title: The "learning curve" for retropubic mid-urethral sling procedures: a retrospective cohort study.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK. paul.hilton@ncl.ac.uk.
authors.forename: Paul
authors.identifier: http://orcid.org/0000-0002-2541-5195
authors.initials: P
authors.lastname: Hilton
authors.affiliation: Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.|Department of Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, Edinburgh, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: Rose
mesh_terms: D002983:Clinical Competence; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology; D059032:Learning Curve; D061646:Operative Time; D000071066:Patient Reported Outcome Measures; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D053825:Suburethral Slings; D001743:Urinary Bladder / Q000293:injuries*; D014550:Urinary Incontinence, Stress / Q000601:surgery; D016055:Urinary Retention / Q000209:etiology; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000592:standards*
keywords: Learning curve; Mid-urethral sling; Stress urinary incontinence; Surgical training; Tension-free vaginal tape