A Cognitive Task Analysis of How to Teach the Retropubic Midurethral Sling Surgery

The retropubic midurethral sling (RP-MUS) surgery poses unique training challenges due to blind trocar passage through a complex retropubic space near critical structures. A structured understanding of how experts teach these high-risk steps is essential to improve trainee learning and support safe surgical performance.

The objective of this study was to generate a comprehensive catalog of teaching techniques to lead novice surgeons through RP-MUS surgery.

Semistructured cognitive task analysis (CTA) interviews were conducted with 11 surgeons from diverse institutions who teach the RP-MUS surgical procedure. Surgeons described their step-by-step teaching process; 4 also reviewed intraoperative videos of themselves instructing trainees. All teaching steps were extracted and mapped to operative CTA steps. Inquiry focused on strategies to help trainees visualize the retropubic space, orient instruments, and optimize ergonomics. Two researchers independently extracted data; 6 researchers iteratively analyzed findings until consensus and thematic saturation was achieved.

This CTA generated 458 teaching microsteps. Categories of teaching steps identified include the following: (1) technical advice, (2) demonstrations outside the surgical field, (3) instruction on how technique changes may cause complications, (4) ergonomic guidance, and (5) high-value assist steps that optimize safety. Many strategies specifically addressed cognitive challenges, including conceptualization of the blind retropubic space.

This study presents an innovative application of CTA to systematically characterize how experts teach the RP-MUS surgical procedure. These findings provide a foundation for iterative refinement of teaching practices and future studies linking specific instructional strategies to trainee performance, teacher confidence, and patient safety.