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Clinical Focus

This episode's guest is Amanda North, MD, associate professor of pediatric urology at Montefiore Medical Center. North discusses the recent Urology Practice paper, The Gender Pay Gap in Urology, for which she served as a study author.

Dr. Finkelstein discusses telemedicine for pediatric post-op visits

Malpractice and stones: What a recent study reveals

What patients undergoing HIFU should expect postoperatively

In this podcast, North discusses the findings of a recent Urology Practice study.

Speaking of Urology: Dr. Amanda North on the gender pay gap in urology

"Major bladder reconstructive surgeries have the most room for improvement, particularly surgeries involving a bowel anastomosis; also our major oncologic surgeries—Wilm's tumor resections, those types of surgeries," says Sarah Hecht, MD.

The how and why of ERAS protocol adoption in pediatric urology

Dr. Butler discusses 2022 milestones from her practice in gender-affirming care and looks ahead to what might be on the horizon for the field in the coming year. 

Year in review: 2022 highlights in gender-affirming care

There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

AUGS-IUGA joint clinical consensus statement on enhanced recovery after urogynecologic surgery

Kidney transplant surgeon Alvin Wee, MD, MBA, presented findings at the 2022 AUA Annual Meeting

New data show transplanting kidneys from donors with COVID-19 is safe

Urology entrepreneurs Neal Patel, MD, and Philip Zhao, MD, proudly tout their handheld, wireless endoscopic camera as a device “designed by urologists for urologists."

Physician innovators disrupt endoscopic visualization

 discusses potential future research following the 

International Journal of Impotence Research 

paper, “Rising vasectomy volume following reversal of federal protections for abortion rights in the United States,” for which she served as senior author. Vij is a urologist at Glickman Urological & Kidney Institute at Cleveland Clinic in Cleveland, Ohio.

There are a few other things that would be interesting to look at. One is to look at female reproductive decisions in terms of something like a tubal ligation, which is sort of the anatomic equivalent [of a vasectomy]. It's a little bit more complicated, because that's often done at the time of a C section, so it's not quite the same thing as an elective vasectomy. But I think it'd be interesting to have our gynecology peers look into what the impact was on female sterilization. And then, if we assume that some of these men that are under 30 or childless are making this decision in haste in a political setting, then you would expect vasectomy reversal numbers to go up in the future. That's not something we're going to know potentially for many years, but I do think all of us are wondering, are we going to see much more interest in vasectomy reversals down the line? I think memory for all of us, especially with the current news cycle, is often short, and sometimes it feels like the Roe v Wade discussion is sort of off the air and no longer in people's minds. So it's hard to know whether it's still impacting decisions without distinctly asking patients. So I'm not sure how much more we can get out of this particular question in this data set. But we do also want to compare our data to others in other regions of the country that that have different laws. Ohio had a heartbeat bill come out, essentially, very shortly after Roe v Wade was overturned; it's still being held up. But abortion access is very different state by state, and so I'm curious if our colleagues in other parts of the country with different political landscapes have seen the same thing.

This transcription was edited for clarity.

Videos

“That's not something we're going to know potentially for many years, but I do think all of us are wondering, are we going to see much more interest in vasectomy reversals down the line?” says Sarah Vij, MD.

What might future research on Roe v Wade reversal’s effects on reproductive care entail?

 discusses notable findings from the recent 

study, “Rising vasectomy volume following reversal of federal protections for abortion rights in the United States,” for which she served as first author. Bole is a male infertility/andrology fellow at Glickman Urological & Kidney Institute at Cleveland Clinic in Cleveland, Ohio.

There were a number of key findings that we found very interesting. Some of them made sense in terms of what patients would be thinking about as this decision came out and the things that they would be worried about happening or not happening. [In terms of] people who had initiated vasectomy consultation requests and then actually showed up to visits, we saw increases in both of those numbers: a 35% increase for people initiating requests, a 22% increase in people actually coming to a clinic visit to discuss vasectomy, and no change from before the decision to after the decision in terms of how many men actually followed through in getting the procedure. So the people who showed up were still interested in having the procedure, once they came to that initial visit. Younger men are getting vasectomies than before. On average, we found a decrease in the average age from 38 years old to 35 years old, 3 years over a very short span of time, so not something that you would think was just due to chance. And not only that, when we dove a little bit deeper into the data, we looked at men under 30...and we found a significant increase in men under 30 getting vasectomies. That number actually doubled. It was 10% of our patients before the decision and went to almost 25% after the decision. Patients are making these big reproductive health decisions much earlier in life than before, and that absolutely has an impact at the population level as well as the individual level. We also found that men without kids were significantly increasing in numbers [in terms] of who was getting vasectomies. Again, that number [went] from 8% before to 16% after the decision. Those findings maybe were a little bit surprising when you just see the numbers written down, but they also make sense based on what that decision meant to many, many patients and many families.

“We found a significant increase in men under 30 getting vasectomies,” says Raevti Bole, MD.

Dr. Bole discusses rise in vasectomies following Roe v Wade reversal

 discusses the background behind the recent 

We noticed anecdotally, and we were hearing from colleagues across the country, that after Roe v Wade was overturned, interest in vasectomy seemed to be going up. We were getting more consults in clinic, we saw people booking out further for our procedures and other peers were saying the same thing. We're very interested in this, and there's a lot of talk about Roe v. Wade affecting the reproductive health of women. This implies that it's also affecting reproductive health decisions for men, which is an interesting spin [that is] important for politicians to understand and for us to understand as providers. We knew that there'd be a little bit of lag time because you've got to get an appointment scheduled for a consultation, then you need to get the procedure scheduled, and we don't always have availability immediately. So we needed to at least wait until a little bit of time passed. What we really wanted to capture was the degree of interest in the procedure, which would be represented by scheduling the consultation, and then conversion to actually having it, as we thought maybe some of these guys are just entertaining the idea, then they think about it more, learn about what's entailed, learn about the permanence, and decide to hold off. And so we looked at follow through. Secondarily, we wanted to see, is this a younger patient population? Are we thinking maybe there are more guys that don't have kids, or people that have fewer kids—maybe you have a family that has 3 [children] and was thinking 4, and now they're worried about possible pregnancy outcomes and not having options. We looked at all of those things and that was really the overall premise.

“There's a lot of talk about Roe v. Wade affecting the reproductive health of women. This implies that it's also affecting reproductive health decisions for men,” says Sarah Vij, MD.

Dr. Vij on trends in vasectomy volume after overturning of Roe v Wade

study, “Optimizing Lymph Node Dissection at the Time of Nephroureterectomy for High-risk Upper Tract Urothelial Carcinoma.” Lange is a urologic oncology fellow at the University of Texas MD Anderson Cancer Center in Houston and Matin is a professor of urology at the University of Texas MD Anderson Cancer Center.

I think that practicing urologists should be considering this in high-risk patients. It's difficult when it's not clearly outlined in the guidelines, but it should be something that we are considering, especially when we look at patients with bladder cancer or testicular cancer where they're using very defined prespecified templates. And it's also something we should be considering here, because it may truly be beneficial for these patients.

I would echo that. I would ask the practicing urologist to keep an open mind and not be dogmatic about how they've practiced in the past, and to consider the multiple lines of both indirect and direct evidence that exist. We know with bladder cancer, which is the most common urothelial cancer we have, it's pretty well established that lymph node dissection is not just diagnostic, but therapeutic. There are some differences with upper tract disease, but they're not such differences that would eliminate the ability to relay that same benefit, in that setting. Again, I would ask practitioners to keep an open mind. The other thing is, it is a rare cancer, and some urologists may not see more than a couple of cases a year. If that's the case, there should be no concern really about referring these patients to higher volume centers.

We are talking more and more about understanding practice patterns of providers in general and then improving the quality of our care. There was one paper we discussed, where they pointed out that this should be considered a quality indicator for management of upper tract urothelial carcinoma, and so they're bucketing it with using intravesical chemotherapy at time of the nephroureterectomy or considering systemic chemotherapy, and the other one was ensuring an adequate bladder cup is taken. It's becoming a very important thing and I think people are highlighting it more, and we have to keep raising attention to it.

“I would ask the practicing urologist to keep an open mind and not be dogmatic about how they've practiced in the past, and to consider the multiple lines of both indirect and direct evidence that exist,” says Surena F. Matin, MD.

Lymph node dissection in high-risk UTUC: Urologists should “keep an open mind”

Based on these findings, are you likely to alter anything about your clinical practice?

 Dr. Matin and I had a discussion about this the other day. For me, this highlighted that it is an important practice and that we should be considering incorporating this more into our guidelines. There are a very limited amount of guidelines for upper tract urothelial carcinoma in the first place, and they are beginning to comment that we should consider lymph node dissection in high-risk disease. That can be very vague [in terms of] how you define it. And then on top of that, like Dr. Matin was talking about, the templates are not very well defined. And so I think it's really important that over time, we work to further incorporate that into the guidelines to ensure that people utilize it more in practice.

 I think for me, it helped highlight some of the practice that we were already performing. On the other hand, we do have to keep an open mind and recognize that we may be overemphasizing some of the benefits as well in some cases, I think that the most difficult part for most practitioners is twofold. Number 1 is correctly identifying which patients you are going to do a lymph node dissection on, and as Dr. Lange said, how you classify high risk is its own debate. Number 2 is the comfort level that a urologist may have in performing lymph node dissection, whether they're doing it open, or increasingly, folks are doing it robotically. And then there's a practical issue; it takes a bit more time. And then there are concerns about potential complications of it as well. So there are several barriers to its incorporation, and we hope that with time, we can address each of those.

And it was a pretty brief review, but we did discuss some of those barriers in our paper and how we [might] overcome those. The data do not really show a significantly increased risk for complications. The big concern is always for chylous ascites, and so you have to be meticulous with sealing those vessels, either with suture or with vessel sealers or clips. We also touched on [the fact] that there are better methods for controlling things like that. IR embolization could be an option. It's very dependent on where you are, but it has been demonstrated to be helpful with that. We also talked about staging because preoperative staging in these patients really is notoriously poor, because it's difficult to get biopsies and imaging lacks granularity. And so, what we discussed in the paper is there are a couple of nomograms that are good for predicting either T2 or higher disease at time of surgery, so on final pathology, or T3 or higher. And so those are good options for people to have in their toolkit when making these decisions.

Yes, and we use those routinely to help guide patient care. We don't rely on them on an absolute fashion, but they do provide helpful guidance.

“There are a couple of nomograms that are good for predicting either T2 or higher disease at time of surgery, so on final pathology, or T3 or higher,” says Suzanne Lange, MD.

Considerations for lymph node dissection in high-risk UTUC

 discuss the background and notable findings from the 

Please discuss the background behind this paper.

The purpose of this paper was to create a top-line review of lymph node dissection use at the time of radical nephroureterectomy for patients with upper tract urothelial carcinoma. Within the paper, we wanted to briefly discuss the evidence supporting clinical benefits of lymph node dissection, highlight the poor utilization and potential barriers to use, and then discuss some of the considerations on how and why we should improve these.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

There were several notable findings. For me, as a more junior urologist, I think some of them were surprising, but Dr. Matin has been working for a long time to build this evidence. We highlighted that there is building evidence suggesting clinical benefits for lymph node dissection, such as a clear benefit of staging, which allows us to perform better prognostication for patients. And then we discussed that there are data that suggest a therapeutic benefit to this as well. The data supporting the therapeutic benefit, have been in patients with renal pelvis and proximal ureteral disease, and not as clearly demonstrated in those with distal ureteral tumors. Of note, although we say that the data do suggest a therapeutic benefit, we can't deny that there are some data that show equivocal findings.

What Dr. Lange is highlighting are some of the pitfalls that we have in the data. One has to look at these studies very critically, because one of the things we're finding is that there appear to be specific areas that lymph node metastases migrate to, depending on where the index tumor is located. And so although the data are pretty good for the renal pelvis and proximal ureter, they're not as clear with the distal ureteral tumors. Part of that may be related to the fact that people just aren't removing the correct lymph nodes in that setting. Typically, for the mid and distal ureter, we focus on the pelvis. But our institution, in collaboration with Memorial Sloan Kettering and Moffitt Cancer Center, have shown that there's cranial migration of lymph node metastases in these cases. So if we're not actually doing a high enough dissection, then obviously we don't have an opportunity to show a benefit in that setting. The other area that I would bring attention to in terms of critically looking at papers in this area, are things like from the national databases that we have, like for example, [Surveillance, Epidemiology, and End Results] or [the National Cancer Database]. The issue there is that we don't know which lymph nodes were removed, and so many studies that try to address this and are not able to identify that adequate templates were removed then essentially, they are really removing the ability for us to confidently assess the therapeutic benefit.

“We highlighted that there is building evidence suggesting clinical benefits for lymph node dissection, such as a clear benefit of staging, which allows us to perform better prognostication for patients,” says Suzanne Lange, MD.

Dr. Lange and Dr. Matin on lymph node dissection at the time of nephroureterectomy

 discusses recent changes to reporting removal of sutures and staples. Rubenstein is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, in Towson, Maryland.

Another change that is important is removal of sutures and staples. If done outside of a global period, such as in the office at the time of an [evaluation and management] code, removing sutures or staples can be reported. The reason that these codes are important is that there is a practice expense for the staple removal or suture removing kit that would otherwise not be captured. So although the codes themselves really reimburse pretty much the cost of the kit, it's still important to report it for one's own practice expense. The suture and staple removal codes are add-on codes. One is CPT code 15853, which is for suture or staple removal, not requiring anesthesia, or 15854 which is suture and staple removal, if you have to do both of those. Now, these are add-on codes that need to be added on to the evaluation and management service that's done on that patient on that day. Remember, they should only be reported if performed outside of a global period.

“These are add-on codes that need to be added on to the evaluation and management service that's done on that patient on that day,” says Jonathan Rubenstein, MD.

Dr. Rubenstein on changes to reporting removal of sutures and staples

, “Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction.” Suskind is an associate professor of Urology and Obstetrics, Gynecology, and Reproductive Sciences, and a chief of Neurourology and Female Pelvic Medicine and Reconstructive Surgery at the University of California, San Francisco.

“We wanted to compare outcomes between nursing home residents and community-dwelling older adults undergoing surgery for bladder and bowel dysfunction,” explains Anne M. Suskind, MD.

Dr. Anne Suskind on study of surgery for bladder/bowel dysfunction in older adults

Alison Schulz, a 3rd year medical student at Albert Einstein College of Medicine discusses the abstract, “Assessment of patient understanding prior to urological surgeries to improve patient education & quality of care, which was presented at the 2022 AUA Annual Meeting (

The researchers stress the need for improved patient education prior to surgery.

Study shows patients have inadequate understanding of procedure prior to urological surgeries

discusses the background, findings, and takeaways of the study, “Representation of women on surgical panels in urology,” which was presented during the Society of Women in Urology Annual Clinical Mentoring Conference. Malik is an assistant professor of Surgery and director of Female Pelvic Medicine and Reconstructive Surgery at the University of Maryland School of Medicine in Baltimore.

“I think that the most important thing to take home is that we all have implicit biases towards people who are underrepresented, whether it's women or minorities,” says Rena D. Malik, MD.