Surgical Education
Learning curves for urological procedures:
a systematic review
Hamid Abboudi, Mohammed Shamim Khan, Khurshid A. Guru*, Saied Froghi†,
Gunter de Win‡, Hendrik Van Poppel§, Prokar Dasgupta and Kamran Ahmed
MRC Centre for Transplantation, King's College London, King's Health Partners, Department of Urology, Guy's Hospital,
London, UK, *Roswell Park Cancer Institute, Buffalo, NY, USA, †The Oxford Cancer Centre, Oxford University, Churchill
Hospital, Oxford, UK, ‡Department of Urology, University Hospital Antwerp, Antwerp, Belgium, and §Department of
Urology, University Hospital, KU Leuven, Leuven, Belgium
Objective
• To determine the number of cases a urological surgeon
must complete to achieve proficiency for various urological
procedures.
Patient and Methods
• The MEDLINE, EMBASE and PsycINFO databases were
systematically searched for studies published up to
December 2011.
• Studies pertaining to learning curves of urological
procedures were included.
• Two reviewers independently identified potentially relevant
articles.
• Procedure name, statistical analysis, procedure setting,
number of participants, outcomes and learning curves were
analysed.
Results
• Forty-four studies described the learning curve for different
urological procedures.
• The learning curve for open radical prostatectomy ranged
from 250 to 1000 cases and for laparoscopic radical
prostatectomy from 200 to 750 cases.
Introduction
The surgical learning curve is the period during which a surgeon
in training finds the procedure more difficult, takes longer to
complete, there is higher rate of complications and lower efficacy
because of inexperience [1,2]. There are no evidence-based
definitions pertaining to the term ‘learning curve’ or how to
measure it, but it can be thought of as an improvement in
performance over time. This improvement is at its maximum
early on in the learning process then tails off over time.
The learning curve is influenced by surgeon-related factors
such as attitude, self-confidence or experience in other
procedures. On the way to mastery of a procedure, the curve
© 2013 The Authors
BJU International © 2013 BJU International | doi:10.1111/bju.12315
Published by John Wiley & Sons Ltd. www.bjui.org
• The learning curve for robot-assisted laparoscopic
prostatectomy (RALP) has been reported to be 40
procedures as a minimum number.
• Robot-assisted radical cystectomy has a documented
learning curve of 16–30 cases, depending on which outcome
variable is measured.
• Irrespective of previous laparoscopic experience, there is a
significant reduction in operating time (P = 0.008),
estimated blood loss (P = 0.008) and complication rates
(P = 0.042) after 100 RALPs.
Conclusions
• The available literature can act as a guide to the learning
curves of trainee urologists. Although the learning curve may
vary among individual surgeons, a consensus should exist for
the minimum number of cases to achieve proficiency.
• The complexities associated with defining procedural
competence are vast.
• The majority of learning curve trials have focused on the
latest surgical techniques and there is a paucity of data
pertaining to basic urological procedures.
Keywords
education, learning curves, training, urology
represents the initial challenges in competence, and the change
in technical proficiency and efficiency with increasing
experience [3]. Patient factors such as case-mix can also
influence the learning curve. The surgical learning curve often
differs depending on the outcome measure being investigated.
For instance, achieving high potency rates at 12 months after a
surgical procedure may require 150 cases, whereas obtaining
mean estimated blood loss (EBL) of <100 mL might be
achieved sooner. Case volume has to be considered in the
context of case frequency, mix and selection. A surgeon
who has been working for 25 years and performs five
prostatectomies a year compared with another who has just
graduated but performs two prostatectomies a week will have
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Abboudi et al.
different outcomes. Often being ‘past’ the learning curve is
taken to imply expertise in that skill, but given that one
surgeon’s definition of expertise may differ from another’s,
learning curve discrepancies may arise.
In urology new surgical technologies and operating techniques
are constantly evolving. With the emergence of new
procedures, there is a period in which, regardless of preclinical
training, the inexperience of the surgeon makes the operation
more difficult or lengthy. This period is also referred to as the
‘procedure development learning curve’. This should be
differentiated from the learning curve of a surgeon who is
learning an established procedure.
Before embarking on a new surgical technique it is imperative
to know how many cases a surgeon is required to perform to
be competent and safe at a new technique. Higher-volume
centres have been associated with more favourable outcomes
across a wide range of procedures and conditions, with the
most consistent absolute differences in peri-operative
mortality rates between high- and low-volume hospitals being
observed for cancer surgery of the pancreas, the oesophagus
and paediatric tumours and surgery for unruptured
abdominal aortic aneurysm [4]. With regard to survival rates
after major oncological surgery, there are associations between
surgical volume and long-term cancer-specific survival after
surgery for rectal and lung cancer [5,6]. This has significant
implications on both training and the adoption of new
techniques. Furthermore, there are implications for patients,
where the surgeon’s workload might become part of the
information required by the patients at the time of
preoperative counselling so they can make an informed
decision about their care.
The aim of the present study was to provide a systematic
review of the published literature on urological learning
curves and make recommendations to establish standardized
definitions of procedural competency.
Materials and Methods
Study Selection
This review was performed according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
statement (http://www.prisma-statement.org/) [7].
A broad search of the literature was performed in December
2011 using the MEDLINE (from 1950 to December 2011),
EMBASE (from 1980 to December 2011) and PsychINFO
(from 1966 to December 2011) databases. The following
keywords were used during the search: ‘urology’, ‘urological
surgery’ and ‘learning curve’. The Cochrane database and the
Database of Abstracts of Reviews of Effectiveness were
reviewed. The selection was limited to English-language
articles only. Empirical studies describing the evaluation of
learning curves, in the operating theatre and on simulators, in
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618 BJU International © 2013 BJU International
urological surgery were included. Review articles, studies
describing models, letters, bulletins, comments and studies
describing non-technical skills were excluded from the
analysis.
The full text of each article was obtained and further screened
for inclusion if it had information pertaining to learning
curves of urological procedures. We included conference
abstracts as well. Studies assessing learning curves within a
virtual reality setting were also included. We excluded
editorials, letters and bulletins and studies not related to
learning curves.
Two reviewers (K.A. and H.A.) independently identified
potentially relevant articles. Conflicts between reviewers were
subsequently discussed, such that agreement was >0.85
(Cohen coefficient).
Data Collection and Analysis
An electronic data collection form (Microsoft Excel 2007,
Redmond, WA, USA) was used to extract data including name
of the procedure, statistical analysis, number of surgeons who
contributed to the development of the learning curve, previous
experience of the surgeons, the procedure setting, the variables
or outcome measures used to measure the learning curve and
the learning curve itself. Disagreement in the assessment and
data extraction were resolved by consensus.
Because of heterogeneous study designs and lack of
comparative variables, direct comparisons or meta-analysis of
data were not feasible; however, if identical tools or outcome
measures were used in different studies the results for the
different items of the framework used were summarized.
Where possible, the collated data were divided into ‘novice’
and ‘expert’ for statistical analysis. Novice subjects were
defined as those on the initial phase of their learning curve
and experts were defined as those subjects who had reached
the plateau phase of their learning curve.
Results
Study Selection
A total of 1439 potentially relevant publications were
identified by the search, of which 1355 were excluded from
analysis after the abstract review. Of the remaining 84 studies
we excluded a further 40 after reviewing the full text because
of repetition, incomplete data and lack of relevance to the
present study; thus, 44 studies were finally included in the
systematic review (Fig. 1). The following procedures had
learning curve evaluations: robot-assisted laparoscopic
prostatectomy (RALP); open retropubic, perineal and
laparoscopic radical prostatectomy (LRP); percutaneous
nephrolithotomy (PCNL); other upper urinary tract
procedures; and robot-assisted radical cystectomy (RARC).
 Learning curves for urological procedures

Fig. 1 Study selection. cases in pT2 cancers, whereas another study on the robotic
surgery outcomes of eight experienced laparoscopic surgeons
1439 potentially relevant articles showed they achieved an acceptable positive surgical margin
identified from MEDLINE, EMBASE
and PSYCHINFO
rate after 200 cases [18]. Chang et al. [19] reported that, after
300 cases, a group of four laparoscopic surgeons could achieve
equal positive surgical margin rates to those of four
experienced robotic surgeons.

1355 articles excluded after The transition from a novice state to an experienced surgeon
abstract review is evident by the improved trend in OT, EBL, complication
and PSM rates (Figs 2,3). Surgeons on the initial learning
curve of RALP generally have longer OTs and higher mean
EBL and complication rates [8,20–22]. This transition depends
40 articles excluded after on a number of factors, such as previous laparoscopic
84 articles reviewed for more experience. The above-mentioned studies show that,
full-text review and
detailed information
removal of duplicates irrespective of a trainee’s previous laparoscopic experience, a
significant transition is reached after 100 cases; the OT and
EBL are significantly reduced (P = 0.008 for both) after this
transition point. In addition, as the level of experience
44 articles identified in final increases and the learning curve reaches its plateau, overall
analysis complications reduce significantly (P = 0.042).

Open RRP, Perineal Prostatectomy and LRP

Robot-Assisted Laparoscopic Prostatectomy Three studies investigated the learning curve for both open
and LRP, while one study evaluated the learning curve for
Seventeen studies investigated the learning curve of RALP
perineal prostatectomy (Table 2 [24–30]). Vickers et al. [26]
(Table 1 [1,8–23]). The number of participating surgeons
evaluated the learning curve of RRP in terms of oncological
ranged from 1 to 13. All studies evaluated outcomes in real
outcomes in a series of >7700 patients operated on by 72
patients. A range of variables were included in the calculation
surgeons at four major US academic medical centres
of the learning curve including; operating time (OT), EBL,
between 1987 and 2003. Specifically, they defined patients
positive surgical margin (PSM) rate, urethrovesical
with biochemical recurrence as those with a PSA level
anastomosis time, complications, length of hospital stay (LOS),
>0.4 ng/mL who then experienced a further PSA increase,
transfusion rate, early continence, potency and conversion
then evaluated the 5-year recurrence-free survival
rate.
probabilities, observing that a plateau in prostate cancer
In the study by Herrell and Smith [1], the learning curve for a recurrence rates was reached after 250 cases. The 5-year
surgeon who had performed >2500 retropubic radical probability of recurrence was 17.9% for patients treated by
prostatectomies (RRPs) was achieved after 250 cases. Gumus surgeons with limited experience (10 previous operations)
et al. [8] investigated the learning curve in laparoscopically and 10.7% for those treated by surgeons who had performed
naïve surgeons, which ranged from 80 to 120 cases. The study 250 previous operations, with the observed differences being
by O’Malley et al. [9] subdivided the learning curve of statistically significant [24,26].
laparoscopically naïve surgeons into mean OT (40 cases),
Eliya et al. [27] were the only authors to investigate the
vesico-urethral anastomosis time (10 cases), and margin status
learning curve for perineal prostatectomy as depicted by two
(200 cases). In 10 studies, the previous experience of the
experienced open prostatectomy surgeons. To determine a
participating surgeon/s was not documented. The mean OT
learning curve, the patients were divided into four groups:
reached a plateau after 50–200 cases [9–14] and the PSM rate
group 1 cases 1–22; group 2 cases 23–53; group 3 cases 54–74;
reached a plateau after 50–1600 cases, depending on the
and group 4 cases 75–96. Although no clear learning curve
authors definition of acceptable PSM rates [9–16]. After 200
was attained after the 96 cases were reviewed, the PSM rate
cases the learning curve was reached for LOS (mean 1.13
gradually improved with increasing experience of the
days), EBL (mean 147.8 mL), pad-free continence rate and
technique, with only two positive margins obtained in the
potency (at 12 months) [14]. The remaining four studies
fourth group compared with six in the first group and 11 in
investigated the learning curve of experienced laparoscopic
both the second and third groups.
surgeons. In the study by Sanchez-Salas et al. [17], three
surgeons with >300 LRP cases in their logbook were able to Hruza et al. [28] analysed complications in 2200 consecutive
achieve acceptable positive surgical margin rates after 100 patients who underwent LRP between 1999 and 2008 at a

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Table 1 Learning curve studies on RALP.

Study* No. of Previous Outcome measures Statistical analysis Learning curve

participating experience No. of cases: outcome
surgeons measure

Herrell and Smith 2005
[1]
Gumus et al. 2011 [8]
O’Malley et al. 2006 [9]
Gyomber et al. 2010 (A)
[10]
Sooriakumaran P et al.
2011 (A) [11]
Doumerc et al. 2010 [12]
Tabata et al. 2011 (A)
[13]
Kim et al. 2010 (A) [14]
Gyomber et al. 2010 (A)
[15]
Gyomber et al. 2011 (A)
[16]
Sanchez-Salas et al. 2011
(A) [17]
Jung et al. 2010 (A) [18]
Chang et al. 2011 (A)
[19]
Yen-Chuan Ou et al.
2011 [20]
Sharma et al. 2011 [21]
Giberti C et al. 2010 (A)
[22]
Linn et al. 2010 (A) [23]
1 >2500 RRPs OT, EBL, LOS, TR,
continence, potency, PSM
1 Laparoscopically naïve OT, EBL, LOS, PSM, EC,
potency
2 Laparoscopically naïve OT, VUAT, PSM
OT, EBL, TR, PSM, CR, C
3 OT, PSM rate
1 OT, PSM, C, EC
1 OT, PSM, C
OT, LOS, EBL, pad free
continence rate, potency
OT, EBL, PSM, LOS, early
postoperative
complications
13 PSM
3 >300 LRPs PSM
8 Laparoscopic surgeons PSM
8 Four robotic surgeons, PSM
four laparoscopic
surgeons
1 OT, console time, EBL, TR,
PSM, node positive rate, C
2 Extensive open and OT, EBL, PSM, C, potency
laparoscopic
experience
OT, TR, CR, CRT, PSM, EC,
potency
1 OT, EBL, LOS, TR, PSM, CR
250
80–120
40: OT, 10: VUAT, 200: PSM
50: OT, 150: PSM
750: OT, 1600: PSM
One-sample t-test, joinpoint 110 : OT; 140 : PSM (pT2);170: PSM
regression, chi-squared (pT3); 200: EC
with Yates correction,
ANOVA
100: PSM; >200: OT
<200: LOS, OT, EBL, PSM, pad-free
continence rate; >200: potency
50: PSM (pT2)
Logistic regression and 50: PSM
weighted means
100: PSM (pT2)
200
Chi-squared test, Individual laparoscopic surgeons =
multivariate analysis robotic surgeons at 40 cases.
laparoscopic surgeons group =
robotic surgeons after 300 cases
Mann–Whitney U-test, 150
Fisher’s exact test, Yates
correction
Multivariable logistic >500
regression, multivariable
linear regression,
chi-squared test
200
>20

*The procedure setting for all studies was real patients. (A), abstract; VUAT, vesico-urethral anastomosis time; C, complications; TR, transfusion rate; EC, early continence; CR,
conversion rate; LOS, length of stay; CRT, catheter removal time; PSM, positive surgical margin rate; EBL, estimated blood loss.

single institution. Complications were classified according
to the modified Clavien system. Five surgeons were divided
into three groups; first-generation surgeons, with vast
open surgical experience with no laparoscopic training,
second-generation surgeons with experience in open
surgery who were trained by first-generation surgeons, and
third-generation surgeons with no or limited experience
in open surgery who were trained by first- or second-
generation surgeons using a special training programme.
The learning curve of third-generation surgeons reached a
plateau earlier compared with that of the first-generation
surgeons (250 vs 700 cases).
Secin et al. [29] analysed records from 8544 consecutive
patients with prostate cancer treated laparoscopically by 51
surgeons at 14 academic institutions in Europe and the USA.
The probability of a PSM was calculated as a function of
surgeon experience with adjustment for pathological stage,
Gleason score and PSA. A second model incorporated
previous experience with open RRP and surgeon generation.
PSMs occurred in 1862 patients (22%). There was an
apparent improvement in PSM rates up to a plateau at 200
to 250 surgeries. Changes in PSM rates once this plateau was
reached were relatively minimal relative to the CIs. The
absolute risk difference for 10 vs 250 previous surgeries was
4.8% (95% CI 1.5, 8.5). Previous open radical prostatectomy
experience was not statistically significant when added to
the model.
In 2009, Vickers et al. [30] conducted a retrospective cohort
study of 4702 patients with prostate cancer treated
laparoscopically by 29 surgeons in seven institutions in Europe

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 Learning curves for urological procedures

Fig. 2 Line Plot for estimated blood loss (mL), complications and operative time (min) in RALP. C1 denotes novice surgeons on their initial learning
curve and C2 denotes experienced surgeons who have reached a plateau on their learning curves.

Line Plot of Blood Loss Line Plot of Complications

350 Row 30 Row
Ou 2011 Gumus 2010
Gumus2011 Ou 2011
300 Sharma 2010*
Estimated Blood Loss (mL)

Sharma 2010*
Doumerc 2009 25
250

% Complications
200
20
150

100
15
50

0 10
C1 C2 C1 C2
* Sharma 2010 paper reports on learning curve from two different surgeons,
here for clarity they are presented as two different lines.

Line Plot of Operative Time

275 Row
Sharma 2010*
Sharma 2010*
Mean Operative Time (min)

250 Giberti 2011

Gumus 2010
Ou 2011
225

200

175

150

C1 C2

Fig. 3 Positive surgical margins in prostatectomies performed by surgeons and North America between January 1998 and June 2007.
of different levels of expertise. Groups are divided based on the number Multivariable models were used to assess the association
of cases performed: <50, 50–99, 100–249, 250 to >1000. With increasing
between surgeon experience at the time of each patient’s
level of experience, the PSM rate decreases.
operation and prostate-cancer recurrence, with adjustment for
Surgical Margin established predictors. The 5-year risk of recurrence decreased
from 17% to 16% to 9% for a patient treated by a surgeon with
40 experience of 10, 250 and 750 previous LRPs, respectively.
The learning curve for LRP was slower than the previously
%Postive Surgical Margin

reported learning curve for open surgery (P < 0.001).

30
Interestingly, surgeons with previous experience of open
RRP had significantly poorer results than those who started
20 the procedure using laparoscopy with no previous open
prostatectomy experience. Although the PSM rate can be
influenced by a number of preoperative factors (PSA level, a
10 patient’s BMI, Gleason score and clinical stage of disease), a
surgeon’s level of experience can affect the PSM rate and
0
thus oncological outcomes (Fig. 3). Data from the above
<50 50–99 100–249 250–>1000
studies [25–27,29,30] suggest there is an improved PSM rate
No. of cases
as the surgeons become more proficient in performing
prostatectomies.

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Table 2 Open RRP, perineal prostatectomy and LRP learning curve studies.

Study Procedure* No of Previous Outcome Statistical analysis Learning curve

participants experience measures No. of cases:
outcome measure

Vickers et al. Open 72 20–102 previous Prostate cancer Multivariable survival time <50: 36% RR; 50–99: 29% RR;
2007 [24] prostatectomy cases recurrence, PSA regression models 100–249: 23% RR; 250–999: 22%
(>0.4 ng/mL) RR; >1000: 11% RR
Saito et al. Open 5 OT, EBL, TR, PSM ANOVA, Fischer’s exact test 29: TR, 20: OT
2011 [25] prostatectomy
Vickers et al. Open 72 20–102 previous PSM Multivariable survival time 10: 40% PSM, 250: 25% PSM
2010 [26] prostatectomy cases regression models
Eliya et al. Perineal 2 Experienced OT, LOS, C, PSM, ANOVA, chi-squared test No clear learning curve
2011 [27] prostatectomy open surgeons capsular penetration after 96 cases, but PSM improved.
status
Hruza et al. LRP 5 <20 previous LRPs C Pearson x2 test and Fisher’s Third-generation surgeons learning
2010 [28] exact test, logistic curve shorter than first- and
regression model was used second-generation
for multivariable analysis
Secin et al. LRP 51 LRP PSM Logistic regression model, 200–250
2010 [29] 22; <50 cases multivariable models,
4; 50–99 cases permutation test
13; 100–249 cases
12; 250 or >
ORP
20; 0
5; 1–10
13; 11–99
13; 100 or >
Vickers et al. LRP 29 RR Multivariable models 10: 17% RR; 250: 16% RR; 750: 9% RR
2009 [30]

*The procedure setting for all studies was real patients. C, complications; RR, recurrence rate; TR, transfusion rate; OT, operative time; EBL, estimated blood loss; PSM, positive surgical
margin rate.

Percutaneous Nephrolithotomy mean fluoroscopy screening time continued in cases 61 to 104,

A total of six studies evaluated the learning curve for PCNL
and renal access (Table 3 [31–36]). In addition to total OT,
complications and LOS the variables measured included stone
extraction rate, stone-free rate (SFR) and fluoroscopy time.
Ziaee et al. [31] reviewed 105 consecutive PCNL operations
performed by a fellow in endourology, with no previous
experience in performing independent PCNL. The OT
decreased from a mean of 95.4 min in the first to 15th patients
to 78.3 min in the 31st to 45th patients, and then remained
unchanged. Minor complications were only observed in the
first to 45th patients. Stone extraction percentage increased
from a mean of 88.3% in the first to 15th patients to 99.3% in
91st to 105th patients. The percentage of patients with no
residual fragments decreased from 53% in the first to 15th
patients to 6.7% in the 91st to 105th patients.
Tanriverdi et al. [32] reviewed 104 procedures in a
PCNL-naïve surgeon. PCNL procedures were analysed in
seven sets of 15 cases regarding the OT and fluoroscopy time,
stone size, SFR, blood transfusion rate and EBL. The mean OT
was 2.4 h for the first 15 cases, which decreased to a mean of
1.5 h for cases 46 to 60. No further decrease in the OT was
observed after case 60. The fluoroscopic screening time
reached a peak of 17.5 min in the first 15 cases, and dropped
to a mean of 8.9 min for cases 46 to 60. The decline in the
but the decline was not significant. There was no significant
difference in stone size, SFR, blood transfusion rate or EBL
among each set of cases. A similar study by Negrete-Pulido
et al. [33] reviewed 92 percutaneous renal accesses in patients
with renal stones or PUJ obstruction performed by an
endourology fellow without previous experience in
percutaneous surgery. The rate of success increased from 82.5
to 97.6% after the first 40 punctures. Puncture time and
fluoroscopy time decreased as the number of procedures
increased. The incidence of complications was 30% for the
first 20 cases, decreasing to 10% in the next 20 cases and 3.7%
in the last 33 cases.
Jang et al. [34] calculated the learning curve for 53 PCNL
procedures performed in the flank position by one
experienced endourological surgeon. The mean OT for the 53
patients was 97.3 ± 43.1 min. The mean OT gradually
decreased as the surgeon accumulated experience. From the
36th case, the mean OT showed a significant decrease to
72.2 ± 24.1 min (P = 0.003). The overall (range) SFR was 64.2
(61.1–76.5)% for all procedures. There were no significant
differences in the drop in haemoglobin level, SFR,
re-treatment rate, LOS or complication rate. There was no
injury to the bowel or renal vessels, and no other major
complications occurred.

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Table 3 Percutaneous nephrolithotomy and percutaneous renal access learning curve studies.

Author Procedure* No of Previous Outcome measures Statistical analysis Learning curve

participants experience No. of cases:
outcome measure

Ziaee et al. 2010 PCNL 1 0 OT, C, SER, SFR, No of access, Chi-squared test, ANOVA 45: C and OT; 105: SER
[31] tubeless cases
Tanriverdi et al. PCNL 1 0 PCNL, extensive OT and fluoroscopy time ANOVA, chi-squared test, 60
2007 [32] experience in other screening Mann–Whitney
endourology U-test, or t-test
procedures i.e.
transurethral resection
and ureterorenoscopy
Negrete-Pulido Percutaneous 1 0 Time to correct puncture, Descriptive analysis, 50
et al. 2010 renal access/ fluoroscopy time screening ANOVA and Markov
[33] puncture chain
Jang et al. 2011 Flank PCNL 1 OT, C, SFR, drop in haemoglobin ANOVA 35
[34] level, LOS, need for additional
procedures after surgery
Godbole et al. PCNL OT, C, success of 1st pass 12
2010 (A) [35] puncture & track formation,
complete stone clearance
Bucuras et al. PCNL OT, LOS, SFR, C 40
2011 (A) [36]

*The procedure setting for all studies was real patients. (A), Abstract; C, complications; SER, stone extraction rate; SFR, stone free rate; OT, operative time; LOS, length of stay.

Other Upper Urinary Tract Procedures
A total of 12 studies investigated the learning curve for upper
urinary tract procedures (Table 4 [37–48]). These consisted of
robot-assisted laparoscopic partial nephrectomy (RALPN)
[37–42], laparoendoscopic single-site (LESS) donor
nephrectomy [43], retroperitoneal laparoscopic donor
nephrectomy [44], laparoscopic pyeloplasty [45],
retroperitoneal laparoscopic partial nephrectomy [46], LESS
pyeloplasty [47] and robot-assisted paediatric pyeloplasty [48].
Robot-Assisted Radical Cystectomy
Two studies investigated the learning curve for RARC (Table 5
[49,50]). Both papers used total OT, cystectomy time, pelvic
lymph node dissection time, EBL, PSM rate, complications and
LOS to deduce a learning curve. In the study by Hayn et al.
[49], 496 patients who underwent RARC by 21 surgeons at 14
institutions from 2003 to 2009 were prospectively studied. The
mean OT was 386 min, the mean EBL was 408 mL and the
mean lymph node yield (LNY) was 18. Overall, 34 of 482
patients (7%) had a PSM. Using statistical models, it was
estimated that 21 patients were required for OT to reach 6.5 h
and 8, 20 and 30 patients were required to reach lymph node
yields of 12, 16 and 20, respectively. For all patients, PSM rates
of <5% were achieved after 30 patients. For patients with
pathological stage higher than T2, PSM rates of <15% were
achieved after 24 patients.
Guru et al. [50] divided 100 RARC procedures into four
groups. Overall OT decreased from 375 min in group 1 to
352 min in group 4, with <1% change in OT after case 16.
Time from incision to bladder extirpation decreased from
187 min in cohort 1 to 165 min in cohort 4. Time for pelvic
lymph node dissection increased from 44 min in cohort 1 to
77 min in cohort 4. Lymph node yield increased from 14
nodes in cohort 1 to 23 nodes in cohort 4. PSMs decreased
from four patients in cohort 1 to no patients in cohort 4.
There was no change in complication rate which was nine
patients in cohorts 1 and 4.
Quality Evaluation of Included Studies
A tool to evaluate educational articles describing learning
curves is not available in the literature. A number of statistical
methods were used to demonstrate learning curves in
operating procedures. While 24 of the 44 studies did not
document the statistical methods, in the remaining 20 studies,
a range of tools were used such as: the Mann–Whitney U-test,
Fisher’s exact test, one-sample t-test, joinpoint regression, the
chi-squared test, ANOVA, multivariable logistic regression,
multivariable linear regression, Pearson’s test and the
Kruskal–Wallis non-parametric test. While ANOVA and the
t-test are relatively simple methods of showing the learning
curve, the performance means are analysed in arbitrary
groups, and one cannot therefore identify where specifically
the learning curve reaches a plateau.
The Friedman test and regression analysis as used by eight
studies [12,16,21,24,26,28,29,42], are more sophisticated
methods, looking at learning curves through the analysis of
repeated measures across time, which allows the identification
of significant changes in performance from repetition to
repetition and enables investigators to identify learning
plateaus on the learning curve.

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Table 4 Learning curve studies for upper urinary tract procedures.

Author Procedure* No of Previous Outcome Statistical Learning curve

participants experience measures analysis No. of cases: outcome
measure

Lavery et al. RALPN 1 >100 RALPs and 15 OT, WIT Chi-squared and 5 to convert from laparoscopic to
20011 [37] robot-assisted Student’s t-test robotic approach
pyeloplasty’s
Pierorazio et al. RALPN 1 Robot-naïve OT, WIT, EBL t-test, chi-squared 25 to convert from laparoscopic to
2011 [38] test, ANOVA robotic approach
Finnegan et al. RALPN 1 OT, WIT, LOS, C, EBL Significant difference in WIT, LOS
2010 (A) [39] and C in 1st 75 vs last 75 cases
Jacobsohn et al. RALPN 1 WIT >72, no plateau
2011 (A) [40]
Tufek et al. 2011 RALPN 1 Extensive previous OT, WIT, EBL 32
(A) [41] robotic surgery
experience
Oh et al. 2011 RALPN 1 OT, WIT, LOS, C Linear regression 20: WIT and C, 50: OT
(A) [42] analysis,
multivariate
analysis
Choi et al. 2011 LESS donor 1 OT, WIT, LOS, C, change 50: OT
(A) [43] nephrectomy in donor GFR
Ye et al. 2011 Retroperitoneal OT, EBL, LOS, C 40
(A) [44] laparoscopic donor
nephrectomy
Naya et al. 2011 Laparoscopic pyeloplasty 1 OT, C intraoperative, C 51
(A) [45] postoperative
Ma 2010 (A) Retroperitoneal 1 OT, WIT, EBL, 65
[46] laparoscopic partial postoperative outcome
nephrectomy
Best et al. 2011 LESS pyeloplasty 1 Experienced 30 days complication 11
[47] laparoscopic rate
surgeon
Sorensen et al. Robot-assisted paediatric 2 No robotic surgery OT, C, postoperative 15–20: OT
2011 [48] pyeloplasty experience, 20 pain, LOS, surgical
laparoscopic success
cases/year

*The procedure setting for all studies was real patients. (A), abstract; C, complications; WIT, warm ischemia time; OT, operative time; EBL, estimated blood loss; LOS, length of stay.

Table 5 Robot-assisted radical cystectomy learning curve studies.

Author Procedure* No of Previous Outcome Statistical analysis Learning curve

participants experience measures

Hayn et al. RARC 21 OT, LNY, EBL, PSM Fisher’s exact test, Kruskal–Wallis non- 21: OT, 30: LNY, 30: PSM
2010 [49] parametric test, nonlinear mixed model
Guru et al. RARC RALP experience OT, LNY, PSM 16: OT, 11: EBL, 12: LOS,
2009 [50] 30: LNY

*The procedure setting for all studies was real patients. LNY, lymph node yield; OT, operative time; EBL, estimated blood loss; PSM, positive surgical margin rate.

Although not used by any of the studies identified in the Discussion

present review, cumulative sum (CUSUM) charts are a useful
way of identifying when performance begins to decline or
improve and, therefore, when remediation is necessary. CUSUM
charts represent a sequential analysis that can identify small
changes to the means of a process. CUSUM involves summing
differences between measured values and a benchmark value to
determine the extent of deviation away from the benchmark. A
threshold for change in both positive and negative value away
from the benchmark is calculated [51].
To our knowledge this is the first systematic review of learning
curve studies within urological surgery (Fig. 4). The number of
procedures required varied from procedure to procedure, and
was often affected by the surgeon’s previous experience.
Broadly speaking, the outcome measures used to calculate
learning curves were either surgery-related (OT, EBL),
oncological, (PSM rate), or related to quality of life (pain,
erectile dysfunction, incontinence).

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624 BJU International © 2013 BJU International
 Learning curves for urological procedures

Fig. 4 An overview of learning curves for urological procedures. LC, learning curve; RR, recurrence rate; C, complications; TR, transfusion rate; SER, stone
extraction rate; OT, operative time; UVT, vesico-urethral anastamosis time; PSM, positive surgical margin; SFR, stone free rate.

RALP Open prostatectomy

NO OPEN OR Outcome measures

OPEN LAPAROSCOPIC
LAPAROSCOPIC OT; EBL; C; TR; PSM; RR;
EXPERIENCE EXPERIENCE
EXPERIENCE potency; continence; LOS

OT − 40 cases
T − 20 cases
UVT − 10 cases
LC as a whole: 250 cases PSM − 100−300 cases PSM (25% +ve): 250 cases
MS − 200 cases
T − 29 cases
LC as a whole: 80−200 cases

LRP PCNL

OUTCOME MEASURES OUTCOME MEASURES

OT; EBL; C; TR; PSM; RR; OT and fluoroscopy time; C;
potency; continence; LOS LOS; SFR; SER

LC as a whole: 12−60
PSM: 200−250 cases OT − 45
RR (16%): 250 cases C − 45
SER − 105

The results of the present review provide a guide for trainees,
trainers and experienced surgeons alike. In a surgical
generation where minimally invasive techniques have
superseded open approaches, the thought of learning how to
perform a RALP or LRP without previous laparoscopic or
even open experience is daunting; however large multicentre
studies investigating, in particular, the learning curve for LRP
showed that the learning curve for complications reached a
plateau earlier for third-generation surgeons compared with
first- generation surgeons (250 vs 700 cases) [28]. When PSM
rate was used as the outcome variable for defining the learning
curve, previous open experience and surgeon generation did
not improve the PSM rate; on the contrary, poorer results
were seen in surgeons with previous experience compared
with those whose first operation was laparoscopic, suggesting
that the rate is primarily a function of specifically laparoscopic
training and experience [29,30]. Similar observations can be
made with respect to RALP. Surgeons with open and
laparoscopic experience have a learning curve of 250 and
100–300 cases, respectively [1,17,19], whereas surgeons
without such experience require 40 cases to reach similar OTs,
10 cases to perform the vesico-urethral anastamosis at an
equivalent time and 200 cases to reach acceptable PSM rates
[8,9]. Converting from laparoscopic to RALPN requires a
learning curve of 5–25 cases [37,38], while learning
robot-assisted paediatric pyeloplasty is associated with a
learning curve of 15–20 cases [48]. These represent relatively
short learning curves and, given the benefit of robot-assisted
laparoscopic surgery, this is a potentially worthwhile
investment for high-volume centres.

© 2013 The Authors

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Abboudi et al.
One of the inherent flaws in the documented learning curves
is the absence of a standardized definition of the optimum
method of calculating a learning curve. Even within the same
procedure authors have measured different variables and set
different endpoints within a given variable. For example, in the
study by Gumus et al. [8], a 6% PSM rate was deemed to be
acceptable to attain competence, whereas in the studies by
Gyomber et al. [15], Sooriakumaran et al. [11] and Doumerc
et al. [12] the overall PSM rates were 19.3, 19.7 and 21%,
respectively, as the benchmark in their learning curves. This
represents a large variation and a potential bias in the
documented learning curves. In addition, the trainer is often
required to take over when the trainee is not progressing
during a case, but this has not been accounted for in the
studies and is inevitably a difficult variable to control for,
unless part of a trial. Furthermore, the complexity of each case
will play a large role in the learning curve outcomes but there
is a paucity of data on the learning curves in this regard.
Within any given procedure there is a separate learning curve
for individuals, which will not follow the learning curve
calculated by analysing a group of surgeons. To minimize the
adverse outcomes associated with an individual’s learning
curve, experienced supervision should be sought [52].
The above-mentioned discrepancies make comparisons
between studies inaccurate and confusing to the learner. For
each procedure there needs to be a consensus about which
variables are most important to measure when defining
competence, e.g. patient outcomes, survival and/or surgical
processes such as OT and EBL, as well as about fixed endpoints
within each variable and what statistical model to use [53].
Extensive laparoscopic training literature has shown that it is
not possible to calculate how many procedures have to be
performed before somebody is competent in a certain
procedure [54]. The learning curve for very basic laparoscopic
exercises differs between subjects, ranging from 5.5 to 21 h
and 171 to 782 repetitions [55]. This indicates that no single
number of surgeries can be identified that applies to all
surgeons because of immense inter-individual differences in
technical aptitude and previous experience. It is more accurate
to define proficiency levels, which have to be reached before a
surgeon is deemed competent in a certain procedure, i.e.
maximum time to perform circumcision or maximum EBL
during RALP. Furthermore analysing the individual steps
involved in a procedure may provide a more accurate
depiction of the learning curve. Certain aspects of a procedure
are more technically challenging than others, therefore, these
will require particular attention during training. The factors
that affect progression within a certain procedure need to be
examined, in particular, the non-technical as well as technical
attributes of the trainee.
The majority of the learning curve studies have focused on
complex, innovative procedures with a paucity of data
© 2013 The Authors
626 BJU International © 2013 BJU International
pertaining to the routine work of a urological surgeon. Junior
trainees and trainers would value learning curve data on
scrotal surgery, circumcisions, flexible and rigid cystoscopy,
TURPs, transurethral resection of bladder tumours,
orchidectomies and other procedures which make up the
majority of the workload of most urologists, in particular
those in training.
The most important single factor to consider when developing
new surgical techniques is patient safety. With large studies
showing that a surgeon’s case volume equates to better
oncological outcomes [24,26,30], there is a lack of studies
examining the learning curve in a simulated setting. Given
that we know that if a surgeon has performed only 10 RRPs
the 5-year probability of prostate cancer recurrence is ∼17.9%,
while 250 previous procedures reduces the risk of recurrence
by 7.2% to 10.7%, is it ethical to train in the real-life
environment? Wet- and dry-laboratory specimens, courses
and fellowships have traditionally been used to overcome the
early stages of the learning curve and to refine existing skills
and techniques; however, with the expansion in surgical
simulation, inanimate trainers are available in many forms and
provide an exciting avenue for future surgical trainees. Direct
comparison between these and the traditional wet-and
dry-laboratory methods have yet to be assessed, and perhaps a
combination of training environments will lead to the most
effective training. Mechanical and virtual reality simulators
have been validated as training and assessment tools and have
been shown to improve a surgeon’s performance in the
operating theatre, suggesting that simulation training may
contribute to the acquisition of the experience necessary to
advance along the learning curve [56–60]. Moreover,
simulation has been shown to shorten the length of the
learning curve for real procedures in the operating theatre
when compared to no simulation training [61]. For effective
simulation-based education, proficiency-based curricula
should be used to ensure individual competency. An example
of one such curriculum is the structured curriculum of skill
acquisition on the virtual reality simulator the MIST-VR,
which was developed by investigating the learning curves of
20 medical students on 12 tasks. Trainees work through all 12
tasks at easy then medium difficulty. The skills acquired at
easy and medium difficulty over repeated practice should then
translate to specific performance targets at the hard difficulty
level where the assessment of skill can occur against
an expert-derived performance standard [62]. Such
performance-based criteria for skill proficiency take into
account that different learners will progress at different rates
along the learning curve. Other validated simulator curricula
include those developed by LapSim and LapMentor [63,64].
A systematic training and assessment of technical skills
framework addresses technical skills training, from early
acquisition to final granting of privileges for practice, by
providing a roadmap to guide the development of a

curriculum to address education along the learning curve [61].
Early education focuses on knowledge-based learning and
then progresses to providing an understanding of the
deconstructed portions of a procedure that can be practised
on a validated model. These skills can then be assessed as they
translate to the real operating theatre, culminating in final
assessment to advance the trainee to independent practice.
Such approaches minimize the inherent risks with learning
fundamental principles of new procedures in the operating
theatre. Cost-effectiveness analyses are still awaited.
The present review has several limitations. The poor quality
and study design of included articles reflects the lack of
well-designed learning curve studies, and led to challenges in
summarizing the procedural learning curves. Within any given
procedure, a variety of different outcome measures were used
with different endpoints, making comparisons between studies
difficult. Often endpoint targets were used for the calculation
of the learning curve as opposed to the rate of achieving the
outcome itself. Because of these inconsistencies of data
reporting, it was not feasible to correlate the various outcome
measures for the given procedures. Medical subject heading
(MeSH) terms on learning curves are lacking in the literature
databases, which leads to the possibility of missing some
articles. We attempted to overcome this bias by searching for
keywords and common authors on the topics. Most of the
studies lacked descriptions of appropriate methodology,
outcome measures and use of statistical tests, thus making a
meta-analytical approach impossible.
Our findings relate to other studies which have shown that it
is possible to quantify learning curves using literature reviews,
even though the process is often hindered by insufficient
reporting which then limits formal statistical estimation.
Standardized reporting and collation of data should be
developed for each procedure to improve overall reporting,
level of consistency and allow more accurate calculations of
learning curves [65].
Conclusions
The current studies can act as a guide for developing
urologists to follow during their training. The complexities
associated with defining procedural competence are vast. The
majority of learning curve trials have focused on the latest
surgical techniques with a paucity of data pertaining to basic
urological procedure information that would be useful for
junior trainees. Future work should include the identification
of outcome measures for individual procedures and validation
of the learning curves with a systematic approach. Learning
curves can either be based on outcome evaluation or
observation of practice by trainers until proficiency is gained.
Acknowledgements
We would like to acknowledge Prof Craig Ramsey, healthcare
assessment programme director at the University of Aberdeen
Learning curves for urological procedures
for his contribution to the review of this manuscript. P.D.
acknowledges financial support from the National Institute for
Health Research (NIHR) Biomedical Research Centre based at
Guy’s and St Thomas’ NHS Foundation Trust and King’s
College London. The views expressed are those of the
author(s) and not necessarily those of the NHS, the NIHR or
the Department of Health. P.D. also acknowledges the support
of the MRC Centre for Transplantation, London Deanery,
London School of Surgery and Olympus. P.D., S.K. and K.A.
acknowledge funding for the SIMULATE project from the
Urology Foundation (TUF) and the BAUS.
Conflict of Interest
Khurshid Guru is a Board Member of Surgical Simulated
Services. No other conflicts declared.
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