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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. sandhuj@mskcc.org
authors.forename: Jaspreet S
authors.initials: JS
authors.lastname: Sandhu
authors.forename: Alexandra C
authors.initials: AC
authors.lastname: Maschino
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Vickers
mesh_terms: D000368:Aged; D002983:Clinical Competence; D006801:Humans; D059032:Learning Curve; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014550:Urinary Incontinence, Stress / Q000601:surgery*; D016741:Urinary Sphincter, Artificial; D013521:Urologic Surgical Procedures, Male / Q000009:adverse effects / Q000295:instrumentation*