- Email: [email protected]
Learning to Fly
EUROPEAN UROLOGY 69 (2016) 691–692
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 686–690 of this issue
Learning to Fly There’s no sensation to compare with this Suspended animation, a state of bliss—Pink Floyd Fabio Castiglione, Michael S. Floyd Jr., Frank Van der Aa, Steven Joniau * Department of Urology, University Hospitals Leuven, Leuven, Belgium
At the beginning of the 21st century, treatment of urethral stricture disease still remains a niche in the field of urology, the prerogative of a few surgeons. Conservative therapies lack efficacy, while various interventional options have been explored with mixed success rates [1]. In terms of surgical treatment, [1_TD$IF]multiple modalities such as urethral dilatation, internal urethrotomy, stent application, and open reconstructive surgery are available to the urologist [1]. Reconstructive urethral surgery has attracted increasing attention during the last two decades owing to its superior outcomes, especially for recurrent urethral strictures [2–4]. However, the learning process for urethral reconstructive surgery requires complex and specialised training, limiting its practice to expert surgeons in highvolume centres. This scenario is rendered even more complex by the heterogeneity of surgical techniques now available, including fasciocutaneous flaps, buccal or skin grafts, and excision and primary anastomosis (EPA), without any scientific proof of superiority of any one of them [1,5]. Furthermore, each technique is characterised by technical tips and tricks that can heavily influence the functional outcome of the procedure. It is clear from this background that the learning process for reconstructive urethral surgery is of utmost importance, and thus a urethral surgeon should be able to perform several techniques with the same dexterity and attain good outcomes. In this issue of European Urology, Fossati et al [6] evaluate the surgical learning curve for one-stage anterior urethroplasty using free grafts. The authors analysed the 20-yr experience of a well-known surgeon, Professor Guido Barbagli, who is considered one of the eminent experts in urethral stricture surgery worldwide. In addition to being
the first study exploring the learning curve for urethral surgery, this paper has important additional strengths. First, all patients were treated by a single surgeon with considerable experience. Second, the median follow-up is just <6 yr and the period in which the majority of failures occur is within the first 5 yr [4]. Finally, the success rate reported is in line with other similar series from renowned institutions [2–4]. The results of the study are intriguing in that they suggest that the learning curve for urethral reconstructive surgery is never-ending, without reaching a plateau even after 600 cases. According to these results, reconstructive urethral surgery should remain the remit of those few surgeons who have the opportunity to operate on a large number of patients considering the low incidence of the disease in western countries (0.9%) [1]. Although the study represents a milestone in the urethral reconstruction literature and is laudable for addressing the learning curve for this intricate surgery, the conclusions arising from this analysis are difficult to interpret. We think that in the surgical field ‘‘heaven is being perfect’’; however, urethral surgery cannot be considered the prerogative of only a few Jonathan Livingston Seagulls [7]. In our opinion, the conclusions of this study could have been affected by several limitations that may impede reaching a plateau in the learning curve. It is not clear why the authors excluded patients who underwent EPA from the analysis. As a procedure, EPA remains the gold standard treatment for bulbar strictures of less than 3 cm in length [1–4]. Surprisingly, more than 40% of the last 200 cases in the series analysed involved a stricture of < 3 cm [6]. The authors justified the exclusion by stating that ‘‘a learning curve study should be focused on
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.09.023. * Corresponding author. Department of Urology, KU Leuven-UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel. +32 16 346930; Fax: +32 16 346930. E-mail address: [email protected] (S. Joniau). http://dx.doi.org/10.1016/j.eururo.2015.10.003 0302-2838/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
692
EUROPEAN UROLOGY 69 (2016) 691–692
a highly specific and standardized procedure’’. To support their argument, Fossati et al compared their analysis with studies exploring the learning curve for radical prostatectomy (RP) [8]. They argue that in these studies, male radical cystectomies are excluded from the analysis despite that fact that this procedure shares important steps with RP. However, we think that this argument is not valid, as the endpoints for the RP learning curve are the rates of positive margins, continence, potency, and disease-free recurrence. Radical resection of the prostate in male cystoprostatectomy is a completely different procedure when compared to RP for organ-confined disease, in which careful attention to surgical resection is directly related to the aforementioned endpoints. In our opinion, EPA shares many more features with one-stage substitution bulbar urethroplasty, in terms of endpoints, than a radical cystoprostatectomy does with a RP. The approaches, including urethral dissection, tissue handling, and attention to detail regarding mucosa-mucosal contact, are similar. Therefore, EPA procedures should have been included in this series by Fossati et al, as this could have influenced the shape of the learning curve reported. A further criticism is the number of cases that were performed year on year. The series presented is a selection of one-stage urethroplasties from 20-yr experience in a single institution by a sole operator. Thus, in theory the surgeon performed 32 such cases per year, equating to an average of three cases per month. However, we hypothesise that the number of procedures performed each year has grown and that the number of procedures in the last year was far greater than the number performed in the first years of the surgeon’s career. From this point of view, the frequency of performing the procedure may be another reason why the learning curve did not reach a plateau [9]. A limitation of the study is the endpoint chosen by the authors. Undoubtedly, treatment failure, defined as any postoperative intervention, represents the most widely used and validated endpoint in the literature. However, this does not mean that it should be the only endpoint taken into account. This is particularly relevant for a type of surgery that has the intention to restore a physiological function and can potentially impair sexual function. Therefore, a trifecta endpoint that measures erectile function recovery
as well as quality of life would perhaps have been more appropriate [10]. Finally, the analysis did not take into account improvements in the field of reconstructive urethral surgery over the last 20 yr. These improvements could in part explain the higher success rate for the later cases. Importantly, a large proportion of these improvements were realised by the surgeon whose learning curve was analysed. In our opinion, it would be interesting to validate these findings by analysing the learning curve of a surgeon who started his career 15 yr after Professor Barbagli and who is not considered one of the ‘‘white seagulls’’ [7] of urethral surgery. Conflicts of interest: The authors have nothing to disclose.
References [1] Hampson LA, McAninch JW, Breyer BN. Male urethral strictures and their management. Nat Rev Urol 2014;11:43–50. [2] Chapple C, Andrich D, Atala A, et al. SIU/ICUD Consultation on Urethral Strictures: The management of anterior urethral stricture disease using substitution urethroplasty. Urology 2014;83(3 Suppl):S31–47. [3] Morey AF, Watkin N, Shenfeld O, et al. SIU/ICUD Consultation on Urethral Strictures: Anterior urethra—primary anastomosis. Urology 2014;83(3 Suppl):S23–6. [4] Barbagli G, Kulkarni SB, Fossati N, et al. Long-term follow up and deterioration rate of anterior substitution urethroplasty. J Urol 2014;192:808–13. [5] Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031–41. [6] Fossati N, Barbagli G, Larcher A, et al. The surgical learning curve for one-stage anterior urethroplasty: a prospective single-surgeon study. Eur Urol 2016;69:686–90. [7] Bach R. Jonathan Livingston seagull: a story. London: Macmillan; 1970. [8] Vickers AJ, Bianco FJ, Serio AM, et al. The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst 2007;99:1171–7. [9] Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single highvolume center. Circulation 2013;128:483–91. [10] Angermeier KW, Rourke KF, Dubey D, et al. SIU/ICUD Consultation on Urethral Strictures: Evaluation and 2014;83(3 Suppl):S8–17.
follow-up. Urology
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 686–690 of this issue
Learning to Fly There’s no sensation to compare with this Suspended animation, a state of bliss—Pink Floyd Fabio Castiglione, Michael S. Floyd Jr., Frank Van der Aa, Steven Joniau * Department of Urology, University Hospitals Leuven, Leuven, Belgium
At the beginning of the 21st century, treatment of urethral stricture disease still remains a niche in the field of urology, the prerogative of a few surgeons. Conservative therapies lack efficacy, while various interventional options have been explored with mixed success rates [1]. In terms of surgical treatment, [1_TD$IF]multiple modalities such as urethral dilatation, internal urethrotomy, stent application, and open reconstructive surgery are available to the urologist [1]. Reconstructive urethral surgery has attracted increasing attention during the last two decades owing to its superior outcomes, especially for recurrent urethral strictures [2–4]. However, the learning process for urethral reconstructive surgery requires complex and specialised training, limiting its practice to expert surgeons in highvolume centres. This scenario is rendered even more complex by the heterogeneity of surgical techniques now available, including fasciocutaneous flaps, buccal or skin grafts, and excision and primary anastomosis (EPA), without any scientific proof of superiority of any one of them [1,5]. Furthermore, each technique is characterised by technical tips and tricks that can heavily influence the functional outcome of the procedure. It is clear from this background that the learning process for reconstructive urethral surgery is of utmost importance, and thus a urethral surgeon should be able to perform several techniques with the same dexterity and attain good outcomes. In this issue of European Urology, Fossati et al [6] evaluate the surgical learning curve for one-stage anterior urethroplasty using free grafts. The authors analysed the 20-yr experience of a well-known surgeon, Professor Guido Barbagli, who is considered one of the eminent experts in urethral stricture surgery worldwide. In addition to being
the first study exploring the learning curve for urethral surgery, this paper has important additional strengths. First, all patients were treated by a single surgeon with considerable experience. Second, the median follow-up is just <6 yr and the period in which the majority of failures occur is within the first 5 yr [4]. Finally, the success rate reported is in line with other similar series from renowned institutions [2–4]. The results of the study are intriguing in that they suggest that the learning curve for urethral reconstructive surgery is never-ending, without reaching a plateau even after 600 cases. According to these results, reconstructive urethral surgery should remain the remit of those few surgeons who have the opportunity to operate on a large number of patients considering the low incidence of the disease in western countries (0.9%) [1]. Although the study represents a milestone in the urethral reconstruction literature and is laudable for addressing the learning curve for this intricate surgery, the conclusions arising from this analysis are difficult to interpret. We think that in the surgical field ‘‘heaven is being perfect’’; however, urethral surgery cannot be considered the prerogative of only a few Jonathan Livingston Seagulls [7]. In our opinion, the conclusions of this study could have been affected by several limitations that may impede reaching a plateau in the learning curve. It is not clear why the authors excluded patients who underwent EPA from the analysis. As a procedure, EPA remains the gold standard treatment for bulbar strictures of less than 3 cm in length [1–4]. Surprisingly, more than 40% of the last 200 cases in the series analysed involved a stricture of < 3 cm [6]. The authors justified the exclusion by stating that ‘‘a learning curve study should be focused on
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2015.09.023. * Corresponding author. Department of Urology, KU Leuven-UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel. +32 16 346930; Fax: +32 16 346930. E-mail address: [email protected] (S. Joniau). http://dx.doi.org/10.1016/j.eururo.2015.10.003 0302-2838/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
692
EUROPEAN UROLOGY 69 (2016) 691–692
a highly specific and standardized procedure’’. To support their argument, Fossati et al compared their analysis with studies exploring the learning curve for radical prostatectomy (RP) [8]. They argue that in these studies, male radical cystectomies are excluded from the analysis despite that fact that this procedure shares important steps with RP. However, we think that this argument is not valid, as the endpoints for the RP learning curve are the rates of positive margins, continence, potency, and disease-free recurrence. Radical resection of the prostate in male cystoprostatectomy is a completely different procedure when compared to RP for organ-confined disease, in which careful attention to surgical resection is directly related to the aforementioned endpoints. In our opinion, EPA shares many more features with one-stage substitution bulbar urethroplasty, in terms of endpoints, than a radical cystoprostatectomy does with a RP. The approaches, including urethral dissection, tissue handling, and attention to detail regarding mucosa-mucosal contact, are similar. Therefore, EPA procedures should have been included in this series by Fossati et al, as this could have influenced the shape of the learning curve reported. A further criticism is the number of cases that were performed year on year. The series presented is a selection of one-stage urethroplasties from 20-yr experience in a single institution by a sole operator. Thus, in theory the surgeon performed 32 such cases per year, equating to an average of three cases per month. However, we hypothesise that the number of procedures performed each year has grown and that the number of procedures in the last year was far greater than the number performed in the first years of the surgeon’s career. From this point of view, the frequency of performing the procedure may be another reason why the learning curve did not reach a plateau [9]. A limitation of the study is the endpoint chosen by the authors. Undoubtedly, treatment failure, defined as any postoperative intervention, represents the most widely used and validated endpoint in the literature. However, this does not mean that it should be the only endpoint taken into account. This is particularly relevant for a type of surgery that has the intention to restore a physiological function and can potentially impair sexual function. Therefore, a trifecta endpoint that measures erectile function recovery
as well as quality of life would perhaps have been more appropriate [10]. Finally, the analysis did not take into account improvements in the field of reconstructive urethral surgery over the last 20 yr. These improvements could in part explain the higher success rate for the later cases. Importantly, a large proportion of these improvements were realised by the surgeon whose learning curve was analysed. In our opinion, it would be interesting to validate these findings by analysing the learning curve of a surgeon who started his career 15 yr after Professor Barbagli and who is not considered one of the ‘‘white seagulls’’ [7] of urethral surgery. Conflicts of interest: The authors have nothing to disclose.
References [1] Hampson LA, McAninch JW, Breyer BN. Male urethral strictures and their management. Nat Rev Urol 2014;11:43–50. [2] Chapple C, Andrich D, Atala A, et al. SIU/ICUD Consultation on Urethral Strictures: The management of anterior urethral stricture disease using substitution urethroplasty. Urology 2014;83(3 Suppl):S31–47. [3] Morey AF, Watkin N, Shenfeld O, et al. SIU/ICUD Consultation on Urethral Strictures: Anterior urethra—primary anastomosis. Urology 2014;83(3 Suppl):S23–6. [4] Barbagli G, Kulkarni SB, Fossati N, et al. Long-term follow up and deterioration rate of anterior substitution urethroplasty. J Urol 2014;192:808–13. [5] Andrich DE, Mundy AR. What is the best technique for urethroplasty? Eur Urol 2008;54:1031–41. [6] Fossati N, Barbagli G, Larcher A, et al. The surgical learning curve for one-stage anterior urethroplasty: a prospective single-surgeon study. Eur Urol 2016;69:686–90. [7] Bach R. Jonathan Livingston seagull: a story. London: Macmillan; 1970. [8] Vickers AJ, Bianco FJ, Serio AM, et al. The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst 2007;99:1171–7. [9] Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single highvolume center. Circulation 2013;128:483–91. [10] Angermeier KW, Rourke KF, Dubey D, et al. SIU/ICUD Consultation on Urethral Strictures: Evaluation and 2014;83(3 Suppl):S8–17.
follow-up. Urology