EDITORIAL COMMENTThe increased use of cross-sectional imaging has led to significant stage migration in renal cell carcinoma (RCC). As more computed tomography (CT) and magnetic resonance imaging scans are performed for unrelated conditions, more RCCs have been detected – particularly small, asymptomatic lesions. For larger RCCs, obtaining chest imaging to rule out synchronous lung metastasis (sLM) remains an important clinical principle, supported by current guidelines. However, regarding chest imaging, guidelines do not necessarily reflect the stage migration in RCC over the past decade.
AUTHOR REPLYWe thank Dr. Singer and colleagues for their thoughtful comments on our investigation of synchronous lung metastasis (sLM) in patients with newly identified renal masses (RMs). As stated in our original investigation and by the editors, we assessed a large cohort of 253,818 patients. Of these patients, 120,386 (47%) had a RM size <40 mm. Furthermore, only 0.9% of patients with a RM size <40 mm displayed sLM. When examining only patients with confirmed sLM we found that only 8% (1,135/14,524) had a RM <40 mm.
EDITORIAL COMMENTThe COVID-19 pandemic drastically changed the world that we live almost overnight. Never before have simple acts, like shaking hands, seemed so unusual. Wearing masks in public has become as reflexive as wearing a seatbelt. The application cycle for the 2021 urology match, coincided with the pandemic surging in multiple states in the Union. Vaccines were still a distant hope, and therefore urology programs had to adapt to the challenges of conducting residency interviews for prospective applicants, while complying with National and local restrictions.
AUTHOR REPLYWe echo the editorial comments made regarding our original article and applaud the ingenuity demonstrated by urology programs while transitioning to a virtual application cycle amidst a pandemic. Indeed, necessity is the mother of invention. The Society of Academic Urologists announced that the 2021-2022 cycle will again be virtual, but how will the lessons learned during the pandemic shape the future of the urology match?
Editorial CommentThe virtues of any mobile application that enhances real time feedback, improves communication, and is easy to use in resident surgical evaluation are self-evident. This article amplifies another opportunity of the times, namely using smartphone apps to provide optimal surgical skills feedback to trainees in real time.
Author ReplyWe appreciate the thoughtful editorial regarding our manuscript. Medicine has long been the pillar of society slowest to adapt to the rapidly shifting technology of the times. The new era of technology driven healthcare is here to stay but has brought with it unique issues that we are still navigating. The sheer number of new gizmos, gadgets, and apps make it difficult to discern which tools improve & simplify surgical education from those that just add more complexity and burden. While not glorious, it is our duty as educators to constantly analyze these new technologies to find those with merit.
EDITORIAL COMMENTThe authors have pursued a thoughtful analysis of the complexities of generating and interpreting the letters of recommendation (LORs) that form a critical component of applications to urology residency.
AUTHOR REPLYAfter years of emphasizing only penile straightening procedures in our Peyronie's reconstruction cases, our patients have taught us that penile concavity deformities (notching and hourglass) are often just as troubling. The extra-tunical grafting (ETG) technique is a promising innovation for addressing these deformities and our series is only the second known published series on the technique. Preservation of the tunica albuginea avoids disruption of the veno-occlusive apparatus at the area of grafting, thus likely lowering the risk of complications.
EDITORIAL COMMENTPenile “hourglass” deformity (PHD) is a rare condition that affects about 1% of patients with Peyronie's disease.1 PHD develops from the Peyronie's disease plaque and the tunica albuginea retraction due to the inflammatory process. The final aspect of a penis during tumescence consists of a “clepsydra” shaped shaft and a subsequent psychological and functional impact on the relational life of the patients.2 Erectile dysfunction was reported in 61% – 68% of the patients although it is not clear if this dysfunction could be considered as psychologically or anatomically related.
EDITORIAL COMMENTThe manuscript entitled “Opioid-Free Discharge is Not Associated with Increased Unplanned Healthcare Encounters after Ureteroscopy: Results from a Statewide Quality Improvement Collaborative” from the University of Michigan demonstrates how a concerted effort by a healthcare system can lead to significant change. In the state of Michigan surgeons are incentivized by the major insurance carrier to limit narcotic prescribing; however, incentivizing surgeons is not enough for a program to succeed. Success requires buy in from all parties- physicians, nurses, residents, and physician's assistants- along with proactive patient education.
AUTHOR REPLYWe appreciate the author's thoughtful assessment and comments on our study. We agree that successful implementation of a post-operativeopioid-free pathway necessitates buy-in from all members of the patient's care team. For surgeons, financial incentives (such as the ability to apply a modifier 22 to a surgery code when no post-operative opioids are prescribed) may influence prescribing patterns; however, at the time of our study no such incentive programs were in place in the state of Michigan.
EDITORIAL COMMENTDigital direct-to-consumer marketing of healthcare services and products has exploded in recent years, adapting to a highly digital society. At-home semen testing has become available to men who wish to pursue a basic fertility evaluation without interfacing with a healthcare professional. The authors sought to determine whether a population of ‘health-conscious’ men without children have interest in pursuing a fertility assessment.
EDITORIALThese authors have developed a very useful and clinically appropriate algorithm to help urologic consultation services determine the likelihood of a difficult catheterization in hospitalized patients who require urethral drainage. While this data came about from a single institution's review of consultations provided to the urology service, the numbers are impressive with 841 patients enrolled. At first glance, the reader may find that some of these findings are unsurprising however, the authors clearly state that data regarding the specific factors identified within their analysis are sparse in the contemporary literature.
EDITORIAL COMMENTSpencer et al1 surveyed urology resident applicants over the last academic year, with approximately 11% responding, finding that the vast majority preferred in person to virtual interviews. In some regards, these results are surprising: in 2008, Kerfoot and colleagues2 found that the cost of residency interviews was an undue burden on applicants, and proposed that measures be taken to mitigate the impact of cost on urology applicants. One option to reduce applicant costs while maintaining a similar experience for all applicants was to conduct all interviews virtually; the 2020 pandemic afforded us an opportunity to assess the efficacy of this medium.
AUTHOR REPLYWe are grateful to Dr. Kieran for her thoughtful analysis of our work exploring urology applicants’ perspective on the virtual match interview process of 2021. Her insights that the preference of applicants for more costly in person interviews is explained by the value applicants place on direct observation of program culture underlies much of our work.1 This perspective continues to be pertinent as the upcoming 2022 interview cycle will, once again, be completely virtual and limit in person away rotations.
EDITORIAL COMMENTThe presence of an elevated AFP excludes the diagnosis of seminoma, regardless of the histologic findings at orchiectomy. There is no dispute that patients with seminoma and an “elevated” AFP should be treated according to stage and risk-specific guidelines for non-seminoma. No published guidelines include radiation therapy as a treatment option for low stage non-seminoma.
AUTHOR REPLYThe editorialist provides incisive commentary on our recent article reporting on discordant, elevated serum alpha-fetoprotein levels among patients diagnosed with seminoma using registry data from the National Cancer Database. As he notes, the proportion of patients with any level of AFP elevation was higher than previously reported. In addition to misclassification, differences may also relate to physiologic processes unrelated to testicular cancer or differences in laboratory reporting conventions.
EDITORIAL COMMENTThe cost of treatment significantly influences patient care in the United States (US). Thought leaders in healthcare management have advocated that the central focus must be on increasing ‘value’ for patients, i.e. the health outcomes achieved per dollar spent.1 However, understanding the true cost of care is difficult. Time Driven Activity Based Costing (TDABC) is a cost accounting methodology that involves the addition of all the “micro-costs” for key activities in the entire patient care cycle, where time is the critical variable.
AUTHOR REPLYWe thank Drs. DiBianco and Ghani for their inciteful commentary. To echo their sentiments, developing more accurate accounting techniques that capture the true cost of care delivery will continue to grow in importance as the United States (US) healthcare system increasingly transitions away from volume to value-base care.1 While Drs. DiBianco and Ghani rightfully draw attention to the absence of episode-based time data as a notable limitation of our study, the detailed cost accounting presented in our work overshadows this limitation and is an important addition to a growing set of literature concerned with accurately describing the denominator of the value equation.
EDITORIAL COMMENTTreatment of post-prostatectomy urinary incontinence is a constantly developing field. This condition has a significant impact on quality of life and is very bothersome to patients. Although the artificial urinary sphincter (AUS) is still considered the gold standard surgical treatment, there is a continuous search for a less invasive solution. As a matter of fact, a new device or procedure is introduced almost on a yearly basis. There are more than 10 different slings available on the market worldwide! The slings can be positioned in a retropubic or trans obturator fashion, some can be adjusted after surgery, and they can be made of polypropylene, silicone, or a combination of both materials.
AUTHOR REPLYThe artificial urinary sphincter (AUS) is the most reliable and efficient treatment for post-prostatectomy incontinence (PPI) in patients with complete or nearly complete sphincteric damage. However, evidence is mounting in favor of the adjustable transobturator male system (ATOMS, A.M.I., Feldkirch, Austria) as another gold standard for PPI in cases with partial sphincteric competence, both primarily or as rescue surgery.
EDITORIAL COMMENTAs our understanding of the social determinants of health rapidly expands, it becomes all the more crucial to factor these variables into the plan of care. The top priority of addressing social determinants of health is improving population health, particularly among historically disparaged communities and those most likely to suffer from systemic barriers to care. Hospital systems also benefit from addressing social determinants of health via reduced hospital strain, decreased follow up, and ultimately, lower rates of physician burnout.
EDITORIAL COMMENTThe Nuremberg Code rarified the concept of “voluntary consent” of the human research subject, transforming what till then had been a nebulous ethos into a legal framework to assess risks and benefits to research subjects and levy investigators a contractual agreement to protect their subjects.1 In 1974, Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research to expand and protect rights of human subjects.
AUTHOR REPLYWe thank the editorial reviewers for contributing to this discussion. Criticisms of Sims are vast, as Dr. Nettey alludes to in her Editorial Comment. Some recent criticisms of Sims apply modern values to the past, which we specifically refrain from in this piece. Sims's greatest critics were his contemporaries and assistants, including Dr. Nathan Bozeman of Alabama and Dr. Thomas Addis Emmet of New York. During his brief and checkered tenure at New York Woman's Hospital, Sims's high rate of mortality saw him expelled (his word) from his own hospital, which is contrary to the claim that he “catapulted it to become the premier institution”.
EDITORIAL COMMENTThe authors present a series of 34 patients that safely underwent immediate reactivation of their artificial urinary sphincter (AUS) after urethral cuff exchange for the diagnosis of recurrent stress urinary incontinence after compression or mechanical failure. Their series included patients that had the cuff exchange in the identical anatomic site from the initial cuff (28) as well as a new urethral position (6). No patients had their control assembly exchanged and 87% underwent cuff downsizing.