title: The role of a surgical learning curve in urethral obstruction following autologous fascial sling: a case-series study.
abstract: OBJECTIVE
  Iatrogenic female urethral obstruction resulting from sling operations may be related to surgical inexperience and must be better understood. Although there are no widely recognized parameters for this type of study, a single-surgeon consecutive series offers an opportunity to study the role of expertise in sling operations over time.
  
  
  METHODS
  This study consecutively examined 176 women who underwent an autologous fascial sling procedure. Postoperative urethral obstruction was identified by the occurrence of voiding dysfunctions. Clinically obstructed patients were invited to undergo a postoperative urodynamic evaluation after 3 months. To enable comparison, patients were placed into 6-month groups according to the time of surgery.
  
  
  RESULTS
  A total of 159 cases were evaluated with a mean follow-up time of 32.4 ± 13.4 months. Stress continence was cured in 97.5% of cases. Although 29 patients were identified as obstructed, only 20 underwent a postoperative urodynamic evaluation. Only five of the clinically obstructed cases showed a high P(det)Q(max). All of the other cases met one or more of the non-classic parameters linked to obstruction. Overactive bladder was present in 14 (63.6%) of the obstructed cases. Iatrogenic urethral obstruction was more common among the early cases (30.4%) than among the later ones (5%) (P < 0.001). Postoperative urodynamic evaluation showed a trend toward obstruction on pressure flow studies.
  
  
  CONCLUSIONS
  Autologous fascial sling operations require expertise and involve a clear surgical learning curve. Iatrogenic obstruction in females does not fit a single model and may be difficult to recognize. Obstruction in females must be identified through clinical indicators and postoperative urinary complaints rather than the high detrusor pressure observed in men. Furthermore, iatrogenic female obstruction can probably be minimized but not eliminated.
authors.affiliation: Division of Neurourology and Voiding Disturbances, Beneficência Portuguesa Hospital of São Paulo, Rua Teixeira da Silva 34-1 Andar, Conj 11, 04002-030 São Paulo, Brazil. paulortrodrigues@uol.com.br
authors.forename: Paulo
authors.initials: P
authors.lastname: Rodrigues
authors.forename: Flávio
authors.initials: F
authors.lastname: Hering
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D000071938:Fasciotomy; D005260:Female; D006801:Humans; D059032:Learning Curve; D008875:Middle Aged; D053825:Suburethral Slings / Q000009:adverse effects*; D014524:Urethral Obstruction / Q000209:etiology* / Q000503:physiopathology; D053201:Urinary Bladder, Overactive / Q000209:etiology; D014550:Urinary Incontinence, Stress / Q000601:surgery; D014555:Urination Disorders / Q000209:etiology* / Q000503:physiopathology; D014563:Urodynamics