title: A Single-center Analysis on the Learning Curve of Male-to-Female Penoscrotal Vaginoplasty by Multiple Surgical Measures.
abstract: OBJECTIVE
  To asses and quantify the learning curve (LC) of the penoscrotal inversion flap vaginoplasty (PSV).
  
  
  METHODS
  We retrospectively reviewed clinical records of 69 patients who underwent PSV from January 2005 to January 2015. Two validated methods were used: a scatterplot representation and a splitting group. We selected as primary outcomes the operative time and vaginal depth. Surgical outcomes including blood losses, hospital stay, and postoperative complications such as vaginal stenosis or atresia or urethral meatus stenosis were also evaluated.
  
  
  RESULTS
  The overall median operative time was 245 minutes. Severe intraoperative complications were not reported. The overall incidence of postoperative major complications was 21.7 %, most of them being urethral issues. The splitting group analysis revealed a statistically remarkable difference between groups for the operative time (P < .01), the vaginal depth (P = .01), the hospital stay (P < .01), and the intraoperative complication rate (P = .01). On the contrary, no differences were evidenced between the cohorts for the amount of blood loss (P = .08). The scatterplot logarithmic analysis demonstrated a clear visible LC for most parameters. The operative time showed a sharp decrease within the first 20-30 cases, reaching a plateau after 40 cases. Considering the analysis of the vaginal depth, the logarithmic scatterplot curve evidenced a slight increase within the first 10 cases, reaching a clear stabilization after nearly 30-40 cases.
  
  
  CONCLUSIONS
  An evident LC for PSV is detectable, consisting of at least 40 cases needed to the surgical team to develop adequate skills to guarantee a safe and high-quality procedure.
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy; St.Peter's Andrology and The Institute of Urology, University College of London Hospital (UCLH), London, UK. Electronic address: marcofalcone1986@gmail.com.
authors.forename: Marco
authors.initials: M
authors.lastname: Falcone
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Timpano
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Ceruti
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Omid
authors.initials: O
authors.lastname: Sedigh
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Oderda
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Arianna
authors.initials: A
authors.lastname: Gillo
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Mirko
authors.initials: M
authors.lastname: Preto
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Sibona
authors.affiliation: St.Peter's Andrology and The Institute of Urology, University College of London Hospital (UCLH), London, UK.
authors.forename: Giulio
authors.initials: G
authors.lastname: Garaffa
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Gontero
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Frea
authors.affiliation: Department of Urology, University of Turin, Città della Salute e della Scienza, Turin, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Rolle
mesh_terms: D002983:Clinical Competence; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D010413:Penis / Q000601:surgery*; D012611:Scrotum / Q000601:surgery*; D057830:Gender-Affirming Surgery / Q000193:education* / Q000379:methods; D013524:Surgical Flaps; D014521:Urethra / Q000601:surgery*; D014621:Vagina / Q000601:surgery*