The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study
The Surgical Learning Curve for One-stage Anterior Urethroplasty: A Prospective Single-surgeon Study
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DOI：
10.1016/j.eururo.2015.09.023
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发表时间：
2016-04-01
期刊：
影响因子：
23.4
通讯作者：
Lazzeri, Massimo
中科院分区：
文献类型：
--
作者：
Fossati, Nicola;Barbagli, Guido;Lazzeri, Massimo
目的：评估一期前尿道成形术的手术学习曲线。设计、设置和对象：前瞻性收集连续641例接受一期前尿道成形术治疗的患者的数据。所有手术在1994-2014年间由一名外科医生完成。干预：使用替代组织的一期前尿道成形术。结果测量和统计分析：结果是治疗失败，定义为术后需要的任何器械，包括扩张。外科医生的经验编码为外科医生在手术前进行的一期尿路成形术的总数。多变量COX回归分析用于评估外科医生经验与治疗失败之间的关系。协变量包括年龄、体重指数、吸烟史(无、有、有吸烟史)、糖尿病病史(无、有)、既往手术治疗(无、有)、狭窄长度、狭窄部位(球、阴茎、泛尿道)。结果和局限性：546例(85%)患者接受了一期口腔黏膜尿路成形术；95例(15%)患者使用了阴茎皮或皮瓣。未经历手术失败的患者的中位随访期为69个月(四分位数范围：35-118)。5年无失败存活率为77%(95%可信区间74-81)。在多变量分析中，外科医生的经验与较低的治疗失败概率显著相关(每20次手术的风险比：0.98；95%可信区间0.97-0.99；p=0.008)。手术学习曲线似乎延长了，即使在600次手术后也没有达到平台期。结论：在这项单一外科医生的分析中，手术经验对一期尿路成形术的治疗成功概率有显著影响。只有在经历了漫长的学习曲线后才能获得更好的结果，这对于职业生涯较晚和低容量的外科医生来说可能是不合理的。患者摘要：一期尿路成形术后手术成功的可能性受到外科医生经验的重要影响。只有经过很长的学习过程才能取得更好的效果。(C)2015年欧洲泌尿外科协会。爱思唯尔出版，版权所有。
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.Design, setting, and participants: 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.Intervention: One-stage anterior urethroplasty using substitute tissues.Outcome measurements and statistical analysis: 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).Results and limitations: 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.Patient summary: 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. (C) 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.