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Varicoceles are dilated veins within the spermatic cord and a relatively common occurrence in men. Fortunately, the large majority of men are asymptomatic, however, a proportion of men with varicoceles can suffer from infertility and testosterone deficiency. Sperm and testosterone are produced within the testis, and any alteration to the testicular environment can negatively affect the cells responsible for these processes. The negative impact of varicoceles on testicular function occurs mainly due to increased oxidative stress within the testicular parenchyma which is thought to be caused by scrotal hyperthermia, testicular hypoxia, and blood-testis barrier disruption. Management of varicoceles involves ligation or percutaneous embolization of the dilated veins. Repair of varicoceles can improve semen parameters and fertility, along with serum testosterone concentration. In this review, we discuss the pathophysiology of varicoceles, their impact on testicular function, and management.

Novel minimally invasive therapies like the prostatic urethral lift are among the many endoscopic options for the treatment of benign prostatic enlargement and lower urinary tract symptoms (BPE/LUTS). To further understand the relative uptake, complications and retreatment rates of contemporary endoscopic procedures for BPE/LUTS across diverse practice types, we performed a retrospective study of inpatient and ambulatory surgery encounters in the Premier Healthcare database.We included men who underwent endoscopic procedures for BPE/LUTS between 2000 and 2018. We determined the utilization of endoscopic therapies for BPE/LUTS, 30-day and 90-day readmission rates, and retreatment rate. Multivariable logistic regression was used to assess the association of procedure type with outcomes for the 3 most commonly performed procedures.We identified 175,150 men treated with endoscopic surgery for BPE/LUTS. The annual percent utilization of the prostatic urethral lift increased from1% in 2014 to 10.4% in 2018. Compared to transurethral resection of the prostate and prostate photovaporization, prostatic urethral lift was associated with a lower odds of readmission at 30 (OR 0.58, p0.01) and 90 (OR 0.55, p0.01) days and a higher odds of retreatment within 2 years of followup (OR 1.78, p0.01).Providers have rapidly adopted prostatic urethral lift which accounted for more than 1 in 10 endoscopic procedures captured for BPE/LUTS in 2018. Men treated with prostatic urethral lift are readmitted less within 30 and 90 days but are more likely to be retreated within 2 years of their index procedure as compared to men treated with transurethral resection of the prostate or prostate photovaporization.

Objective To determine whether the academic achievement of Department Chairperson (DC) and Research Director (RD), when present, is associated with increased scholarly productivity and National Institutes of Health (NIH) funding of faculty members in academic urology departments. Materials and Methods We identified the DC, RD and faculty members of 145 academic urology departments. The scholarly productivity and NIH funding for each individual faculty member was assessed from 2018 to 2019 using an h-index extrapolated from the Scopus database and the NIH RePORTER tool, respectively. The Spearman correlation coefficient was employed to define the correlation of these parameters. Hypothesis testing was conducted using the Mann-Whitney U test. Results After excluding 13 departments due to missing faculty listing, our final sample included 132 departments and 2227 faculty members. In 2018, the NIH provided $55,243,658 in urology research grants to 24.2% of departments and 4.0% of faculty members. Of departments with NIH funding, 68.8% employed a RD. DC and RD h-index were positively correlated with departmental h-index. DC h-index positively correlated with department NIH funding. Moreover, NIH funding was significantly higher for departments with a RD vs those without a RD ($1,268,028 vs $62,941, P Conclusion Academic success of a DC and RD was associated with urology departmental scholarly productivity and NIH funding. The presence of a RD, funded or unfunded, was associated with increased departmental NIH funding.

Overactive bladder syndrome is a prevalent condition impacting quality of life, activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes. We review the benefits and challenges of overactive bladder treatments and propose approaches to improve patient management, with the goals of initiating therapy earlier and achieving better patient satisfaction, functioning, and quality of life.

Aim Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. Methods This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. Results Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. Conclusion This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

A minimum number of index procedures is required for graduation. Without thresholds for surgical technique, it is unclear if robotic and open learning is balanced. We assessed the distribution of robotic and open surgeries performed by residents upon graduation.Voluntary Accreditation Council for Graduate Medical Education resident case logs from 11 institutions were de-identified and trends in robotic and open major surgeries were compared using Wilcoxon rank sum and 2-sample t-tests.A total of 89,199 major cases were recorded by 209 graduates from 2011 to 2017. The median proportion of robotic cases increased from 2011 to 2017 in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) (all values p0.001). Robotic and open cases remained most divergent in reconstruction, with a median of 12 robotic (IQR 9-19) to 70 open cases (IQR 55-106) being performed by residents in 2017. Similar observations occurred in pediatrics. In oncology the number of robotic procedures superseded that of open in 2016 and rose to a median of 148 robotic (IQR 108-214) to 121 open cases (IQR 90-169) in 2017, with the driver being robotic prostatectomy. Substantial differences in surgical technique were observed between institutions and among graduates from the same institution.Although robotic volume is increasing, the balance of surgical technique and the pace of change differ in reconstruction, oncology and pediatrics, as well as among individual institutions and graduates themselves. This raises questions about whether more specific guidelines are needed to ensure equity and standardization in training.

Objective To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood. Methods The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden. Results The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects). Conclusion NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Male circumcision (MC) is one of the oldest surgical procedures still completed today. Medical indications for MC include phimosis, recurrent balanitis, cosmesis, and infection prevention. In this review, we mainly focus on the role of MC in the prevention of human immunodeficiency virus, human papillomavirus, herpes simplex virus, gonorrhea, chlamydia, chancroid, and syphilis, and the subsequent impact of these genitourinary infections on male fertility. Overall, many compelling data support that MC may play an essential role in both genitourinary infection prevention and male fertility.

Context In recent years, new technologies have been developed to treat benign prostatic enlargement (BPE). Three of these devices may be utilized in office and are promising additions. Objective To systematically review all clinical trials investigating prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND), with emphasis on clinical efficacy and complications. Evidence acquisition We performed a systematic review of PubMed/Medline database in November 2020 according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Evidence synthesis Of 168 articles identified, 18 met the inclusion criteria. Evidence consisted of few randomized controlled trials, and multiple single-arm prospective and retrospective studies. Among the three modalities, PUL demonstrates rare occurrence of serious complications but higher retreatment rates at short- and long-term follow-up. WVTT offers lower retreatment rates with a similar safety profile. TIND studies report varying rates of retreatment and complications. All technologies offer low rates of erectile and ejaculatory dysfunction, although the risk appears to be highest for WVTT ( Conclusions Among the emerging technologies introduced to treat BPE, the in-office PUL, WVTT, and TIND systems are valuable additions to the current surgical options. These systems offer unique advantages that should be considered in the shared decision-making process. Patient summary In this report, we identified all clinical trials reporting on the efficacy and safety of the in-office prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND) systems for the treatment of benign prostatic enlargement. We found that PUL and WVTT demonstrate acceptable outcomes in terms of functional improvement, retreatment, and complications. More data with longer follow-up are required to further evaluate TIND, but early results are promising.

INTRODUCTION AND OBJECTIVE:The World Health Organization (WHO) has established a target of 27 million male circumcisions (MC) by the year 2021 for HIV prevention in sub-Saharan Africa, with an emph...

Introduction: We examined temporal trends in urology residency applicant statistics and characteristics through time.Methods: Match statistics during 2006 to 2016 were obtained from the Ame...

Prostate artery embolization (PAE) is a promising new treatment option for men with symptomatic benign prostatic hyperplasia (BPH). Our goal is to review the data on PAE with regard to outcomes, risks versus benefits, and safety. Current data suggests that PAE is safe and effective for men with symptomatic BPH. The two most robust randomized controlled trials comparing PAE with TURP both found comparable short-term results with regard to improvements in symptoms. However, the side effects of PAE were higher than those of TURP. There remain ongoing randomized controlled trials comparing the two modalities of treatment. Though the largest randomized controlled trials comparing these two modalities of treatment of BPH are still underway, current data suggest PAE may be a promising, safe, and effective treatment option for men with symptomatic BPH. Additionally, PAE can be safely performed on larger prostates of any size and is generally performed via a single, femoral artery puncture under local anesthesia. Therefore, it is particularly appealing for patients with prostate glands > 80 g and who are poor candidates for general anesthesia.

Lower urinary tract symptoms (LUTS) consist of a common set of urologic symptoms that can affect the elderly. The prevalence of LUTS is expected to rise owing to the continued increase of numbers of the elderly. Although benign prostatic hyperplasia is considered a common cause of LUTS, the broader potential causes of LUTS are myriad. A wide range of diagnostic modalities and treatments are available to manage patients with LUTS and their utilization should not be limited to the urologist.

Transurethral resection of the prostate (TURP) is considered the gold standard for minimally invasive treatment of lower urinary tract symptoms due to benign prostate enlargement of

Purpose of Review The clinical utility of the digital rectal exam (DRE) in the workup of lower urinary tract symptoms has been questioned in the literature. This review aims to critically examine the recent literature regarding the accuracy and reliability of the DRE in the assessment of lower urinary tract symptoms (LUTS) and benign prostatic hypertrophy (BPH). Here, we specifically focus on the clinical importance of the DRE in the evaluation of nocturia.

Introduction To evaluate access to urological care and potential work force shortages it is essential to understand geographic variation in physician supply and practice patterns among urologists. We sought to quantify differences between urban and nonurban urologists in the United States and evaluate these trends with time. Methods We obtained procedural case logs from the ABU (American Board of Urology) for 9,390 urologists undergoing ABU initial certification or recertification during 2003 through 2015. We performed summary statistics to characterize the practice patterns and case mix of nonurban urologists (practice setting less than 100,000 population) and urban urologists (practice setting greater than 100,000 population). Results Of 8,180 urologists (87.1%) with practice setting information 6,907 (84.4%) practiced in an urban setting vs 1,273 (15.6%) in a nonurban setting. The proportion of nonurban urologists decreased from 2003 to 2015 (19.4% to 14.2%, p = 0.06). A higher proportion of urban urologists were female (9.5% vs 6.8%, p = 0.007). Nonurban urologists were more likely to be general urologists (88.0% vs 71.8%, p Conclusions Imbalance in the geographic distribution of urologists appears to be growing. With an aging nonurban urological work force that is performing fewer major operations Americans residing in nonurban areas may face barriers in access to care.

Physician burnout-a constellation of depersonalization, emotional exhaustion, reduced feelings of personal attachment, and a low sense of accomplishment-is a term that has been around since the 1980s. Burnout rates among residents and fellows are higher than medical students, attending physicians, and age-matched college graduates, with rates ranging from 40-80% of trainees across subspecialties. Unfortunately, burnout among residents and trainees has been linked to lower scores on in-service examinations for internal medicine residents as well as poorer overall health and exercise habits. The purpose of this review is to quantify the extent of burnout among urology residents and examine effective techniques and measures to prevent burnout and practically what can be done to combat this growing epidemic.

INTRODUCTION AND OBJECTIVES:Clinical trials in Africa have shown that voluntary medical male circumcision (VMMC) can reduce HIV transmission by up to 60%. Part of the barrier to the scale up of VMM...

AIMS: To assess efficacy and safety as well as predictive factors of dry rate and freedom from surgical revision in patients underwent AUS placement. The artificial urinary sphincter (AUS) is still considered the standard for the treatment of moderate to severe post-prostatectomy stress urinary incontinence (SUI). However, data reporting efficacy and safety from large series are lacking. METHODS: A multicenter, retrospective study was conducted in 16 centers in Europe and USA. Only primary cases of AUS implantation in non-neurogenic SUI after prostate surgery, with a follow-up of at least 1 year were included. Efficacy data (continence rate, based on pad usage) and safety data (revision rate in case of infection and erosion, as well as atrophy or mechanical failure) were collected. Multivariable analyses were performed in order to investigate possible predictors of the aforementioned outcomes. RESULTS: Eight hundred ninety-two men had primary AUS implantation. At 32 months mean follow-up overall dry rate and surgical revision were 58% and 30.7%, respectively. Logistic regression analysis showed that patients without previous incontinence surgery had a higher probability to be dry after AUS implantation (OR: 0.51, P = 0.03). Moreover institutional case-load was positively associated with dry rate (OR: 1.18; P = 0.005) and freedom from revision (OR: 1.51; P = 0.00). CONCLUSIONS: The results of this study showed that AUS is an effective option for the treatment of SUI after prostate surgery. Moreover previous incontinence surgery and low institutional case-load are negatively associated to efficacy and safety outcomes. ispartof: NEUROUROLOGY AND URODYNAMICS vol:38 issue:2 pages:710-718 ispartof: location:United States status: published

Introduction We compare the use of bulking agents and slings for the treatment of stress urinary incontinence among female Medicare beneficiaries. Methods We analyzed data from a 5% national random sample of Medicare claims from 2000 to 2011. Female beneficiaries who underwent a sling or bulking agent procedure were identified based on CPT-4 and ICD-9 procedure codes. Statistical analysis for categorical data determined differences in the distribution of patient demographics and comorbidities. The 90-day adverse events and reinterventions were compared between treatment groups. Time to event analysis was used to determine freedom from reintervention after therapy. Results We identified 21,134 and 3,475 patients treated with sling and bulking procedures, respectively. There was a 29.7% increase in the number of sling procedures and a 59.5% decrease in bulking procedures from 2001 to 2011. Patients treated with bulking agents had higher rates of diabetes, cardiovascular disease, heart failure and renal failure (p Conclusions Sling and bulking procedures are safe in terms of short-term performance, although the rates of retention were high in both groups. Patients treated with reinterventions tend to repeat the same therapy instead of converting to another procedure.

Objective To examine trends in international medical graduate (IMG) representation within urology and compare these trends to those of other specialties. Methods Urology match data were obtained from the American Urological Association from 1987 to 2015. IMG representation among residencies was extracted from reports on Graduate Medical Education published in Journal of the American Medical Association from 1978 to 2013. We analyzed trends in the number of IMG urology applicants, match rates in urology for IMGs vs US medical graduates, and the annual percentage of IMGs among all urology residents vs residents of other specialties. Results Between 1987 and 2015, 6790 applicants matched into urology. The number of positions offered increased by 24% (224 to 295) between 1987 and 2015. However, the number of IMG urology applicants did not increase accordingly (r = −0.55, P = .78). Match rates for US students and IMGs ranged from 68% to 91% and 6% to 33%, respectively. From 1978 to 2013, the proportion of IMGs across all specialties remained relatively stable (25% to 27%), whereas the proportion of IMGs in urology decreased substantially (27% to 5%). Conclusion The proportion of IMGs in urology training has dramatically decreased over time and remains lower than most other specialties. IMGs are critical to urology as they can assist in meeting workforce demands, contribute diversity to the workplace, and help to propel the field forward through urologic research. Further efforts should be directed toward understanding the unique needs of IMG residents and helping them to navigate the challenges of practicing in a foreign country.

Objectives To evaluate the utility of the digital rectal examination (DRE) in estimating prostate size and the association of DRE with nocturia in a population-based cohort. Subjects and Methods We identified all men randomized to the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial for whom DRE results were available. Men were excluded if they had a history of prostate surgery or incident prostate cancer. Prostate posterior surface area was derived from DRE sagittal and transverse estimates. Relationships between prostate posterior surface area, transrectal ultrasonography (TRUS), prostate-specific antigen (PSA) and nocturia were analysed using intraclass correlation coefficients (ICCs), Spearman's rank correlation and multivariable logistic regression. Results A total of 30 500 men met the inclusion criteria, with 103 275 screening visits containing paired DRE and PSA data. Digital rectal examination posterior surface area estimates had an ICC of 0.547 (95% CI 0.541–0.554) and were significantly yet modestly correlated with elevated PSA level (rs = 0.18, P < 0.001) and TRUS prostate volume (rs = 0.32, P < 0.001). Prostate posterior surface area was significantly associated with nocturia on multivariable analysis, but was not significant in stratified analysis of men with cardiovascular risk factors (hypertension, diabetes, high body mass index, stroke). In men without these risk factors, the highest quintile of DRE posterior surface area had 22% greater odds of nocturia than the lowest quintile (odds ratio 1.216, 95% CI 1.036–1.427). Conclusions Digital rectal examination is a modestly accurate tool for measuring prostate volume. While DRE posterior surface area represents a statistically significant predictor of nocturia, the magnitude of effect suggests it has limited clinical utility for assessing this condition, particularly in the presence of cardiovascular risk factors.

Objective To evaluate changes over time in female representation among urology residents compared to those within other specialties. Materials and Methods Urology match data were obtained from the American Urological Association from 1996 to 2015. Trends in match rates of male and female urology applicants were assessed. Data for gender representation among residencies were extracted from reports in the Journal of the American Medical Association from 1978 to 2013. We compared the annual percentage of women among urology residents vs residents of other specialties over time. Results Mean number of male vs female urology applicants per year was 285.0 ± 27.1 vs 76.5 ± 21.8 ( P P = .36). From 1978 to 2013, the proportion of female residents across all specialties rose from 15.4% to 46.1%, whereas female residents in urology rose from 0.9% to 23.8%. Between 2009 and 2013, obstetrics and gynecology and orthopedics had the highest and lowest average proportion of women, respectively (80.7% and 13.5%). The largest growth occurred in urology among all other specialties ( P Conclusion Male and female applicants to urology residency have similar match rates. Although urology demonstrated the greatest fold-increase in proportion of women among all specialties during the study period, women have remained a minority among urology residents. Gender representation within urology is a reflection of many factors and demonstrates a need for further improvement.

In July 2011, the US Food and Drug Administration (FDA) issued a safety communication regarding serious complications associated with surgical mesh for pelvic organ prolapse, prompting increased media and public attention. This study sought to analyze internet search activity and news article volume after this FDA warning and to evaluate the quality of websites providing patient-centered information. Google Trends™ was utilized to evaluate search engine trends for the term “pelvic organ prolapse” and associated terms between 1 January 2004 and 31 December 2014. Google News™ was utilized to quantify the number of news articles annually under the term “pelvic organ prolapse.” The search results for the term “pelvic organ prolapse” were assessed for quality using the Health On the Net Foundation (HON) certification. There was a significant increase in search activity from 37.42 in 2010 to 57.75 in 2011, at the time of the FDA communication (p = 0.021). No other annual interval had a statistically significant increase in search activity. The single highest monthly search activity, given the value of 100, was August 2011, immediately following the July 2011 notification, with the next highest value being 98 in July 2011. Linear regression analysis of news articles per year since the FDA communication revealed r2 = 0.88, with a coefficient of 186. Quality assessment demonstrated that 42 % of websites were HON-certified, with .gov sites providing the highest quality information. Although the 2011 FDA safety communication on surgical mesh was associated with increased public and media attention, the quality of relevant health information on the internet remains of poor quality. Future quality assurance measures may be critical in enabling patients to play active roles in their own healthcare.

Objective To characterize the safety and efficacy of the 180-W XPS-Greenlight laser in patients on systemic anticoagulation. Materials and Methods A retrospective analysis of 384 patients who underwent photoselective vaporization of the prostate with the 180-W XPS-laser between 2010 and 2013 at two centers in the United States and Switzerland was performed. The primary outcome was the intraoperative and postoperative complication rates for those on anticoagulation undergoing photoselective vaporization of the prostate. The secondary outcome was International Prostate Symptom Scores, postvoid residual, maximum flow rate, and prostate-specific antigen levels. Results Of 384 patients, aspirin, clopidogrel, and warfarin were used in 146 (38%), 34 (8.9%), and 57 (14.8%) patients, respectively. Single-drug, two-drug, and three-drug combinations were used in 142 (35.5%), 37 (9.3%), and 7 (1.7%) of the cases. Median lasing time (39 min vs 36 min; P = .99) and number of fibers used (1.0 vs 1.0; P = .63) were comparable between patients on vs off systemic anticoagulation. Postoperatively, urinary symptoms (International Prostate Symptom Score, quality of life) and objective voiding parameters (maximum flow rate, postvoid residual) improved in both groups of patients. During a maximum follow-up of 2 years, patients on vs off systemic anticoagulation did not show any significant differences in the rate of postoperative urinary tract infection (3.8% vs 5.1%; P = .71), retention (5.1% vs 5.9%; P = .71), urethral stricture (1.5% vs none, P = .05), and reoperation (2.2% vs 1.5%; P = .49). The primary limitation is the retrospective nature of the study. Conclusion Photovaporization of the prostate with the 180-W XPS-laser is a safe and effective minimal-invasive treatment option for patients on systemic anticoagulation.

Introduction We report the implementation of time driven, activity based costing for competing treatments of small renal masses at an academic referral center. Methods To use time driven, activity based costing we developed a process map outlining the steps to treat small renal masses. We then derived the costs of supplying every resource per unit time. Known as the capacity cost rate, this included equipment and its depreciation (eg price per minute of the operating room table), personnel and space (eg cost per minute to rent clinic space). We multiplied each capacity cost rate by the time for each step. Time driven, activity based costing was defined as the sum of the products for each intervention. Results Robot-assisted laparoscopic partial nephrectomy was the most expensive treatment for small renal masses. It was 69.7% more costly than the most inexpensive inpatient modality, laparoscopic radical nephrectomy ($17,841.79 vs $10,514.05). Equipment costs were greater for laparoscopic radical nephrectomy than for open partial nephrectomy. However for laparoscopic radical nephrectomy vs open partial nephrectomy the lower personnel capacity cost rate due to faster operating room time (195.2 vs 217.3 minutes, p = 0.001) and shorter length of stay (2.4 vs 3.7 days, p = 0.13) were the primary drivers in lowering costs. Radiofrequency ablation was 48.4% less expensive than laparoscopic radical nephrectomy ($5,093.83 vs $10,514.05) largely by avoiding inpatient costs. Renal biopsy contributed 3.5% vs 12.2% to the overall cost of robot-assisted laparoscopic partial nephrectomy vs radiofrequency ablation but it may allow for increased active surveillance. Conclusions Using time driven, activity based costing we determined the relative resource utilization of competing small renal mass treatments, finding significant cost differences among various treatments. This informs value considerations, which are particularly relevant in the current health care milieu.

Objective We sought to examine the surgical trends and utilization of treatment for mixed urinary incontinence among female Medicare beneficiaries. Methods Data was obtained from a 5% national random sample of outpatient and carrier claims from 2000 to 2011. Included were female patients 65 and older, diagnosed with mixed urinary incontinence, who underwent surgical treatment identified by Current Procedural Terminology, Fourth Edition (CPT-4) codes. Urodynamics (UDS) before initial and secondary procedure were also identified using CPT-4 codes. Procedural trends and utilization of UDS were analyzed. Results Utilization of UDS increased during the study period, from 38.4% to 74.0% prior to initial surgical intervention, and from 28.6% to 62.5% preceding re-intervention. Sling surgery (63.0%) and injectable bulking agents (28.0%) were the most common surgical treatments adopted, followed by sacral nerve stimulation (SNS) (4.8%) and Burch (4.0%) procedures. Re-intervention was performed in 4.0% of patients initially treated with sling procedures and 21.3% of patients treated with bulking agents, the majority of whom (51.7% and 76.3%, respectively) underwent injection of a bulking agent. Risk of re-intervention was not different among those who did or did not receive urodynamic tests prior to the initial procedure (8.5% vs. 9.3%) Conclusions Sling and bulk agents are the most common treatment for MUI. Preoperative urodynamic testing was not related to risk of re-intervention following surgery for mixed urinary incontinence in this cohort. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc.

Transurethral resection of the prostate (TURP) is the standard surgical therapy for lower urinary tract symptoms (LUTS) due to prostatic enlargement. Following TURP, LUTS may persist in a proportion of patients. Persistent LUTS necessitates proper evaluation and management. In this review, we sought to describe the prevalence, pathophysiology, and predictors of LUTS following TURP, as well as the recommended evaluation and management. Among the different techniques utilized for TURP, the prevalence of postoperative LUTS is similar. The chronically obstructed bladder has been shown to vary in its expression of collagen, tissue factors, and receptors when compared to the normal bladder which could contribute to the pathophysiology of LUTS after TURP. Although androgen receptors exist in the urinary epithelium, the role of sex hormones in LUTS remains obscure. GreenLight laser can lead to postoperative irritative voiding symptoms as a result of tissue necrosis. A large proportion of patients have persistent LUTS following TURP, with similar incidences between different techniques that can be used to perform TURP. LUTS after TURP should be evaluated with a thorough history and physical, including International Prostate Symptom Score, and urine culture to rule out infection. Noninvasive uroflow, post-void residuals, and subsequent urodynamic study or cystoscopy can be utilized as needed. Further research is necessary to be able to more precisely predict the patients who will experience no improvement in or worsening of LUTS following TURP.

There is an abundance of devices for adolescent and adult male circumcision (MC). It has been shown that the safety and efficacy of device-assisted MC are equal to or better than those for MC via conventional surgery. MC devices have the potential to simplify the procedure and increase the acceptability of circumcision among patients.

Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries.We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software.A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p0.0001) were more likely to be treated. Minority patients (OR 0.38, p0.0001) and those living in the western United States (OR 0.52, p0.0001) were less likely to receive treatment.Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.

We evaluate the efficacy and complications after retropubic and transobturator mid urethral slings in the treatment of female stress urinary incontinence.A systematic literature review was performed using MEDLINE®, limited to randomized controlled trials with a minimum followup of 1 year and type 1 grafts. Statistical analyses were performed using StatsDirect Version 2.7.9 (StatsDirect Ltd, Altrincham, UK).Retropubic mid urethral sling procedures showed statistically significant improvements in objective cure (OR 1.35, 95% CI 1.10-1.67, p=0.005) and subjective cure (OR 1.24, 95% CI 1.04-1.49, p=0.02). Bladder perforations (OR 5.72, CI 2.94-11.12, p0.0001) and bleeding (OR 2.65, CI 1.54-4.59, p=0.0005) were significantly more common with retropubic mid urethral slings, whereas vaginal perforations (OR 0.29, CI 0.15-0.56, p=0.0002) and neurological symptoms (OR 0.35, CI 0.25-0.5, p0.0001) were more common with transobturator mid urethral slings. Operative time was significantly longer for retropubic mid urethral slings than transobturator mid urethral slings (OR 1.38, p0.0001). No significant differences were noted in mesh erosions and exposure, urinary retention, infection, lower urinary tract symptoms and length of hospital stay.Retropubic mid urethral slings showed better objective and subjective cure rates than transobturator mid urethral slings. However, bladder perforation and bleeding were more common with retropubic mid urethral slings. Operative time was longer for retropubic mid urethral slings. Transobturator mid urethral slings were associated with more cases of neurological symptoms and vaginal perforation.

Introduction We determine national trends in costs of care as well as associated growth and adoption of minimally invasive surgery for major uro-oncology procedures. Methods Using a nationally representative sample we identified patients diagnosed with prostate, renal and bladder cancer who underwent prostatectomy, nephrectomy, partial nephrectomy and cystectomy from 2000 to 2011. Temporal trends in patient demographics, hospital and procedure related characteristics, surgical volume, minimally invasive surgery use and costs of hospitalization over the years were analyzed. Hierarchical linear regression was performed to evaluate the effects of hospital volume, time and surgery type on costs of hospitalization. Results Overall 836,563, 440,337 and 122,992 patients underwent prostatectomy, nephrectomy and cystectomy from 2000 to 2011, respectively. There was a 33.6%, 50.8% and 25.5% increase in annual surgical volume for these 3 surgeries during the 10 years, with the most prominent increase at high volume hospitals. The use of minimally invasive surgery increased 65.6% for prostatectomy, 22.0% for nephrectomy and 12.5% for cystectomy, and this increase was more prominent at high volume hospitals. For all 3 surgeries the hospital stay for minimally invasive surgery cases was more expensive than for open procedures, but decreased during the study period from $17,367 to $11,145 for prostatectomy and from $54,209 to $28,753 for cystectomy. Conclusions High volume hospitals experienced greater growth in surgery caseloads and minimally invasive surgeries but this did not lead to higher costs of care. While minimally invasive surgery has consistently been more expensive than open surgery, the costs of minimally invasive prostatectomy and cystectomy have decreased in the last decade.

We aim to summarize the literature on international patterns of care for patients with neurogenic bladder (NGB) from spinal cord injury (SCI). We performed a PubMed database search, hand review of references, communication with professional societies, and registry evaluations for pertinent data. Established patterns of care, including SCI registries and specialty centers, are available in high-resource countries such as the US and UK. As such, mortality rates from complications of NGB/SCI are lower. Access to intermittent catheterization supplies, among other resources, may be inadequate in many low-income regions. Cultural and religious beliefs may also hinder integration of proper bladder management in SCI patients. While guidelines exist in many parts of the world, it is unclear how rigorously they are disseminated or followed. While there is a paucity of high-level evidence, the differences in patterns of care are closely related to socioeconomic status and resources of the geographic area. Future research efforts should focus on improving access to diagnostic modalities, supplies, and specialists in these areas.

Purpose of review The metabolic syndrome (MetS) is an ever growing pandemic consisting of a constellation of abnormalities. Many hypotheses have been put forth to establish a link between this syndrome and voiding dysfunction. We created a layout of the possible, probable, and proven relationships connecting the MetS with voiding dysfunction in men. Recent findings There has been growing interest in the relationship linking MetS and voiding dysfunction, with or without benign prostatic hyperplasia, during the past several years. Different mechanisms have been proposed to establish the connection. Summary A clear-cut association between MetS and voiding dysfunction is not clearly defined; rather, voiding dysfunction occurring in men with MetS has been shown to be related to numerous pathologies. MetS is a complex disease that includes numerous pathophysiological aspects that may contribute to the causation and advancement of voiding dysfunction. In light of this association, future research is needed to better define this relationship to enable therapy targeted against MetS in patients with voiding dysfunction.