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To evaluate the applicant experience with preference signaling during the 2022 Urology Residency Match.An anonymous electronic survey was emailed to all urology residency applicants who applied to Rutgers Robert Wood Johnson Medical School during the 2021-2022 application cycle. The survey collected information regarding applicant demographics, applicant characteristics, preference signal destinations, match outcomes, and attitude towards preference signaling.A total of 601 applicants applied to the 2022 Urology Residency Match, 283 of which applied to the urology residency program at Rutgers Robert Wood Johnson Medical School. Of the 283 applicants, 53 (19%) responded to our survey. Rate of interview for preference signaled programs was 54.23%, with a significantly lower rate of interview for comparative, non-signaled programs (40.54%; P = .001). Of respondents, 14.29%, 26.19%, and 35.71% matched to their home program, a program they signaled, or a program where they completed an away rotation, respectively. 96% of applicants favored continuation of the preference signaling program.Our study suggests preference signaling in the 2022 Urology Match may have been an effective method of expressing interest in a program. Respondents of our survey overwhelmingly favor continuation of the program in future urology matches. However, it may not address the underlying, growing problem of the increasing application burden on applicants and programs alike. We encourage more comprehensive studies to further clarify the effects of preference signaling on the Urology Match.

The management of urinary tract stricture disease has evolved over the last several decades, with robotic surgery representing a bourgeoning method for urologic reconstruction. Conventionally, proximal and mid-ureteral strictures, as well as lengthy urethral strictures, have presented a challenge for surgeons to create tension-free repairs. Options for repair include endoscopic dilation, endopyelotomy, ureteroplasty or pyeloplasty, and urethroplasty. Small and large bowel can be incorporated into various urinary tract stricture repairs. Their use has proven successful in reconstructing both upper and lower urinary tract strictures and offers flexibility for complex cases such as lengthy or multifocal strictures. While the use of bowel, most notably the appendix, for stricture repair is not a novel concept, a growing body of evidence supports its use with minimally invasive robotic approaches. In addition, there has been a substantial amount of recent data suggesting low rates of postoperative complications and long progression-free survival after robotic stricture repair using small bowel or rectum. We present a comprehensive review of literature outlining the role of the small bowel, appendix, and rectum in the minimally invasive repair of urinary tract stricture disease, as well as a description of the various techniques employed.

Inguinal lymph node dissection (ILND) is used for diagnosis and treatment in penile cancer (PC), vulvar cancer (VC), and melanomas draining to the inguinal lymph nodes. However, ILND is often characterized by its morbidity and high wound complication rate. Consequently, we aimed to characterize wound complication rates after ILND.The NSQIP database was queried for ILND performed from 2005 to 2018 for melanoma, PC, or VC. Thirty-day wound complications included wound disruption and superficial, deep, and organ-space surgical site infection. Multivariable logistic regression was performed with covariates, including cancer type, age, American Society of Anesthesiologists score ≥3, BMI ≥30, smoking history, diabetes, operative time, and concomitant pelvic lymph node dissection.A total of 1,099 patients had an ILND with 92, 115, and 892 ILNDs performed for PC, VC, and melanoma, respectively. Wound complications occurred in 161 (14.6%) patients, including 12 (13.0%), 17(14.8%), and 132 (14.8%) patients with PC, VC, and melanoma, respectively. Median length of stay was 1 day (interquartile range 0 to 3 days), and median operative time was 152 minutes (interquartile 83 to 192 minutes). Readmission rate was 12.7%. Wound complications were associated with longer operative time per 10 minutes (odds ratio 1.038, 95% CI 1.019 to 1.056, p0.001), BMI ≥30 (odds ratio 1.976, 95% CI 1.386 to 2.818, p0.001), and concomitant pelvic lymph node dissection (odds ratio 1.561, 95% CI 1.056 to 2.306, p = 0.025).Predictors of wound complications after ILND include BMI ≥30, longer operative time, and concomitant pelvic lymph node dissection. There have been efforts to decrease ILND complication rates, including minimally invasive techniques and modified templates, which are not captured by NSQIP, and such approaches may be considered especially for those with increased complication risks.

To assess whether urologists are able to accurately estimate the cost of commonly used endourologic disposable devices.An anonymous questionnaire was presented to resident and attending urologists in one academic healthcare system. Respondents estimated the cost of 15 disposable devices commonly used in ureteroscopy. Twenty-five surgeons (9 resident and 16 attending urologists) participated for a response rate of 96.2%. Respondents' cost estimates were compared to actual institutional costs and considered accurate if the absolute percentage error was within 20%. Additional information obtained included: years in practice, participation in purchasing activities, practice setting, number of ureteroscopy procedures performed monthly, degree of confidence in ability to estimate cost, and the importance of cost in device selection for each respondent.Of 375 total responses, 62 (16.5%) were accurate, 308 (82.1%) were inaccurate, and 5 (1.3%) were unanswered. The mean percentage error (MPE) for all responses was 178.8% (IQR 35.1%-211.4%). Overall, 73% of responses were overestimations and 27% were underestimations. Residents had an MPE of 128.4%, while attending urologists had an MPE of 207.8%. The most inaccurately estimated cost was for an endoscopic y-adapter, while the most accurate estimations were for a 1.5Fr nitinol ureteroscopic stone basket.Neither attending nor resident urologists are able to accurately estimate the cost of commonly used disposable devices. Improving urologists' understanding of device costs is necessary for improved cost control and a reduction in healthcare expenditures.

To compare endourology versus pediatric urology exposure to pediatric stone cases during fellowship, comfortability in treating pediatric stone cases, and access to pediatric surgical equipment.A survey was distributed to all pediatric urology fellowship programs and the Endourological Society. Age was stratified into12 months old, 12 months-4 years, 5-12 years, and 13-18 years. Exposure and comfortability performing extracorporeal shock wave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) were assessed across age groups. Exposure was assessed as 'yes/no' and comfortability was scaled from 1-5 ('would not do' to 'very comfortable').Seventy-two surveys met inclusion criteria, with 23 (31.9%) from pediatric urologists and 49 (68.1%) by endourologists. During fellowship, pediatric urologists had more exposure to SWL in toddlers (p = 0.03) and school age children (p = 0.045), URS in toddlers (p = 0.012) and school age children (p = 0.002), and PCNL in infants (p = 0.031) and school age children (p = 0.025) compared to endourologists. Pediatric urologists were significantly more comfortable performing SWL in toddlers (p = 0.04), URS in toddlers (p = 0.04) and school age children (p = 0.04), and PCNL in school age children (p = 0.02) compared to endourologists. Endourologists were significantly more uncomfortable than pediatric urologists in performing URS in toddlers (p = 0.03) and PCNL in infants (p = 0.04) and school age children (p = 0.03). There were no differences in availability of pediatric equipment.Pediatric urologists, have significantly more exposure than endourologists during fellowship and are more comfortable performing surgical treatment for urolithiasis in most pediatric ages. Endourology fellowships may benefit from greater exposure to pediatric patients with stones.

Objective To compare the metabolic profile of patients who form mixed calcium oxalate (CaOx)/uric acid (UA) stones to those of pure CaOx and pure UA stone formers. Methods We performed a retrospective review of 232 patients, with both stone composition analysis and 24-hour urine collection, seen between March 2002 and April 2012. Analysis of 24-hour urine constituents across the 3 stone groups (pure UA, pure CaOx, and mixed CaOx/UA) was performed using univariate analysis of variance and multivariate linear regression models adjusting for clinical and demographic factors and 24-hour urine collection elements. Results A total of 27 patients (11.6%) had mixed CaOx/UA, 122 (52.6%) had pure CaOx, and 83 (35.8%) had pure UA calculi. Univariate analysis demonstrated significant differences between mixed CaOx/UA patients and pure CaOx patients for urine pH (mixed, 5.63 ± 0.49 vs pure, CaOx 5.93 ± 0.51; P = .009) and supersaturation (SS) UA (mixed, 1.84 ± 1.09 vs pure, CaOx 1.26 ± 0.93; P = .01), and a significant difference between mixed CaOx/UA patients and pure UA patients for SS CaOx (mixed, 7.18 ± 4.23 vs pure, UA 4.90 ± 2.96; P = .005). Multivariate analysis demonstrated that mixed CaOx/UA patients had no significant difference in SS CaOx as compared with pure CaOx patients (difference, −0.27; P = .66), whereas at the same time had no significant difference in SS UA as compared with pure UA patients (−0.07; P = .69). Conclusion The metabolic profile of patients who form mixed CaOx/UA stones demonstrates abnormalities that promote both CaOx and UA stone formation. Dietary and medical management for this group of patients should address treatment of both defects.

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction.

Aspirin, as an inhibitor of platelets, is traditionally discontinued prior to percutaneous nephrolithotomy (PCNL) given the concern for increased surgical hemorrhage. However, this practice is based on expert opinion only, and mounting evidence suggests holding aspirin perioperatively can be more harmful than once thought. We sought to compared PCNL outcomes and complications in patients continuing aspirin to those stopping aspirin perioperatively.A retrospective review was performed of 321 consecutive PCNLs done between July 2012 and March 2014. Patients were separated into two groups. The on-aspirin group consisted of patients continuing aspirin throughout the perioperative period. The off-aspirin group had aspirin held temporarily pre- and postoperatively. Surgical outcomes and complications were compared between groups.Of the 321 PCNLs, 60 (18.7%) occurred in patients chronically taking aspirin. The on-aspirin group included 17 PCNLs (5.2%), while the off-aspirin group included 43 PCNLs (13.4%). There were no differences between groups in terms of operative time (77 minutes vs 74 minutes, p=0.212), hemoglobin change (p=0.522), stone size (21 mm vs 22 mm, p=1.0), stone-free rate (p=0.314), median length of hospitalization (p=0.642), transfusion rate (p=0.703), or total complications (p=1.0). No patient experienced a thromboembolic event.PCNL is safe in patients continuing aspirin perioperatively and does not result in more blood transfusions, angioembolization procedures, or complications. Patients with large stone burdens who are at high risk for thromboembolic events appear to be able to safely undergo PCNL without discontinuing aspirin.

Urology practices frequently encounter individuals who experience various degrees of pain/discomfort after ureteral stent removal. These symptoms have been previously proved to greatly affect functionality, convalescence time, quality of life, and healthcare costs. The etiology is unclear, but the condition is often self-limiting. We counsel individuals on their risk of having post-ureteral stent removal pain based on anecdotal data. We sought to evaluate the incidence of post-ureteral stent removal pain and attempt to find the probable cause.All individuals who had a ureteral stent placed and subsequently removed for various etiologies (between January 2012 and May 2013) were evaluated by filling a survey conducted by a member of the healthcare team 1 to 3 weeks after ureteral stent removal. Univariate and multivariate analysis were used to assess correlation between demographics, operative procedures, convalescent time, and post-ureteral stent removal symptoms. All statistical analyses were performed using SAS(®) software, and a P value of less than 0.05 was considered to indicate statistical significance.Of the 104 individuals in the final cohort, 64% had symptoms after stent removal (pain, hematuria, frequency, urgency, or fever), and among those with symptoms, 60% experienced pain/discomfort. On univariate analysis, stone basketing and indwelling stent discomfort correlated positively with pain after stent removal. On the other hand, the use of anticholinergics and a longer indwelling stent duration were associated with less pain after stent removal. On multivariate analysis, correlation with procedures involving basket extraction and indwelling stent discomfort maintained significance.Our series suggests that two of three individuals who undergo ureteral stent removal experience symptoms thereafter. Individuals undergoing stone basket extraction and those who experienced stent discomfort were more likely to have pain after stent removal. Anticholinergic use and stents indwelling for a longer time were associated with less pain after stent removal.

To evaluate the perception of urologists who have participated in live case demonstrations (LCDs) regarding safety, educational value/benefits, and ethics.A 19-question anonymous survey was sent to urologists who performed and/or moderated LCDs at the World Congress of Endourology meetings from 2008 to 2012. E-survey was distributed via e-mail, and automatic reminders were sent 2 weeks after original distribution if no response was obtained.Eighty-one percent (92/113) of the urologists responded to the survey of whom 75% practice full time in an academic setting. Only 48.0% were fellowship trained, however. More than 60% had performed more than five LCDs at their home and/or away institutions. Performing LCD at an away institution was associated with a higher level of anxiety when compared with performing LCDs at a home institution (79.8% vs 34.6%; P0.01). Respondents considered film equipment and crew; audience and moderator discussions; unfamiliar team, instruments and tools; language barrier; and having to narrate the procedure, as distractors. Seventy-nine percent considered LCD as an ethical practice, and 90.5% regarded LCDs as a "beneficial" and a "great way" to educate. Similarly, considering the various factors and conditions associated with LCDs, 95% would agree to participate in another LCD.LCDs are perceived to be an effective mode of education by performers and moderators of LCDs. Standard guidelines and policies are needed, however, for the selection of patient, surgeon and team, equipment, and facility. Studies are needed to evaluate the impact of this education process.

To examine the differences in 24-h urine composition between nephrolithiasis patients with and without diabetes mellitus (DM) in a large cohort of stone-formers and to examine differences in stone composition between patients with and without DM.A retrospective review of 1117 patients with nephrolithiasis and a 24-h urine analysis was completed. Univariable analysis of 24-h urine profiles and multivariable linear regression models were performed, comparing patients with and without DM. A subanalysis of patients with stone analysis data available was performed, comparing the stone composition of patients with and without DM.Of the 1117 patients who comprised the study population, 181 (16%) had DM and 936 (84%) did not have DM at the time of urine analysis. Univariable analysis showed significantly higher total urine volume, citrate, uric acid (UA), sodium, potassium, sulphate, oxalate, chloride, and supersaturation (SS) of UA in individuals with DM (all P0.05). However, patients with DM had significantly lower SS of calcium phosphate and pH (all P0.05). Multivariable analysis showed that patients with DM had significantly lower urinary pH and SS of calcium phosphate, but significantly greater citrate, UA, sulphate, oxalate, chloride, SSUA, SS of calcium oxalate, and volume than patients without DM (all P0.05). Patients with DM had a significantly greater proportion of UA in their stones than patients without DM (50.2% vs 13.5%, P0.001).DM was associated with multiple differences on 24-h urine analysis compared with those without DM, including significantly higher UA and oxalate, and lower pH. Control of urinary UA and pH, as well as limiting intake of dietary oxalate may reduce stone formation in patients with DM.

To evaluate perspectives of urologists viewing live case demonstrations (LCD) and taped case demonstrations (TCD).A 15-question anonymous survey was distributed to attendees of the live surgery session at the American Urological Association 2012 national meeting (Atlanta) and the second International Challenges in Endourology meeting (Paris).Of 1000 surveys distributed, 253 were returned completed (response rate 25%). Nearly half of respondents were in the academic practice setting and nearly 75% were beyond training. Just over 30% had performed a LCD previously. The perceived benefit of an LCD was greater than unedited and edited videos (chi-squared P = 0.014 and P0.001, respectively). Nearly no one selected 'not helpful' and a few selected 'minimally helpful' for any of the three forms of demonstration. Most respondents identified that opportunity to ask questions (61%) and having access to the full unedited version (72%), two features inherent to LCD, improved upon the educational benefit of edited videos. Most (78%) identified LCD as ethical. However, those that did not perceived lower educational benefit from LCD (P = 0.019). A slim majority (58%) would allow themselves or a family member to be a patient of a LCD and the vast majority (86%) plan to transfer knowledge gained at the LCD session into their practice.Urologists who attended these LCD sessions identified LCDs as beneficial and applicable to their practice. LCDs are preferred over videos. The large majority considers LCD ethical, although not as many would volunteer themselves for LCD. Further studies are necessary to determine if there is actual benefit from LCD over TCD to patient care.