Welcome to our next installment of So You Want to Be. In this series, we highlight a specific specialty within medicine, such as urology, and help you decide if it’s a good fit for you.
So you want to be a urologist. You like the idea of dick jokes and, well, more dick jokes. Let’s debunk the public perception myths of what it means to be a urologist, and give it to you straight. This is the reality of urology.
What is Urology?
Urologists are surgeons of the urogenital tract. If you need it to urinate or to reproduce, chances are urologists operate on it. This includes the kidneys, ureters, bladders, prostate, urethra, testes, and more.
Urology also deals with some of the most sensitive parts of health, including sexual function, fertility, urinary continence, and gender identity. For this reason, urologists are well versed in having complex, quality of life conversations and delivering compassionate care.
Many people have never even heard of the field of urology. But when you get intractable pain from a kidney stone or a testis that has twisted on itself at 2 AM, you’ll thank your stars for the field of urology.
Contrary to popular belief, urologists are in fact real surgeons. They don’t just treat STI’s all day. Urology residency involves rigorous surgical training, and they are the experts at operating on various structures within the pelvis.
Many also believe that urology only applies to men. Turns out many women seek treatment from urologists for cancers of the urogenital tract and issues with voiding. In fact, there are even some subspecialties within urology that treat women almost exclusively.
Although there is some overlap between OBGYN and urology, gynecologists focus primarily on the female reproductive tract, whereas urologists typically focus on the male reproductive tract and the urinary tract of both men and women.
Clinic vs Operating Room
Urology is unique amongst surgical subspecialties because of the blend of clinical medicine and surgery. Earlier on in a urologists career, they may focus more on surgery, but it’s common for older urologists to phase out and focus more on clinic, as they may be less enthusiastic about standing in the operating room for hours at a time.
In clinic, urologists share many similarities with medical doctors. They’ll be counseling patients on lifestyle modifications for an overactive bladder, prescribing medications to assist with erectile dysfunction, and working up the causes of recurrent kidney stones. They may also perform small procedures in clinic, such as vasectomies and cystoscopies, where they insert a camera through the urethra to visualize the bladder. Sounds comfortable, right?
In the operating room, cases are varied. Urologists may break up kidney stones or vaporize prostates using lasers. Or they may use robots and laparoscopic procedures to remove kidney or bladder cancers. Urologists also perform a variety of open surgeries with kidney transplants or lymph node dissections.
Small vs Big Cases
Urology has a high degree of procedural variation. One day, you may be performing a quick in-office vasectomy that takes less than 30 minutes. And the next, a complex bladder reconstruction lasting several hours.
Some urologists may enjoy the complex, life-or-death surgeries where you carefully dissect all around the aorta and vena cava, removing lymph nodes and curing a patient of cancer. Others may like the quick but equally satisfying cases where you retrieve a large stone and relieve a patient of some of the worst pain of their life — all in under 30 mins.
You can be the cancer-slaying hero who saves the day or the quality-of-life captain that helps a man stay continent or anything in between.
Academic vs Community
Urologists that practice in academic settings focus on research, teach residents and take care of patients inside and outside of the operating room. Some academic urologists spend most of their time engaged with teaching and clinical work while others may have just a half-day of clinic and procedures per month while the rest of their time is spent doing basic science research.
The practice of a community urologist can vary quite a bit from spending most of their time in the clinic to spending the majority of their days in the operating room. Regardless, these urologists devote 100% of their time to patient care.
How to Become a Urologist
After 4 years of medical school, urology residency is an additional 5 or 6 years, depending on the program (6-year programs have a dedicated research year built-in).
In your first year of residency, also known as the intern year, you’ll be developing fundamental operating room skills, but the majority of your time will be spent learning how to manage floor patients. As a PGY2 and PGY3 (meaning postgraduate year 2 and 3) you’re a urology junior resident, and you’ll be seeing urology patients that come in from the emergency department, managing patients on the urology floor, and working on smaller cases. As a fourth and fifth year, you’re now a senior resident, and you’ve paid your dues. Now, it’s time to shine and learn as much as you can in the OR. You’ll be doing larger open cases, like kidney transplants and large reconstructive and oncologic cases. You’ll also be mastering the use of the surgical robot to resect kidney, bladder, and prostate cancers. While it’s much more fun, there’s also much more responsibility that comes with it. You’ll be the top-level resident, and as such, there are additional administrative duties to make sure everything within the urology service is running smoothly.
If a program has a research year, it’s typically done between the third and fourth years. However, these are becoming less common as urology trainees are valuing the prospect of shorter training and sooner opportunity for independent practice.
There are several benefits to a research year, though. You can explore an intellectual curiosity whether it’s basic science research to understand how checkpoint inhibitors work in prostate cancer or develop a new device to address premature ejaculation. You can explore barriers to healthcare access and many other facets applicable to urology. If you have a research itch, this is your time to scratch it full time, for an entire year.
Research years are also often a much-appreciated pause from the rigorous and high-intensity surgical training that is the norm of residency. If you’re interested in a career in academic medicine, a research year gives you an opportunity to publish additional papers, present at conferences, and network with the top dogs in the field.
Urology is unique in that it participates in its own match, rather than the NRMP that is the norm for other medical and surgical specialties. The application process is quite similar, but you’ll be applying sooner than your NRMP colleagues, and you’ll match in January or February, rather than March.
As I’ve covered in my Surgical Stereotypes post, urologists have the best jokes in the business. A robust sense of humor is almost required to be a part of this field. After all, a good part of your day is speaking with patients about their erections. The stereotypical medical student applying to urology has a great sense of humor, doesn’t take themself too seriously, and loves to be in the OR. These are the “happy surgeons”, some of the kindest and most affable in the operating room. Unlike some other surgeons, you won’t see them throwing instruments in the OR or having a temper tantrum with the scrub nurse. Think of them as having the skills of a general surgeon, but the kindness of a family medicine doctor.
In terms of competitiveness, urology is up there with other surgical subspecialties. In 2020, 484 applied and 354 successfully matched. That’s a match rate of 73%. The precise Step scores are not well defined since they don’t participate in NRMP. Estimates for Step 1 and Step 2 are similar to those of something like ENT or orthopedic surgery, around 245 to 250.
While board scores are important, letters of recommendation hold heavier weight than usual. That’s because urology is a smaller specialty where urologists all know one another more or less. A glowing letter from a prominent urologist can transform an applicant with below-average board scores into a more attractive applicant. For this reason, away rotations, whereby medical students rotate for 1 month at an outside program, are quite important in urology. This allows students to impress prominent leaders in the field and secure strong letters of recommendation.
Subspecialties within Urology
After completing a urology residency, you can subspecialize further with a 1 or 2-year fellowship.
Little known fact: 50% of infertility in couples is due to the man. Urologists specializing in andrology are men’s health champions and specialists in infertility and sexual dysfunction disorders. The bread-and-butter is varied, including varicocelectomies (surgically treating dilated veins near the testis which can compromise fertility), or even performing surgical sperm extraction while operating under a microscope! If you want to get botox on your scrotum, also known as scrotox, then these are your guys.
Andrology fellowship will also teach you how to perform penile prostheses, spermatic cord denervation, and even reverse a vasectomy. This is a 1-year clinical fellowship but may also include 1 year of research as well.
Female Pelvic Medicine & Reconstructive Surgery (FPMRS)
Female pelvic medicine and reconstructive surgery, or FPMRS for short, is a fellowship available to those who have completed either urology or OBGYN residency. From urology, it’s a 2-year fellowship, and if you’re coming from OBGYN, it’s 3 years.
These are the masters of reconstructive surgery of the urogenital region, including repairing fistulas, reconstructing urethras, creating urinary diversions from the intestine, and resolving vaginal prolapse, just to name a few.
Many FPMRS programs also offer training in gender-affirming surgery for transgender patients. Examples include metoidioplasties, or female-to-male surgery, whereby you reconstruct the lower urogenital tract to create a small penis from the clitoris. Depending on the complexity of the surgery, urologists may work alongside plastic surgeons during these cases. If you want to learn more about plastic surgeons, including gender reassignment surgery, we’ve covered that in a previous post of So You Want to Be.
A transplant fellowship in urology, lasting 2 years, is relatively small compared to others, as most transplant surgeons come from general surgery residency and are trained to perform other solid-organ transplants in addition to the kidney.
The hours for this fellowship are intense, as you’ll be woken up in the middle of the night to take a private plane or helicopter to harvest an organ and transplant it to a new recipient. These are the adrenaline junkies and perfectionists of urology. After all, every detail and every suture needs to be perfect to have a successful transplant.
Endourology and robotics is a 1-year fellowship dealing with the sci-fi of urology. You’ll hone your skills on the surgical robot, dealing with some of the most complicated urology cases with minimally-invasive approaches. There are even treatment modalities for benign prostate disease using lasers and water vapor. Talk about futuristic!
Uro-oncology is a 2 or 3-year fellowship, often with a dedicated research year, where you’ll be specializing in the minutiae of urological cancers. These surgeons have a reputation of being more on the serious side, as their bread-and-butter is something life or death for their patients.
Urologic oncologists build long-term relationships with their patients, as they’ll follow a patient’s cancer for several years before deciding to operate, and will continue to follow their patients for the rest of their lives, as urologic cancers tend to recur.
Pediatric urology is a 2-year fellowship, but don’t worry. It’s much more than just circumcisions. They deal with all the urologic issues of children, including hypospadias repairs whereby the urethra opening is on the underside of the penis rather than at the tip. There are more complex cases too. For example, children born with severe anatomical birth defects precluding normal urination may need surgery that allows them to catheterize themselves from their belly button.
Peds urologists are especially meticulous and precise as they are dealing with smaller structures than other urologists.
What You’ll Love About Urology
There’s a lot to love about urology. First, life as an attending has a much better work/life balance compared to most other surgical specialties. After residency, expect 40-60 hour work weeks.
Your patients will also love you because many of your interventions will have an immediate and positive effect on their quality of life. Urology patients tend to suffer from sensitive health issues for many years before they seek care, and they’re understandably incredibly grateful when you can help them maintain a robust sex life or even help them be continent (not leaking urine) throughout the day.
There’s a great deal of variety in urology and you can adjust based on your preferences over the course of your career. Younger urologists with more energy may choose to perform more complex oncologic surgeries most days of the week. But as you get older, maybe you want to transition to primarily a clinic-focused practice with some minor surgeries on the side.
Compensation is also on the higher end, as it is with most surgical subspecialties, and urologists make on average $408,000 per year.
What You Won’t Love About Urology
While urology is an amazing field, it’s not perfect. In fact, urologists have some of the highest burnout rates reported amongst all of the medical fields. In a recent Medscape Burnout report, urologists topped the list at 54%.
As with other surgical residencies, you can expect 80-hour workweeks as the norm during your training.
Urology is also a specialty that has conditions requiring immediate and urgent treatment. That means you can be called in during the middle of the night for a patient that is septic from an infected kidney stone.
Although infrequent, urological complications can be some of the worst including gnarly penile prosthesis infections and extreme electrolyte abnormalities that can be life-threatening in patients who have had their bladders or kidneys removed.
Should You Become a Urologist?
If you want to work with your hands, enjoy the pathophysiology of medicine, like building long-lasting relationships, love the operating room, and are prone to making dick jokes, then urology may be a good fit for you.
If you want to be a surgeon but still have a healthy work-life balance, urology is unique in being able to provide that. Urologists also love playing with new gadgets, lasers, and toys in the operating room, as it’s a highly innovative field.
And in terms of personality, those who are happiest in urology have a great sense of humor and don’t take themselves too seriously.
Lastly, because urology is a highly competitive field, you’ll need to crush your boards, home and away rotations, and knock it out of the park with research too. And who better to learn from and be mentored by than urologists themselves! Big shout out to the urologists at Med School Insiders that helped me in the creation of this post. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or urology residency, our urologists can share the ins and outs of what it takes and how to navigate the competitive process most effectively.
Thank you all so much for reading! See you in the next one.