Defining the Learning Curve for Transobturator Tape Surgery: A Prospective LC-CUSUM Study of Surgical Competency...

The objective of this study was to apply the Learning Curve-Cumulative Summation (LC-CUSUM) method to objectively evaluate the learning curve and competency acquisition of surgical trainees performing transobturator tape (TOT) surgery for the treatment of stress urinary incontinence (SUI).

This prospective observational study followed two board-certified specialists with no prior experience in mid-urethral sling procedures. A total of 80 consecutive TOT operations (40 per trainee) were analyzed. Before practicing independently, trainees completed a structured three-stage program: a theoretical course, hands-on cadaveric dissection, and individualized mentorship. Surgical performance was monitored using the LC-CUSUM test, with a predefined acceptable failure rate of 5% and an unacceptable rate of 10%.

LC-CUSUM analysis showed that the competency threshold was achieved after the 21st procedure for Trainee 1 and after the 11th procedure for Trainee 2. Notably, Trainee 1 operated on patients with a significantly higher mean Body Mass Index (31.8 vs. 27.0 kg/m²), which contributed to longer operative times (84.2 vs. 51.6 min) and a higher rate of de novo urgency (10% vs. 0%). Overall complication rates were low in both groups, and both trainees maintained stable performance once proficiency was reached.

The learning curve for TOT surgery is relatively short, with competency typically acquired within 11-21 cases. The LC-CUSUM method serves as a robust and individualized tool for monitoring surgical performance, supporting a shift from traditional volume-based requirements to objective, competency-based training models. Structured educational frameworks, including cadaveric training and mentorship, are essential for ensuring patient safety during the skill acquisition phase.