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Objective: To identify the risk factors for Otolaryngology-Head and Neck Surgery (OHNS) resident attrition., Study Design: Retrospective cohort study., Setting: Annual Graduate Medical Education track survey., Methods: We conducted a retrospective analysis of OHNS residents who matriculated between 2006 and 2015. Variables analyzed included age at matriculation, sex, race/ethnicity, medical degree type, program location, attrition status, and matriculation year period (2006-2010, 2011-2015). A logistic regression model was used to determine factors predictive of attrition, with a significance level set at P < .05., Results: A total of 3073 residents were analyzed. The overall attrition rate was 3.7%. Multivariable regression showed older residents (≥30 years) had a 2.1 times higher risk of attrition compared to younger residents (≤29 years) (adjusted odds ratio [aOR]: 2.1; 95% confidence interval, CI [1.383-3.316], P < .001). Underrepresented minorities in medicine (URiM) residents had a 3.5 times higher risk of attrition compared to whites (aOR: 3.5; 95% CI [1.823-6.806], P < .001). Southern US programs had a 2.5 times higher risk of attrition compared to northeastern programs (aOR: 2.5; 95% CI [1.480-4.315], P < .001). There was no statistically significant difference in attrition based on sex, medical degree type, or matriculation year period., Conclusion: A higher risk of attrition was found among OHNS trainees who were older, self-identified as URiM, and in the southern US programs. There was no significant difference in attrition risk based on gender, medical degree type, or matriculation period. Further research is needed to understand the reasons for attrition and to develop strategies to promote inclusion and diversity in OHNS., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: Infantile subglottic hemangioma (SGH) poses a risk of airway compromise if untreated. Traditionally, operative endoscopy (OH) diagnoses SGH, but since the discovery of beta-blockers' efficacy in treating infantile hemangiomas (IHs) in 2008, and advances in endoscopic technology, nonoperative methods have emerged. This review identifies endoscopic practices for diagnosing and monitoring infantile SGH during the oral beta-blocker treatment era., Data Sources: A comprehensive literature search in October 2022 and August 2023 covered PubMed, Embase, Cochrane Library, SCOPUS, and Web of Science., Review Methods: The search was limited to English-language studies published since 2008, considering this when propranolol was demonstrated as an effective treatment option for IH. The articles were screened for relevance based on predefined inclusion and exclusion criteria., Results: After inclusion and exclusion criteria, sixty final studies were identified, describing 240 cases of infantile SGH. Most children were diagnosed using OE alone (73.3%; n = 176/240), 23.3% (n = 56/240) using office-based laryngoscopy procedures (OBPs) followed by OE, 3.3% using OBP alone (n = 8/240). There were no reported diagnostic endoscopy-related complications. Twenty-nine studies described using endoscopy plus diagnostic imaging to either confirm an SGH lesion, characterize the extent of disease spread, or rule out other causes of presenting symptoms. The proportion of infants diagnosed with OE alone decreased from 2008 to 2023., Conclusion: Operative endoscopy remains the SGH diagnostic standard, but OBP adoption is increasing. Further research is needed to determine the optimal SGH diagnosis and management approach., Level of Evidence: NA Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Vocal tremor (VT) poses treatment challenges due to uncertain pathophysiology. VT is typically classified into two phenotypes: isolated vocal tremor (iVT) and essential tremor-related voice tremor (ETvt). The impact of phenotypes on upper aerodigestive tract physiology during swallowing remains unclear. Qualitative and quantitative measures were employed to characterize tremor phenotypes and investigate the effects on swallowing physiology., Methods: Eleven ETvt participants (1 Male, 10 Female; x̄ age = 74) and 8 iVT participants (1 Male, 7 Female; x̄ age = 71) swallowed 20 mL boluses in cued and uncued conditions under standardized fluoroscopic visualization. Sustained/a/productions were captured to assess the rate and extent of fundamental frequency (F0) modulation. Penetration and Aspiration Scale (PAS) scores were obtained and swallowing biomechanics were captured using Swallowtail™ software. Participants also completed the Swallowing Quality of Life (SWAL-QOL) questionnaire., Results: Hypopharyngeal transit was faster in both VT phenotypes compared with Swallowtail™ normative reference data. Total pharyngeal transit times, however, were only faster in patients with iVT, relative to reference data. No significant differences were observed on the SWAL-QOL or PAS between tremor phenotypes. SWAL-QOL scores revealed that these patients rarely reported dysphagia symptoms., Conclusions: Subtle differences in swallowing patterns were observed across VT phenotypes, possibly related to adaptive mechanisms resulting in quicker pharyngeal bolus transit. Most patients did not report swallowing issues or dysphagia symptoms. This study is foundational for larger studies on this challenging population., Level of Evidence: 4 Laryngoscope, 134:4599-4603, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: External Jugular Thrombophlebitis (EJT) is a rare clinical phenomenon with few reports in the literature, especially in the pediatric population. This is a report of an unusual case of right-sided EJT in a pediatric patient secondary to acute pharyngitis with sinusitis most prominent on the left side., Case Presentation: A 13-year-old presented to the emergency department with worsening upper respiratory infectious (URI) symptoms and facial swelling, cough, throat pain, and emesis. The patient had traveled to Switzerland and received amoxicillin for strep throat 6 weeks before this hospitalization. Physical examination revealed nasal purulence, allodynia over the right side of the face without overlying erythema, and oropharyngeal exudate. CT scan revealed left-sided predominate sinusitis and right external jugular vein thrombosis. Blood cultures confirmed the presence of group A streptococcus infection. Treatment included IV antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), IV steroids, and anticoagulation. Follow-up imaging demonstrated improvement in thrombosis, cellulitis, and sinus disease. The patient was discharged on antibiotics for 6 weeks and anticoagulation for 10 weeks. Follow-up imaging at 6 months revealed no EJT, and medications were discontinued., Conclusions: EJT is a rare condition, and to our knowledge, no reports of EJT with sinusitis most pronounced on the contralateral side have been published. Physicians will benefit from noting clinical signs of EJT such as facial edema, headache, erythema, and palpable neck mass, especially if these symptoms occur with URI symptoms refractory to treatment. The use of anticoagulation is controversial for internal jugular vein thrombosis, and while no guidelines for EJT exist, anticoagulation is likely not necessary save for severe complications., (© 2024. The Author(s).)

Objective: The objective of this study is to assess disparities in adherence to swallowing therapy for clinically diagnosed oropharyngeal dysphagia (OD) patients., Methods: Analysis was conducted on data from 600 patients with OD and confirmed impairments in swallowing safety and/or efficiency on a videofluoroscopic swallow study. Patients were classified based on their adherence to treatment sessions, defined as the number of swallow treatment sessions attended. The outcome of treatment adherence was categorized into two groups: those who attended fewer than 50% of the prescribed treatment sessions and those who attended 50% or more of the sessions. Continuous variables were presented as mean ± standard deviation or median ± interquartile range. Categorical variables were compared using Pearson chi-square tests and Fisher's exact test when appropriate. Univariable and multivariable binary logistic regression models were employed to identify factors associated with successful adherence., Results: Approximately 79% adhered to swallowing treatment. We found no significant relationship between adherence and age, sex, race, ethnicity, primary language, marital status, insurance status, occupation, median income, distance, education, OD severity, and diagnosis year ( p  > 0.05). We found no covariables to be significant predictors to swallowing treatment nonadherence in both univariable and multivariable binary regression models ( p  > 0.05)., Conclusion: The variables analyzed in this study were not significantly associated with nonadherence to swallow therapy. Nevertheless, our study still addressed an important knowledge gap and future studies would benefit from exploring other relevant socioeconomic and disease-related factors., Level of Evidence: Level 4., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: There are 54,000 new cases of oral cavity and oropharyngeal cancer in the United States and more than 476,000 worldwide each year. Oral cavity and oropharyngeal squamous cell carcinoma make up most tumors with five-year survival rates of 50% due to prevalence of late-stage diagnoses. Improved methods of early detection in high-risk individuals are urgently needed. We aimed to assess the tumorigenic biomarkers soluble CD44 (solCD44) and total protein (TP) measured using oral rinses as affordable convenient screening tools for cancer detection., Methods: In this prospective cohort study, we recruited 150 healthy current or former smokers through a community screening program. Baseline and four annual visits were conducted from March 2011-January 2016 with records followed until August 2020. Participants provided oral rinses, received head and neck exams, and completed questionnaires. SolCD44 and TP levels were measured and compared across groups and time. Participants were placed in the cancer group if malignancy developed in the study period, the suspicious group if physical exams were concerning for premalignant disease or cancer in the head and neck, and the healthy group if there were no suspicious findings. This analysis used two-sample t-test for comparison of means and two-sample Wilcoxon Test for comparison of medians. For subjects with follow-ups, estimated means of biomarkers were obtained from a fitted Repeated Measures Analysis of Variance (RANOVA) model including group, visit, and their interaction. Pairwise comparisons of mean solCD44 were made, including intergroup and intragroup comparison of values at different years., Results: Most participants were males (58.7%), < 60 years of age. (90.7%), and Black (100%). Baseline mean solCD44 was elevated (2.781 ng/ml) in the cancer group compared to the suspicious group (1.849 ng/ml) and healthy group (1.779 ng/ml)., Conclusion: This study supports the feasibility of a CD44-based oral rinse test as an affordable and convenient adjunctive tool for early detection of aerodigestive tract and other cancers in high-risk populations., (© 2024. The Author(s).)

Objective: The process of resident recruitment is costly, and our surgical residency program expends significant time on the resident selection process while balancing general duties and responsibilities. The aim of our study was to explore the relationship between otolaryngology-head and surgery (OHNS) residents' National Residency Matching Program (NRMP) rank-list position at our institution and their subsequent residency performance., Study Design: Retrospective cohort study., Setting: Single site institution., Methods: We retrospectively reviewed 7 consecutive resident classes (2011-2017) at a single tertiary OHNS residency program. We reviewed each resident's absolute rank order in the NRMP matches. Measures of residency performance included overall faculty evaluation during postgraduate year 5 (PGY5), annual in-service examination scores (scaled score), and the number of manuscripts published in peer-reviewed journals. Correlations between NRMP rank order and subsequent residency performance were assessed using Spearman's rho correlation coefficients ( ρ )., Results: Twenty-eight residents entered residency training between 2011 and 2017. The average rank position of the trainees during this study was 9.7 (range: 1-22). We found no significant correlation between rank order and faculty evaluation during PGY5 ( ρ  = 0.097, P  = .625) or number of publications ( ρ  = -0.256, P  = .189). Additionally, when assessing the association between rank order and annual Otolaryngology Training Examination-scaled scores, no statistically significant relationship was found between the 2 ( P  > .05)., Conclusion: Our results showed that there were no significant correlations between OHNS rank order and various measures of success in residency training, which aligns with existing literature. Further investigation of this relationship should be conducted to ensure the applicability of our findings., Competing Interests: All authors declare no commercial conflicts of interest., (© 2024 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: To report our institutional experience in diagnosing and surveilling patients with infantile subglottic hemangioma (SGH) using in-office flexible fiberoptic laryngoscopy (FFL) with video technology, without requiring operative endoscopy in the era of propranolol use., Methods: A retrospective case series was conducted on 4 children diagnosed with SGH between 2016 and 2022 at our institution., Results: Awake FFL with video technology provided adequate visualization of SGH lesions for diagnosis, without any complications. Serial examinations of the airway were performed in the outpatient setting and each SGH gradually regressed, with marked improvement in respiratory symptoms within 48 hours of oral propranolol initiation., Conclusion: Our findings showed that in select patients, FFL with video technology can successfully identify SGH lesions without general anesthesia exposure. FFL may be used as a low-risk screening tool for propranolol therapy initiation in some patients, but operative endoscopy should remain the gold standard procedure for others. By utilizing FFL in this manner, it is possible to diagnose SGH lesions and start propranolol therapy without exposing all patients to the risks of operative endoscopy., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives/hypothesis: This study assessed the vocal health of performers returning to full-time performance after the COVID-19 pandemic shutdown and investigated how differences in voice usage, exposure to voice care professionals, and vocal pathology before and during the pandemic contributed to variability in self-perceived and instrumental vocal outcome measures., Study Design: This was a prospective, case-control observational study conducted at a single outpatient site., Methods: Twenty-two patients, 11 cases and 11 controls, were enrolled for the study. All participants were full-time singing professionals prior to the COVID-19 pandemic. Cases were recruited from patients presenting to a tertiary care voice center for vocal or pharyngeal complaints. Controls were healthy volunteers recruited from the general population of professional singers in the surrounding metropolitan area. All participants provided responses to the Voice Handicap Index-10, Evaluation of Ability to Sing Easily, and Laryngopharyngeal Measure of Perceived Sensation validated questionnaires as well as a study survey with questions regarding vocal use and history prior to and during the pandemic. All participants underwent instrumental acoustic and videostroboscopic voice evaluations., Results: Cases had poorer outcome measures overall and were more likely to report their voices were worse at study enrollment when compared to their prepandemic perception (P = 0.027). Cases tended to be older and less likely to have pursued alternative employment during the pandemic that involved increased speaking voice use (27% vs 55%), but these differences were not statistically significant., Conclusions: There was a variable response among performers to the prolonged hiatus from performing during the COVID-19 pandemic. Those with poorer outcomes tended to be older and may have used their voice less during the pandemic. These findings are consistent with detraining periods in the exercise physiology literature and support the construct of treating vocal performers as vocal athletes., Competing Interests: Declaration of Competing Interest The authors of this manuscript declare that they have no financial or personal relationships with other people or organizations that could inappropriately influence or bias their work. We affirm that there are no conflicts of interest, including but not limited to employment, consultancies, stock ownership, honoraria, or any other financial or personal relationships that could potentially be perceived as affecting the integrity and impartiality of our research and its findings., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the association of social determinants of health (SDOH) on the presentation and management of unilateral vocal fold immobility (UVFI)., Methods: Retrospective chart review of 207 adult UVFI patients evaluated at a tertiary-care hospital between 2018 and 2019 was performed. Sociodemographic factors including gender, median household income, preferred language, and insurance type were recorded. Confounding clinical factors including etiology of UVFI, Voice Handicap Index-10 (VHI-10) score, laryngoscopic findings, and intervention history were extracted from medical records. Multivariable logistic regression was performed using sociodemographic and clinical factors., Results: Patient demographics and socioeconomic status were not associated with time to presentation. Patients presenting with glottic insufficiency and UVFI due to malignancy or recurrent laryngeal nerve (RLN) sacrifice had a shorter time to presentation. Higher household income was associated with greater number of interventions (p = 0.02), but neither income nor insurance type affected intervention type or timing. Female patients were less likely to undergo injection medialization laryngoplasty (odds ratio [OR] 0.25, p = 0.005). Older patients were more likely to undergo injection (OR 1.04, p = 0.027). Patients with large glottic gaps (OR 21.2, p = 0.014) and higher VHI-10 scores (OR 1.06, p = 0.047) were more likely to undergo surgery., Conclusion: Higher household income was associated with greater number of interventions and longer duration of care at a private tertiary-care hospital. RLN sacrifice, known malignancy, and glottic insufficiency significantly reduced the time to presentation. Type of intervention received was a complex interplay of both demographic and clinical factors. Large prospective studies should examine the role of SDOH in the presentation and management of UVFI., Level of Evidence: 4 Laryngoscope, 134:297-304, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Identify predictors of overall survival (OS) after hypopharyngeal/laryngeal cancer in Florida., Material and Methods: We conducted a retrospective cohort study using data from the Florida Cancer Data System (FCDS) on patients diagnosed with hypopharyngeal or laryngeal cancer from 2010-2017. Primary outcome was OS. Hazard ratios (HRs) were estimated from univariable and multivariable Cox regression models for OS. Data was analyzed from November 1, 2022, to June 30, 2023., Results: We analyzed 6771 patients, who were primarily male (81.2%), White non-Hispanic (WNH) (78.2%), publicly insured (70.1%), married (51.8%), and residents of urban counties (73.6%). Black patients were more likely to be younger at diagnosis (38.9%), single (43.4%), to have distant SEER stage disease (25.6%). Median OS were lowest among patients who were uninsured (34 months), with hypopharyngeal site disease (18 months), and a smoking history (current: 34 months, former: 46 months, no smoking: 63 months). Multivariable Cox regression analysis showed worse OS for single/unmarried vs married (HR 1.47 [95%CI: 1.36-1.59], P < .001), history of tobacco use (current: HR 1.62 [95%CI: 1.440-1.817], P < .001; former smokers: (HR 1.28 [95%CI: 1.139-1.437], P < .001) vs no history). Improved OS was observed among White Hispanics (WH) vs WNH (HR .73 [95%CI: .655-.817], P < .001) and women vs men (HR .88 [95%CI: .807-.954], P = .002). Geographical mapping showed that mortality rates were highest in census tracts with low income and education., Conclusion: Our findings suggest that sociodemographic and clinical factors impact OS from hypopharyngeal/laryngeal cancer in Florida and vary geographically within the state. These results will help guide future public health interventions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To compare the effectiveness of disinfection protocols utilizing a ultraviolet (UV) Smart D60 light system with Impelux™ technology with a standard Cidex ortho-phthalaldehyde (OPA) disinfection protocol for cleaning flexible fiberoptic laryngoscopes (FFLs)., Methods: Two hundred FFLs were tested for bacterial contamination after routine use, and another 200 FFLs were tested after disinfection with one of four methods: enzymatic detergent plus Cidex OPA (standard), enzymatic detergent plus UV Smart D60, microfiber cloth plus UV Smart D60, and nonsterile wipe plus UV Smart D60. Pre- and post-disinfection microbial burden levels and positive culture rates were compared using Kruskal-Wallis ANOVA and Fisher's two-sided exact, respectively., Results: After routine use, approximately 56% (112/200) of FFLs were contaminated, with an average contamination level of 9,973.7 ± 70,136.3 CFU/mL. The standard reprocessing method showed no positive cultures. The enzymatic plus UV, microfiber plus UV, and nonsterile wipe plus UV methods yielded contamination rates of 4% (2/50), 6% (3/50), and 12% (6/50), respectively, with no significant differences among the treatment groups (p > 0.05). The pre-disinfection microbial burden levels decreased significantly after each disinfection technique (p < 0.001). The average microbial burden recovered after enzymatic plus UV, microfiber plus UV, and nonsterile wipe plus UV were 0.40 CFU/mL ± 2, 0.60 CFU/mL ± 2.4, and 12.2 CFU/mL ± 69.5, respectively, with no significant difference among the treatment groups (p > 0.05). Micrococcus species (53.8%) were most frequently isolated, and no high-concern organisms were recovered., Conclusion: Disinfection protocols utilizing UV Smart D60 were as effective as the standard chemical disinfection protocol using Cidex OPA., Level of Evidence: NA Laryngoscope, 133:3512-3519, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To compare outcomes between two standard-of-care anesthesia regimens for operative laryngoscopy: general anesthesia with a neuromuscular blocking agent (NMBA) versus remifentanil and propofol (non-NMBA)., Methods: This was a prospective, single-blinded, randomized controlled trial at a tertiary care center. Patients were randomized to either anesthesia using rocuronium (NMBA) or with remifentanil/propofol infusion alone (non-NMBA). Intraoperative impressions, anesthesia data, and post-operative patient surveys were collected., Results: Sixty-one patients who underwent suspension laryngoscopy from 2020 to 2022 were included (25 female, 36 male, ranging 20-81 years). Thirty patients were enrolled in the NMBA arm and 31 patients in the non-NMBA arm. Heart rate and mean arterial pressure were higher in the NMBA (p < 0.01). Patients in the non-NMBA group were more likely to require vasopressors (p = 0.04, RR = 3.08 [0.86-11.05]). Surgeons were more frequently satisfied with conditions in the NMBA group (86.7%) compared to the non-NMBA group (58.1%, p < 0.01). Procedures were more likely to be paused due to movement in the non-NMBA group (45.1%) compared to the NMBA group (16.6%, p < 0.03, RR = 2.26 [1.02-4.99]). Patients in the non-NMBA group were more likely to endorse myalgia the week after surgery (44%) compared to the NMBA group (8.3%, p < 0.01) and reported higher average pain levels on a 0-10 pain scale (3.7) compared to the paralysis group (2.0)., Conclusions: Anesthesia with rocuronium was associated with better intraoperative conditions and postoperative pain compared to anesthesia with remifentanil/propofol. Remifentanil/propofol were associated with lower blood pressure and suppression of laryngoscopy-associated tachycardia., Level of Evidence: 2 Laryngoscope, 133:2654-2664, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Intracranial dural arteriovenous fistulas (DAVFs) have been documented to occasionally spontaneously regress. However, the mechanism responsible for this occurrence remains speculative., Methods: We present a case of a Borden II - Cognard IIa+b DAVF involving the superior sagittal sinus (SSS) with bilateral external carotid artery supply that regressed spontaneously. A systematic literature review was conducted to explore the current theories explaining the spontaneous regression of DAVFs according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines., Results: A total of 26 studies and 54 cases were included in our results. Of the included cases, 57.14% of cases were Borden I, 16.33% were Borden II, and 26.53% were Borden III. Ruptured status or intracranial hemorrhage was documented in 24.1% of all cases, the majority of which (69.2%) were in cases with aggressive lesions (Borden II or greater). The most commonly involved location was the transverse sinus (38.89% of cases, n = 21), and the SSS was only involved in 12.96% of all cases. 50% of included cases proposed a mechanism responsible for spontaneous regression. The most frequently proposed mechanisms were thrombosis of the involved sinus/chronic inflammatory changes or direct endothelial injury, endoluminal stasis, and thrombogenic effects of contrast medium during angiography. We present the case of a 54-year-old woman with an aggressive ruptured DAVF that likely developed following a pediatric traumatic brain injury that was left untreated before she presented to our institution after significant delay. Her DAVF regressed on repeat angiography before neurovascular intervention without a clear identifying mechanism as proposed by the current literature., Conclusion: Our results suggest that spontaneous regression is not necessarily associated with lower risk DAVFs. The present case offers a unique long-term insight into the natural history of an aggressive ruptured DAVF of the SSS that regressed without intervention. Further research into the natural history of DAVFs will be helpful in deducing key factors leading to spontaneous regression., Competing Interests: There are no conflict of interest., (Copyright: © 2023 Surgical Neurology International.)

Objective: To add to the literature which has reported higher attrition rates amongst General Surgery residents who identify as female or underrepresented in medicine (URM), we aimed to determine how these factors contribute to attrition within Urology. We hypothesized that women and URM Urology residents will similarly have higher attrition rates., Methods: The Association of American Medical Colleges surveyed residents to obtain matriculation and attrition status from 2001 to 2016. Data included demographics, medical school type, and specialty. A multivariable logistic regression model was performed to identify predictors of attrition amongst Urology residents., Results: In our sample of 4321 Urology residents, 22.5% were female, 9.9% were URM, 25.8% were older than 30 years, 2.5% were Doctor of Osteopathic Medicine graduates and 4.7% were International Medical Graduates. On multivariable analysis, being female (Odds ratio [OR] = 2.3, P < .001) was associated with increased residency attrition when compared to male residents. Additionally, residents who matriculated between 30 and 39 years old (OR = 1.9, P < .001) or ≥40 years old (OR = 10.7, P < .001) had an increased risk of residency attrition when compared to residents who matriculated between 26 and 29 years old. Attrition rates for URM trainees have recently increased., Conclusion: Women, older, and URM Urology residents experience higher rates of attrition compared to their peers. It is essential to identify trainees with a higher likelihood of attrition to determine system-level changes to combat departures from training programs. Our study highlights the need to foster more inclusive training environments and change institutional cultures to diversify the surgical workforce., Competing Interests: Declaration of Competing Interest The authors report no conflict of interest., (Copyright © 2023. Published by Elsevier Inc.)