Analysis of the surgical learning curve using the cumulative sum (CUSUM) method.
OBJECTIVE
The concept of the "learning curve" is a term that has become increasingly prevalent in medical literature. Using a unique Female Urology fellowship program running over the last 3 years, we set out to better define the learning process for mid-urethral slings.


METHODS
We examined surgical outcomes for six urology trainees who participated in the 6-month program from 2006 to 2011. We identified all retropubic mid-urethral sling procedures they had performed. Demographics included age, BMI, and smoking status. Outcomes focused on complication rates, as well as a subjective patient assessment. Analysis was by the cumulative sum method.


RESULTS
Six trainees performed 187 retropubic slings during their fellowships. Mean age was 54 (SD ± 12.7), mean BMI was 29.5 (SD ± 5.5). One hundred sixty-five (88%) patients only underwent a mid-urethral tape with 22 (12%) undergoing a concomitant procedure. There were 5 cases of bladder perforation, 1 case of urethral injury, 25 cases of voiding dysfunction, and 8 cases of mesh exposure. One hundred sixty-seven out of 180 patients reported a cure or improvement. All complications occurred in the first 4 months of training. CUSUM analysis of voiding dysfunction showed that four out of six trainees did not reach the expected incidence of voiding dysfunction within the completed fellowship. Bladder perforation showed a similar trend.


CONCLUSIONS
CUSUM analysis is an underused tool for the analysis of surgical competence. The learning curve for retropubic sling surgery is variable and may be longer than is often acknowledged. We suggest the focus of surgical training should move away from absolute numbers to look at training in an individualized manner.
Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK. tmaguire@doctors.org.uk
Turlough
T
Maguire
Christopher J
CJ
Mayne
Tim
T
Terry
Douglas G
DG
Tincello
D000328:Adult; D000368:Aged; D002983:Clinical Competence; D004503:Education, Medical, Graduate / Q000379:methods*; D005260:Female; D006801:Humans; D059032:Learning Curve; D008875:Middle Aged; D015233:Models, Statistical; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D053825:Suburethral Slings; D013647:Task Performance and Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000009:adverse effects / Q000193:education* / Q000295:instrumentation
female; learning curve; mid-urethral sling; surgery; urinary incontinence