Prostate Leiomyosarcoma: a rare misleading tumour A 73 year-old male patient presented with a history of moderate LUTS, namely frequency, nocturia and weak urinary stream. He had no history of previous surgery, or any medical conditions of notice, and he is a non-smoker, nonalcoholic. He has been diagnosed with benign prostate hyperplasia (BPH) ten years before, for which he was then being treated with dutasteride and tansulosin. Because of having slightly elevated PSA, which had been stable at 6ng/mL over the past years, the patient had also undergone to two twelve-core transrectal ultrasound guided (TRUS) biopsies.
An Uncommon Case of a Traumatic Corporal Cutaneous Fistula Penetrating perineal trauma is an unusual urologic injury. Even less common is a delayed presentation. Herein we present the case of a patient with delayed development of a corporal cutaneous fistula three months following perineal trauma.
Small bowel adenocarcinoma of ileal ureter 40 years after ureteral reconstructive surgery Malignant neoplasm arising from ileal ureter used for ureteral reconstructive surgery is an exceedingly rare event. Ureteroileoplasty was being performed since the beginning of the last century, but it was described more extensively in literature during the 1950s.1,2 Recurrent urinary infections, chronic renal failure, urolithiasis, anastomotic stricture, metabolic acidosis and chronic dilation of the graft had been described as late complications of ureteroileoplasty.3,4 Herein, we describe history, imaging and pathologic findings of a small bowel adenocarcinoma arising from ileal ureter in a woman of 78 year-old, subjected to ureteroileoplasty about forty years earlier.
Possible drop metastasis after treatment of renal cell carcinoma with percutaneous cryoablation A 69-year-old male with no documented past medical history presented to an outside institution with a 2.9 cm left lower pole renal mass that was incidentally discovered on imaging performed for abdominal and back pain. He denied any history of hematuria or flank pain. He was referred to the interventional radiology service for CT-guided percutaneous biopsy and cryoablation of the left renal mass. Three core needle biopsies were performed using a 20 gauge cutting needle with coaxial technique. Hydrodissection was used to displace the colon in preparation for cryoablation due to the lesion's anterior location.
A Thoughtful Pause for Sparing Oopherectomy We read with interest the recent article by Abboud et al1 regarding ovarian malignancy in women after radical cystectomy (RC). The authors demonstrate a low rate of subsequent ovarian malignancy, and conclude that oophorectomy at the time of RC may be omitted. While we applaud the goal to spare the undesirable morbidity of oophorectomy, we suggest a pause to blanket implementation of this recommendation.
OVOTESTICULAR DISORDER OF SEX DEVELOPMENT: A RARE CASE OF LATERAL SUBTYPE 45X/46XY KARIOTYPE DIAGNOSED IN ADULTHOOD A 53-year-old male referred to our Centre because of hypergonadotropic hypogonadism detected during urological follow-up for urethral lithiasis. Physical Examination showed short stature, micropenis, ambiguous external genitalia, normal secondary sexual characteristics. Karyotype: 45 × 0/46XY. Abdominal MRI revealed the presence of uterus-like structure, right annex and left testes without prostate. He underwent laparoscopic removal of dysgenetic tissues; histological examination confirmed the presence of little uterus, fallopian tubes, little atrophic ovary, and vaginal tract; left testes was atrophic with sclero-jalinosis of seminal tubes and Leydig's cells hyperplasia.
Genetic and Environmental Influences on Urinary Conditions in Men: A Classical Twin Study To evaluate the genetic and environmental relationship among prostatitis and other urological conditions, including benign prostatic hyperplasia (BPH) and prostate cancer (CaP), a classical twin design and biometric modeling was used. While prostatitis – characterized by pain and voiding symptoms, no clear etiology, and functional and quality of life impairments – co-occurs with other urinary conditions, the degree of shared overlapping etiological processes among them remains unclear. We examined the contribution of genetic and environmental factors to these conditions and the etiology of their associations at the level of genetic and environmental influences.
The Impact of 68Ga-PSMA PET/CT and PET/MRI on the Management of Prostate Cancer Prostate-specific-membrane-antigen (PSMA) is a transmembrane protein with significantly increased expression in the cells and metastases of prostate carcinoma (PCa). PSMA-expression correlates with higher serum levels of prostate-specific-antigen (PSA) and a higher Gleason Score (GS). This finding has led to the development of novel imaging modalities such as 68Ga-/18F-labeled PSMA PET/CT and PET/MRI. This article reviews the literature pertaining to various new imaging technologies for the management of PCa.
Second reported case of pediatric bladder alveolar soft part sarcoma as secondary malignancy after prior cytotoxic chemotherapy Alveolar soft part sarcoma (ASPS) is a rare malignancy with high rates of metastasis at presentation, defined by an unclear cellular origin and a unique unbalanced ASPSCR1-TFE3 translocation (der(17)t(X:17)(p11:q25))1. ASPS is insensitive to chemotherapy and has been reported to involve the bladder only twice in the pediatric literature; once as a primary malignancy2, and once as a secondary malignancy after cytotoxic chemotherapy3. Herein, we report the third case of pediatric bladder ASPS in a female patient who received cytotoxic chemotherapy for low-risk neuroblastoma.
ROBOT-ASSISTED PARTIAL NEPHRECTOMY AND BILATERAL PYELOLITHOTOMY IN ECTOPIC PELVIC KIDNEYS To show how to perform a robot-assisted partial nephrectomy and bilateral pyelolithotomy in ectopic pelvic kidneys. This is a congenital abnormality of position and rotation1 frequently associated with urolithiasis.2 Renal cell carcinoma is a very rare event in pelvic kidneys.3,4 These two findings in the same patient could be a surgical challenge and whenever possible a “one stage” treatment is preferred.
Contemporary Management of Incident Prostate Cancer in Large Community Urology Practices in the United States To characterize the contemporary management of prostate cancer patients in large community practices. The optimal management of incident prostate cancer has changed in the last decades to include active surveillance for a large number of men. At the same time, many community practices have merged into larger groups. The adoption of evidence-based guidelines is of increasing importance, but poorly understood in this newer practice setting.
Increasing Utilization of Multi-Parametric Magnetic Resonance Imaging in Prostate Cancer Active Surveillance To characterize the use of multiparametric magnetic resonance imaging (mpMRI) in male Medicare beneficiaries electing active surveillance for prostate cancer. Multi-parametric resonance imaging (mpMRI) has emerged as a tool that may improve risk-stratification and decrease repeated biopsies in men electing active surveillance. However, the extent to which mpMRI has been implemented in active surveillance has not been established.
A Case of Metastatic Prostate Cancer to the Urethra That Resolved After Androgen Deprivation Therapy An 83 year-old male with Gleason score 4+3 prostatic adenocarcinoma status post brachytherapy developed obstructive voiding symptoms 9 years after brachytherapy. Prostate-specific antigen was 0.67. Cystoscopy noted multiple papillary urethral tumors concerning for primary urethral carcinoma. Immunophenotype of biopsies supported diagnosis of Gleason score 4+4 prostatic adenocarcinoma. Androgen deprivation therapy was started. Cystoscopy performed 4 years later, for microhematuria workup, noted complete resolution of the urethral tumors.
Acute Urinary Retention Due to Late Migration of a Retained Bullet to the Urethral Meatus Urethral obstruction due to retained bullets migrating into the genitourinary system has rarely been reported. The literature describes 2 main methods of retained bullet removal from the genitourinary system: (1) spontaneous expulsion during voiding and (2) manual extraction due to urethral obstruction causing acute urinary retention. We present a case in which a 21-year-old man presented with acute urinary retention 3 years after suffering a gunshot wound to the abdomen. A retained bullet eroded through the bladder wall, migrated through the bladder and urethra, and eventually became lodged in the external urethral meatus, causing obstruction and urinary retention.
Right Testicular Infarction Secondary to Spontaneous Testicular Vein Thrombosis in a Child: Case Report and Literature Review Pediatric testicular vein thrombosis is a rare entity with only six reported cases. Diagnosis depended on preoperative clinical suspicion, radiological and intraoperative findings. The literature is very limited in the pediatric population with different etiologies and different managements. We present a case of a 14-year-old boy who suffered from spontaneous right testicular vein thrombosis and was treated with right orchiectomy and oral anticoagulation. We also reviewed and summarized the previously described cases of pediatric testicular vein thrombosis.
A Rare Cause of Urinary Peritonitis: Intra-abdominal Adhesion Rupture Intra-abdominal adhesions are a common complication following any surgical procedure involving the abdominopelvic cavity. The mechanism behind adhesion formation is still not well understood, however, is thought to be caused from inflammatory signaling and mesothelial surface disruption.1 Adhesion occurrence following a laparotomy is estimated to be as high as 95%1 with the other 2 main causes of adhesion formation being chronic inflammation of the bowel and postradiation therapy.2-4 Bladder perforation due to intra-abdominal adhesions has never been reported but may be something to consider when other causes of peritonitis have been excluded.
Free-floating Paratesticular Calcifying Fibrous Pseudotumors in a Pediatric Patient Paratesticular masses are a relatively common finding in males. The majority are benign, as opposed to testis masses, which tend to be malignant. Fibrous pseudotumors are rare, but are the third most common paratesticular tumor after adenomatoid and lipoma. The exact cause is unclear but likely from a fibroinflammatory reaction. Because of the non-specific findings on physical exam and scrotal ultrasound, patients may undergo scrotal exploration and occasionally orchiectomy, in spite of the benign nature of this lesion.
Three Cases of Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia—A Diagnostic and Therapeutic Challenge A 23-year-old man presented with massive enlargement of his testes. He had a known history of salt-wasting congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) and was on glucocorticoid and mineralocorticoid replacement since initial diagnosis at birth with a current treatment regimen of prednisolone 7.5 mg and fludrocortisone 75 µg daily. However, compliance was poor as reflected by hormonal control parameters out of target range (Table 1). Ultrasound of the testes revealed the presence of massive bilateral tumors with mixed hypo- and hyperechogenic appearance.
Outpatient Robot-assisted Radical Prostatectomy: A Feasibility Study To evaluate the feasibility of routine outpatient management after robotic-assisted radical prostatectomy (RARP). Prostate cancer is indeed the second most common cancer in men. Surgical technics have evolved from open surgery to robot-assisted surgery with a reduction of postoperative complications. Such technical improvements associated with modern anesthesia allow outpatient surgery in various types of procedures.
Transobturator Tape: Over 10 Years Follow-up To assess subjective and objective outcomes in incontinent patients following “out-in” TOT, at >10-year follow-up; to evaluate effect on quality of life and other urinary symptoms, late adverse events and predictive factors for failure.
Examining Genitalia—Chaperone or Go it Alone? Whenever a male physician examines a female patient's breast or genitalia, it has long been standard practice to always require that a chaperone be present. On the other hand, there has been no widely-accepted expectation, when a woman physician examines the genitalia of her patient, whether male or female, that a chaperone should likewise be present. However, the winds may now be changing. The #METOO movement is encouraging women to speak out against various forms of inappropriate behavior which, in the past, they might have tolerated in silence.
A Reliable Technique in the Reconstruction of Large Penoscrotal Defect: Internal Pudendal Artery Perforator Flap To reconstruct the defect secondary to Fournier's gangrene, which is an infection localized in the perineum and the lower abdominal region, characterized by large tissue loss following debridement. A large tissue loss caused by Fournier's gangrene brings with repair problems. The primary goal is to achieve cosmetically and functionally successful results. The purpose of this article is to share the results of reconstruction of large penoscrotal defects with internal pudendal artery perforator (IPAP) flap.
Combined Robotic-assisted Laparoscopic Radical Prostatectomy and Partial Nephrectomy, Rare Coincidence The incidence of second primary cancer detection in patients with prostate cancer undergoing cross-sectional imaging for staging workup is 1.5%.1 Concomitant prostate cancer and clear-cell renal cell carcinoma is a rare condition. The coexistence of 2 synchronous neoplasm is highly infrequent. In this case, we present a combined robot-assisted operation for both procedures concurrently with a port strategy allowing reuse of ports.
Renal Infarction Associated With Extra-Adrenal Pheochromocytoma Pheochromocytomas have been described to be associated with renal infarction in a few sporadic cases. The underlying pathophysiologic mechanisms are catecholamine-induced vasospasm and direct compression or invasion of the tumor on renal artery or its branches. However, renal infarction caused by extra-adrenal pheochromocytoma is rarely reported. We describe an unusual case of benign extra-adrenal pheochromocytoma complicated with left renal infarction by severe vasospasm.
The Urology Match Process and the Limited Value of Post-Interview Communication for Program Directors To understand the urology Match process from the perspective of residency program directors, with a particular focus on the role of postinterview communication. Recent surveys of urology applicants revealed that postinterview communication from programs often violates the rules of the American Urological Association Urology Residency Matching Program (the “Match”), and that such communication may influence applicant rank lists.
How Do Astronauts Urinate? The History of Innovations Enabling Voiding in the Void Urination in microgravity is a challenge that bedevils all space travelers and intrigues all space watchers. The absence of gravity defies one's terrestrial voiding behaviors. Scientists, engineers, and astronauts refined the interface between man and machine, solving problems, and improving astronaut comfort. From forgotten to familiar technology, the nearly 60-year history of manned spaceflight serves as a testament to the innovation and fortitude necessary to boldly “go” where no man has gone before.
Rectal Mucosa Graft Take in Staged Urethroplasty When an oral mucosa graft is not a viable option for urethroplasty, colonic mucosa grafts have served as a promising alternative since described by Igor A. Thyrmos in 1902.1 In previous studies, colonic mucosa graft retrieval required sigmoid resection2-3 which limited adoption of this technique. We previously described the success of a minimally-invasive transanal endoscopic microsurgical technique of rectal mucosa graft harvest for urethroplasty.4 Here, we pictorially demonstrate the take of a transanal endoscopically harvested rectal musosa graft used in a 2-stage anterior urethroplasty (to our knowledge, the first such 2-stage procedure) with 6 months of follow-up.
Intermittent Urinary Incontinence Secondary to Inverted-Y Ureteral Duplication With Perianal Ectopia Inverted-Y ureteral duplication is one of the rarest anomalies of ureteral branching, which has been found to be more prevalent in females.2 Females commonly present with urinary incontinence often associated with distal limb ectopia to the bladder neck, uterus, or vagina.2 We present the case of a 7-year-old female with intermittent urinary incontinence who was found to have an inverted-Y ureteral duplication with perianal ectopia. We highlight the role of magnetic resonance urography in the evaluation of females with urinary incontinence and a normal renal/bladder ultrasound who are refractory to behavioral therapy.
Primary High-grade Peripheral T-cell Lymphoma of the Testis Clinically Confused With Scrotal Abscess Testicular T-cell lymphomas are rare and heterogeneous. Their rarity, nonspecific clinical and radiologic features, histomorphologic heterogeneity, and aberrant immunohistochemical expression may impose diagnostic difficulties for clinicians and pathologists. They may mimic germ cell neoplasms, infectious orchitis, and scrotal abscess. We report a case of a high-grade T-cell lymphoma of the testes in an elderly man with uncontrolled diabetes mellitus. It was clinically and radiologically unexpected and was confused with viral or tuberculous orchitis with abscess formation and systemic sepsis.
Re: Comparing Off-clamp and On-clamp Robot-assisted Partial Nephrectomy: A Prospective Randomized Trial We commend with Anderson and coworkers for their efforts. They performed a prospective randomized trial addressing the comparison of on-clamp vs off-clamp technique for robotic partial nephrectomy (RPN).1 Recent systematic literature reviews already showed no impact of the technique used to manage the renal pedicle on either surgical or oncological outcomes.2 This is debatable and based on pooled analyses of mostly small sample size studies, affected by several confounders, including selection bias (off-clamp approach is more likely performed in low complexity tumors) and heterogeneity in the surgical techniques used.
The Natural History of Wilms Tumor–A Case Comparison of Two Different Tumors Due to the rarity of Wilms tumor (WT) and the relative urgency with which pediatric renal tumors are treated, there is little reported data on the natural history and growth of WTs. Historical reports of estimated doubling times of WTs were based on time to disease recurrence after initial diagnosis and treatment, and were published before the current advancements in molecular biomarker testing. We compare 2 cases of WT with sequential imaging, and postulate how the growth parameters of these tumors may be associated with differing chromosomal traits.
A Rare Case of Uterine Torsion With Juvenile Granulosa Cell Tumor in the Pediatric Patient Juvenile granulosa cell tumors of the ovary are rare sex cord-stromal ovarian tumors that are typically diagnosed during the first 2 decades of life. Most patients present with precocious puberty in the early stages of disease. We present a rare case of asymptomatic uterine torsion from a 15-cm juvenile granulosa cell tumors in a 5-year-old girl with elevated inhibin B, breast development, vaginal bleeding, and a palpable right-sided abdominal mass.
Left Kidney Within a Large Left Inguinal Hernia The patient is an 86-year-old male who presented with hematuria and discoloration of his left hemiscrotum. He had a past medical history significant for atrial fibrillation on apixaban, coronary artery disease, hypertension, diabetes, and a repaired 8-cm abdominal aortic aneurysm. He had recently been successfully treated for a urinary tract infection. He also had history of inguinal hernia for over 3 years for which he had consulted a general surgeon who recommended observation in view of the patient's multiple comorbidities and absence of symptoms.
Reply to: Letter-to-the-editor: Understanding the Popcorn Effect During Holmium Laser Lithotripsy for Dusting We thank the authors for their interest in our study. Our fundamental finding was that increasing the pulse frequency and the overall power led to significantly more fragmentation during popcorning. This was similar to what was also reported by Emiliani et al.1 Moreover, we found that increasing the distance between the fiber tip and the stone decreased fragmentation. As noted, figure 2 showed that the percentage of submillimeter fragments when utilizing 40 Hz and 80 Hz at 0.5 J was 67% and 73%, respectively.
Examining Trends in Underrepresented Minorities in Urology Residency To examine trends in underrepresented minority (URM) representation in urology residency. Comparison is made between URM representation in urology residency and URM representation in other surgical fields as well as all medical fields. We hypothesized that percentage of URM in urology has been limited when compared to both surgical fields and all other fields.
Malignant Renal Solitary Fibrous Tumor With Two Local Recurrences and Distant Pulmonary Metastasis A 53-year-old man presented to our hospital with right upper quadrant pain alongside nausea and vomiting. Physical exam revealed right upper quadrant tenderness, Murphy sign, and fever. He otherwise had no significant past medical or surgical history. Subsequent abdominal ultrasound showed signs of cholecystitis and an incidental lobulated hypoechoic mass of the left kidney with heterogeneous echotexture and hypervascularity on Doppler. The patient had a cholecystectomy without complications during the postoperative period.
Rare Abdominal Cutaneous Presentation of Clear Cell Renal Cell Carcinoma: A Case Report Cutaneous metastasis from renal cell carcinoma is rare, typically involves the head and neck, and occurs inlatestage disease, usually in the context of previously diagnosed and treated primary tumour, and after lymphaticspread.This patients’ initial presentation of clear cell renal cell carcinoma was a cutaneous lesion to the ipsilateral abdominal wall. The primary renal tumour was subsequently demonstrated on CT; this also showed no apparent lymph nodeinvolvement despite cutaneous metastatic disease.
BCG Renal Granuloma A 66-year-old man with a history of recurrent urothelial carcinoma in situ treated with endoscopic resection and induction Bacillus Calmette-Guerin (BCG) developed a new renal mass on surveillance computerized tomography and was referred to our institution for surgery. Biopsy was performed and pathology showed BCG granuloma. The patient was clinically asymptomatic. No surgical intervention was required. This is a rare entity in those undergoing intravesical BCG therapy. To avoid unnecessary surgery, a careful patient history and judicious use of renal mass biopsy is critical.
Ex-vivo Imaging of Upper Tract Urothelial Carcinoma Using Novel ICG-Var3 pHLIP Imaging Agent To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studies using the novel pH low insertion peptide (pHLIP) variant 3 (Var3) conjugated to indocyanine green (ICG) have demonstrated high sensitivity and specificity for imaging of bladder urothelial carcinoma. Here, we describe a novel approach for the imaging of UTUC using ICG-Var3 pHLIP.
Metachronous Isolated Splenic Metastasis in a Young Patient With Renal Cell Carcinoma: Case Report and Literature Review Splenic metastasis is uncommon and is usually associated with widespread disease.1,2 Isolated splenic metastases from renal cancer are also rarer and are often an incidental finding. This eventuality may turn into a dangerous scenario due to a spontaneous splenic rupture leading to sudden death.2,3 At the best of our knowledge, only few cases of metastasis from renal cell carcinoma (RCC) have been documented in the literature.4-11 We hereby present a literature review of these cases and report a case of isolated splenic metastasis in a young man on active follow-up for a clear cell RCC clear cell Renal Cell Carcinoma (ccRCC).
A Case of Primary Paratesticular Wilms Tumor in an Undescended Testis Extrarenal Wilms tumor is rare. We describe the first reported case of primary paratesticular extrarenal Wilms tumor with regional metastasis in 8-month old male with left undescended testis. Patient underwent left radical orchiectomy with regional lymph node excision. The inguinal node and paratesticular mass demonstrated the classic Wilms triphasic pattern, stained positively for WT-1 and demonstrated no loss of heterozygosity of chromosomes 1p and 16q. Work-up was negative for primary renal Wilms tumor or distant metastasis.
Adult Wilms Tumor During Pregnancy: Case Report and Literature Review Adult Wilms tumor (WT) is a well-known, albeit rare entity and has historically been associated with worse overall clinical outcomes when compared to younger patients. Because WT is uncommon in adult patients, it is often misdiagnosed and treated off standardized pediatric protocols. WT associated with pregnancy is even more rare, and there is not a standardized approach to this small subset of patients. We present a case of an adult WT discovered and managed during the perinatal period and review prior published cases.
Dermatofibrosarcoma Protuberans in a Male Infant Dermtofibrosarcoma protuberans is a rare cutaneous malignancy known to be locally aggressive. It is uncommonly seen in the pediatric population and can be difficult to distinguish from other benign skin lesions. We present a case of dermatofibrosarcoma protuberans of the penis in a 6-month-old child managed with surgical resection. This case highlights the challenges of diagnosis of genital lesions in children and the complexities of genitourinary reconstruction following surgical resection.
The Prognostic Value of PIK3CA Copy Number Gain in Penile Cancer To determine whether phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha (PIK3CA) copy number gain in penile cancer has prognostic value and association with histopathological parameters, human papillomavirus (HPV), and clinical outcome.
Dual Pathology Causing Congenital Bladder Outlet Obstruction Anterior urethral syringocele is an uncommon congenital deformity characterised by cystic dilatation of bulbo-urethral gland ducts and is usually asymptomatic. We present a case on 4-day-old male neonate who presented with bilateral antenatal hydroureteronephrosis and renal impairment and found to have urethral syringocele and posterior urethral valves (PUV).
Author Reply The comments of the editor truly reflect the findings of our study on the surgical treatment of giant penoscrotal lymphedema. All the 19 patients described in the study were to be treated by surgery. Eight patients, however, defaulted, possibly because of their belief in alternative traditional herbal medicine and or financial constraint, because health insurance schemes are yet to be fully established in our environment.
WITHDRAWN: Stented or Unstented Distal Hypospadias Repair The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2017.04.057. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
WITHDRAWN: Reply The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2015.08.053. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
WITHDRAWN: Editorial Comment The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2013.02.086.The duplicate article has therefore been withdrawn.
Editorial Comment Recent prospective studies, including randomized clinical trials, have provided compelling evidence in favor of the use of multiparametric magnetic resonance imaging (MRI) for the detection of clinically significant prostate cancer. Nevertheless, questions remain regarding how these results compare to those obtained in routine clinical practice when MRI examinations are interpreted by readers with variable levels of experience.
AUTHOR REPLY The authors agree that all interactions within the healthcare systemhave the potential for negative impact not only on the resident, but also on patient care. Further, we agree that it is imperative that we gain a better understanding of at-risk individuals and especially problematic intersections. Further, the specialty of urology has a chance to be an early leader, as the concept of physician well-being gains national momentum.
EDITORIAL COMMENT The authors of this study should be commended for providing meaningful data on the phenomenon of bullying in residency training. This issue is not unique to urology or to the residency training environment, but it does deserve formal and proactive attention within our specialty. They correctly point out the pervasive impact of hostile and disrespectful behavior on the quality of job satisfaction, work burnout, and patient care and outcomes. In this study, 98% of residents perceived bullying, 36% felt that bullying affected patient care, and 63% felt that it harmed the learning environment.
Author Reply We appreciate and agree with the editorial comment. Urology is indeed a gem of a specialty. Despite the increasing recognition of physician burnout in urology, we cannot rely on the healthcare system to change or improve the drivers of dissatisfaction in the near future. Payers and regulators are not likely to substantively decrease the administrative burden of practicing medicine. We will not have less interaction with the electronic health record. In the increasing quest for efficiency, proof of value, and ultimately financial margin, urologists will likely have to cope with more pressure for documentation and administration.
Editorial Comment Urology is a gem in the surgical subspecialty world, as evidenced by a highly competitive match with increasing numbers of outstanding applicants.1 This has been attributed to the diversity of patients and pathology, the range of surgical techniques, the generally promising outcomes in many cases, and, additionally, the potential to balance personal and work life. Surprisingly, Urology has recently suffered from increasing job dissatisfaction and we now stand as one of the most burnt out specialties in medicine (references 1–4 in manuscript).
EDITORIAL COMMENT In 2016, the Harvard Business Review published an essay on the impact of diversity on the effectiveness and productivity of teams. The authors cited many studies including a trial that demonstrated a more than 50% improvement in diverse teams pricing stocks compared with more homogenous teams. The authors concluded that “enriching your employee pool with representatives of different genders, races, and nationalities is key for boosting your company's joint intellectual potential.”1 Census data from the American Urological Association demonstrated that African American, Latino, and Indigenous American comprised 3.3% of the total urologic workforce in 2016, and yet represent nearly 30% of the United States population.
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