Urology

OBJECTIVES:To diversify the understanding of Body Mass Index's (BMI) influence on vaginoplasty outcomes. As previous studies have assessed the role of increased BMI on gender-affirming vaginoplasty outcomes, no studies are currently published on the risks associated with an underweight BMI, nor do current studies present with statistical power due to limited sample sizes. This analysis represents the first and largest bidirectional assessment of BMI on vaginoplasty post-operative and functional outcomes. METHODS:A retrospective cohort study was conducted of 766 patients undergoing primary vaginoplasty between 2016 and 2023 at a single institution. The primary exposure was body mass index (BMI): underweight (<18.5 kg/m²), normal (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), and obese (≥30 kg/m²). Continuous variables were analyzed using Kruskal-Wallis tests, and categorical outcomes using Chi-square or Fisher's exact tests, with p<0.05 considered significant. The final dataset was analyzed using R version 4.5.1. RESULTS:Obese patients had significantly greater estimated blood loss (p<0.05). Postoperative urinary tract infection (UTI) rates differed by BMI (p=0.02), highest among underweight (14.8%) and obese (10.7%) groups. Surgical site infection (SSI) also varied by BMI (p=0.05), occurring primarily in underweight patients (3.7%). Partial graft failure requiring reoperation was more frequent among lower-BMI cohorts (p=0.04). All other complications did not differ significantly across groups. Functional outcomes were uniformly favorable, with tactile sensation (≥98%), cosmetic satisfaction (>97%), and penetrative intercourse ability (20-40%) consistent across BMI categories (p>0.05). CONCLUSIONS:Ultimately, BMI influences perioperative morbidity but should not preclude patients from gender-affirming vaginoplasty.

OBJECTIVE:To examine the current state of urology residency mentorship from the trainee viewpoint. METHODS:The 2022 American Urology Association Annual Resident/Fellow Census included 17 specific questions concerning residency mentorship. These questions provided insight into trainees' experiences, including types of mentorship programs, selection/assignment processes, needs assessments, barriers, satisfaction, and evaluation models. Statistical analysis was performed using SPSS software. RESULTS:360 responses were collected from the survey (269 residents and 91 fellows). Overall, 22% of urology trainees indicated that they lacked a mentorship program or current mentor. Of those with mentors, 34% of trainees reported informal mentorship (no formal assignment), while 33% reported mentor assignment by program director or chair, and only 23% of trainees self-selected their mentors. The most common areas of mentorship assistance were career planning (82%), obtaining surgical skills (62%), manuscript preparation/support (58%), and research idea generation (57%). The least common areas of support were maintaining wellness (49%) and work-life balance (47%). Only 40% of respondents noted that they evaluated their mentorship programs or mentors, while 85% felt that mentor training would be beneficial to mentors. CONCLUSIONS:Although most trainees receive mentorship in their training programs, their experience is largely informal and unstructured. Mentorship primarily focuses on career and academic development, with less than half of trainees noting support with work-life balance. Mentor training may be beneficial for strengthening mentorship programming.

Objective To evaluate the association between heat index and kidney stone recurrence in a national Veterans Affairs cohort of kidney stone formers. Methods This retrospective cohort study of patients with an index kidney stone event from 2010-2020 used Veterans Healthcare Administration data. Heat exposure was defined as number of days per year exceeding the 95th percentile heat index and was modeled both as a continuous and categorical (quartiles) variable. Cox proportional hazards models additionally adjusting for demographics, rurality, social deprivation, and high-risk status for kidney stone recurrence, were used to assess the association with subsequent stone recurrence. Results Among 136,340 patients, crude rates of recurrence ranged from 10.1% in the second quartile to 12.7% in the fourth quartile of heat exposure over the seven-year follow-up period. In adjusted analysis, patients in the highest quartile of heat exposure had a 5% greater risk compared with the lowest quartile (HR, 1.05; 95% CI, 1.01 to 1.10; P=0.028). Modeling heat exposure as continuous, each 10-day increase in annual extreme heat days was associated with a 3% higher risk (HR, 1.03, 95% CI, 1.01 to 1.05); P=0.003). Conclusion Higher heat index is associated with kidney stone recurrence risk in U.S. Veterans. These findings suggest clinicians should consider environmental heat index when counseling high-risk patients.

OBJECTIVE:To analyze active surveillance/observation (AS/O) trends, treatment selection, treatment-free survival, and surveillance regimen intensity in men ≤65 using a national commercial health insurance claims database. MATERIALS AND METHODS:We retrospectively reviewed the Merative Marketscan Commercial Database for localized prostate cancer among men ≤65 years between 2004 and 2023. Each had a newly-diagnosed prostate cancer, a biopsy <180 days before diagnosis, and ≥2 evaluation and management visits for prostate cancer. The primary outcomes were treatment selection and health services claims after diagnosis. Descriptive statistics and Kaplan-Meier analyses are reported. RESULTS:We identified 29,484 men ≤65 years with localized prostate cancer, with median age 58.0 years (IQR 55.0-61.0). AS/O increased from 10.4% to 35.1%, while prostatectomy decreased from 55.5% to 42.8%. Overall, 5861 (19.9%) men underwent AS/O in the first year after diagnosis; 4561 (77.8%) remained on AS/O. After 1 year of AS/O, treatment-free survival rates at 2-, 3-, and 5-years were 86.1% (95%CI:85.1%-87.0%), 79.0% (77.8%-80.2%), and 68.8% (67.1%-70.4%), respectively. In the first 2 years of AS/O, men who had a urologist visit rose from 88.5% to 91.1%, biopsy from 18.0% to 48.9%, MRI from 0.0% to 63.7%, and PSA from 59.0% to 97.0%. CONCLUSION:Younger men have increased adoption of AS/O and intensified AS/O regimens over time. These shifting treatment patterns could be due to improved guideline implementation or acceptance of AS/O to preserve functional status.

OBJECTIVE:To compare donor and recipient outcomes after minimally invasive living donor nephrectomy based on kidney laterality. METHODS:We performed a retrospective cohort study of living donor kidney transplants recorded in UNOS (2021-2025). Donor and recipient demographic, perioperative, and functional outcomes were analyzed. Continuous and categorical variables were compared using adequate statistical tests. Graft survival was assessed using Kaplan-Meier and Cox regression analysis. Multivariable logistic models were constructed. RESULTS:We analyzed 29,874 transplants. Right-sided minimally invasive living donor nephrectomy was associated with longer cold ischemia time (1.9 [IQR:1.1-4.4] vs 1.6 [IQR:1.0-3.8] hours; P < .001) and higher rates of delayed graft function (4.7% vs 2.5%; P < .001). In the overall cohort, right-sided kidneys demonstrated higher rates of graft thrombosis, early graft loss, and lower 4-year graft survival. However, these differences were dependent on procurement technique and not observed in non-hand-assisted laparoscopic cases. Donor and recipient creatinine levels at last follow-up were clinically comparable. CONCLUSION:Right-sided minimally invasive living donor nephrectomy is associated with greater cold ischemia times and delayed graft function rates but otherwise yields comparable outcomes when stratified by procurement technique. Despite registry follow-up constraints and combined non-hand-assisted classification (pure laparoscopic/robotic), these findings suggest right-sided procurement remains a reasonable option in experienced centers using non-hand-assisted laparoscopy.

OBJECTIVE:To evaluate the effect of metronome-based rhythmic auditory stimulation at different tempos on pain, anxiety, satisfaction, and willingness to undergo repeat flexible cystoscopy. METHODS:This single-center, prospective, non-randomized observational study included 250 patients undergoing first-time office-based flexible cystoscopy under local anesthesia. Patients were allocated into five groups: control, 60 bpm, 80 bpm, 100 bpm, and 120 bpm, with 50 patients in each group. Metronome stimulation was delivered from room entry until completion of cystoscopy. The primary outcome was overall procedural pain assessed using a visual analogue scale (VAS). Secondary outcomes included VAS satisfaction, willingness to undergo repeat cystoscopy, change in State-Trait Anxiety Inventory-State score, hemodynamic changes, and procedural duration. RESULTS:Baseline demographic, psychological, and hemodynamic parameters were comparable between groups. Overall procedural pain differed significantly across groups (p<0.001), with all metronome tempos showing lower pain scores than control. The 100 bpm group demonstrated the most favorable outcomes, including lower pain scores, higher satisfaction, greater willingness to repeat cystoscopy, greater reduction in state anxiety, and lower pulse rate increase compared with control. No significant differences were observed in blood pressure changes or procedural duration. CONCLUSION:Metronome-based rhythmic auditory stimulation is a simple, low-cost, and feasible non-pharmacological intervention for improving procedural comfort during flexible cystoscopy. A 100 bpm rhythm may offer the greatest clinical benefit.

OBJECTIVE:To better characterize population-level data on utilization trends, patient-level predictors, and downstream costs of telehealth use across GU malignancies using a national commercial insurance claims database. METHODS:We extracted bladder, kidney, prostate, and testis cancer outpatient claims from the Merative MarketScan database. Telehealth claims were flagged from 2010 to 2023, and multivariable modeling was used to identify patient-level factors. Weighted generalized linear models were used to compare twelve-month insurer-paid and out-of-pocket spending after telehealth or in-person new patient visits. Two time-range cohorts were analyzed: pre-pandemic (2010-2019) and pandemic-era (2020-2022). RESULTS:There were 85,237 telehealth visits, which represented 0.25% of GU oncology claims. Telehealth use reached 1.93% in 2020 and fell to 1.06% by 2023. Men (OR 1.4; P <.001), patients in the West (OR 1.6; P <.001), and those with non-PPO insurance (OR 1.2; P <.001) were more likely to use telehealth; non-urban patients (OR 0.68; P <.001) and those with higher comorbidity burden (OR 0.92; P <.001) were less likely. Prostate and kidney cancer had the highest telehealth rates; bladder cancer had the lowest. New patient oncology visits initiated via telehealth had lower patient out-of-pocket (OOP) spending in the pre-pandemic (SR 0.49; P = .011) and pandemic-era (SR 0.82; P = .0001) cohorts. Insurer-paid spending was comparable. CONCLUSION:Telehealth use in urologic oncology varies by cancer type, location, and insurance. It may lower costs for patients, which warrants further investigation and policy investment.

OBJECTIVE:To describe our experience with contemporary management and short-term outcomes of firearm-related genital trauma presenting to a Level 1 safety-net trauma hospital. METHODS:We conducted a retrospective chart review of patients who presented to a Level 1 safety-net trauma hospital in an urban setting with firearm-related penile/urethral and scrotal trauma between 2019 and 2024. Data collected included demographics, injury complex, follow-up rates, and short-term complications. Pre-specified multivariable logistic regressions were performed to identify predictors of follow-up rates and complications. RESULTS:Of 198 patients with firearm-related genital trauma, 85 (42.9%) had penile/urethral injuries and 113 (57.1%) had scrotal injuries. Ninety-seven (48.9%) patients had concomitant injuries to other GU organs, while 99 (50%) had concomitant injuries to non-GU organs (Table 1). Multivariable regression demonstrated that concomitant injury to other GU organs (p=0.004), non-GU organ systems (p=0.050), and surgical repair (p < 0.001) were associated with adherence to follow-up (Table 2). Penile/urethral involvement (p=0.008) and surgical repair (p=0.024) were associated with having a 30-day complication (Table 3). Of 38 (34.2%) patients who completed scrotal ultrasound, 24 did not have sonographic evidence of testicular injury. Of these, 21 were managed conservatively with no short-term complications (Table 4a). CONCLUSIONS:Penile/urethral involvement, surgical repair, and multi-organ injury were associated with higher complication and follow-up rates. The variations we observed in management pathways demonstrate that in certain clinical scenarios, invasive management may be deferred while maintaining acceptable outcomes and minimizing complications.

Objective To compare the cost-effectiveness of all guideline-supported surgical management options for BPH, stratified by prostate size. Methods Using a microsimulation model, a cost-effectiveness analysis was performed comparing all guideline-supported surgical management options for BPH, stratified by prostate size. Model probabilities were based on published values and effectiveness was calculated using post-operative outcomes. Costs were from a U.S. Medicare payer perspective, with quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) used to assess cost-effectiveness. Results At a lifetime horizon for patients with 30-80cc prostate size, HoLEP resulted in the highest QALYs (12.25), followed by iTIND (12.02) and WVTT (11.98). BPH costs per patient ranged from $6,557 (WVTT) and $8,431 (HoLEP) to $16,230 (PAE), with a low ICER for HoLEP ($6,931/QALY). For large glands (80-150cc), HoLEP resulted in nearly identical effectiveness relative to SP (12.25 vs. 12.26 QALYs) and more than RWT (12.19 QALYs). HoLEP had a significantly lower cost ($8,361) than SP ($19,012), RWT ($11,969), and PAE ($16,230) and was therefore cost-effective. However, for both index patients, cost-effectiveness was dependent on the value placed on post-operative ejaculatory dysfunction and post-surgery urinary symptom improvement. Conclusion At base-case with population-level assumptions, HoLEP is the most cost-effective BPH surgical option for patients with average or large prostate size. However, this is highly dependent upon patient priorities, highlighting the importance of surgical selection driven by individual patient preferences.

OBJECTIVE:To compare the associations of preoperative urinalysis (UA) and urine culture (UCx) findings, including concordant and discordant results, with postoperative infectious complications following common urologic procedures. PATIENTS AND METHODS:Using TriNetX adult patients who underwent radical prostatectomy, partial or radical nephrectomy, or transurethral resection of bladder tumor (TURBT) between 2006 and 2026 were identified. Patients were stratified by preoperative UA and UCx findings. Postoperative outcomes within 30-day of surgery were compared using measures of association. RESULTS:A total of 278,653 patients, including 109,605 radical prostatectomy, 79,613 partial or radical nephrectomy, and 89,435 TURBT patients, were included. Abnormal preoperative UA findings were present in 6.9% of radical prostatectomy, 11.2% of nephrectomy, and 22.1% of TURBT patients. Among patients with abnormal UA findings, only 5.9%, 7.1%, and 10.4%, respectively, also had a positive urine culture. Across all procedural cohorts, abnormal UA findings (without positive UCx) were associated with increased risks of postoperative UTI, sepsis, pyelonephritis, bacteremia, inpatient encounters, emergency department visits, and systemic antibiotic use. Among patients with abnormal UA findings, concurrently positive UCx provided limited additional prognostic information. Additionally, isolated positive UCx findings without abnormal UA demonstrated less consistent associations with adverse postoperative outcomes. CONCLUSION:Abnormal preoperative UA findings were more strongly and consistently associated with postoperative infectious complications than isolated positive UCx findings. These findings do not support omission of clinically indicated UCx but warrant prospective research on UA-guided or selective reflex UCx strategies to inform future preoperative testing practices.