UNASSIGNED: In the use of medical device procedures, learning effects have been shown to have a significant impact on the outcome, and are a critical component of medical device safety surveillance. To support estimation of these effects, we evaluated our methods for modeling these rates within several different actual datasets representing patients treated by physicians clustered within institutions to show the flexibility of this method across applications.
UNASSIGNED: In order to estimate the learning curve effects, we employed our unique modeling for the learning curves to incorporate the learning hierarchy between institution and physicians, and then modeled them within established methods that work with hierarchical data such as generalized estimating equations (GEE). Within the actual datasets, we looked at two device types and also two procedure types which had not been observed before: off pump coronary artery bypass (CABG) experience, and radial access experience. We also tried mediation analyses within the GEE framework for these various devices/procedures as well.
UNASSIGNED: We found that the choice of shape used to produce the \"learning-free\" dataset would still be dataset specific depending upon needs for modeling fast or slow learning but that in general the power series or logarithmic shapes would be better for modeling slower learning while exponential may be better for faster learning. Mediation analysis also showed promise in adapting the modeling of the learning curve.
UNASSIGNED: In showing the flexibility of using our method in various applications; this time utilizing more than one possible procedure done per patient so that each physician had more volume, we were able to show the flexibility of applying our method in different data applications to allow for more accurately capturing the learning curve rates in physicians nested within institutions. This can, therefore, be used across the board for device and procedure safety.

BACKGROUND: We aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve.
METHODS: One hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome.
RESULTS: In total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (-0.09 case number2) + (12.88 case number) - 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications.
CONCLUSIONS: Our modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.

UNASSIGNED: The direct anterior approach (DAA) for conducting total hip arthroplasty (THA) is gaining popularity worldwide. However, careful selection of patients and surgeon experience are important. Although promising outcomes have been reported in international studies, research on DAA in Southern and Southeast Asia has been limited.
UNASSIGNED: This prospective study included 157 patients who underwent THA using the DAA between January 2019 and June 2022. The patients were divided into three groups for the comparison. Data on preoperative, intraoperative, and postoperative variables were acquired. Improvement of the surgeon\'s performance to use of a DAA approach was examined using the CUSUM (cumulative summation method).
UNASSIGNED: The mean age of the patients was 43.9 years. Differences in intraoperative variables and complications were observed among the three groups, and improved outcomes were reported in later cases. Functional outcomes showed significant improvement, and no differences were observed between groups. The results of learning curve analysis indicated a shift towards consistent success after the 82nd case, reaching an acceptable rate of failure by the 118th case.
UNASSIGNED: The findings of this study suggest that DAA can offer benefits but there is a learning curve. Complications were initially high but began decreasing after approximately 80 cases. Careful selection of patients is critical, particularly in the effort to minimize being presented with a challenging case. This study provides insights that may be helpful to surgeons when considering DAA; however, further study is warranted.

Background and Objectives: In the surgical treatment of benign prostatic hyperplasia (BPH), laser enucleation of the prostate is recommended as an alternative to transurethral resection (TURP) and open prostatectomy (OP). The thulium fiber laser, with its superficial penetration depth, can offer a rapid learning process by causing less heat injury and capsule damage. This study compares the first 60 cases of an endourologist performing thulium fiber enucleation of the prostate (ThuFLEP) without a mentor to the results of OP and TURP performed by experienced surgeons. It also identifies the case number at which the operation time for ThuFLEP starts to plateau. Materials and Methods: Between 1 November 2021 and 1 November 2023, the initial 60 ThuFLEP cases of an endourologist with no prior enucleation experience were compared with TURP and OP operations performed by experienced surgeons. Since the first 60 ThuFLEP cases involved 80-120 cc prostates, TURP and OP operations within this size range performed during the same period were included in the study. The groups were assessed for age, preoperative and postoperative prostate volume, PSA levels, the IPSS, the IPSS Quality of Life (QoL), and maximum urinary flow (Qmax). The 60 consecutive ThuFLEP cases were divided into three groups of 20 (Groups 1, 2, and 3) and compared for operation time, IPSS, and Qmax. Results: The operation time for TURP was shorter than for ThuFLEP and OP (p < 0.001). There was no significant difference between ThuFLEP and OP in postoperative Qmax and IPSS, while TURP had lower values than the other two methods. For ThuFLEP, the operation time was longer in the first 20 cases but plateaued in groups 2 and 3 (p < 0.001). Postoperative Qmax and IPSS values showed no significant differences among the three ThuFLEP groups (p > 0.05). Conclusions: For large prostates, ThuFLEP provides better postoperative results than TURP and offers shorter catheterization and hospital stay times than OP. Its short learning curve makes it a preferable method for treating BPH compared to other laser techniques.

Background and Objectives: Percutaneous nephrolithotomy (PCNL) is a current treatment method with high success rates and low complication rates in treating large kidney stones. It can be conducted in different positions, especially supine and prone positions. PCNL in the supine position is becoming increasingly common due to its advantages, such as simultaneous retrograde intervention and better anesthesia management. This study aimed to assess how the choice of position impacts the PCNL learning curve. Materials and Methods: The results of the first 50 consecutive PCNL cases performed by two separate chief residents as primary surgeons in supine and prone positions in a reference center for stone treatment between August 2021 and January 2023 were evaluated. The two groups\' demographic and clinical data, stone-free rates, operation times, and fluoroscopy times were compared. Results: While the mean operation time was 94.6 ± 9.8 min in the supine PCNL group, it was 129.9 ± 20.3 min in the prone PCNL group (p < 0.001). Median fluoroscopy times in the supine PCNL and prone PCNL groups were 31 (10-89) seconds and 48 (23-156) seconds, respectively (p = 0.001). During the operation, the plateau was reached after the 10th case in the supine PCNL group, while it was reached after the 40th case in the prone PCNL group. Conclusions: For surgeons who are novices in performing PCNL, supine PCNL may offer both better results and a faster learning curve. Prospective and randomized studies can provide more robust conclusions on this subject.

Ovarian cystectomy, aimed at preserving fertility, has advanced through minimally invasive surgical techniques. This study evaluates the learning curves and surgical outcomes of three such approaches: DaVinci Robotic Single-Site (RSS), DaVinci Robotic Single-Port (RSP), and laparo-endoscopic single-site surgery (LESS). To analyze the learning curves and surgical outcomes for these techniques, providing insights into their effectiveness and proficiency development. Retrospective analysis of 104 patients with ovarian tumors, divided into RSS (n = 52), RSP (n = 22), and LESS (n = 30) groups. Metrics analyzed included age, BMI, tumor size, hemoglobin drop, operative time, docking time, console time, and tumor location. No significant differences in age, BMI, transfusion rate, hemoglobin drop, or length of stay were found among the groups. RSS had larger tumors on average, and LESS had a higher occurrence rate on the right side. LESS demonstrated the shortest operative time, while RSS and RSP had comparable times. Docking and console times did not differ significantly between RSS and RSP. RSP reached proficiency faster than RSS in docking and console times, while LESS exhibited the greatest variability in operative time. RSP offers a faster and more consistent learning curve, making it advantageous for complex procedures, whereas LESS provides shorter operative times but with higher variability. These findings are crucial for surgical training and resource allocation in medical institutions.

OBJECTIVE: Oblique lumbar interbody fusion (OLIF) still has a steep learning curve that many spinal surgeons who want to develop are hesitant. The purpose of this study is to provide reference for beginners through the comparative analysis of the application of two kinds of retraction devices in the early stage of learning curve.
METHODS: We prospectively included the first 60 patients with lumbar degenerative diseases treated with OLIF by a surgeon in our department. According to the application of different retraction devices during the operation, the patients were divided into hook retractor group and tubular retractor group. The clinical effects and complications of the two groups were compared.
RESULTS: The average age of hook retractor group was 62 years old, the average age of tubular retractor group was 65 years old. There was no significant difference in age, sex, operative segment, follow-up time and blood loss between the two groups. The operation time in hook retractor group was less than that in tubular retractor group. The incidence of complications in hook retractor group (11.8%) was significantly lower than that in tubular retractor group (38.5%).
CONCLUSIONS: The tubular retractor group has a higher risk of neurovascular injury in the initial stage of learning, as well as the risk of vertebral fracture. In contrast, the hook retractor group has the advantages of simple method, high fault tolerance and relatively low incidence of complications. Therefore, we believe that the application of hook retractor in the early stage of OLIF learning curve is easier to increase the operator\'s confidence and make OLIF more acceptable.

UNASSIGNED: The deep inferior epigastric artery perforator (DIEP) free flap is the gold-standard for breast reconstruction but is technically demanding, resource intensive and time-consuming, making it a daunting task for the junior surgeon.
UNASSIGNED: To report the lessons learnt from the experience of a single surgeon performing their first 150 DIEP reconstructions as a guide for junior surgeons.
UNASSIGNED: Data regarding patient demographics and surgical outcomes from April 2021 to October 2022 were collected retrospectively from medical records. Surgical outcomes were analysed using Microsoft Excel.
UNASSIGNED: Over 17 months, 150 flaps were completed in 97 patients by the senior author (BS). Operative duration was negatively correlated with case number for unilateral DIEPs (r = -0.73, p < 0.05) and for bilateral DIEPs (r = -0.67, p = 0.14). Raise time and ischaemic time were also negatively correlated with case number (r = -0.82, p < 0.05 and r = -0.79, p < 0.05, respectively). There were 10 complications and no flap losses.
UNASSIGNED: The data demonstrate an expected improvement in surgical efficiency with increased experience. We describe the key factors contributing to efficiency in our series, such as preoperative CT angiography, surgical markings prior to the day of surgery, a two-team approach with three diathermy sets, flap raise using monopolar diathermy, preference towards choosing a single dominant perforator and early commitment to perforator choice. This case series acts as a guide for the junior plastic surgeon in achieving safe, aesthetic and efficient results when completing free DIEP flap breast reconstructions.

UNASSIGNED: Recently, an innovative tool called \"proficiency score\" was introduced to assess the learning curve for robot-assisted radical prostatectomy (RARP). However, the initial study only focused on patients with low-risk prostate cancer for whom pelvic lymph node dissection (PLND) was not required. To address this issue, we aimed to validate proficiency scores of a contemporary multicenter cohort of patients with high-risk prostate cancer treated with RARP plus extended PLND by trainee surgeons.
UNASSIGNED: Between 2010 and 2020, 4 Italian institutional prostate-cancer datasets were merged and queried for \"RARP\" and \"high-risk prostate cancer.\" High-risk prostate cancer was defined according to the most recent European Association of Urology guidelines as follows: prostate-specific antigen >20 ng/mL, International Society of Urological Pathology ≥4, and/or clinical stage (cT) ≥ 2c on preoperative imaging. The selected cohort (n = 144) included clinical cases performed by trainee surgeons (n = 4) after completing their RARP learning curve (50 procedures for low-risk prostate cancer). The outcome of interest, the proficiency score, was defined as the coexistence of all the following criteria: a comparable operation time to the interquartile range of the mentor surgeon at each center, absence of any significant perioperative complications Clavien-Dindo Grade 3-5, no perioperative blood transfusions, and negative surgical margins. A logistic binary regression model was built to identify the predictors of 1-year trifecta achievement in the trainee cohort. For all statistical analyses, a 2-sided p < 0.05 was considered significant.
UNASSIGNED: A proficiency score was achieved in 42.3% patients. At univariable level, proficiency score was associated with 1-year trifecta achievement (odds ratio, 8.77; 95% confidence interval, 2.42-31.7; p = 0.001). After multivariable adjustments for age, nerve-sparing, and surgical technique, the proficiency score independently predicted 1-year trifecta achievement (odds ratio, 9.58; 95% confidence interval, 1.83-50.1; p = 0.007).
UNASSIGNED: Our findings support the use of proficiency scores in patients and require extended PLND in addition to RARP.

Robotic surgery has undergone much development and increased use over the years; it has offered many benefits for the operating surgeon compared to the more restrictive nature of conventional laparoscopic surgery (CLS) which is the current standard of care. However, to the best of our knowledge, no studies have attempted to draw a comparison between the two in terms of the cases required for the learning curve to be achieved. The systematic review was performed at Barts Cancer Institute. A search of Cochrane, PubMed and Embase was made on 15 March 2024. Screening and risk of bias were done by two reviewers. Screening was done via the eligibility criteria by two reviewers. Data collection was done using Excel (Microsoft® Corp., Redmond, USA) and information was double-checked by another reviewer and transferred into a tabulated format. Seventeen studies were included, with the learning curve reported in 14 studies. The cases required to achieve the learning curve for multiport robotic cholecystectomy (MRC) ranged from 16 to 134 and for single-site robotic cholecystectomy (SSRC), it ranged from 10 to over 102 cases. Conventional laparoscopic cholecystectomy (CLC) was from 7 to 200. The improvement in operating times was measured in very different ways and was reported in 10 of the 17 studies. The studies that were available had a high level of heterogeneity making it difficult for comparisons to be made between studies. Several studies included only one surgeon resulting in the sample size of surgeons being too small and vulnerable to bias. As robotic surgery is still relatively novel, higher-quality studies have to be made in order for more conclusive conclusions to be made on the benefits of the learning curve of MRC and SSRC.