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Objective: To better understand the pain requirements of urologic patients in the post-operative outpatient setting. Healthcare providers are one of the leading contributors to the current opioid epidemic. Understanding opioid prescribing practices and patients' narcotic requirements while not over-prescribing opioids is a public health priority.Methods: We conducted a prospective study to examine opioid consumption among adult patients who presented for outpatient urologic surgery at the University of California San Francisco (UCSF) and Zuckerberg San Francisco General (ZSFG) hospitals. We administered a Pre-Operative Pain Requirement Assessment Tool (POPRAT) electronically via text message 3 days prior to surgery to identify objective factors that may predict post-operative pain and opioid requirements. Patients were followed for 7 days post-operatively, in a similar fashion, to assess daily pain, and opioid use.Results: Two hundred and sixty-four participants were eligible for the study and 211 completed the study. Urology patients undergoing outpatient elective procedures used a mean of 5 morphine milligram equivalents (MME) (SD = 14.9) in a 7-day period. Women and patients less than 45 years of age had the highest opioid use. Based on the POPRAT, major predictors of post-operative pain were pre-operative anxiety (0.34 estimate, P value <.001) and anticipated pain (0.34 estimate, P value <.001). Anticipated opioid use, however, did not predict actual opioid use.Conclusion: Urologic outpatient surgeries require minimal opioids for pain management. The POPRAT may help identify which patients may experience more pain after surgery. Certain factors such as age and gender may need to be considered when prescribing opioids. [ABSTRACT FROM AUTHOR]

Objective: To promote the recognition and care of patients with female genital mutilation/cutting (FGM/C), we aimed to evaluate the awareness, clinical experience and knowledge of FGM/C among female pelvic medicine and reconstructive surgery (FPMRS) specialists. FGM/C is a cultural practice whereby there is removal of external female genitalia for non-therapeutic reasons. Despite the high prevalence of urogynecologic complications, there is a paucity of literature discussing FGM/C from the lens of urologists and urogynecologists.Methods: By cross-sectional design, we distributed a 27-item survey via email to members of the Society of Urodynamics, Female Pelvic Medicine and Reconstructive Surgery. We collected variables pertaining to previous FGM/C education, clinical confidence, cultural and medical knowledge, and desire for future education.Results: A total of 54 US-based, mostly urologists and FPMRS specialists, completed the survey. All providers had heard of FGM/C; however only 13% received formal education during medical training. Over 50% had encountered a patient with FGM/C in clinical practice. Only 19% and 13% felt completely confident recognizing and discussing FGM/C, respectively. Seventy percent believed religious doctrine informed FGM/C practice and 24% correctly identified FGM/C type on clinical representation. Finally, only 17% of respondents were aware of FGM/C guidelines, and providers expressed a desire for increased availability of multimodal resources.Conclusion: Education regarding FGM/C remains sparse and variable for US FPMRS specialists. Cultural and clinical knowledge is also lacking, which is a detriment to patient care. In order to strengthen awareness and knowledge, we must develop high-quality FGM/C educational resources for urologists and gynecologists. [ABSTRACT FROM AUTHOR]

Objective: To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success.Materials and Methods: The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census.Results: We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p<0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64).Conclusions: Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement. [ABSTRACT FROM AUTHOR]

Diabetic autonomic neuropathy affects the entire autonomic nervous system and can lead to dysfunction of the cardiovascular, gastrointestinal, and genitourinary organ systems. Genitourinary dysfunction associated with diabetic autonomic neuropathy includes diabetic bladder dysfunction, sexual dysfunction, and recurrent urinary tract infections. Urological complications in diabetes mellitus are very common; in fact, genitourinary complications are more common than diabetic neuropathy or nephropathy. While several studies have reported on genitourinary dysfunction in individuals with diabetes, UroEDIC, an ancillary study to the Diabetes Control and Complications Trial (DCCT) and its observational follow up, the Epidemiology of Diabetes Interventions and Complications study (EDIC), comprehensively characterized the association between urologic complications and cardiovascular autonomic neuropathy. UroEDIC demonstrated significant associations between autonomic neuropathy and urologic complications in type 1 diabetes, specifically erectile dysfunction, female sexual dysfunction, and lower urinary tract symptoms. In this narrative review, we review the current literature on urological complications in diabetes. [ABSTRACT FROM AUTHOR]

Objective: To determine if there is an association between patient race and physician time spent with the patient during outpatient urology consultations.Methods: We identified all adult urology new outpatient visits in the National Ambulatory Medical Care Survey dataset for 2012-2016. Patient race was dichotomized as White or non-White. Our primary outcome was time spent during the visit between the patient and urologist. Using population-level weighting, we compared differences in mean time spent during visits with White and non-White patients. Mixed-effects linear regression was used to adjust for confounding factors and to account for clustering among individual physicians. Secondary outcomes included number of services provided and if ancillary providers were seen.Results: Over the 5 year period, 1668 raw visits met criteria and were used to estimate 21million new outpatient urology visits nationwide. 80% of all visits were with White patients. Mean physician time spent among visits with white patients was 23.9 minutes and 24.4 minutes for non-White patients. There was no difference in number of services provided but visits with non-white patients were less likely to include an ancillary provider. After adjustment, there was no significant difference in mean time spent with the urologist among visits with White and non-White patients (difference 0.9 minutes, 95% CI: -0.6-2.4). There were also no differences in adjusted mean time spent among return visits or new visits for hematuria, urologic cancers, or BPH.Conclusion: We found no statistically significant difference in time spent with a urologist during outpatient office consultations between White and non-White patients. [ABSTRACT FROM AUTHOR]

To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset. Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1 year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy. [ABSTRACT FROM AUTHOR]

Objective: To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma.Material and Methods: Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy.Results: A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan.Conclusion: Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization. [ABSTRACT FROM AUTHOR]

Objective: To describe the use of Lean in urology at Zuckerberg San Francisco General, a community safety-net and trauma hospital that serves as a major teaching site for the University of California San Francisco.Methods: We examined our process improvement activities from 2016 to 2018. Our Lean Daily Management System (DMS) includes a 15-minute team huddle ("urology Lean work") of service residents, faculty, clinic and operating room nursing staff, and anesthesia liaisons. Our DMS also includes a 5-minute preoperative huddle. Besides team-building, urology Lean work surfaces logistics, safety or equipment improvement ideas, and ensures progress and completion of initiated projects.Results: Over a 2-year period we developed and completed 67 projects. Projects impacted the outpatient setting (57%), followed by the operating room (22%), the Urology service (12%), and inpatient setting (9%). We completed projects in the following domains: safety (26%), quality (22%), care experience (21%), workforce care and development (13%), equity (11%), and financial stewardship (7%). Urology Lean work reduced new patient clinic access time (119-21 days) and Bacillus Calmette-Guérin in clinic treatment time (180-105 minutes). The average proportion of urology on-time surgeries was better than the overall surgery on-time surgeries (71% v 61%).Conclusion: Urology Lean work successfully applied DMS in a service specific yet holistic approach. Urology Lean work improved resident engagement in quality and safety endeavors and served as a DMS model throughout perioperative and clinic areas. [ABSTRACT FROM AUTHOR]

Objective: To elucidate current understanding on the pathophysiological mechanism of genital lichen sclerosus (LS), urologic manifestations, and treatment options.Materials and Methods: The Medline/PubMed and Embase databases were systematically reviewed for publications pertaining to LS. After applying inclusion and exclusion criteria, references were assessed for relevance to the pathophysiology, presentation, and treatment of LS by title and abstract review by 2 independent reviewers, yielding 186 articles for assessment.Results: The contemporary understanding of the epidemiology and histology of LS is reviewed herein. Additionally, we explore in detail the 3 hypotheses regarding the pathophysiological mechanism contributing to disease presentation: infectious etiology, primary immune dysregulation, and the isotraumatopic response. We summarize the available biological evidence supporting each hypothesis. This discussion provides context for understanding LS morbidity and may spur new avenues of research. For the clinician, we review the clinical presentation of disease, including the risk of progression to squamous cell carcinoma. The current medical and surgical treatment options are also detailed.Conclusion: LS remains a potentially insidious disease which may lead to debilitating urinary and sexual dysfunction. Cross disciplinary research should aim for earlier detection, as well as more effective and durable treatment. The exact cause of LS remains unknown. [ABSTRACT FROM AUTHOR]

Objective: To examine the most cited literature in urethral reconstruction, review types of work published, and observe research trends.Methods: The 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.Results: The 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.Conclusion: In 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. [ABSTRACT FROM AUTHOR]