et al showed a significantly higher level and percentage of fPSA, 0.45 μg/L and 47.2%, respectively, compared to controls, 0.29 μg/L and 29.9%, respectively (5). The strength of their study was the use of iohexol clearance, a gold standard for measurement of GFR. The current paper {URL-D-09-00510} takes another approach. The authors used a large group (n=3782) from NHANES, which is a well-established cohort with a representative population. The participation rate was high. The authors used estimated GFR (eGFR) from the 6-variable MDRD formula; this approach is less accurate than iohexol clearance but was the only possible way to define GFR in this large cohort. Among 382 men with eGFR 15–59 mL/min/1.73m2, fPSA and %fPSA were significantly elevated, and values were also higher in those with eGFR 60–89 mL/min/1.73m2. The strength of this study is the large sample size that ensures representative material. Both the current report, and a recently published study by Bruun et al, shows that fPSA and percent fPSA are importantly influenced by moderately impaired renal function in men with chronic kidney disease. Interestingly, both demonstrate that fPSA is also affected by slight renal impairment (GFR 60–89 mL/min/1.73m2). As noted above, slight and moderate renal impairment are highly prevalent in the general population, and they are even more frequent among elderly men. This means that a significant number of men may have reduced elimination of fPSA, which has implications for the use of %fPSA to discriminate prostate cancer from benign prostate hyperplasia. Use of the current clinical decision limits for percent fPSA could cause some men with decreased GFR and prostate cancer to be misdiagnosed as having benign disease. Therefore, one alternative could be to not use fPSA to diagnose prostate cancer in these patients. This new knowledge also does, however, create the possibility for strengthening %fPSA in the diagnosis of prostate cancer, especially for screening purposes. The present clinical decision limits were developed without this knowledge. Contingent of a proper accounting for the GFR, %fPSA may therefore have an even greater potential for differentiating prostate cancer from benign prostate hyperplasia.

When asked to write this editorial, I initially demurred. Reasoning: the subject at hand is the subject of two randomized controlled studies of almost 1500 subjects; both have reported initial results. The EORTC trial, a study of about 1,000 men has reported short-term results: a significant reduction in PSA relapse with radiation.1 SWOG 8794, with longer followup showed an even greater reduction in biochemical failure, delaying median time to failure by 7 years.2 However, the primary endpoint for our study – metastasis-free survival – was reduced by 25%, but just missed statistical significance (p=0.06). We recently reported updated data at the 2008 AUA meeting.3 What’s the point of this editorial? The SWOG and EORTC trials were developed in response to hundreds of case series and reviews on this subject. Some are pro-radiation and some are pro-observation, following PSA, and treating later – either at PSA relapse or for symptoms. Clinicians can find support for either approach, based on which case series they read or opt to cite. This is not the way to advance medical care; with the completion of phase 3 trials, it is my opinion that reporting of case studies, with their inherent biases (patient selection, uneven followup regimens, differing prompts for adjuvant therapy, non-standardized treatments, lack of quality assurance for treatment and followup, etc), should stop. Readers should examine a single reference.4 The authors report how long journals and authors take to stop publishing papers on unproven therapies after the completion of an enormous clinical trial; curiously, publications continued for years after the treatment was debunked. Sorry folks, but history has demonstrated that when it comes to determining which of two treatments is optimal, little can be learned from case series, no matter how hard the investigators try to control for covariates; there are so many confounds which you cannot control or measure so that your results and comparisons are unreliable. Only through randomized trials can you get an answer. Our plaintive reply is “they’re too hard, they take too long, we can’t do them”. That’s not an excuse; our colleagues in other disciplines expect these challenging studies to be accomplished, do not rely on observational data, and with perseverance, accomplish difficult trials.5,6 Ultimately, our patients deserve them. Finally, I would encourage journals (and authors) to consider a modest proposal: once phase 3 data are available, think twice about publishing another case series; devote your effort into registering a patient.