Assessment of the Male Urethral Reconstruction Learning Curve

Abstract

Objective To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. Materials/Methods We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes versus time since fellowship and case number. Results A total of 613 consecutive cases from six surgeons were analyzed, with a functional success rate of 87.3%. The success for bulbar urethroplasties was higher than for penile urethroplasties (88.2% vs 78.3%, p = 0.0116). The success of anastomotic repairs was higher than for substitution repairs (95.0% vs 82.4%, p = 0.0001). There was a statistically significant trend towards improved outcomes with increasing number of cases (p = 0.0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (> 90% success), was approximately 100 cases for all types of reconstruction were considered and 70 cases for bulbar urethroplasties. There were statistical differences in success rates among the participating surgeons (p = 0.0014). Complications decreased with time (p = 0.0053). Conclusions This study shows success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.

Nontransecting Anastomotic Repair in Urethral Reconstruction: Surgical and Functional Outcomes

“…It is possible that a longer learning curve as compared to TAR might be present in debutant urethral surgeons. An important learning curve effect has indeed been described in debutant urethral surgeons 21,22 . Although NTAR is technically more challenging as compared to TAR, it can be regarded as a further enrichment of the armentarium of the urethral surgeon.…”

Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews

“…reported a series of 613 cases from six surgeons, and that there was a significant trend toward improved surgical outcomes with increasing number of cases . They also noted that the average number of anterior urethroplasties required to reach proficiency, defined as a success rate of >90%, was approximately 100 cases after reconstructive urological fellowship . Fossati et al .…”

“…Some anterior urethral strictures might be amenable to EPA, but the majority of them are too long, or located in the distal bulbar or penile urethra and require substitution urethroplasty . Substitution urethroplasty is technically more demanding than EPA, and high expertise is required before high success rates can be achieved, implying that a significant learning curve exists . Faris et al .…”

“…65 Substitution urethroplasty is technically more demanding than EPA, and high expertise is required before high success rates can be achieved, implying that a significant learning curve exists. 66,67 Faris et al reported a series of 613 cases from six surgeons, and that there was a significant trend toward improved surgical outcomes with increasing number of cases. 66 They also noted that the average number of anterior urethroplasties required to reach proficiency, defined as a success rate of >90%, was approximately 100 cases after reconstructive urological fellowship.…”

“…66,67 Faris et al reported a series of 613 cases from six surgeons, and that there was a significant trend toward improved surgical outcomes with increasing number of cases. 66 They also noted that the average number of anterior urethroplasties required to reach proficiency, defined as a success rate of >90%, was approximately 100 cases after reconstructive urological fellowship. 66 Fossati et al reported an experience of 546 bulbar urethral strictures mainly reconstructed by dorsal onlay urethroplasty using oral mucosa graft carried out by Barbagli, an undisputed world-wide expert, and the success rate has been improved by approximately 10% during two decades of his experience, which they attributed to surgeon experience.…”