Internet and postal survey of endourologic practice patterns among American urologists

PURPOSE: We determine endourological practice patterns among American urologists for the management of distal ureteral calculi, ureteropelvic junction obstruction, staghorn calculi and the use of ureteral stents with extracorporeal shock wave lithotripsy (ESWLdagger). MATERIALS AND METHODS: Surveys were mailed by the United States postal service to 1,000 American urologists selected randomly from the American Urological Association membership roster. The same survey was sent via the Internet to 3,065 American urologists with an electronic mail address listed in the roster. RESULTS: Responses were received from 1,029 urologists (postal 601, Internet 428). Ureteroscopy was the preferred treatment for all distal ureteral calculi less than or equal to 10 mm. Acucisedouble dagger endopyelotomy was the most frequently selected therapy for adults with ureteropelvic junction obstruction (50.3%, 514 of 1,022). Open pyeloplasty was recommended by a significantly greater percentage of urologists in practice longer than 15 years compared with the remaining survey respondents (166 of 485, 34.2% versus 92 of 427, 21.5%). For patients with renal pelvic stones 10, 15 or 20 mm. who are treated with ESWL routine stent placement was preferred by 25.3% (259 of 1,022), 57.1% (584 of 1,022) and 87.1% (888 of 1, 019) of urologists, respectively. Percutaneous nephrolithotomy was preferred for patients with staghorn calculi by 80.5% (828 of 1,028) of survey respondents. CONCLUSIONS: Most urologists follow the American Urological Association practice guidelines for patients with distal ureteral calculi and staghorn stones. There is a significant difference of opinion regarding the use of stents with ESWL. No clear consensus has been reached concerning the management of adults with ureteropelvic junction obstruction. These data may be useful in designing physician education programs and/or future investigations to help define standard treatment practices for urological diseases.     

Laparoscopic practice patterns among North American urologists 5 years after formal training

PURPOSE: We assessed urologist laparoscopy practice patterns 5 years after a postgraduate training course in urological laparoscopic surgery. Results were compared to findings from similar studies performed on the same cohort at 3 and 12 months after training. MATERIALS AND METHODS: Between January 1991 and November 1992, 11, 2-day university sponsored, postgraduate laparoscopic surgery training programs were held. A survey was mailed to the 322 North American participants in the summer of 1997 to determine current laparoscopic use and experience. RESULTS: Of the 166 respondents (51% response rate) 53.6% (89) had performed 1 or more laparoscopic procedures in the previous year, compared to 84% 1 year following course completion. Of the respondents 37% believed their laparoscopic experience was sufficient to maintain skills compared to 66% at 1 year. Of the respondents 6% had performed more laparoscopic procedures while 82% had performed fewer than anticipated. Reasons cited for decreased use included decreasing and/or lack of indications, increased cost, decreased patient interest, higher complication rates, decreased institutional support and increased operative time. Respondents practicing in academic or residency affiliated centers, or those who had completed residency after 1980 were more likely to have performed more procedures than anticipated (p = 0.044) compared to community based colleagues. CONCLUSIONS: Laparoscopic use by urologists trained in the postgraduate setting is decreasing. Few respondents are maintaining the skills acquired during the original training course. Decreased use appears to be multifactorial.     

To oophorectomy or not to oophorectomy: Practice patterns among urologists treating bladder cancer

Objectives

Classically, radical cystectomy (RC) involves hysterectomy and bilateral salpingo-oophorectomy (BSO). Current understanding of ovarian cancer pathogenesis and effect of premature oophorectomy has lead to a shift within gynecology toward risk-reducing salpingectomy without oophorectomy in the absence of gynecologic malignancy. The purpose of this study was to assess knowledge base and practice patterns of urologic oncologists with regard to management of the gynecological organs at the time of RC.

Analyzing the current practice patterns and views among urologists regarding focal therapy for prostate cancer

Introduction and objective

Focal therapy (FT) for localized prostate cancer (CaP) has been shown to have encouraging short-term oncological outcomes, excellent preservation of functional outcomes and is increasing in popularity in urologic community. We aim to evaluate the preferences and practice trends among urologists regarding this treatment strategy.

Practice patterns in vasectomy reversal surgery: results of a questionnaire study among practicing urologists

Purpose

Although vasectomy reversal surgery is a common procedure for male factor infertility, little is written on the common practice patterns of the practicing urologist. We designed a questionnaire to assess the practice patterns of community and academic urologists with respect to surgical technique, followup care, patient selection and the definition of success.

Materials and Methods

A 20-question survey pertaining to vasectomy reversal surgery was mailed to members of the Western Section, American Urological Association and to members of the Society of Government Service Urologists. Survey results were tabulated in a computer data base and statistical analysis was performed.

Results

A total of 1,508 questionnaires were mailed and 622 completed questionnaires were returned. Of the respondents 367 (59%) indicated that they perform vasectomy reversals, including 29 (8%) who were fellowship trained in infertility, 86 (23%) who were affiliated with residency training and 252 (69%) who practiced in a community setting. As expected, on average fellowship trained urologists performed more reversals yearly than academic or community urologists (26.4, 12.2 and 7, respectively). Patient selection criteria varied. Of fellowship trained urologists 12.5% would elect not to operate if it were greater than 15 years since vasectomy compared with 41.9% for academic and 57.1% of community urologists. Just more than half (50.2%) of respondents indicated they did not recommend routine gynecologic evaluation of the patient partner. When comparing fellowship, academic and community practitioners, an operating microscope was used in 93%, 65% and 56% of procedures (p <0.001), and vasal fluid was examined in 83%, 75% and 67%, respectively. Fellowship trained urologists also used finer suture material (p <0.001). An average of 8 anastomotic sutures were placed in 2 layers but significant differences existed between fellowship trained urologists, and their academic and community counterparts. Most urologists (71%) defined their success by the presence of sperm in the ejaculate. Only 10.9% of urologists recommended sperm cryopreservation at surgery and 90% recommended postoperative sexual abstinence (average 3 weeks). All urologists recommended postoperative semen analysis done at an average of 3 months.

Conclusions

The practice of vasectomy reversal varies among urologists. Differences in surgical technique, postoperative care and selection criteria exist. Knowledge of these variations may assist practicing urologists to tailor their practice patterns in the selection for and performance of vasectomy reversal.     

Intravesical botulinum toxin: Practice patterns from a survey of Canadian urologists

IntroductionThe objectives of this study were to conduct a survey of intravesical botulinum toxin administration practices in Canada, to compare practices based on level of training, and to identify barriers to delivery.MethodsA voluntary online survey was sent to all members of the Canadian Urological Association. Respondents who provide intravesical botulinum toxin were questioned on training, surgical volume, workup, technique, and followup practices. Those with formal training in functional urology were compared to those without. Barriers to treatment delivery were identified.ResultsThe overall response rate was 26% (148/570). Most providers (59%) perform 1–10 treatments/month. Preoperatively, 51% perform cystoscopy and 43% perform urodynamics. A majority (66%) give routine antimicrobial prophylaxis; however, regimen and duration varied. Most (79%) perform some treatments under local anesthetic, and 66% instill lidocaine solution for analgesia. There was a wide variation in technique with regards to the number of injections administered (range <10 to >20), volume administered per injection (range 0.5–2 mL), location of injections (bladder body vs. trigone vs. both), and depth of injection. Postoperative followup ranged from three days to three months. Respondents with fellowship training in functional/reconstructive urology performed more treatments per month and administered fewer injections per treatment. Common barriers to delivery included lack of experience/training among non-providers (45%), lack of resources (34%), and lack of medication funding (32%).ConclusionsDespite intravesical botulinum toxin being a widely accepted treatment, significant variability in practices and several barriers to delivery exist in Canada. Further study is required to optimize treatment access and quality.

KEY MESSAGES

• No formal guidelines exist on intravesical botulinum toxin evaluation, administration, or followup, and as such, there is a wide range of practice patterns among Canadian urologists.
• Further research is required to identify appropriate, evidence-based practices for patients undergoing intravesical botulinum toxin injections.
• Several barriers to administration of intravesical botulinum toxin exist among providers and nonproviders within the Canadian healthcare system.

     

Current laparoscopic practice patterns in urology: results of a survey among urologists in Germany and Switzerland

OBJECTIVES: A survey was performed to assess the current practice patterns in laparoscopy among urologists in Germany and Switzerland. METHODS: Using the database directory of the German and Swiss Urological Association urological departments were identified. A detailed questionnaire was designed and sent by postal service. Responding questionnaires were analyzed. RESULTS: The overall response rate was 64%. Fifty-four percent of respondents in Germany and 33% in Switzerland already perform laparoscopy; another 50% and 56% are planning to introduce laparoscopy. Thirty-six percent think that laparoscopy is economical and 77% await shortening of hospital stay. Major concerns are: Economical aspects, lengthy learning curve, investment, and lack of scientific data. The number of laparoscopic procedures during 12 months was registered for 19 indications. More than 40 procedures for one indication are performed by only 6% of the departments. CONCLUSIONS: The survey reveals an increasing number of departments performing laparoscopy and broad acceptance of the technology but combined with some major concerns. Currently only a minority of the departments perform more than 40 procedures for one indication suggesting that at present laparoscopy is mainly a center-based technology.     

Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data

Introduction  Estimates of osteoporosis (OP) prevalence based on bone mineral density testing and fracture occurrence may be imprecise for small demographic groups. Medicare data are a useful supplemental source of information on OP. Methods  We studied people ages ≥65 years covered by Medicare 2005. Cases of presumed OP were beneficiaries with physician services or inpatient claims for OP or for an associated fracture (hip, distal forearm, spine) in 1999–2005. Results  Among 911,327 beneficiaries with 6 or 7 years of Medicare coverage, the overall prevalence of OP and associated fractures was 29.7%. Prevalence was four times higher for women than men, increased with age, and was two times higher for whites, Hispanic Americans, and Asian Americans than African Americans. Among people with OP-associated fracture claims, the proportion with an OP diagnosis was 49.7% overall (women, 57.1%; men, 21.9%) and was lower for men than women and for African Americans than other ethnic groups. Conclusions  The low proportion of beneficiaries who had an OP-associated fracture and also had an OP diagnosis, particularly among men and African American women, suggests suboptimal recognition and management of OP. Study limitations included lack of validation of our definition of OP and potential misclassification of race/ethnicity. This research was supported by a contract between the University of Alabama at Birmingham (UAB) and Amgen, Inc. Only the authors from UAB had access to the Medicare data used. The analysis, presentation, and interpretation of the results were solely the responsibility of the authors.     

Insight into current surgical techniques and practice patterns associated with robotic-assisted radical prostatectomy: a national survey of urologists within the USA

Robotic-assisted radical prostatectomy (RARP) has been rapidly adopted throughout the USA. The purpose of this study is to describe the prevailing RARP operative techniques and perceptions within the USA. An anonymous web-based survey was sent electronically to a list of 920 robotic urological surgeons. The survey assessed surgeon demographics, surgical technique, and postoperative care related to RARP. The study was comprised of urologists from community hospitals (76%) and university hospitals/specialty centers (24%). All geographic sections of the American Urological Association were represented. The most common neurovascular preservation techniques were ante/retrograde approach (48%), athermal (22%), and preservation of lateral pelvic fascia (17%). Surgeon choice of neurovascular preservation technique varied with the average number of procedures performed per year (P = 0.0065). High-volume surgeons tended to require a higher number of robotic cases in order to go through the learning curve of the “comfortable” (P = 0.001) and “expert” levels (P < 0.0001). The majority of surgeons reported that RARP (as compared with open surgery) improved urinary continence (77.2%), sexual function (65.6%), and surgical margin rates (53.8%). RARP is an evolving surgical procedure with significant variability in practice patterns among US surgeons. Further studies are necessary to compare the various techniques in order to improve surgical outcomes.