Urology open case volume

[throwaway123334]

Incoming M1 and I absolutely love urology. However, above all i'm mainly attracted to open surgeries, and this is the only thing holding me back from planning on gunning uro. I understand that most surgeries are robotic/lap/endo and this is fine, but I would still like to do at least 1 open abdominal or pelvic case, and at least 2 open genital or scrotal cases a week.

My question is how realistic is that goal for a private practice urologist, or for an academic uro-onc?

I know that it's pretty early in my training, but if I could settle with urology early then next step would be to join a urology lab and immediately work on urology specific research.

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[cpants]

Open genital and scrotal you will be able to do plenty.

Open urologic oncology surgery is rare these days. It is mostly limited to very large renal cell carcinomas especially with vascular involvement. All radical and simple prostates and 95% of kidneys are done lap/robotic. Cystectomies are also mostly done robotic now depending on your geographic location.

It would be reasonable to offer open cystectomies, but the issue is that there are still not a ton of these cases. To do a big open abdominal case every week would require you to be part of a large group where all of the other urologists are feeding you these type of cases and/or they are being referred to you from lots of outside urologists. Doing 50+ open onc cases per year is very rare. For reference, I belong to a group with 30+ urologists, and we have one guy that does all the big open whacks for the group (big kidney cases, rplnd, open cystectomies for locally advanced BC, nasty adrenal tumors). He is fed by all of us and some outside urologists. Even with all that referral base, my guess would be he only does roughly 1-2 open onc cases a month. The rest of the time he is doing major lap/robotic cases.

My point is that if big open surgeries is your passion, urology may not be the best fit. You will need to do an oncology fellowship and develop a very niche practice to accomplish this. Something like surg onc, gyn onc, transplant, etc may fit your goal better.

 

[throwaway123334]

Open genital and scrotal you will be able to do plenty.

Open urologic oncology surgery is rare these days. It is mostly limited to very large renal cell carcinomas especially with vascular involvement. All radical and simple prostates and 95% of kidneys are done lap/robotic. Cystectomies are also mostly done robotic now depending on your geographic location.

It would be reasonable to offer open cystectomies, but the issue is that there are still not a ton of these cases. To do a big open abdominal case every week would require you to be part of a large group where all of the other urologists are feeding you these type of cases and/or they are being referred to you from lots of outside urologists. Doing 50+ open onc cases per year is very rare. For reference, I belong to a group with 30+ urologists, and we have one guy that does all the big open whacks for the group (big kidney cases, rplnd, open cystectomies for locally advanced BC, nasty adrenal tumors). He is fed by all of us and some outside urologists. Even with all that referral base, my guess would be he only does roughly 1-2 open onc cases a month. The rest of the time he is doing major lap/robotic cases.

My point is that if big open surgeries is your passion, urology may not be the best fit. You will need to do an oncology fellowship and develop a very niche practice to accomplish this. Something like surg onc, gyn onc, transplant, etc may fit your goal better.

Thanks for the reply. Any insight on the recon fellowship route? How are case volumes looking there in terms of urethroplasties and other open cases?

 

[cpants]

Thanks for the reply. Any insight on the recon fellowship route? How are case volumes looking there in terms of urethroplasties and other open cases?

Recon does a lot of open work, but again it is all relative to finding a job where you will be referred lots of patients. There have been a lot of new recon fellowships opening in the last 5-10 years but my sense is there is still demand for people recon people. Female urology and peds also do a lot of open stuff.

 

[DoctwoB]

Will echo most of what Cpants said. A true general urologist like myself is doing mostly endoscopic, lap/robotic, and some open scrotal/penile/urethral surgery. The ongoing trend is for more and more stuff to be done in a minimally invasive fashion, though scrotal, inguinal, perineal, and vaginal surgery are all open at this time.

If you want to do open belly surgery, then you should do a uro-onc fellowship at an institution that still has a reasonable volume of open surgery. You would then tailor your practice to join a mega group or academic institution as the "open guy" who gets referred major open cases. Keep in mind, you're not getting referrals for routine kidneys, bladders, prostates, etc. You'd be getting referrals for patients with tons of prior belly surgeries or severe adhesions, revision uretero-enteric strictures, massive kidney tumors with IVC involvement, post-chemo RPLNDs, etc.

These are all very time/labor intensive, highly stressful cases, that despite being high stakes and stressful are often extremely tedious. Lysing adhesions for 4 hours to then start the surgery that you planned to do is not my idea of fun, but i'm glad there are those who take on these cases.

Even then, you wouldn't be doing these cases full time and would need some bread and butter onc or general urology to fill time.

If you just like open surgery but are fine with smaller cases, then recon, peds, or female fellowships are also all great options.

 

[throwaway123334]

Will echo most of what Cpants said. A true general urologist like myself is doing mostly endoscopic, lap/robotic, and some open scrotal/penile/urethral surgery. The ongoing trend is for more and more stuff to be done in a minimally invasive fashion, though scrotal, inguinal, perineal, and vaginal surgery are all open at this time.

If you want to do open belly surgery, then you should do a uro-onc fellowship at an institution that still has a reasonable volume of open surgery. You would then tailor your practice to join a mega group or academic institution as the "open guy" who gets referred major open cases. Keep in mind, you're not getting referrals for routine kidneys, bladders, prostates, etc. You'd be getting referrals for patients with tons of prior belly surgeries or severe adhesions, revision uretero-enteric strictures, massive kidney tumors with IVC involvement, post-chemo RPLNDs, etc.

These are all very time/labor intensive, highly stressful cases, that despite being high stakes and stressful are often extremely tedious. Lysing adhesions for 4 hours to then start the surgery that you planned to do is not my idea of fun, but i'm glad there are those who take on these cases.

Even then, you wouldn't be doing these cases full time and would need some bread and butter onc or general urology to fill time.

If you just like open surgery but are fine with smaller cases, then recon, peds, or female fellowships are also all great options.

long time lurker and I remember you mentioning that at one point in your practice you had done 6 open abdominal cases that year, or something like that. I really do find urology to be a perfect specialty, except for the seemingly low open case volume. If the scrotal or penile open case volume is sufficient, then I feel like I would be fine with that 6 per year number at the very least.

Apologies for the barrage of questions, but if you don't mind sharing: how frequently do you do open scrotal or penile cases? Robotic/lap cases? Open abdominal or pelvic?

 

[DoctwoB]

long time lurker and I remember you mentioning that at one point in your practice you had done 6 open abdominal cases that year, or something like that. I really do find urology to be a perfect specialty, except for the seemingly low open case volume. If the scrotal or penile open case volume is sufficient, then I feel like I would be fine with that 6 per year number at the very least.

Apologies for the barrage of questions, but if you don't mind sharing: how frequently do you do open scrotal or penile cases? Robotic/lap cases? Open abdominal or pelvic?

Robotic/lap is about 4/month. Mostly prostatectomy or partial/radical nephrectomy, occasionally things like pyeloplasty or ureteral reimplant. Note that a typical general urologist may have a somewhat lower volume then this, I have one of my partners who does not do these cases who refers theirs to me.

scrotal/penile/inguinal cases is probably like 4/month as well. Typically hydrocele/spermatoceles and circs, sometimes reconstructive or peyronie's cases.

open abdomen/pelvic are pretty rare. Perhaps 3-4/year. Sometimes done with or at the request of colleagues in gyn or vascular surgery with things like ureteral obstruction due to fibrosis around a vascular graft, or a transected ureter during another case.

Majority of cases are endoscopic, lot of stones, lot of BPH (bit of a subspeicalization for me as I'm the person who performs HOLEP in our group), reasonable number of bladder tumors.

 

[cpants]

I'd say my surgical mix is fairly similar to DoctwoB with a bit lower robotic volume. I would guess these are pretty typical numbers for a general urologist. Bread and butter is definitely endoscopic work (stones, BPH, bladder cancer). Plenty of opportunity to do lap/robotic work if its an interest.

If you really love doing open work I might think about peds or female urology. Tons of open genital cases. Just won't be in the abdomen.