The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience Journal Article


Authors: Sandhu, J. S.; Maschino, A. C.; Vickers, A. J.
Article Title: The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience
Abstract: Background: The artificial urinary sphincter (AUS) is a well-established treatment for male stress urinary incontinence. Objective: We aimed to characterize the surgical learning curve for reoperation rates after AUS implantation. Design, setting, and participants: The study cohort consisted of 65 602 adult males who received an AUS between 1988 and 2008, constituting close to 90% of all operations conducted during that time. Data on reoperations were obtained from the manufacturer, which requires documentation for warranty coverage. Measurements: Surgeon experience was calculated as the number of original AUS implants performed prior to the index patient's surgery. Multivariable logistic regression models were used to examine the association between experience and reoperative rates, adjusted for case mix. Results and limitations: There was a slow but steady decrease in reoperative rates with increasing surgeon experience (p = 0.020), showing no plateau through 200 procedures. The risk of reoperation for a surgeon with five prior cases was 24.0%, which decreased to 18.1% for a surgeon with 100 prior implants (absolute risk difference [ARD]: 5.9%; 95% confidence interval [CI], 1.3-10.1%) and to 13.2% for a surgeon with 200 prior implants (ARD: 10.7%; 95% CI, 2.6-16.6%). Two-thirds of contemporary patients (having AUS procedure between years 2000 and 2008) saw a surgeon who had done ≤25 prior AUS implants; only 9% saw a surgeon with ≥100 prior procedures. Conclusions: The learning curve for AUS surgery appears to be very long and without an obvious plateau. This is in contrast to typical surgeon experience, suggesting a considerable burden of avoidable reoperations. Efforts to flatten the learning are urgently needed. © 2011 European Association of Urology.
Keywords: adult; treatment outcome; aged; middle aged; surgical technique; major clinical study; united states; comparative study; sensitivity analysis; logistic models; cohort analysis; risk factors; time factors; risk assessment; clinical competence; surgeon; surgical training; experience; reoperation; surgical risk; medical practice; clinical effectiveness; urinary incontinence; urologic surgical procedures, male; bladder sphincter prosthesis; stress incontinence; urinary incontinence, stress; urinary sphincter, artificial; learning curve; artificial urinary sphincter
Journal Title: European Urology
Volume: 60
Issue: 6
ISSN: 0302-2838
Publisher: Elsevier Science, Inc.  
Date Published: 2011-12-01
Start Page: 1285
End Page: 1290
Language: English
DOI: 10.1016/j.eururo.2011.05.048
PROVIDER: scopus
PUBMED: 21665357
PMCID: PMC3646622
DOI/URL:
Notes: --- - "Export Date: 9 December 2011" - "CODEN: EUURA" - "Source: Scopus"
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  1. Jaspreet Sandhu
    115 Sandhu
  2. Andrew J Vickers
    678 Vickers