title: The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study.
abstract: BACKGROUND
  The learning process for one-stage anterior urethroplasty has never been addressed before.
  
  
  OBJECTIVE
  To evaluate the surgical learning curve for one-stage anterior urethroplasty.
  
  
  METHODS
  Data from 641 consecutive patients treated with one-stage urethroplasty for urethral stricture were collected prospectively. All the procedures were performed by a single surgeon between 1994 and 2014.
  
  
  METHODS
  One-stage anterior urethroplasty using substitute tissues.
  
  
  METHODS
  The outcome was treatment failure, defined as any postoperative instrumentation needed including dilation. Surgeon experience was coded as the total number of one-stage urethroplasties performed by the surgeon before the operation. Multivariable Cox regression analysis was used to evaluate the association between surgeon experience and treatment failure. Covariates consisted of age, body mass index, smoking history (no, yes, ex-smoker), diabetes history (no or yes), previous surgical treatments (no or yes), stricture length, and stricture site (bulbar, penile, panurethral).
  
  
  CONCLUSIONS
  Overall, 546 patients (85%) were treated with one-stage oral mucosa urethroplasty; penile skin or skin flap was used in 95 patients (15%). Median follow-up among patients who did not experience surgical failure was 69 mo (interquartile range: 35-118). The failure-free survival at 5 yr was 77% (95% confidence interval [CI], 74-81). At multivariable analysis, surgeon experience was significantly associated with a lower probability of treatment failure (hazard ratio per 20 procedures: 0.98; 95% CI, 0.97-0.99; p=0.008). The surgical learning curve appeared lengthened, without reaching a plateau even after 600 procedures.
  
  
  CONCLUSIONS
  In this single-surgeon analysis, surgical experience has a significant impact on the probability of treatment success for one-stage urethroplasty. Better results are achieved only after a long learning curve that may not be justifiable for late-career and low-volume surgeons.
  
  
  RESULTS
  The probability of surgical success after one-stage urethroplasty is importantly influenced by surgeon experience. Better results are achieved only after a very long learning process.
authors.affiliation: Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy. Electronic address: nicola.fossati@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: Fossati
authors.affiliation: Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy; Centro Chirurgico Toscano, Arezzo, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Barbagli
authors.affiliation: Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Larcher
authors.affiliation: Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Dell'Oglio
authors.affiliation: Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Sansalone
authors.affiliation: Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Rozzano, Milan, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Lughezzani
authors.affiliation: Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Humanitas University, Rozzano, Milan, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Guazzoni
authors.affiliation: Division of Oncology/Unit of Urology, IRCCS Ospedale San Raffaele, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.affiliation: Department of Urology, Istituto Clinico Humanitas IRCCS, Clinical and Research Hospital, Rozzano, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Lazzeri
mesh_terms: D000328:Adult; D002983:Clinical Competence; D018572:Disease-Free Survival; D006801:Humans; D007558:Italy; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014521:Urethra / Q000503:physiopathology / Q000601:surgery*; D014525:Urethral Stricture / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D013521:Urologic Surgical Procedures, Male / Q000009:adverse effects
keywords: Learning curve; Male; Urethral diseases; Urethral stricture/surgery; Urologic surgical procedures