Analysis of the surgical learning curve using the cumulative sum (CUSUM) method.

AIMS: The concept of the "learning curve" is a term that has become increasingly prevalent in medical literature. Using a unique Female Urology fellowship program running over the last 3 years, we set out to better define the learning process for mid-urethral slings. METHODS: We examined surgical outcomes for six urology trainees who participated in the 6-month program from 2006 to 2011. We identified all retropubic mid-urethral sling procedures they had performed. Demographics included age, BMI, and smoking status. Outcomes focused on complication rates, as well as a subjective patient assessment. Analysis was by the cumulative sum method. RESULTS: Six trainees performed 187 retropubic slings during their fellowships. Mean age was 54 (SD ± 12.7), mean BMI was 29.5 (SD ± 5.5). One hundred sixty-five (88%) patients only underwent a mid-urethral tape with 22 (12%) undergoing a concomitant procedure. There were 5 cases of bladder perforation, 1 case of urethral injury, 25 cases of voiding dysfunction, and 8 cases of mesh exposure. One hundred sixty-seven out of 180 patients reported a cure or improvement. All complications occurred in the first 4 months of training. CUSUM analysis of voiding dysfunction showed that four out of six trainees did not reach the expected incidence of voiding dysfunction within the completed fellowship. Bladder perforation showed a similar trend. CONCLUSION: CUSUM analysis is an underused tool for the analysis of surgical competence. The learning curve for retropubic sling surgery is variable and may be longer than is often acknowledged. We suggest the focus of surgical training should move away from absolute numbers to look at training in an individualized manner.

Culturally sensitive continence care: a qualitative study among South Asian Indian women in Leicester.

BACKGROUND: Urinary incontinence is a significant health problem with potentially serious physical, psychological and social consequences. The true prevalence is difficult to ascertain, especially in hard to reach groups such as ethnic minority populations and research in this area is lacking. The UK has an increasingly diverse population, and ascertaining the needs for incontinence care among ethnic minority groups is crucial. OBJECTIVES: This study aimed to explore views and experiences of incontinence and perceptions of care among South Asian Indian women in Leicester, UK. METHODS: A qualitative focus group study involving four focus groups, each of six women, was undertaken. Focus groups were conducted in the participants' chosen language and facilitated by a bilingual moderator. Groups were tape-recorded, transcribed and analysed in a systematic and iterative way based on the constant comparative method. RESULTS: Women commonly normalized symptoms of urinary incontinence, attributing them to the ageing process or consequences of childbirth. Help-seeking behaviour was hindered not only by feelings of embarrassment in discussing sensitive problems, especially with male health professionals, but also the perceived embarrassment felt by doctors. Women reported a lack of available information in culturally sensitive media. Talk-based media were more highly valued than text-based media. Generational differences in help-seeking behaviour were apparent. CONCLUSIONS: This exploratory study provides valuable understanding of the continence needs of South Asian Indian women. Common needs were identified, as were important generational differences. Suggestions offered by women for the existing service improvement seemed relatively modest in terms of resources required.

Morbidity of incontinence surgery in women over 70 years old: a retrospective cohort study.

OBJECTIVE: To compare the success rate and complications after colposuspension and tension-free vaginal tape (TVT) insertion in women aged 70 years or more compared with younger women. DESIGN: A retrospective study of patients having surgery between November 2000 and October 2002. SETTING: A tertiary referral, academic urogynaecology unit in a University teaching hospital. POPULATION: Two hundred and twenty-six women having surgical treatment for urinary incontinence. METHODS: Data on cure/improvement and complications were extracted from the notes. Patients were grouped by age at surgery and the odds ratios (OR) and 95% confidence intervals (CI) for each outcome were calculated. MAIN OUTCOME MEASURES: Subjective cure rate and the incidence of complications by age group. RESULTS: One hundred and three patients had colposuspension, 11 (10.7%) aged 70 or more. One hundred and twenty-three patients had TVT insertions, 23 (18.7%) aged 70 or more. The cure rate for each procedure was similar between age groups. After colposuspension, urinary tract infection (UTI; OR 11.33; 95% CI 2.61, 49.28) and long term self-catheterisation (percentage of difference 9.1; 95% CI 3.0, 15.2) were more common in women over 70. After TVT, repeat urodynamics (OR 3.91; 95% CI 1.11, 13.76), recurrent UTI (OR 4.22; 95% CI 1.03, 17.26) and tape division (OR 29.12; 95% CI 3.20, 264.86) were more common in older women. CONCLUSIONS: Incontinence surgery carries a higher risk of complications in the elderly including UTI and voiding dysfunction. Extended antibiotic prophylaxis and intermittent self-catheterisation training should be offered to elderly women before surgery.

Objective assessment of urinary incontinence in women: comparison of the one-hour and 24-hour pad tests.

OBJECTIVE: To compare the performance and clinical usefulness of the one-hour and 24-hour pad tests in terms of the relationship with reported symptoms and urodynamic diagnosis. METHODS: 341 women aged 40 years and over reporting lower urinary tract symptoms who were recruited to a nurse led continence service, and went on to receive urodynamics, a one-hour and a 24-hour pad test and completed a urinary diary. RESULTS: For both pad tests, there was a significant difference in the amount of urine leaked between the different urodynamic diagnoses (p<0.0001, for the one-hour and p=0.001 for the 24-hour test). Women with sphincter incompetence leaked significantly more than women with detrusor instability, or those with no abnormality. There was a significant difference between the proportion of women dry on a one-hour pad test and those dry on a 24-hour pad test (26.0% versus 38.4%, difference 12.4%; CI 5.5; 19.4). There is a positive relationship between amount of urine leakage and symptom severity expressed in terms of number of incontinent episodes for both pad tests. CONCLUSION: Both pad tests bore little relationship to the underlying urodynamic diagnosis but there was a positive relationship with symptom severity. The 24-hour pad test appears to be clinically a more useful too than the one-hour test. The two types of pad test are probably assessing incontinence in different ways. We suggest that the minimum data set should include structured questions, diaries and the 24-hour pad test.