The "learning curve" for retropubic mid-urethral sling procedures: a retrospective cohort study

Mid-urethral tape procedures brought a paradigm shift in surgery for stress incontinence; little research into the development and maintenance of surgical competence for the procedure exists. The hypothesis behind this study is that the  "learning curve" for retropubic mid-urethral sling procedures, judged by the surrogate of bladder perforation, is longer than previously thought.

This was a retrospective single-centre database and case note review of retropubic mid-urethral tape procedures. Unadjusted rates of bladder perforation, operating time, postoperative voiding difficulty, tape extrusion, and patient reported outcome were calculated; progress was evaluated using the cumulative sum method. Outcomes were assessed for 1 consultant, 2 subspecialty trainees (fellows), 7 advanced training skills module (ATSM) trainees (senior residents) and 6 core specialty trainees (residents) in years 4-7 of training.

A total of 1,568 women were identified as having mid-urethral tape procedures; 568 (36 %) had additional procedures concurrently; 259 (20 %) were secondary procedures. The overall perforation rate for individual surgeons varied between 0 and 31 % and averaged 10. 3 % amongst the core and ATSM trainees (a mean of 11 procedures), 4. 5 % amongst the subspecialty trainees (a mean of 66 procedures) and 1. 3 % for the consultant (1,284 procedures). The number of perforations for individual surgeons peaked at between 10 and 30 procedures undertaken. The number of cases performed to reach a target level of ≤5 % perforations varied between 20 and 80.

Whilst seductively simple in concept, mid-urethral tape procedures are not without risk; their inherently "blind" nature makes them difficult to teach. The "learning curve" to independent practice may be longer than previously considered.

International urogynecology journal. 2015 Oct 02 [Epub ahead of print]

Paul Hilton, Karen Rose

Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.  Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.


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