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Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?

Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?

Accepted Manuscript Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate? Jamie S. Pak, Mark Silva, Christopher M. Deibert, ...

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Accepted Manuscript Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate? Jamie S. Pak, Mark Silva, Christopher M. Deibert, Kimberly L. Cooper, Gina M. Badalato PII:

S0090-4295(15)00737-2

DOI:

10.1016/j.urology.2015.05.052

Reference:

URL 19353

To appear in:

Urology

Received Date: 3 April 2015 Revised Date:

28 May 2015

Accepted Date: 29 May 2015

Please cite this article as: Pak JS, Silva M, Deibert CM, Cooper KL, Badalato GM, Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?, Urology (2015), doi: 10.1016/ j.urology.2015.05.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate? Jamie S Paka, Mark Silvaa, Christopher M Deiberta,b, Kimberly L Coopera, Gina M Badalatoa a

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NYP-Columbia University Medical Center, 161 Fort Washington Ave., Herbert Irving Pavilion 11th floor, New York, NY 10032.

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Corresponding author information: Jamie S. Pak Columbia University College of Physicians and Surgeons Department of Urology 161 Fort Washington Ave Herbert Irving Pavilion, 11th floor New York, NY 10032 Telephone: 212-305-6665 Fax: 212-305-0116 Preferred e-mail: [email protected] Secondary e-mail: [email protected]

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Medical College of Wisconsin, 8701 W Watertown Plank Rd., Milwaukee, WI 53226.

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Word counts: Abstract – 250 Manuscript – 2,263

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Key words: residency; learning curve; urethra; urethral stricture; urinary sphincter, artificial; suburethral slings

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ABSTRACT Objective: To evaluate trends in male urethral and penis/incontinence case volumes among urology residents and assess these for adequate surgical training/competency.

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Methods: ACGME case logs of urology residents graduating from U.S. programs from 2009 to 2013 were reviewed to determine the surgical volume of select index categories. Male urethral cases encompass urethrectomy and urethroplasty, while male penis/incontinence cases include urethral slings and sphincters. Case volumes as “surgeon,” “assistant,” and “teaching assistant” were reviewed and compared to ACGME minimum requirements.

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Results: A total of 1,032 graduating residents reported case logs. For male urethral surgery, residents reported weighted averages (SD) of 12.7 (9.0) cases as “surgeon,” 1.5 (3.5) cases as “assistant,” and 0.2 (1.0) as “teaching assistant.” The minimum requirement for these cases is 5. The annual 10th percentiles as “surgeon” ranged from 4 to 5 cases throughout the study period. For male penis/incontinence cases, residents reported weighted averages (SD) of 45.5 (22.7) cases as “surgeon,” 3.6 (5.5) cases as “assistant,” and 1.5 (3.0) cases as “teaching assistant.” The minimum requirement is 10 cases. The 10th percentiles as “surgeon” ranged from 19 to 23 cases.

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Conclusions: Although the majority of residents met the minimum standard for these cases, about 10% of residents did not meet the requirement for male urethral surgery. In addition, a review of learning curves for these procedures suggests that the ACGME minimum requirements may be insufficient to confer actual competency in skill. Increasing this number in training or specialized post-graduate training programs is needed to provide actual competency.

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INTRODUCTION

A strong correlation exists between surgeon volume and patient outcomes in urologic surgery,1-5

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but certain urologic procedures are not performed in significant numbers throughout the United States. Endoscopic approaches for urethral cases—including dilation and urethrotomy—have remained the most common treatment for male urethral stricture disease,6-9 despite literature

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showing improved outcomes with open repairs.6 Repeat urethrotomy and dilation have also been criticized as neither clinically nor cost- effective long-term compared to urethroplasty.10-11 It has

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been suggested that this underutilization of urethroplasty can be partly attributed to practicing urologists’ unfamiliarity with current urethroplasty techniques.8

A report on another genitourinary reconstructive procedure—implantation of an artificial urinary

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sphincter (AUS)—revealed that urology resident exposure was significantly inadequate in relation to the learning curve.12 Combined with the underutilization of urethroplasty in practice, indications of inadequate reconstructive surgery training warrant a study investigating the case

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volumes of these procedures during residency training. In fact, an increasing focus has been placed upon examining current residency training regimens and case volumes in urology

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programs.13 Substitutes have been proposed, including extending residencies or alternative sources of training, including fellowships (e.g., Society of Genitourinary Reconstructive Surgeons, Society of Urodynamics, Female Pelvic Medicine, & Urogenital Reconstruction) and residency rotations on transplantation surgical services.14-15

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We aimed to study residents’ experience with male urethral and penis/incontinence cases by reviewing the Accreditation Council for Graduate Medical Education (ACGME) database of urology residents’ operative case logs. The case numbers and minimum requirements for male

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urethral and penis/incontinence surgeries were compared to other ACGME-defined index categories including female reconstructive surgery and urologic oncological procedures.

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METHODS

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The ACGME-Residency Review for Urology Operative Log Reports were reviewed for the academic years 2009-2013. “Surgeon” case logs were analyzed for the following index categories (which are listed here with a sample of the most common CPT codes per category according to the ACGME16): 1) Reconstructive surgery: male urethra (e.g., 53410, 53215), male

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penis/incontinence (e.g., 54360, 54405, 54440, 53440, 53445), female (e.g., 57288, 57260, 53500, 53230, 57320) 2) Oncology: pelvic – bladder (e.g., 51595, 51596, 51597, 51550), pelvic – prostate (e.g., 55866, 55840, 55842, 55845), retroperitoneal – kidney (e.g., 50230, 50240,

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50542, 50543, 50545, 50547, 50548). Cases logged as “assistant” and “teaching assistant” were

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also analyzed for male urethra and male penis/incontinence cases.

The case logs were tallied for each index category per academic year of graduating residents, and ACGME-defined minimum requirements recommended for graduation were noted. To report means and standard deviations for each index category throughout the study period, annual means and standard deviations (SD) were weighted by the number of residents reporting case logs per academic year. Benchmarks of 10th, 30th, 50th, 70th, and 90th percentiles were gathered

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and reported per index category per academic year. These were compared in reconstructive surgery and urologic oncology cases. We also divided the case logs by type of resident surgical

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participation, as described below.

To be credited for an index case towards the ACGME minimum requirement, the resident can function as the “surgeon,” “assistant,” or “teaching assistant.” For cases to be logged as

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“surgeon,” a resident “must be present for all of the critical portions of the case, and must perform a significant number of the critical steps of the procedure.” On a given case, “only one

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resident can claim credit as an assistant.” To be logged as a “teaching assistant,” the chief or senior resident “acts as teaching assistant (supervisor), directing and overseeing major portions of the procedure being performed by the more junior resident surgeon, while the supervising

RESULTS

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attending physician (staff member) functions as a second assistant or observer.”16

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The total number of residents reporting case logs to the ACGME was 247 from 115 programs in 2009-2010, 256 from 117 programs in 2010-2011, 259 from 117 programs in 2011-2012, and

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270 from 118 programs in 2012-2013.

For cases logged as “surgeon” throughout the study period, residents reported a weighted mean of 12.7 (SD 9.0) male urethral cases during their training. The percentage benchmarks for the index categories as “surgeon” are reported in Table 1. With a minimum requirement of 5 procedures, the 10th percentile from 2009-2010 was 4 procedures, while the 10th percentile from

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2010 to 2013 was 5 procedures. The 90th percentile of male urethral cases was >25 procedures for all four years.

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For male penis/incontinence cases, residents reported a weighted mean of 45.5 (SD 22.7) cases for the minimum requirement of 10 cases, with the 10th percentile ranging from 19 to 23 cases throughout the study period. During this time, the 10th percentile of “surgeon” case volumes for

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female reconstructive surgeries ranged from 16 to 17 cases, prostatectomies from 25 to 33 cases, cystectomies from 10 to 12 cases, and for kidney surgeries from 42 to 44 cases. The ACGME

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minimum required number of cases for these index categories were 15, 25, 8, and 30, respectively.

As “assistant,” residents reported weighted means of 1.5 (SD 3.5) male urethral cases and of 3.6

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(SD 5.5) male penis/incontinence cases. As “teaching assistant,” residents reported weighted means of 0.2 (SD 1.0) male urethral cases and of 1.5 (SD 3.0) male penis/incontinence cases.

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DISCUSSION

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Percentile benchmarks for “assistant” and “teaching assistant” cases are reported in Tables 2 and

In this review, the ACGME case log reports from 2009 to 2013 were analyzed to assess the exposure of urology residents in the United States to male urethral and male penis/incontinence surgical cases. The majority of residents were found to meet the ACGME minimum requirement of 5 male urethral cases, with a weighted mean of 12.7 cases (SD 9) and median ranging from 9

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to 11 cases across the four academic years as “surgeon.” However, an average of 26 urology residents graduate per year with inadequate exposure to urethral cases, even when incorporating the cases logged as “assistant” and “teaching assistant.” Of all the index categories reported by

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residents to the ACGME, male urethral surgery was the only to have its 10th percentile benchmark consistently at or below the minimum requirement. Exposure to male penis/incontinence cases, in contrast, was well above the requirement of 10 cases throughout the

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study period, with the 10th percentile ranging from 19 to 23 cases.

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The value of procedures in which the resident is listed as “assistant” and “teaching assistant” cannot be overlooked. Critical engagement by the resident as the active “surgeon” increases competence and confidence to perform the procedure independently after graduating. However, even merely watching or assisting in parts of a case can help a resident understand the steps of a

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procedure and the thought process when a complication is encountered. This is acknowledged by the ACGME, who credits resident participation as an index case whether the resident functions as the “surgeon,” “assistant,” or “teaching assistant.”16 When a resident becomes a “surgeon” for

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the case, however, he or she engages in a more active role, completing >50% of the case under

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the direction of a skilled attending surgeon.

Case volume, though an important metric for standardization of training, is but one component in the achievement of competence in surgical performance. In its “Case Log Information” guide, the ACGME recognizes the role of the program director of “taking into account each resident’s particular abilities” in tailoring the comprehensive experience of each trainee.16 For this purpose, the ACGME’s list of minimum procedures is only a fraction of the total minimum number of

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procedures required for accreditation purposes to allow flexibility in each resident’s surgical experience based on their strengths and weaknesses. Measures of resident competence by case volume, therefore, must be supplemented with the unique learning curve of each resident for

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each particular procedure.

For urethroplasties alone, the different types of reconstruction have been shown to involve

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distinct learning curves, though most studies’ findings are confounded by patient selection, choice of surgical techniques, patient population, and surgeon skill. Anastomotic urethroplasty

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appears to be a simpler procedure that does not require significant experience, as suggested by Barbagli and colleagues’ study. In this retrospective analysis of 153 patients who underwent anastomotic urethroplasty for bulbar urethral strictures, the first 25 cases of the learning curve had a similar success rate to the last 25 cases (92% vs. 88%, respectively).17 This is in contrast to

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the same group’s findings concerning augmented anastomotic repairs, in which the success rate of augmented anastomotic repairs with preputial skin grafts (PSG) (33.3%) was lower than that of dorsal oral mucosal grafts (79.2%). Although factors intrinsic to the nature of these grafts

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likely contributed to the different outcomes, the authors of the study speculated that PSG repairs being performed earlier in the learning curve also had a significant impact within this series.18

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The effect of a learning curve has also been shown with substitution urethroplasties by Fall and colleagues. Their prospective, single-center study of 75 patients reported a particularly low success rate with Quartey’s and Blandy’s techniques (23.7% and 25.0%, respectively) compared to the literature, which they attributed to incorrect technical implementation by the center’s less experienced surgeons. In fact, the success rate of urethroplasties performed by younger surgeons with fewer than 3 years experience was significantly lower than that of their more experienced

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colleagues (53.7% vs. 81.0%, p=0.02).19 In light of the literature, some have suggested that urethroplasty

procedures

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reserved

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with

established

post-

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fellowship/clinical experience in reconstructive urological surgery.20

However, seeking better success rates by referrals to higher-volume or fellowship-trained urologists must be considered within the context of the general underutilization of urethroplasty

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compared to dilation or urethrotomy.6-9 Investigation into the etiologies of this trend is sparse, but one survey by Bullock and Brandes revealed that most urologists erroneously believe that

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urethoplasty is only indicated after repeat failure with endoscopic methods.8 The authors also suggested that urologists’ unfamiliarity with current urethroplasty techniques, the inability to maintain operative skills due to insufficient number of cases, and financial disincentives to perform urethroplasty may be to blame. This reveals the compounding problem between case

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volume and surgeons’ attitudes, as reluctance to perform the procedure due to insufficient volume only decreases the case numbers needed to maintain the confidence in operative skills. The solution may be to emphasize urethroplasty training during residency, and in this respect

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there has been an encouraging trend: certifying urologists are three times more likely to perform

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urethroplasty for urethral strictures than older recertifying urologists.9

Though the current study reveals that the vast majority of residents exceed the ACGME minimum requirement for male penis/incontinence cases, the literature suggests that competence in these cases may not be achieved by the minimum of 10 cases. Additionally, this category is inclusive of both penile and AUS cases, so the true number of each is not known, potentially overestimating the actual number of AUS cases completed. Specifically for AUS implantations,

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Sandhu and colleagues showed the absence of a plateau in reoperation rates through 200 procedures.21 A more modest learning curve was reported by Lai and Boone, whose single surgeon series revealed a significant decrease in complication and reoperation rates after 25

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cases of virgin AUS placements.12 In either instance, the surgical learning curve for AUS implantation alone (25 cases) exceeds the ACGME minimum requirement for all male

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penis/incontinence cases in total (10 cases).

The failure of 10 percent of residents to meet the ACGME minimum for male urethral cases, the

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underutilization of urethroplasty in practice, and the substantial learning curve for AUS implantations highlight the need to increase the number of these procedures in residency training or specialized post-graduate training programs. Currently, there are few programs that provide exclusive male incontinence fellowship level training, and further training in male urethral cases

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can be developed in fellowships including reconstruction/trauma or oncology.

The current study involved a few limitations. First, the resident case logs are self-reported, which

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may bias the case numbers upwards in order for residents to meet the minimum number of procedures required for graduation. However, this would suggest that the reported case logs are

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an overestimate of the actual cases performed, which would only support the conclusion that resident exposure to these index categories is insufficient. Second, as addressed before, case volume in itself is not a comprehensive measure of ability, as an inadequate volume for one resident may be sufficient for another to achieve competence in a particular operation. In addition, the types of procedures could not be specified beyond the index categories outlined by the ACGME Case Log.16 Even so, about 10 percent of residents did not meet the ACGME

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requirement for male urethral cases and many did not achieve the learning curve in the literature for AUS implantation even with their case volume for all male penis/incontinence cases. Also, the types of procedures could not be specified beyond the index categories assigned by the

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ACGME. We have provided a sample of the most common CPT codes per index category, but the case volumes for individual CPT codes were not available. Lastly, the case logs do not contain resident-level data, such as their respective training programs, preventing any

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investigation into the predictors of inadequate case volumes.

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CONCLUSION

This study reports two important findings concerning the case volumes of U.S. urology residents as reported to the ACGME. About 10 percent of residents failed to meet the ACGME minimum

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requirement for the case volume of male urethral surgeries. Also, the 10th percentile of residents performed twice the number of male penis/incontinence cases as required by the ACGME, but the ACGME minimum may be insufficient in light of the literature on the learning curve for

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these cases. These findings highlight the urgent need to increase the case volume for these

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procedures during residency and to bolster the postgraduate training available in these fields.

REFERENCES

1. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27. 2. Hu JC, Gold KF, Pashos CL, Mehta SS, Litwin MS. Role of surgeon volume in radical prostatectomy outcomes. J Clin Oncol 2003;21:401-5. 3. Nuttall M, Meulen JVD, Phillips N, et al. A systematic review and critique of the literature relating hospital or surgeon volume to health outcomes for 3 urological cancer procedures. J Urol 2004;172:2145-52.

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4. Konety BR, Dhawan V, Allareddy V, Joslyn SA. Impact of hospital and surgeon volume on in-hospital mortality from radical cystectomy: data from the Health Care Utilization Project. J Urol 2005;173:1695-1700. 5. Leow JJ, Reese S, Trinh QD, et al. Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population-based analysis. BJU Int 2015;115:713-21. 6. Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol 2007;177:166774. 7. Anger JT, Scott VC, Sevilla C, Wang M, Yano EM. Patterns of management of urethral stricture disease in the Veterans Affairs System. Urology 2011;78:454-8. 8. Bullock TL, Brandes SB. Adult anterior urethral strictures: a national practice patterns survey of board certified urologists in the United States. J Urol 2007;177:685-90. 9. Burks FN, Salmon SA, Smith AC, Santucci RA. Urethroplasty: a geographic disparity in care. J Urol 2012;187:2124-7. 10. Greenwell TJ, Castle C, Andrich DE, MacDonald JT, Nicol DL, Mundy AR. Repeat urethrotomy and dilation for the treatment of urethral stricture are neither clinically effective nor cost-effective. J Urol 2004;172:275-7. 11. Rourke KF, Jordan GH. Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture. J Urol 2005;173:1206-10. 12. Lai HH, Boone TB. The surgical learning curve of artificial urinary sphincter implantation: implications for prosthetic training and referral. J Urol 2013;189:1437-43. 13. Mamut AE, Afshar K, Mickelson JJ, Macneily E. Surgical case volume in Canadian urology residency: a comparison of trends in open and minimally invasive surgical experience. J Endourol 2011;25:1063-7. 14. Hoag NA, Flannigan R, Macneily AE. Organ procurement surgery as a means of increasing open surgical experience during urology residency training. Can Urol Assoc J 2014;8:36-8. 15. Gunter JW 3rd, Simmons JD, Mitchell ME, Ahmed N. A solution to the decreased resident exposure to open operations in the era of minimally invasive surgery and restricted duty hours may be with organ procurement and transplantation surgery. J Surg Educ 2012;69:575-9. 16. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/480-UrologyCase-Log-Info_.pdf. Accessed March 13, 2015. 17. Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term followup of bulbar end-toend anastomosis: a retrospective analysis of 153 patients in a single center experience. J Urol 2007;178:2470-3. 18. Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients. Eur Urol 2008;53:828-33. 19. Fall B, Sow Y, Diallo Y, et al. Urethroplasty for male urethral strictures: Experience from a national teaching hospital in Senegal. Afr J Urol 2014;20:76-81. 20. Andrich DE, Mundy AR. A Fellowship programme in reconstructive urological surgery: what is it and what is it for? BJU Int 2010;106:108-11. 21. Sandhu JS, Maschino AC, Vickers AJ. The surgical learning curve for artificial urinary sphincter procedures compared to typical surgeon experience. Eur Urol 2011;60:1285-90.

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Table 1. Percentile benchmarks of program averages for cases logged as “surgeon” with ACGME minimum requirements for select index categories. *At or below the minimum requirement.

Male urethra Male penis/incontinence Female 10th 30th 50th 70th 90th 10th 30th 50th 70th 90th 10th 30th 50th 70th 90th 4* 6 9 14 25 22 32 40 52 78 16 24 36 51 82 5* 7 10 15 25 19 29 40 52 73 17 27 37 52 89 5* 7 11 15 26 23 32 40 53 77 17 25 35 48 84 5* 7 11 16 26 21 33 43 57 74 16 24 33 44 79

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Year 09-10 10-11 11-12 12-13 ACGME Min. Req.

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RECONSTRUCTIVE SURGERY

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10 11 10 12 11

Pelvic - bladder Pelvic - prostate th th th th th 30 50 70 90 10 30th 50th 70th 17 23 30 55 33 54 74 95 17 22 30 47 33 54 71 92 16 23 32 48 30 50 77 97 16 22 31 45 25 47 66 86

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Year 09-10 10-11 11-12 12-13 ACGME Min. Req.

th

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ONCOLOGY

25

th

90 144 144 149 133

Retroperitoneal - kidney 10th 30th 50th 70th 90th 42 60 73 87 128 42 58 73 89 121 42 60 75 90 117 44 60 72 87 121

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Table 2. Percentile benchmarks of program averages for cases logged as “assistant” with ACGME minimum requirements for male urethra and male penis/incontinence categories. Male urethra

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10th 30th 50th 70th 90th 10th 30th 50th 70th 90th 0 0 1 2 4 0 0 2 5 10 0 0 0 1 4 0 0 1 4 11 0 0 0 1 3 0 0 2 3 7 0 0 0 1 4 0 0 1 4 10

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Year 09-10 10-11 11-12 12-13 ACGME Min. Req.

Male penis/incontinence

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Table 3. Percentile benchmarks of program averages for cases logged as “teaching assistant” with ACGME minimum requirements for male urethra and male penis/incontinence categories. Male urethra

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10th 30th 50th 70th 90th 10th 30th 50th 70th 90th 0 0 0 0 0 0 0 0 1 3 0 0 0 0 1 0 0 0 1 4 0 0 0 0 1 0 0 0 2 5 0 0 0 0 1 0 0 1 2 6

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Year 09-10 10-11 11-12 12-13 ACGME Min. Req.

Male penis/incontinence