Introduction Although women remain vastly underrepresented in urology, the proportion of female urology residents and practicing urologists has steadily increased over the last four decades. However, it remains critical to evaluate the representation of females in the pipeline when examining trainees and practicing urologists. As it pertains to leadership positions, the gender distribution among the board of directors (BOD) and committee chairs in the American Urological Association (AUA) subspecialties has not been studied to date. Therefore, we plan to analyze the proportion of females among the BOD and committee chairs in different subspecialty societies recognized by the AUA over time. Methods We conducted a cross-sectional observational study, quantitatively comparing the composition of gender in BOD and Committee Chair members belonging to different AUA-recognized subspecialty societies from 2014 to 2020. The websites for each subspecialty society were searched and contacted. Results We evaluated BODs from 10 AUA subspecialty societies and committee chair members from 6 AUA subspecialty societies. From 2014 to 2020, the total proportion of female BOD amongst all AUA sub-specialty societies did not change significantly, with a small increase from 10.6% (n = 29) to 13.5% (n = 36). However, female representation among committee chair members significantly increased from 9.8% (n = 20) to 19.2% (n = 44; p = 0.006), along with the total number of women in urology, from 897 (8.9%) to 1,375 (10.3%). Increases in female representation were seen in the Society for the Study of Male Reproduction (SSMR) from 0% to 9% and in the Indian American Urological Association (IAUA) from 4% to 13%. Of note, there were no elected female board members in the Society of Urologic Oncology (SUO) or the Urologic Society for Transplantation and Renal Surgery (USTRS) from 2014 to 2020. Conclusion Females remain a minority in leadership positions at AUA sub-specialty societies despite increased female representation in recent years. Future efforts should promote the advancement of women to positions of leadership to reflect the changing landscape of the urology workforce and surgical specialties.

The American Urological Association\'s (AUA) and National Comprehensive Cancer Network\'s (NCCN) provide highly recognized guidelines for staging prostate cancer (CaP). However, both are vague as to specific type of cross-sectional imaging (CT vs. MRI) and extent (abdominal vs. pelvis), thereby raising concern for overlapping imaging. We investigated if current AUA and NCCN CaP staging guidelines can become more specific yet maintain sufficient staging.
We identified 493 patients diagnosed with CaP between 2011 and 2017 and focused analysis on those with AUA and NCCN Intermediate risk (IR) and High risk (HR) groups. Type of staging imaging was recorded and frequency of overlapping (CT + MRI) and abdominal imaging determined. Significance of radiologist findings, for both overlapping and abdominal imaging, were classified as nonurologic, nonsignificant urologic, and CaP significant.
Among IR and HR AUA and NCCN risk groups, 82 (35.7%) and 95 (37.3%) patients, respectively, experienced overlapping imaging, of which only 7 patients in AUA and 9 patients in NCCN risk groups had an abnormal CT with normal MRI. However, only 3 of these CTs had CaP significant findings, of which 2 identified bone metastases, which were subsequently detected on bone scan. In regard to the extent of imaging, a total of 157 (68.2%) AUA and 178 (69.8%) NCCN IR and HR patients received abdominal scans, of which only 46 (20.0%) and 49 (19.2%) were abnormal among AUA and NCCN risk groups, respectively. Among these abnormal abdominal scans, only 10 showed CaP significant findings, of which half were suspected bone metastases, and confirmed on recommended bone scan.
Due to nonspecific staging guidelines in IR and HR CaP regarding type and extent of cross-sectional imaging, patients are frequently receiving imaging of overlapping locations. Based on low occurrences of unique CaP significant findings on CT and abdominal imaging, our exploratory analysis suggests that narrowing cross-sectional imaging recommendations to pelvic MRI may reduce imaging overlap while maintaining sufficient staging.

OBJECTIVE: The objective of this study isto present the content of existing Guidelines on medical management of urinary stone disease.
METHODS: A search for current Guidelines from national and international urological Associations was performed in Societe International d\'Urologie and American Urological Association websites, along with a search in Pubmed/MEDLINE until 30/06/2020. Two authors performed an independent search and data extraction regarding medical management of acute renal colic, medical expulsive treatment, dietary modifications and pharmaceutical interventions for prevention of stone disease recurrence. Quality of Guidelines was assessed by the two reviewers using the AGREE II instrument.
RESULTS: Literature search revealed 82 Associations, while eight of them provide recommendations/Guidelines on medical management of stone disease. Non-steroidalanti-inflammatory drugs or paracetamol are the most common 1st line treatment proposed for acute pain management, with opiates following next. Use of a-blockers is also indicated by most Guidelines for facilitating expulsion of distal ureteral stones 5-10 mm, after shockwave or laser lithotripsy or for alleviating stent-related symptoms. Adequate fluid in take, normal dietary calcium consumption and sodium restriction with varying daily limits, are universal dietary modifications from urological Associations on prevention of stone disease. Thiazidesand alkaline citrates are proposed usually for calciumoxalate stone formers with differences in grading of the recommendations, while urinary alkalization with allopurinol or febuxostat as a second line treatment is acommon treatment algorithm for urate stones, but with differences in target urine pH. European and American Urological Association Guidelines, along with National Institute for Health and Care Excellence recommendations were the most highly rated based on AGREE II.
CONCLUSIONS: Despite methodological heterogeneity and subjective rating of recommendations, an acceptable degree of consensus was noted on Guidelines regarding medical management of stone disease.
UNASSIGNED: El objetivo de este estudio es presentar el contenido de las guías clínicas existentes enel manejo medico de las litiasis urinarias. MATERIALES Y MÉTODOS: Una búsqueda de las guías clínicas actuales de las asociaciones nacionales e internaciones se realizó en la pagina web de la Societe International d’ Urologie y la American Urological Association, junto con una búsque da en Pubmed/Medline hasta el 30 junio 2020. Dos autores realizaron una búsqueda independiente y la extracción de datos en relación al manejo medico del cólico renal agudo, tratamiento medico expulsivo, modificaciones en la dieta e intervenciones farmacológicas para la prevención de la recurrencia en la litiasis. La calidad de las guías se determinó por dos revisores externos utilizando el instrumento AGREE II.
UNASSIGNED: La búsqueda en la literatura demostró 82 asociaciones, mientras que ocho de estas promueven recomendaciones/guías en el manejo medico de la litiasis. Antiinflamatorios no-esteroideos o paracetamol son los tratamientos de primera línea mas comunes para el manejo del dolor agudo, siendo los opioides el siguiente. El uso de alfa-bloqueantes esta también indicado por la mayoría de las guías para facilitar la expulsión de litiasis del uréter distal de 5 a 10 mm, después de litotricia o después de lasertricia o para aliviar los síntomas relacionados con los catéteres. La ingesta de fluidos adecuada, consumo normal de calcio en la dieta y restricción de sodio con limites variables, son las recomendaciones dietéticas universales de las asociaciones urológicas en la prevención de las litiasis. Tiazidas y citratos alcalinos se proponen para los formadores de litiasis de oxalato cálcico con diferencias en el grado de las recomendaciones, mientras la alcalinización de la orina con alopurinol o febuxostat es la segunda línea de tratamiento en el algoritmo de las litiasis de urato, pero con diferencias en el pH urinario final. Las guías europeas y americanas, junto con las guías del instituto nacional de salud y las recomendaciones care excellence fueron las mejor reportadas en relación a AGREE II.CONCLUSIÓN: A pesar de todo y con la heterogeneidad metodológica y las recomendaciones subjetivas, hay un grado aceptable de consenso en las guías clínicas en relación al manejo medico de la enfermedad litiásica.

The objective was to develop a laboratory procedure to validate American Urological Association (AUA) Guideline on vasectomy success when nonmotile spermatozoa are found in the post-vasectomy ejaculate. The neutral α-glucosidase (NAG) an epididymal protein assay modified to determine the activity at 30 and 90 min of incubation from 24 pre- and 47 post-vasectomy ejaculates. The difference between the two points in the relative activity was calculated and if the difference was nonsignificant will confirm vasectomy success. The mean differences in the relative NAG activity were significantly different in pre- and post-vasectomy ejaculates, respectively. The mean differences in the relative NAG activity were similar in post-vasectomy ejaculates with and without nonmotile spermatozoa. No difference in relative NAG activity in post-vasectomy ejaculates between two time points of incubation may be a reliable method to confirm occlusion of the vas deferens. It also validates the recommendation by AUA Guideline on vasectomy success in the presence of few nonmotile spermatozoa.

To compare metastasis-free survival, overall survival, and patient-reported quality of life (QOL) of men with National Comprehensive Cancer Network high or very high risk prostate cancer after definitive surgery and/or multimodal radiotherapy (RT).
We studied a retrospective cohort study of 586 patients treated between the years 2000 and 2017 receiving radical prostatectomy with or without postoperative RT, external-beam RT (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (Brachy) boost + ADT. Patient-reported QOL for urinary, bowel, sexual, and overall physical and mental functioning was assessed using the American Urological Association symptom scale, the Sexual Health Inventory in Men, the Rectal-Function Assessment Scale, the Expanded Prostate Cancer Index Composite, and the Veterans RAND 12-Item Health Survey.
Median follow-up for survival was 5 years. No significant differences between the treatments were observed for overall survival or metastasis-free survival at the P < .05 threshold. The propensity-adjusted 5-year metastasis-free survival estimates for EBRT + ADT, EBRT + Brachy + ADT, and surgery were 74.6%, 94.8%, and 83.1%, respectively. The EBRT + Brachy + ADT and surgery cohorts had significantly worse mean American Urological Association symptom scores at 6 months than the EBRT + ADT cohort, which resolved by 1 year. Surgical patients had better rectal function scores than EBRT + ADT patients at years 1 to 3, but similar function thereafter. Adjuvant or salvage RT resulted in significant declines in various Expanded Prostate Cancer Index Composite urinary, sexual, and bowel domains, and Veterans RAND 12-Item Health Survey physical but not mental domains.
Men with very and/or high-risk localized prostate cancer are likely to require multimodal therapy. The overall differences in survival and long-term QOL are similar for men choosing surgical versus RT pathways.

BACKGROUND: Dysuria following prostate radiation therapy is a common toxicity that adversely affects patients\' quality of life and may be difficult to manage.
METHODS: Two hundred four patients treated with stereotactic body radiation therapy (SBRT) from 2007 to 2010 for localized prostate carcinoma with a minimum follow-up of 3 years were included in this retrospective review of prospectively collected data. All patients were treated to 35-36.25 Gy in five fractions delivered with robotic SBRT with real time fiducial tracking. Dysuria and other lower urinary tract symptoms were assessed via Question 4b (Pain or burning on urination) of the expanded prostate index composite-26 and the American Urological Association (AUA) Symptom Score at baseline and at routine follow-up.
RESULTS: Two hundred four patients (82 low-, 105 intermediate-, and 17 high-risk according to the D\'Amico classification) at a median age of 69 years (range 48-91) received SBRT for their localized prostate cancer with a median follow-up of 47 months. Bother associated with dysuria significantly increased from a baseline of 12% to a maximum of 43% at 1 month (p < 0.0001). There were two distinct peaks of moderate to severe dysuria bother at 1 month and at 6-12 months, with 9% of patients experiencing a late transient dysuria flare. While a low level of dysuria was seen through the first 2 years of follow-up, it returned to below baseline by 2 years (p = 0.91). The median baseline AUA score of 7.5 significantly increased to 11 at 1 month (p < 0.0001) and returned to 7 at 3 months (p = 0.54). Patients with dysuria had a statistically higher AUA score at baseline and at all follow-ups up to 30 months. Dysuria significantly correlated with dose and AUA score on multivariate analysis. Frequency and strain significantly correlated with dysuria on stepwise multivariate analysis.
CONCLUSIONS: The rate and severity of dysuria following SBRT is comparable to patients treated with other radiation modalities.

OBJECTIVE: To report early findings from a prospective United States clinical trial to evaluate the efficacy and safety of prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH).
METHODS: From January 2012 to March 2013, 72 patients were screened and 20 patients underwent treatment. Patients were evaluated at baseline and selected intervals (1, 3, and 6 mo) for the following efficacy variables: American Urological Association (AUA) symptom score, quality of life (QOL)-related symptoms, International Index of Erectile Function score, peak urine flow rate, and prostate volume (on magnetic resonance imaging at 6 mo). Complications were monitored and reported per Society of Interventional Radiology guidelines.
RESULTS: Embolization was technically successful in 18 of 20 patients (90%); bilateral PAE was successful in 18 of 19 (95%). Unsuccessful embolizations were secondary to atherosclerotic occlusion of prostatic arteries. Clinical success was seen in 95% of patients (19 of 20) at 1 month, with average AUA symptom score improvements of 10.8 points at 1 month (P < .0001), 12.1 points at 3 months (P = .0003), and 9.8 points at 6 months (P = .06). QOL improved at 1 month (1.9 points; P = .0002), 3 months (1.9 points; P = .003), and 6 months (2.6 points; P = .007). Sexual function improved by 34% at 1 month (P = .11), 5% at 3 months (P = .72), and 16% at 6 months (P = .19). Prostate volume at 6 months had decreased 18% (n = 5; P = .05). No minor or major complications were reported.
CONCLUSIONS: Early results from this clinical trial indicate that PAE offers a safe and efficacious treatment option for men with BPH.

OBJECTIVE: To evaluate the utility of cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia.
METHODS: From January 2012 to January 2013, 15 patients (age range, 59-81 y; mean, 68 y) with moderate- or severe-grade lower urinary tract symptoms, in whom medical management had failed were enrolled in a prospective United States trial to evaluate PAE. During pelvic angiography, 15 cone-beam CT acquisitions were performed in 11 patients, and digital subtraction angiography was performed in all patients. Cone-beam CT images were reviewed to assess for sites of potential nontarget embolization that impacted therapy, a pattern of enhancement on cone-beam CT suggesting additional PAs, confirmation of prostatic parenchymal perfusion before embolization, and contralateral prostatic parenchymal enhancement.
RESULTS: Cone-beam CT was successful in 14 of 15 acquisitions, and PAE was successful in 14 of 15 patients (92%). Cone-beam CT provided information that impacted treatment in five of 11 patients (46%) by allowing for identification of sites of potential nontarget embolization. Duplicated prostatic arterial supply and contralateral perfusion were each identified in 21% of patients (three of 11). Prostatic perfusion was confirmed before embolization in 50% of acquisitions (seven of 14).
CONCLUSIONS: Cone-beam CT is a useful technique that can potentially mitigate the risk of nontarget embolization. During treatment, it can allow for the interventionalist to identify duplicated prostatic arterial supply or contralateral perfusion, which may be useful when evaluating a treatment failure.

OBJECTIVE: The purpose of this guideline is to provide a clinical framework for the use of radiotherapy after radical prostatectomy as adjuvant or salvage therapy.
METHODS: A systematic literature review using the PubMed®, Embase, and Cochrane databases was conducted to identify peer-reviewed publications relevant to the use of radiotherapy after prostatectomy. The review yielded 294 articles; these publications were used to create the evidence-based guideline statements. Additional guidance is provided as Clinical Principles when insufficient evidence existed.
RESULTS: Guideline statements are provided for patient counseling, the use of radiotherapy in the adjuvant and salvage contexts, defining biochemical recurrence, and conducting a re-staging evaluation.
CONCLUSIONS: Physicians should offer adjuvant radiotherapy to patients with adverse pathologic findings at prostatectomy (i.e., seminal vesicle invasion, positive surgical margins, extraprostatic extension) and should offer salvage radiotherapy to patients with prostatic specific antigen or local recurrence after prostatectomy in whom there is no evidence of distant metastatic disease. The offer of radiotherapy should be made in the context of a thoughtful discussion of possible short- and long-term side effects of radiotherapy as well as the potential benefits of preventing recurrence. The decision to administer radiotherapy should be made by the patient and the multi-disciplinary treatment team with full consideration of the patient\'s history, values, preferences, quality of life, and functional status. Please visit the ASTRO and AUA websites (http://www.redjournal.org/webfiles/images/journals/rob/RAP%20Guideline.pdf and http://www.auanet.org/education/guidelines/radiation-after-prostatectomy.cfm) to view this guideline in its entirety, including the full literature review.

OBJECTIVE: Thromboprophylaxis with subcutaneous heparin or low molecular weight heparin is now an integral part of national surgical quality and safety assessment efforts, and has been incorporated into the current AUA Best Practice Statement. We evaluated familiarity and compliance with the AUA Best Practice Statement, assessed practice patterns in terms of perioperative thromboprophylaxis and specifically examined self-reported compliance in high risk patients undergoing radical cystectomy.
METHODS: An electronic survey was sent to AUA members with valid e-mail addresses (10,966). Associations between AUA Best Practice Statement adherence and factors such as urological specialty, graduation year and guideline familiarity were assessed using chi-square analyses and generalized estimating equations.
RESULTS: With 1,210 survey responses the largest group of respondents was urological oncologists and/or laparoscopic/robotic specialists (26.0%). This group was more likely to use thromboprophylaxis than nonurological oncologists and/or laparoscopic/robotic specialists in high risk patients (OR 1.3, CI 1.1-1.5). Respondents aware of the AUA Best Practice Statement guidelines (50.7%) were more likely to use thromboprophylaxis (OR 1.4, CI 1.2-1.6). Although 18.1% of urological oncologists and/or laparoscopic/robotic specialists and 34.2% of nonurological oncologists and/or laparoscopic/robotic specialists avoided routine thromboprophylaxis in patients undergoing radical cystectomy, the former were more likely to use thromboprophylaxis (p <0.0001) than other respondents. Urologists graduating after the year 2000 used thromboprophylaxis in high risk patients undergoing radical cystectomy more often than did earlier graduates (79.2% vs 63.4%, p <0.0001).
CONCLUSIONS: Although younger age and self-reported urological oncologist and/or laparoscopic/robotic specialist status correlated strongly with thromboprophylaxis use, self-reported adherence to AUA Best Practice Statement was low, even in high risk cases with clear AUA Best Practice Statement recommendations such as radical cystectomy. These data identify opportunities for quality improvement in patients undergoing major urological surgery.