Bradley A. Erickson, MD, MS

 Editorial Council, is associate professor of urology at the University of Iowa, Iowa City.

I’m learning a lot about what I do by not being allowed to do it. It’s frustrating to be told your services are not vital in the time of a national emergency. Pre-COVID, there were days that I would leave the hospital after a long day in the operating room feeling like I had accomplished the surgically impossible, had maybe even saved a life. During COVID, I’m often leaving the hospital (if I even bother to show up) in an existential crisis. Is this what 7 years of training and 10 years of practice have led to? An inconsequential expertise?

I realize our lives will return to a new normal someday and my clinics and my operating room schedules will once again fill up with urethral strictures and curved penises. But until they do, I’m trying to enjoy my time away from the grind of medicine as much as I can. For my two young, impressionable boys, these months will likely represent their first societal “shared experience.” Like the Challenger explosion, the start of the first Gulf War, and 9-11 for me, they will never forget the COVID months and what their family did, or didn’t do, when isolating from society. My wife and I are finding that boredom is striking a creative flame in all of us that I hope does not extinguish.

Professionally, I am mentally and logistically preparing for a different medical environment when we all return from isolation. I doubt it will ever be business as usual again. Telehealth is being forced upon all of us and there will be no going back from it. Good. The transition might be painful for some hospitals and non-vital health employees, but I strongly believe that it will greatly benefit providers and patients in the long run.

The inefficiencies of requiring our patients to uproot their lives to drive, park, wait, and then wait some more, all for 10 minutes (if lucky) of face time with their provider are finally being exposed for what they are-primitive and unnecessary. Let’s finally, and fully, embrace technology in medicine, not just for billing purposes, but for its ability to free us from the mundane and from the mind-numbing churn of the medical industrial complex. Let’s finally try to fix physician burnout by not accepting a return to business as usual.

Finally, while I am sincerely appreciative of my non-medical friends for reaching out to me and others who are on the “front lines” of this epidemic, I think I can speak for most of us in saying that I hope this epidemic does more than simply remind people of the importance of doctors in society. I hope it also reminds society of the importance of scientific rigor and of scientific facts, the importance of individual expertise but also teamwork, and the importance of having a health care system that understands that none of us are truly healthy until we are all healthy.

Stay safe. Wash your hands. Wear a mask. Hug your family. Facetime your friends.

Articles

"Professionally, I am mentally and logistically preparing for a different medical environment when we all return from isolation. I doubt it will ever be business as usual again," writes Bradley A. Erickson, MD, MS.

No business as usual post COVID? Maybe a good thing

 is associate professor of urology and surgery, and 

 is a reconstructive urology fellow, University of Iowa Carver College of Medicine, Iowa City.

asked readers about their practice’s utilization and understanding of the 2016 AUA urethral stricture disease guidelines and the impact the guidelines have had on their clinical management of urethral strictures. In addition, given the rise in popularity of careers in reconstructive urology among graduating urology residents (17 Genitourinary Reconstruction Society fellowship programs now participate in the match, with a resident match rate of only 58% in 2017), we surveyed urologists about their individual comfort with urethral reconstruction, the presence of a urethral “specialist” within their group, and their referral patterns for complicated urethral reconstruction.

Overall, the survey results suggest that the AUA urethral stricture guidelines have made a positive impact and the management of urethral stricture disease continues to shift from endoscopic treatment to open surgical repairs.

The majority of readers (72%) have read the AUA urethral stricture guidelines 

 with only 8% being unaware of their existence. When asked how the guidelines have changed their clinical management, 18% said they are doing more urethroplasties and 38% are referring more cases to centers of expertise.

TURP duration linked with complication rate

In a case-based question, readers were asked how they would manage a 1.5-cm bulbar urethral stricture that has failed multiple urethrotomies, the last being 18 months ago. The guidelines would suggest here that urethroplasty is the most appropriate choice for this patient. Encouragingly, over 40% of the respondents would either perform an anastomotic urethroplasty (31%) or a urethroplasty utilizing a buccal graft (13%). An additional 43% would refer the patient to a center that routinely performs urethroplasties, while only 13% would repeat the urethrotomy.

When asked about a pelvic fracture urethral distraction defect case, 73% indicated that they are comfortable in the initial trauma management, of whom 42% would initially attempt retrograde catheter placement, 38% would immediately place a suprapubic tube, and 39% would only place a suprapubic tube after initially failing retrograde catheter placement. A much smaller percentage (6%) would attempt open realignment.

Continue to the next page for additional survey results.

A multitude of recent studies have shown that experience matters when it comes to urethroplasty outcomes 

 with one study showing that acceptable outcomes may not be achieved until 100 cases 

 and another showing that results may continue to improve even after 500 cases 

 The survey responses suggest that most urologists understand that not all urologists should be doing urethral reconstruction. Indeed, when asked specifically how they manage urethral strictures in their practice, only 32% of urologists stated they manage all the male stricture cases in their practice, with the vast majority either referring to a provider inside (16%) or outside (47%) of their practice.

Compared to those in other practice settings, urologists in academic practice were more likely to manage all cases of urethral stricture themselves (70%). Similarly, although only 43% of respondents stated they had a urologist in their practice who “specialized” in urethral reconstruction, specialization was much more common in academic/government practices (73%) and in larger practices with 10-19 urologists (70%) and 20+ urologists (69%), as compared to practices with fewer than seven physicians (24%).

Ureteral access sheaths: Tips on when and how to use

Interestingly, regardless of practice type, those with less overall experience were significantly more likely to manage all urethral strictures themselves, with 91% of respondents 1-4 years out of residency saying they do all their own urethroplasties, compared to only 23% who were 20-29 years out. We suspect that this is related to an increase in surgical exposure during residencies, likely the direct result of greater penetrance of reconstructive urologic specialists within training programs.

In general, it appears that the effect of the AUA urethral stricture guidelines has been positive and that the condition’s clinical management is evolving from endoscopic to open surgical repairs. This finding is supported by recent data looking at overall trends in urethral stricture management 

 which show a practice shift away from repeat endoscopic management, as reported in a survey of urologists published a decade ago 

Specialization in urethral reconstruction is no longer just found in academics, with many larger private practice groups having a designated urethral expert. With more reconstructive faculty in training programs nationwide, comfort with urethroplasties will continue to improve, which we believe represents a positive impact in our overall management of urethral stricture disease.

Recent survey results suggest that the AUA urethral stricture guidelines have made a positive impact and the management of urethral stricture disease continues to shift from endoscopic treatment to open surgical repairs.

Author | Bradley A. Erickson, MD, MS

Articles

No business as usual post COVID? Maybe a good thing

AUA guideline positively impacts stricture management