A 5-year audit of trainees experience and outcomes with two-stage hypospadias surgery

The results of a 5-year audit of trainee plastic surgeons' experience and outcomes with two-stage hypospadias surgery are presented. Between June 1991 and October 1996, 87 patients had at least one of their operations performed by trainees; 79 patients had completed their surgery and were available for study. All patients underwent two-stage hypospadias correction; median duration of follow-up was 707 days. 69.5% of patients required correction of glans tilt and/or chordee correction; a small meatus was present in 62%. Trainees performed 73.2% of the first stage surgery (23.2% supervised by the consultant and 50% as most senior surgeon). The total complication rate for the first stage was 6.1%; the complications were: residual chordee and/or insufficient skin graft take (4 cases) and haematoma (1 case). Trainees performed 58.2% of the second stage surgery (24.1% supervised by the consultant and 34.2% as most senior surgeon). The fistula rate for the trainee stage 2 cases was 15.2% and the stricture rate 4.3%. All fistulae and strictures were successfully treated by one additional procedure. Complications rates for the first stage were similar between grades; consultant 4.5%; supervised trainee 5.3% and unsupervised trainee 7.3%. However, unsupervised trainees had a much higher complication rate for the second stage: 29.6%, versus consultant 3.0% and supervised trainee 5.3%. These complication rates represent the cumulative learning curve of 17 trainee surgeons. Outcomes for two individual trainees after the same number of cases (47) were studied further. These trainees had the highest and lowest complication rates for the procedure; 24% versus 9%. These figures might better reflect the range of the learning curve of this procedure. A major difference between these two trainees was the time taken to accrue 47 cases; 15 months versus 25. In the former case this concentration of training was felt to be beneficial. Further analysis of one trainee's results suggested that complications occur early in the learning curve and with appropriate supervision acceptable complication rates can be achieved.