Elsevier

European Urology

Volume 69, Issue 4, April 2016, Pages 686-690
European Urology

Platinum Priority – Reconstructive Urology
Editorial by Fabio Castiglione, Michael S. Floyd Jr., Frank Van der Aa and Steven Joniau on pp. 691–692 of this issue
The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study

https://doi.org/10.1016/j.eururo.2015.09.023Get rights and content

Abstract

Background

The learning process for one-stage anterior urethroplasty has never been addressed before.

Objective

To evaluate the surgical learning curve for one-stage anterior urethroplasty.

Design, setting, and participants

Data from 641 consecutive patients treated with one-stage urethroplasty for urethral stricture were collected prospectively. All the procedures were performed by a single surgeon between 1994 and 2014.

Intervention

One-stage anterior urethroplasty using substitute tissues.

Outcome measurements and statistical analysis

The outcome was treatment failure, defined as any postoperative instrumentation needed including dilation. Surgeon experience was coded as the total number of one-stage urethroplasties performed by the surgeon before the operation. Multivariable Cox regression analysis was used to evaluate the association between surgeon experience and treatment failure. Covariates consisted of age, body mass index, smoking history (no, yes, ex-smoker), diabetes history (no or yes), previous surgical treatments (no or yes), stricture length, and stricture site (bulbar, penile, panurethral).

Results and limitations

Overall, 546 patients (85%) were treated with one-stage oral mucosa urethroplasty; penile skin or skin flap was used in 95 patients (15%). Median follow-up among patients who did not experience surgical failure was 69 mo (interquartile range: 35–118). The failure-free survival at 5 yr was 77% (95% confidence interval [CI], 74–81). At multivariable analysis, surgeon experience was significantly associated with a lower probability of treatment failure (hazard ratio per 20 procedures: 0.98; 95% CI, 0.97–0.99; p = 0.008). The surgical learning curve appeared lengthened, without reaching a plateau even after 600 procedures.

Conclusions

In this single-surgeon analysis, surgical experience has a significant impact on the probability of treatment success for one-stage urethroplasty. Better results are achieved only after a long learning curve that may not be justifiable for late-career and low-volume surgeons.

Patient summary

The probability of surgical success after one-stage urethroplasty is importantly influenced by surgeon experience. Better results are achieved only after a very long learning process.

Introduction

The management of urethral strictures remains a challenging issue in the urologic practice [1]. Endoscopic procedures such as optical internal urethrotomy and urethral dilation continue to play an important role for initial treatment. However, reconstructive urethral surgery has gained effectiveness in recent years due to its superior long-term outcomes [2], [3], [4]. Open urethroplasty is also regarded as the gold-standard treatment of resistant urethral stricture disease [5].

The learning curve for several urologic [6], [7], [8], [9] and nonurologic surgeries [10], [11], [12] was previously reported. However, the learning process for one-stage urethroplasty has never been addressed before. This is of utmost importance because the learning curve has relevant clinical implications for patient safety and surgical outcomes during the learning process [13].

With this in mind, we aimed to evaluate the first largest single-surgeon experience for one-stage anterior urethroplasty. We hypothesized that surgical experience has a significant impact on the probable success of the procedure. We evaluated the surgical learning curve for one-stage anterior urethroplasty in a large cohort of patients treated by a single surgeon over the last 2 decades.

Section snippets

Patient population

The study cohort consisted of 641 consecutive patients treated with one-stage anterior urethroplasty for urethral stricture by a single surgeon (G.B.) between 1994 and 2014. Data were prospectively collected from the first case treated by the surgeon during his career. We therefore were able to analyze data on all the surgeon's patients throughout his career to date.

Surgical technique

All patients were treated with one-stage anterior urethroplasty using substitute tissues. Detailed information regarding our

Results

Table 1 shows the descriptive characteristics of the patient population. Overall, 546 patients (85%) were treated with one-stage oral mucosa urethroplasty; penile skin or skin flap was used in 95 patients (15%). Overall, 514 (80%) had bulbar stricture, 101 (16%) had penile stricture, and 26 (4.0%) had panurethral disease. Previous treatments were administered to 529 patients (83%).

Median follow-up among patients who did not experience surgical failure was 69 mo (interquartile range: 35–118).

Discussion

The learning process for one-stage anterior urethroplasty has never been addressed before. However, a specific evaluation of the surgical learning curve is needed to ensure better surgical outcomes and patient safety that must be preserved during the surgeon's learning process.

Our hypothesis stated that surgical experience significantly affects the probability of success of one-stage urethroplasty. Our results confirmed our hypothesis and showed that surgical experience was a significant

Conclusions

In this single-surgeon analysis, surgical experience has a significant impact on the probability of treatment success for one-stage anterior urethroplasty, after adjusting for patient and stricture characteristics. Better results are achieved only after a long learning curve that may not be justifiable for late-career and low-volume surgeons. Clinical, educational, and research initiatives are required to moderate the negative effects of the learning curve on surgical care.

References (26)

Cited by (0)

Please visit www.eu-acme.org/europeanurology to read and answer questions on-line. The EU-ACME credits will then be attributed automatically.

View full text