The 'learning curve' in hypospadias surgery

To provide an insight into the 'learning curve' of fellowship-trained paediatric urologists associated with hypospadias repair, as hypospadias surgery is one of the most common yet difficult procedures used by the paediatric urologist.

Prospective data were collected on 231 consecutive hypospadias operations performed by one paediatric urologist (M.H.) over a 5-year period, beginning with his first year after completing his fellowship. All patients were having their first surgery and none had a staged repair. Fistula formation was used as a surrogate for the complication rate, as it is an objective measurable outcome that is easily identified with little interobserver or parental/physician variability. The follow-up included several visits in the 15 months after repair, during which virtually all complications could be identified and addressed.

The operative results improved throughout the 5 years of observation; there was a statistically significant decline in the fistula rate in each year of observation (P < 0.001; Kruskal-Wallis exact test for ranked groups). The absolute reduction in fistula rates between the first 2 and the last 2 years was 12.7% (P < 0.02; chi squared).

The science and surgery of hypospadiology is mostly and correctly delegated to the paediatric urologist. Even in the hands of a fellowship-trained paediatric urologist, a successful repair, as measured by complication rate, statistically improves with time and experience.