Feature Articles

New Podcast Series Coming Soon to AUAUniversity—Urologic Diseases in America

Understanding the burden of urologic diseases on American society has never been more critical, given the growing population of older Americans and rising healthcare costs. The Urologic Diseases in America (UDA) project seeks to generate large-scale, epidemiologic assessments that inform our understanding of these diseases, which can guide research efforts to areas of greatest impact. The UDA project was recently renewed with the Johns Hopkins University School of Medicine and Social & Scientific Systems, who are partnering with the AUA to help disseminate UDA findings through a new podcast series.

The UDA project dates back to 2001 when the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) tasked it with the goal of quantifying the burden of urologic diseases on American society. This project’s first efforts, coordinated by Dr. Mark Litwin’s team at UCLA and RAND Health, quantified the immense costs, both in human and economic measures, associated with benign and malignant urologic diseases. Since that time, the UDA has become the reference standard on the prevalence, incidence, treatment, and economic impact of urologic disease in the United States. Findings from the UDA project are typically published as research compendia on NIDDK’s website.

In 2015, the NIDDK renewed the UDA, with the following broad goals: to quantify the demographics, incidence, prevalence, and changes over time in benign urologic diseases; to identify variation in physician practice patterns, and to assess clinical and economic results of therapeutic interventions. The analytics for these questions were undertaken by a partnership of researchers from Johns Hopkins University School of Medicine and Social & Scientific Systems. More recently, in 2019, this project was again renewed with the Johns Hopkins and Social & Scientific Systems partnership design.

The present UDA project will rely primarily on three datasets: the National Health and Nutrition Examination Survey (NHANES); the Centers for Medicare & Medicaid Services Medicare 5% Sample (CMS 5% Sample) for subjects aged >65 years; and the Optum© Clinformatics® Data Mart (CDM) dataset of privately insured subjects aged <65 years. The NHANES is a nationally representative sample of the US civilian population that permits assessment of the prevalence of certain diseases and their impact on quality of life. Both the CMS 5% Sample and the CDM are insurance claims datasets. A great benefit of insurance claims datasets is that they permit longitudinal analyses to assess disease incidence, recurrence, and treatment outcomes. In addition to characterizing disease burden and healthcare delivery, they also provide information on pharmaceutical utilization and expenditures.

One of the preset aims of UDA is to broaden the dissemination of the project’s findings beyond the typical research compendia format. These large-scale, epidemiologic assessments inform the urologic community’s understanding of the scope of urologic disease that affects the US population. In this way, research efforts may be guided to areas of greatest impact. To that end, Johns Hopkins and Social & Scientific Systems have formed a new partnership with the AUA that will leverage the AUA’s far-reaching dissemination platform and share the UDA findings with the larger urologic community. A focus of these new dissemination efforts will be a new UDA podcast series that will be hosted on the AUAUniversity podcast channel. Topics will include things such as key findings from the project and how best to use the UDA reference materials. By making the UDA findings more accessible to the broader urologic community, this project, which started with visionary leadership almost two decades ago, will continue to benefit the field of urology.

Report: Inaugural Society of Genitourinary Reconstructive Surgeons Academic Congress

The inaugural meeting of the Society of Genitourinary Reconstructive Surgeons (GURS) was held in Athens, Greece on October 15–16, just prior to the Society of International Urology meeting. The goal of this academic congress is to create an annual meeting for expert updates, review of innovative surgical techniques, and scientific presentations in order to encourage collaborations and friendships across different cultures and borders to improve the care of our reconstructive urology patients. The meeting was chaired and organized by Dr. Francisco Martins, the incoming President of GURS, and by Dr. Jeremy Myers, the current Secretary of GURS, and incorporated expert lectures, crossfire debates, and numerous academic sessions. The academic sessions included podium, oral, video, and moderated poster sessions.

The podium format was unique among urologic meetings and involved an assigned reviewer. Podium abstract authors delivered a fifteen-minute presentation and then the assigned reviewers critiqued the work and posed questions about the methodology, results, and conclusions. This podium format allowed for a much more in-depth discussion of important research being performed in reconstructive urology. Highlights of the section were a presentation, by Dr. Jessica Delong (Eastern Virginia Medical Center, Norfolk, Virginia), on the preliminary results of ROBUST I, which is a paclitaxel-coated balloon for dilation of urethral strictures. The results showed anatomic success via direct cystoscopic exam or passage of a catheter in 70% of the cohort at one year. These preliminary results show promise and a randomized trial (ROBUST III) is underway in the United States. Other highlights included a presentation by Dr. Virginia Li (Kaiser Permanente, Los Angeles, California) on sexual outcomes and decisional regret in patients undergoing vaginoplasty. The patients answered questionnaires, both validated and non-validated, at a minimum of 6 months after vaginoplasty about sensation, orgasm, and regret. Almost all patients had clitoral and vaginal sensations, with about three-quarters of the patients being able to achieve orgasm. Decisional regret was virtually non-existent.

Prizes were awarded for the best oral, video, and moderated poster presentations. The best oral presentation was given by Dr. Ross Anderson (University of Utah, Salt Lake City, Utah) and was entitled “Contemporary management and complications of extraperitoneal bladder injury – A multi-institutional prospective study from the genitourinary trauma study group.” The best video presentation was given by Dr. Kevin Hebert (Mayo Clinic, Rochester New York) and was entitled “Open field fluorescence imaging (SPY-PYI) is a useful tool to assess tissue integrity in complex, open, genitourinary reconstructive surgery.” The best-moderated poster was presented by Dr. Charlotte Wu (Emory, Atlanta, Georgia) and was entitled “All grown up: An adult urology practice’s experience of 128 patients with congenital disorders involving the bladder.”

Highlights from the experts included Dr. Jill Buckley (University of California San Diego, San Diego, California), who covered the application of robotics to ureteral reconstruction. An international panel gave several expert talks on the current state of gender affirmation surgery including both feminizing and masculinizing surgeries. There were also several outstanding crossfire debates including bulbo-membraneous radiation-induced stenosis; the treatment of pan-urethral strictures; and transection vs. non-transection of the urethra during urethroplasty. These expert lectures and debates will be available in the near future on the new GURS website for members to view at any time.

Finally, Dr. Leonard Zinman was honored with the GURS lifetime achievement award. The dedication was entitled “In honor of his long career committed to education and his outstanding contributions in developing the field of reconstructive urology.” Dr. Alex Vanni accepted the award for Dr. Zinman and described his contributions to the field of reconstructive urology. He emphasized Dr. Zinman’s exceptional ideas, such as the use of mitomycin C for bladder neck contractures, development of techniques for urethroplasty after failed urethral stent placement, and the use of rectal mucosa graft for pan-urethral strictures failing buccal graft urethroplasty. Dr. Zinman will give his GURS lifetime achievement lecture at the AUA Annual Meeting in Washington, DC this coming May.

Ensuring Equitable Access to Neonatal Circumcision

Emilie Johnson, MD, MPH, is an Assistant Professor of Urology at the Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine. She is a pediatric urologist and Health Services and Outcomes Researcher (HSOR) whose work focuses on improving healthcare delivery and outcomes for children with a range of urologic conditions. A main aim of her current research is to improve access to desired neonatal circumcision for families in the United States.

Parents desire circumcision for their infant boys for a variety of reasons, including religious, cultural, hygienic, and health-related. While healthcare professionals generally do not recommend for or against routine neonatal circumcision, there are some evidence-based health benefits of circumcision, including decreased risk of urinary tract and sexually transmitted infections. These benefits are greatest, and periprocedural risks and costs are lowest, when performed as a neonatal circumcision under local anesthesia, rather than as an operative circumcision under general anesthesia later in infancy or childhood. Given this, the 2012 American Academy of Pediatrics (AAP) Circumcision Task Force recommends third-party reimbursement for neonatal circumcision for families who elect for the procedure. However, available data indicate that boys of lower socioeconomic status, particularly boys who are publicly insured, may have more difficulty obtaining a neonatal circumcision.^1‐3

Dr. Johnson and her group have analyzed and begun to expand upon the available data to generate a multi-pronged strategy for (1) characterizing potential disparities in access to neonatal circumcision, and (2) ensuring access to neonatal circumcision for all families who desire the procedure for their infant boys. In a recent parent survey, Dr. Johnson and colleagues noted that most boys presenting to outpatient clinic for a delayed elective circumcision were black/African-American, and publicly insured.¹ Additionally, >25% reported that their birth hospital/physician did not offer neonatal circumcision.

In support of her continued work on neonatal circumcision, Dr. Johnson was recently awarded a two-year Urology Care Foundation Research Scholar Award, sponsored by the Societies for Pediatric Urology Sushil Lacy, MD Research Fund. Under the mentorship of Jane L. Holl, MD, MPH, a national HSOR leader, Dr. Johnson, and her team are currently using two large, national databases characterize recent longitudinal and demographic trends in neonatal and operative circumcision. Analyses conducted thus far confirm that publicly insured boys less frequently undergo neonatal circumcision, with no change before and after the release of the 2012 AAP Circumcision Task Force recommendation for coverage.⁵ In a follow-up, state-specific analysis, rates decreased over time in states where Medicaid coverage was discontinued for neonatal circumcision. Concerningly, this trend was most dramatic among black/African-American boys.⁶

As part of her AUA-funded research, Dr. Johnson will also conduct interviews of Chicago-area birth hospital clinicians and hospital administrators to determine underlying healthcare institutional reasons for difficulties accessing desired neonatal circumcision. In preparing for these interviews, Dr. Johnson’s team has determined that all Chicago–area birth hospitals report offering neonatal circumcision, even though 1 in 4 parents in their prior survey reported lack of circumcision availability at the time of birth.⁷ The team is currently recruiting clinicians (obstetrics, pediatrics, and others who may perform circumcisions) for in-depth interviews about neonatal circumcision provision and availability.

Along with her research interests, Dr. Johnson is committed to training future urologists in high-quality HSOR methodology. She is proud that three medical students and two pediatric urology fellows are involved in the studies described in this article. In describing her work with urology trainees, Dr. Johnson indicated, “I look forward to the continued involvement of students, residents, and fellows in generating the data necessary to ensure equitable access to neonatal circumcision. This work will also help our trainees build skills in a range of HSOR methodologies, including analysis of administrative data, survey research, and qualitative interviews.”

Ultimately, Dr. Johnson and her team plan to create a clinical “toolkit” that will allow for targeting of specific strategies to optimize neonatal circumcision access based on the needs of diverse geographic regions, hospitals, and families.

References:

1. Gutwein, L. G., Alvarez, J. F., Gutwein, J. L. et al.: Allocation of healthcare dollars: analysis of nonneonatal circumcisions in Florida. Am Surg, 79: 865, 2013
2. Leibowitz, A. A., Desmond, K., Belin, T.: Determinants and policy implications of male circumcision in the United States. Am J Public Health, 99: 138, 2009
3. Warner, L., Cox, S., Whiteman, M. et al.: Impact of Health Insurance Type on Trends in Newborn Circumcision, United States, 2000 to 2010. Am J Public Health, 105: 1943, 2015
4. Jacobson, D. L., Holl, J. L., Lautz, T. B. et al.: PD49-Nationwide Neonatal Circumcision Trends: 2003-2016. Journal of Urology, 201: e909, 2019
5. Jacobson, D. L., D'Oro, A., Abdullah, F, et. al.,: Reasons for Delay of Neonatal Circumcision. Presented at: 2019 Pediatric Urology Fall Congress, Manuscript Under Review
6. Zambrano Navia M., Jacobson D. L., Balmert, L.C, et. al.: Impact of State-Level Public Insurance Coverage on Neonatal Circumcision Rates. Presented at: 2019 Pediatric Urology Fall Congress, Manuscript in Progress
7. Jain-Poster, K, Rosoklija, I., Svigos, F., et. al.: Hospital-Level Access to Neonatal Circumcision in the Chicago Metropolitan Area. Presented at: 2019 Pediatric Urology Fall Congress, Manuscript in Progress

Tumor Avatars—A New Path to More Effective Cancer Treatments

Cancer is a complex disease that develops, evolves, and responds to treatment in different ways that can vary unpredictably between patients, even those with the same disease. Michael M. Shen, PhD at Columbia University has teamed up with several Urology Care Foundation-funded researchers to help solve this problem.

Dr. Shen’s laboratory specializes in research on stem cells, which are cells that can give rise to many other cell types, and he has used this approach to better understand prostate and bladder cancer. Dr. Shen’s team of scientists achieved a major breakthrough when they successfully created an “organoid” of a normal prostate gland. Organoids are “mini-tissues” that are similar to the cell types and tissues found in the body. Dr. Shen’s team went on to show that organoids could be developed from cancer derived from genetically engineered mice, which set the stage for creating specific models of prostate cancer that are similar to different types of human prostate cancer. These could then be used to study, outside of the body, the different ways the disease may progress and how best to stop its progression.

More recently, Dr. Shen’s team expanded this work to study bladder cancer and successfully generated an organoid with bladder cancer using a sample from a patient’s tumor. These organoids serve as patient-specific “avatars” of the original tumor and can be screened for their response to a wide range of drug treatments. Ongoing research in the lab is examining whether the drug responses of patient-derived organoids resemble the responses observed in patients. If so, the establishment and analysis of patient-derived organoids will represent an important step in designing precision therapies (or ‘personalized medicine’) for patients with bladder cancer.

According to Dr. Shen, the Urology Care Foundation played a critical role in this research by supporting three of his trainees. Flaminia Talos, MD, PhD, a 2012 Research Scholar Awardee, investigated the mechanisms that led to prostate tumor organoid development. LaMont J. Barlow, MD, a 2013 Residency Research Awardee, initiated efforts to remove bladder tumors from patients and grow organoids for the study. Most recently, 2016 Research Scholar Awardee Suk Hyung Lee, PhD characterized and performed drug screening on the patient-derived bladder tumor organoids.

Thanks to the combined efforts of Dr. Shen, his Urology Care Foundation-supported trainees, and many others at Columbia University, we are now closer to developing individualized and more effective treatments for bladder cancer.

Eligibility Expanded for the Residency Research Award Program

The Urology Care Foundation’s Residency Research Award program was initiated in 2010 with the goal of providing urology residents with research training to enable them to build momentum towards a career that includes research. This award was made possible by the generous support of the Russell Scott Jr., MD Urology Research Fund, which provided $40,000 per year to support either six months or one year of research training. The Foundation also partnered with industry and other sponsors—most recently the Kahlert Foundation—to provide additional awards over the years.

Given that protected research time during residency is declining and the availability of research funding for training is contracting, the Urology Care Foundation decided to expand the eligibility requirements for this award and reduce the funding amount to provide for wider support to more urologists.

The AUA Research Grants and Investigator Support Committee, aligned under the AUA Research Council, conducted a thorough assessment of residency research prior to this change. This included a landscape study of both surgical and non-surgical medical associations that provide research funding for residents, collecting feedback from previous Foundation-supported residents to better understand how institutions were appropriating their funding, and ongoing assessment of the program’s financial health. Following careful deliberation and in consultation with AUA leadership, the following structural changes will take effect with the 2020 competition:

• The funding amount per award has been reduced to $10,000. This amount is commensurate with other surgical-specialty medical associations and will enable the Foundation to offer more awards per year, as well as more-easily raise future support.
• An institutional match is no longer required, but the institution must provide a letter of support attesting to their commitment to the resident’s research training and protected time.
• Allowable costs are restricted to direct costs that benefit the resident’s research training. This includes training costs not typically covered by residency programs such as the purchase of research supplies, services, and database access, as well as research education courses or workshops.
• The range of project duration has been increased to three to 12 months.

The AUA and the Urology Care Foundation are confident that these changes will continue to provide quality training and a positive research experience for residents. More information can be found in the Program Announcement and questions may be directed to grantsmanager@auanet.org.

Rich Urology Data and Consulting Resources to Investigators at All Stages: AUA Data Department

The AUA provides data and statistical consulting services to investigators at all career stages. The unique urology-specific data are collected through the AUA Quality (AQUA) Registry, the AUA Annual Census, national urology workforce records, insurance claims and national surveys, which together continually create a robust data repository that can be analyzed independently or combined with researcher-provided datasets to examine urologic care from multiple angles. In addition, to assist members in meeting their research needs, the AUA offers professional statistical consulting services through a team of experienced statisticians and health services researchers.

Clinical data collected through the AQUA Registry provide real-world treatment and outcomes data to explore the entire patient journey, including urologic conditions, clinical procedures and treatment outcomes from millions of patients. The AUA Annual Census, which is completed by urologists, other care providers, and researchers worldwide, allows for longitudinal and cross-sectional analyses on workforce characteristics and practice patterns. In addition, the Census collects data on many emerging topics such as burnout, electronic health record usage, and treatment options, to name a few. For a complete list of topics reported in the previous Census, please visit AUAnet.org/census.

Urology physician scientists and researchers can also use AUA statisticians as part of their research teams in applying for and/or executing research grants.

AUA data are utilized in a growing number of research studies and are the basis for impactful manuscripts like the following:

• The Near Future Impact of Retirement on the Urologic Workforce: Results from the AUA Census Data, 2016
• Utilization of the American Urologic Association Clinical Practice Guidelines: Data from the AUA Census, 2016
• Burnout in Urology—Findings from the 2016 AUA Annual Census, 2017
• A Snapshot of Contemporary Urologic Practice From The American Urological Association’s Quality Registry (AQUA), 2019
• Sling Reoperation Rates in the AUA Quality (AQUA) Registry , 2019

To present your research questions and find out how the AUA Urology Data Repository and Statistical Consulting Services can help your research and publication, please email dataservices@AUAnet.org.

AUA Research Advocacy Committee Responds to Threat in Peer Review Process

Over recent years, the AUA has worked to establish relationships with members of Congress and cultivate congressional champions who demonstrate ongoing support for growing critical research programs needed to help patients with urologic diseases and conditions. This was demonstrated at the 2019 Annual Urology Advocacy Summit where more than 200 members of the urologic community met with lawmakers to thank them for a $2 billion increase in National Institutes of Health (NIH) funding for Fiscal Year (FY) 2019, and urged continued momentum by increasing NIH funding to at least $41.6 billion for FY 2020 (a $2.5 billion increase). This grassroots advocacy effort was echoed by several of the AUA’s coalition partners including One Voice Against Cancer, Rally for Medical Research, and the Ad Hoc Group for Medical Research. The strong, unified voice was well received by both the House and the Senate. Currently, both chambers are working to complete an FY20 spending package that is expected to include an additional $2-3 billion increase for NIH.

Additional advocacy efforts that promote support for protecting and securing funds for urologic research are carried out by the AUA’s Research Advocacy Committee (RAC). The RAC demonstrates an ongoing effort to effectively champion for public, private and philanthropic support of urologic research. The committee’s strategic efforts include legislative advocacy that seeks to cultivate relationships with lawmakers and expand the urologic research footprint within federal research agencies.

In an effort to advance relationships with members of Congress and ensure that funding for urologic research remains a top priority on Capitol Hill, RAC members regularly initiate contact with their respective federally elected officials. The goals of this outreach are to provide updates regarding groundbreaking research taking place in home districts and to express concern for threats to urologic research as they arise. Most recently, RAC members responded to proposed legislation (H.R. 1608), the Federal Advisory Committee Act Amendments of 2019 that has the potential to seriously hinder the NIH peer review process.

H.R. 1608 is designed to increase transparency and accountability in the participant selection process and conduct of federal advisory committees. Many view the goal of this bill as commendable; however, as written there are several unintended consequences that would severely disrupt the peer review research grant process, which is so critical to scientific findings and discoveries. According to officials at the NIH, if enacted, H.R. 1608 would add months to the appointment process, generate piles of additional paperwork, and discourage scientists from volunteering to serve on the 173 NIH study sections that assess the scientific merit of research proposals.

H.R. 1608, written it in its current form, is a long way from being enacted by Congress. Regardless, this type of outreach received a favorable response from congressional offices who appreciated being informed of the proposed threat and welcome additional information as it becomes available.

The AUA’s Patient & Research Advocacy (PRA) Department works closely with the RAC and other members of the urologic research community. For more information on these activities or to learn how to get involved, please contact PRA’s Senior Manager, Jessica Bateman, at JBateman@AUAnet.org.