E. Will Kirby

Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis

OBJECTIVE To evaluate how varicocele repair (VR) impacts pregnancy (PRs) and live birth rates in infertile couples undergoing assisted reproduction wherein the male partner has oligospermia or azoospermia and a history of varicocele. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Azoospermic and oligospermic males with varicoceles and in couples undergoing assisted reproductive technology (ART) with IUI, IVF, or testicular sperm extraction (TESE) with IVF and intracytoplasmic sperm injection (ICSI). INTERVENTION(S) Measurement of PRs, live birth, and sperm extraction rates. MAIN OUTCOME MEASURE(S) Odds ratios for the impact of VR on PRs, live birth, and sperm extraction rates for couples undergoing ART. RESULT(S) Seven articles involving a total of 1,241 patients were included. Meta-analysis showed that VR improved live birth rates for the oligospermic (odds ratio [OR] = 1.699) and combined oligospermic/azoospermic groups (OR = 1.761). Pregnancy rates were higher in the azoospermic group (OR = 2.336) and combined oligospermic/azoospermic groups (OR = 1.760). Live birth rates were higher for patients undergoing IUI after VR (OR = 8.360). Sperm retrieval rates were higher in persistently azoospermic men after VR (OR = 2.509). CONCLUSION(S) Oligospermic and azoospermic patients with clinical varicocele who undergo VR experience improved live birth rates and PRs with IVF or IVF/ICSI. For persistently azoospermic men after VR requiring TESE for IVF/ICSI, VR improves sperm retrieval rates. Therefore, VR should be considered to have substantial benefits for couples with a clinical varicocele even if oligospermia or azoospermia persists after repair and ART is required.

Gender Differences in Compensation, Job Satisfaction and Other Practice Patterns in Urology

PURPOSE The proportion of women in urology has increased from less than 0.5% in 1981 to 10% today. Furthermore, 33% of students matching in urology are now female. In this analysis we characterize the female workforce in urology compared to that of men with regard to income, workload and job satisfaction. MATERIALS AND METHODS We collaborated with the American Urological Association to survey its domestic membership of practicing urologists regarding socioeconomic, workforce and quality of life issues. A total of 6,511 survey invitations were sent via e-mail. The survey consisted of 26 questions and took approximately 13 minutes to complete. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction and compensation. RESULTS A total of 848 responses (660 or 90% male, 73 or 10% female) were collected for a total response rate of 13%. On bivariable analysis female urologists were younger (p <0.0001), more likely to be fellowship trained (p=0.002), worked in academics (p=0.008), were less likely to be self-employed and worked fewer hours (p=0.03) compared to male urologists. On multivariable analysis female gender was a significant predictor of lower compensation (p=0.001) when controlling for work hours, call frequency, age, practice setting and type, fellowship training and advance practice provider employment. Adjusted salaries among female urologists were

Economic Impact of Training and Career Decisions on Urological Surgery

76,321 less than those of men. Gender was not a predictor of job satisfaction. CONCLUSIONS Female urologists are significantly less compensated compared to male urologists after adjusting for several factors likely contributing to compensation. There is no difference in job satisfaction between male and female urologists.

Factors Related to Job Satisfaction in Urology

PURPOSE Medical students and residents make career decisions at a relatively young age that have significant implications for their future income. While most of them attempt to estimate the impact of these decisions, there has been little effort to use economic principles to illustrate the impact of certain variables. MATERIALS AND METHODS The economic concept of net present value was paired with available Medical Group Management Association and Association of American Medical Colleges income data to calculate the value of career earnings based on variations in the choice of specialty, an academic vs a private practice career path and fellowship choices for urology and other medical fields. RESULTS Across all specialties academic careers were associated with lower career earnings than private practice. However, among surgical specialties the lowest difference in value between these 2 paths was for urologists at only

Low Testosterone Has a Similar Prevalence among Men with Sexual Dysfunction Due to Either Peyronie's Disease or Erectile Dysfunction and Does Not Correlate with Peyronie's Disease Severity

334,898. Fellowship analysis showed that training in pediatric urology was costly in forgone attending salary and it also showed a lower future income than nonfellowship trained counterparts. An additional year of residency training (6 vs 5 years) caused a

Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles

201,500 decrease in the value of career earnings. CONCLUSIONS Choice of specialty has a dramatic impact on future earnings, as does the decision to pursue a fellowship or choose private vs academic practice. Additional years of training and forgone wages have a tremendous impact on monetary outcomes. There is also no guarantee that fellowship training will translate into a more financially valuable career. The differential in income between private practice and academics was lowest for urologists.

Levels of Evidence and Clinical Guidelines—Considerations for the Practicing Urologist

Introduction: There is little information on job satisfaction in the extant literature in urology. The purpose of this study is to examine 1) the current state of job satisfaction among urologists in the United States, and 2) the demographic and work place factors that have the greatest influence on satisfaction. Methods: We collaborated with AUA (American Urological Association) to query its domestic membership of practicing urologists regarding socioeconomic, work force and quality of life issues. A total of 848 responses were collected for a total response rate of 13%. Linear regression models were used to evaluate bivariable and multivariable associations with job satisfaction scores on a 1 to 5 scale. Results: Of providers 70% reported being satisfied, 63% reported that they would choose medicine again and 83% would choose urology again. Age and job satisfaction did not demonstrate a linear association on statistical analysis but rather a U‐shaped relationship. On bivariate analysis significant factors associated with higher job satisfaction included younger and older age, higher income (p = 0.047), fewer call days (p = 0.006), fellowship training (p = 0.006) and academic practice (overall p = 0.002). On multivariate analysis age (younger and older ages) and academic practice remained significant predictors of job satisfaction (p = 0.01) as did higher income (p = 0.038). Conclusions: The current study helps describe the current state of job satisfaction among American urologists and examined work place factors that influence satisfaction. Income, hours worked, academic practice and age each have a significant impact on job satisfaction for the practicing urologist. Keeping abreast of the drivers of job satisfaction is critical to ensure that urologists continue to care for patients, perform research, educate future physicians and provide service to their communities.

Reduced Resident Work Hours in Urology: The History and Impact of Duty Hour Restrictions

INTRODUCTION Low testosterone (T) has been suggested as a risk factor for Peyronies disease (PD) that may correlate with disease severity. Low T is common in men with sexual dysfunction but its role in the pathogenesis of PD remains unclear. AIM The aim of this study was to compare the prevalence of low T (<300 ng/dL) in patients presenting with PD or erectile dysfunction (ED), as well as disease severity between men with PD and either low T or normal T (≥300 ng/dL). METHODS Retrospective review of 300 men with either PD or ED was conducted. Men were excluded for combined PD and ED, psychogenic ED, or prior T use. For men with PD, plaque size, degree of curvature, and surgical correction rate were compared. MAIN OUTCOME MEASURES The main outcome measures were (i) mean T levels in men with PD or ED and (ii) plaque size, degree of curvature, and surgical correction rates among men with PD and either low T or normal T. RESULTS Eighty-seven men with PD and 98 men with ED were identified. Men with PD had mean total T and free T of 328 ng/dL and 11.5 ng/dL, while men with ED had mean levels of 332 ng/dL and 12.1 ng/dL, respectively (P > 0.05). Of PD men, 52.9% had low T, compared with 45.9% of men with ED (P = 0.35). T levels did not correlate with plaque size or degree of curvature in the PD group (P > 0.05). CONCLUSIONS Men with sexual dysfunction characterized by either PD or ED had similarly low T levels, and low T did not correlate with PD severity or surgical correction rate. The comparable prevalence of low T in men with PD or ED suggests the high rate of low T in PD men may be related to a common process among men with abnormal erectile physiology and not specifically causative in plaque formation.

Projecting the Urology Workforce Over the Next 20 Years

Introduction: Projections suggest a significant shortage of urologists coupled with an increasing burden of urological disease due to an aging population. To meet this need, urologists have increasingly partnered with advanced practice providers. However, to this point the advanced practice provider workforce has not been comprehensively evaluated. Understanding the impact of advanced practice providers on the urology workforce is essential to maximize collaborative care as we strive for value and quality in evolving delivery models. Methods: A 29‐item, web based survey was administered to advanced practice providers identified by the AUA (American Urological Association), UAPA (Urological Association of Physician Assistants) and SUNA (Society of Urologic Nurses and Associates), querying many aspects of their practice. Results: A total of 296 advanced practice providers completed the survey. Advanced practice nurses comprised 62% of respondents while physician assistants comprised the remaining 38%. More than two‐thirds of the respondents were female and median age was 46 years. Only 6% reported having participated in formal postgraduate urological training. Advanced practice providers were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of advanced practice providers practice in the ambulatory setting (74%) and characterize their practice as general urology (72%). Overall 81% reported performing procedures independently, with 63% performing some procedures considered to be of moderate or high complexity. Conclusions: Advanced practice providers are active in the provision of urological care in many roles, including complex procedures. Given future workforce needs, advanced practice providers will likely assume additional responsibilities. As roles shift we must ensure we have the necessary educational and training opportunities to equip this vital part of our workforce.

PD27-06 SHIFT WORK SLEEP DISORDER AND NIGHT SHIFT WORK SIGNIFICANTLY IMPAIR ERECTILE FUNCTION.

INTRODUCTION It is important for urologists to remain up-to-date regarding research and clinical guidelines within their specialty. This has become increasingly difficult as the volume of research increases while the quality of evidence has not followed suit. It is, therefore, important for urologists to understand the methodology of critical appraisal of evidence, for both the assessment of individual journal articles as well as the construction of organizational clinical guidelines. METHODS The methodology for clinical guideline creation used by the American Urological Association (AUA) is reviewed along with that of the U.S. Preventive Services Task Force (USPSTF). Two popular grading schemas are then reviewed to provide an overview of existing methods for the critical analysis of research. We conclude with a description of the Grading of Recommendations Assessment Development and Evaluation (GRADE)-a classification system that attempts to unify various grading systems and is rapidly gaining popularity among well-reputed national organizations. RESULTS The AUA uses a systematic and evidence-based approach to creating clinical guidelines. The USPSTF is similar to the AUA in its approach to reviewing the literature and creating guidelines. The Centre for Evidence Based Medicine offers a novel approach to evidence-based literature review, providing a metric for the analysis of the literature to answer specific clinical questions. GRADE is working toward the development of a more transparent and standardized approach to the creation and reporting of clinical guidelines. CONCLUSIONS A number of organizations have attempted to standardize and clarify the literature review process to provide physicians with tools to critically evaluate higher quality evidence and apply guidelines to clinical practice. As urologists, we must understand how national organizations review the literature and develop clinical guidelines. Additionally, we must develop our own process for reviewing the literature in order to answer questions that have not yet been addressed by these organizations. Kirby EW, Borawski KM, and Smith AB. Levels of evidence and clinical guidelines-Considerations for the practicing urologist. Sex Med Rev 2013;1:17-23.