Assessment of the Male Urethral Reconstruction Learning Curve

Objective To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. Materials and Methods We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. Results A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P =.0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P =.0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P =.0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P =.0014). Complications decreased with time (P =.0053). Conclusion This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.