Purpose: To describe trends in urologic fellowship training and subspecialization nationwide and to identify areas of need in the national distribution of subspecialists.Materials and Methods: Data from the American Urological Association Annual Census of United States Practicing Urologists from 2014-2024 was analyzed using weighted responses to account for non-response bias. Trends regarding fellowship training, subspecialization, and practice patterns were examined. The analysis was descriptive to identify shifts over time.Results: From 2014 to 2024, an average of 2088 urologists practicing in the United States completed the census yearly with an average response of 16.3%. The proportion of fellowship-trained urologists has increased over time (4 0% in 2014 to 46% in 2024) while the proportion of general urologists has decreased (63% in 2014 to 54% in 2024). Urologic oncology is the most common specialty (13% in 2024) and there have been increasing trends in several other specialties such as urogynecology, urologic reconstructive surgery, and robotics. There has been a decrease in urologists in private practice (64% in 2014 to 42% in 2024) and an increase in academic and hospital employment. Subspecialized urologists are more likely to practice in academic settings (66% in 2024). Fellowship-trained and subspecialized urologists are more likely to practice in metropolitan areas. Conclusions: Subspecialization and fellowship-training has increased among urologists practicing in the United States with a corresponding decrease in general urology practice. Subspecialized urologists more often practice in urban and academic settings. This trend may affect nationwide access to urologic care.

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 coping mechanisms and willingness to seek professional help for burnout using the 2023 American Urological Association (AUA) Annual Census. METHODS:A total of 1918 urologists, representing 14% of practicing urologists in the US, completed the 2023 AUA Census. Post-stratification weighting was performed to adjust for non-response bias. The survey collected demographics, practice patterns, and experiences with burnout, coping mechanisms, willingness to seek professional help, and barriers for seeking professional help. We performed bivariate analysis to examine associations between responding urologist characteristics and burnout, coping, and professional help seeking. RESULTS:Of the respondents, 45.4% of urologists reported experiencing burnout, and 33.5% report using unhealthy coping mechanisms for burnout. Only 17% of respondents have sought professional help for burnout. One-third of respondents reported external factors as deterrents for seeking professional help. Finally, 43% of respondents reported they would seek help if those questions regarding mental health were not included in the records for state licensure. Younger age was significantly associated with being more likely to seek help if questions were not included in their state licensure board records, with <34 years having the highest percentage (65%, P <.05). CONCLUSION:Responding urologists have identified questions surrounding mental health conditions on state licensure boards as a factor deterring them from seeking professional help for burnout. With an ongoing urologic workforce shortage, policy changes, such as removing mental health questions pertaining to medical licensing and credentialing, are imperative to protect the health of the current workforce.

OBJECTIVE:To examine regional variation in prostate biopsy practices in the United States and identify specific provider characteristics associated with performing different types of prostate biopsy. METHODS:Weighted data from the 2022 American Urological Association Annual Census regarding urologists' conduct of prostate biopsies, including transrectal (TR), transperineal (TP), and magnetic resonance imaging (MRI)-fusion biopsies were analyzed. Prostate biopsy utilization was examined overall and at the state level. Multiple logistic regression was used to examine the association between provider characteristics and the odds of performing each type of biopsy. RESULTS:In 2022, 78% (n = 10,729) of practicing urologists reported performing diagnostic prostate biopsies. TR and TP biopsies were performed by 99.4% and 37.2% of these providers, respectively, and MRI-fusion biopsies by 60.8%. Variation was observed in prostate biopsy utilization at the state level, including up to 2.7, 6.8, and 8.9-fold differences in the use of TR, TP, and MRI-fusion biopsy, respectively. Certain states were routinely in the bottom 5 in terms of reported use of TP and/or MRI-fusion biopsy. Urologists with fellowship training in urologic oncology, who had a primary subspeciality of urologic oncology, robotics, or laparoscopy, who were younger, and who were busier were more likely to perform each biopsy approach. CONCLUSION:Substantial variation exists in the use of different approaches to prostate biopsy across the U.S. Prostate biopsy approach is currently highly dependent on where and whom patients see for their urologic care.

INTRODUCTION:Although the enthusiasm for artificial intelligence (AI) to enhance surgical decision-making continues to grow, the preceding advance of risk prediction tools (RPTs) has had limited impact to date. To help inform the development of AI-powered tools, we evaluated the role of RPTs and prevailing attitudes among urologists. METHODS:We conducted a national mixed methods study using a sequential explanatory design. Through the 2019 AUA Census, we surveyed urologists on RPT use, helpfulness, and trust. Based on responses, we interviewed 25 participants on RPTs, risk evaluation, and surgical decision-making. Coding-based thematic analysis was applied and integrated with survey findings. RESULTS:Among 2081 urologic surgeons (weighted sample 12,366), 30.4% (95% CI, 28.2%-32.6%) routinely used RPTs and 34.3% (95% CI, 31.9%-36.6%) found them helpful while 47.0% (95% CI, 44.6%-49.5%) generally trusted their own assessment over RPT-generated estimates. More years in practice was negatively associated with RPT use, helpfulness, and trust (P < .001). Qualitatively, participants described relying on their intuition for surgical risks and benefits and using gist-based approximations rather than numerical information, which RPTs provide. RPT helpfulness centered on risk/benefit confirmation, calibration, and communication, but methodological (eg, individual vs group estimates and missing variables) and operational (eg, ease of use and clinical workflow) challenges limit greater RPT use. CONCLUSIONS:Despite their wide availability, RPTs remain limited in their use and helpfulness. This reflects both the intuitive nature of surgical decision-making and implementation challenges. For AI to reach its promise and improve surgical care and outcomes, both types of barriers will need to be addressed.

OBJECTIVES:To identify and evaluate the clinical and demographic determinants of benign prostatic hyperplasia (BPH) surgical care access and selection. MATERIALS AND METHODS:The American Urological Association Quality registry was utilized to evaluate all patients with a BPH diagnosis. This cohort was then queried for patient clinical and demographic factors and physician and practice parameters. The primary outcome was undergoing BPH surgical intervention with further classification by procedural type. Descriptive statistics, as well as univariate and multivariate regression were performed to identify predictors of surgical intervention. RESULTS:Between 2014 and 2023, 2,197,045 patients with a BPH diagnosis were included, and 159,073 (7.2%) underwent surgery. Resective/ablative procedures were most common (62,173; 39%), followed by minimally invasive surgical techniques (MIST) (51,038; 32%) and enucleation (3350; 2%). On multivariate regression, more severe clinical presentation (older age, longer time from diagnosis, symptoms and sequelae of BPH) were associated with a higher likelihood of surgical intervention (p<0.001). Demographically, higher income patients and non-metropolitan, smaller practices were associated with surgical intervention (p<0.001). When evaluating specific surgical type, factors associated with MIST on multivariate regression included less severe clinical presentation and a nonacademic urology practice. CONCLUSIONS:BPH surgical selection is complex and multifactorial. Patient clinical factors, demographic factors, and provider characteristics all play a role in determining when and what surgery is performed. By identifying these factors, we can begin to assess barriers to care, resource utilization, and decision making.