key: cord-0836473-w3bvu1xc
authors: Tan, Yi Quan; Pek, Xiang Wen Gregory; Wang, Ziting; Tiong, Ho Yee; Chiong, Edmund
title: Impact of the COVID-19 Pandemic on the Urology Residency Match in Singapore
date: 2020-09-30
journal: Urology
DOI: 10.1016/j.urology.2020.05.037
sha: fd523af4264633a3e293d172f95b4dcd6f54dec4
doc_id: 836473
cord_uid: w3bvu1xc

nan

such as the blue dot or presence/absence of cremasteric reflex as clinical diagnostic adjuncts to distinguish between true testicular torsion and testicular appendage torsion. Current literature encourages the use of these physical exam findings given that the blue dot sign is pathognomonic for appendage torsion.

We applaud the authors on their inquisitiveness on this subject, as there is an unfortunate lack of literature in the diagnosis and treatment of testicular appendage torsion, necessitating the need for further studies in order to delineate the standard of care. Standardizing the operative technique for appendage torsion, by either routinely performing or not performing ipsilateral orchiopexy, would eliminate confusion in patients who re-present with symptoms on previously explored side. If orchiopexy is routinely performed on all patients undergoing exploration, it would eliminate the need for surgical re-exploration to rule out spermatic cord torsion upon re-presentation to the ED. However, if there is no true benefit to fixating the affected testicle in terms of rate of future spermatic cord torsion, violation of the physiologically normal testicle should be avoided. 

In a recent review of the differential diagnosis of acutely declining renal function, the discussant states: "the absence of hydronephrosis on renal ultrasonography rules out [urinary tract] obstruction." 1 Many urologists and nephrologists believe this. But it is not true. I learned this the hard way 35 years ago when I evaluated an elderly man with three days of anuric renal failure. Renal ultrasonography showed no hydronephrosis, so I inferred parenchymal disease. To my surprise, a renal biopsy showed only interstitial edema and normal glomeruli. A colleague suggested nondilated obstruction. 2 Placement of a ureteral catheter led to a large diuresis and marked improvement in renal function. 3 Though uncommon, many similar cases of nondilated obstructive uropathy have been reported; most of these have involved elderly patients with cancer, retroperitoneal fibrosis, or pelvic surgery. [2] [3] [4] [5] The cause of this phenomenon is unclear but seems related to ureteral pathology such as encasement by cancer or fibrosis, edema, or debris accumulation. Whatever the mechanism, the message is clear: the absence of hydronephrosis does not exclude urinary tract obstruction; when the index of suspicion is high, obstructive uropathy should be pursued even if renal ultrasonography is normal. 

To the Editor:

The COVID-19 pandemic has led to significant disruptions in undergraduate and postgraduate Urology education and training. In this letter, we examine the wideranging impact of the COVID-19 pandemic on the Urology Residency Match in Singapore, and share strategies to proactively mitigate these consequences.

Urology Residency in Singapore is a 6-year program accredited by the Accreditation Council for Graduate Medical Education-International. Nationwide, there are 3 Sponsoring Institutions (SI) as training sites. Applicants are required to submit their Curriculum Vitae, Referee letters, and participate in Multiple Mini Interviews, conducted by the Ministry of Health. 1 Successful applicants are asked to rank their preference for a SI, and the 3 SIs will similarly rank the applicants. Potential residents are only allowed to apply in their second year after graduation, and have typically completed at least one formal postgraduate Urology clerkship.

Due to social distancing measures, medical student education has relied primarily on remote-teaching via videoconferencing platforms. Medical student electives have been cancelled. Valuable hands-on exposure to diverse Urologic procedures, known to significantly influence decisions to enter Urology residency, 2 have been lost. Due to manpower redistribution, doctors have been redeployed from Urology departments to frontline departments. Potential residents have faced difficulties securing clinical clerkships and electives in Urology. Even within Urology clerkships, potential residents have been confronted with reduced surgical exposure due to deferment of non-urgent surgeries. Local and international conferences and workshops, typically keenly attended by potential residents, have been cancelled. In Singapore, experiences during clinical clerkship, positive working environments, quality of education, and quality of mentorship have been found to be the most important factors influencing residency choices among applicants. 3 These factors are fundamentally related to the experiences of working and learning in the speciality of interest, and interacting with faculty and residents. These have been significantly disrupted and restricted by the pandemic. The feared eventual impact would be declining interests in Urology residency, and less-informed choices on preferred training sites. From the Program's perspective, the pandemic has undoubtedly limited first-hand opportunities to evaluate potential residents.

To guard against the detrimental effects of reduced Urology exposure, 4 core Urology curriculum for medical students was maintained via video-conferencing. Didactic teaching was deliberately modified to include more casebased learning, and a variety of Urology procedures was intentionally introduced to students, leveraging on online resources. Interns rotating through the Urology department were also actively engaged through hands-on exposure to various procedures. Potential residents and students who were unable to secure clerkships or electives were engaged in scholarly activities through research participation. Moving forward, we would strongly consider forming Urology Interest Groups, which have been shown to be a significant positive predictor of Urology residency application. 5

With no clear end in sight for the COVID-19 pandemic, it is timely for Residency Programs worldwide to examine the impact on their respective Urology Residency Match Exercises, and proactively implement measures to mitigate these consequences for the foreseeable future.

Case 13-2020: A 29-year-old man with high blood pressure, renal insufficiency, and hematuria

Nondilated obstructive nephropathy

Nondilated obstructive uropathy

Nondilated obstructive uropathy: percutaneous nephrostomy performed to reverse renal failure

Non-dilated obstructive uropathy − an unrecognized cause of acute renal failure in hospitalized US patients: three case reports seen over 6 months in a northwestern Wisconsin Nephrology practice

General surgery (GS) residency selection process: a comparison between Singapore (Singhealth) and United States

The urology applicant: an analysis of contemporary urology residency candidates

Factors affecting choice of sponsoring institution for residency among medical students in Singapore

An update on the current status of medical student urology education in the United States

Reversing the decline in urology residency applications: an analysis of medical school factors critical to maintaining student interest