TY - JOUR
T1 - The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience
AU - Sandhu, Jaspreet S.
AU - Maschino, Alexandra C.
AU - Vickers, Andrew J.
N1 - Funding Information:
Funding/Support and role of the sponsor : The data in this study were received under a data use agreement with American Medical Systems. American Medical Systems had no role in the design, analysis, or funding of this study. This work was supported by the US National Cancer Institute (P50-CA92629); the Sidney Kimmel Center for Prostate and Urologic Cancers; and David H Koch, through the Prostate Cancer Foundation. The study sponsors had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
PY - 2011/12
Y1 - 2011/12
N2 - 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.
AB - 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.
KW - Artificial urinary sphincter
KW - Surgical technique
KW - Urinary incontinence
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U2 - 10.1016/j.eururo.2011.05.048
DO - 10.1016/j.eururo.2011.05.048
M3 - Article
C2 - 21665357
AN - SCOPUS:80255131281
SN - 0302-2838
VL - 60
SP - 1285
EP - 1290
JO - European Urology
JF - European Urology
IS - 6
ER -