Differences in Early Career Operative Experiences Among Pediatric Urologists
Kristina D. Suson, MD1, Cortney Wolfe-Christensen, PhD2, Jack S. Elder, MD3, Yegappan Lakshmanan, MD1.
1Children's Hospital of Michigan, Detroit, MI, USA, 2Cook Children's, Fort Worth, TX, USA, 3MassGeneral Hospital for Children, Boston, MA, USA.
BACKGROUND: Previous research suggests that pediatric urologists (PUROs) feel well-trained by their fellowship for cases encountered early in their career. We questioned whether this represents adequate education or straightforward patients.
METHODS: Case logs of urologists from 7/30/07-6/30/13 applying for oral boards who self-identified as PUROs were reviewed. The urologist must have performed ≥75% of the cases on patients 0-21 years and submitted a 6 month log. Data points included cases/dates, and surgeon demographics. The 51 cases analyzed in depth and their assigned complexity level are presented in Table 1. Operative experience was also compared between male and female surgeons.
RESULTS: The cases of 74 PUROs were included for analysis. Surgeons submitted a mean 300.8±20.6 (117-1043, first quartile 181.25, median 256.5, third quartile 365.75) total cases. Males, comprising 60.8% of urologists, performed more cases than females (mean 345.7±30.3 vs 231.1±17.6, p=0.01). Compared to the bottom quartile, surgeons in the top quartile performed more cases of minimal (110.0±8.0 vs 66.8±7.7, p<0.001), moderate (32.5±3.0 vs 11.1±1.4, p<0.001) and significant (11.3±1.7 vs 1.6±0.3, p<0.001) complexity. Table 2 presents the most and least common cases. No PURO performed all procedures. Of the 51 CPT codes studied, surgeons submitted at least one of 17.2±0.5 (range 5-28) unique codes. Surgeons with the least case diversity performed a higher percentage of low complexity cases (r = .60, p<0.001), and lower percentages of moderate (r = -.45, p<0.001) and complex (r = -.57, p<0.001) cases. Male surgeons averaged more cases of minimal (94.3±6.4 vs 73.2±4.4, p=0.008) and significant (6.5±1.0 vs 2.8±.50, p=0.001) complexity, but there was no difference in cases of moderate complexity (21.7±1.8 vs 18.0±2.0, p=0.234). No procedure was performed more frequently by female surgeons. Male surgeons performed more circumcisions (37.3±4.2 vs 24.9±2.7, p=0.015), ureteroscopies with stone manipulation (1.5±0.3 vs 0.6±0.2, p=0.022), laparoscopic pyeloplasties (2.2+0.42 vs 1.14+0.03, p=0.04), laparoscopic partial nephrectomies (0.13±0.05 vs 0.0, p=0.013), partial nephrectomies (0.22±0.08 vs 0.03±0.03, p=0.03), 1-stage perineal hypospadias repairs (0.20±0.03 vs 0.0, 0.037), and 2-stage proximal hypospadias repairs (0.18±0.08 vs 0.0, p=0.031).
CONCLUSIONS: Case diversity and degree of complexity varies among newly trained PUROs. The urologist with the greatest case diversity never performed 45% of the 51 analyzed CPT codes, while those with the least case diversity never performed 90% of the codes. Male surgeons performed more surgeries, particularly those of minimal and significant complexity. The variability in operative experience reinforces the importance of continuing education and mentorship after completion of fellowship.
Table 1: Case Complexity
| Low Complexity | Moderate Complexity | Significant Complexity |
| Circumcision/revision | Distal hypospadias | Proximal, penoscrotal, and perineal hypospadias |
| Orchiopexy | Simple fistula repair | Complex fistula repair |
| Inguinal hernia repair | Abdominal orchiopexy | Radical nephrectomy |
| Ureterocele incision | Lap orchiopexy | Lap radical nephrectomy |
| Valve ablation | Varicocelectomy | Nephroureterectomy |
| Subureteric injection | Lap varicocelectomy | Lap nephroureterectomy |
| Ureteroscopic stone treatment Hydrocelectomy | Simple nephrectomy | Partial nephrectomy |
| Lap nephrectomy | Lap partial nephrectomy | |
| Simple pyeloplasty | Complex pyeloplasty | |
| Lap pyeloplasty | Reimplant with tailoring | |
| Ureteral reimplantation | Enterocystoplasty | |
| Lap ureteral reimplantation | Continent stoma | |
| Percutaneous nephrolithotomy < 2 cm | Exstrophy closure | |
| Epispadias repair | ||
| Clitoroplasty | ||
| Vaginoplasty | ||
| PCNL > 2 cm | ||
Table 2: Procedures Performed by the Most and Least Pediatric Urologists
| Most Commonly Performed Procedures | # Peds Uro who performed at least one | Least Commonly Performed Procedures | # Peds Uro who performed at least one |
| Circumcision | 74 (100%) | Complete Male Epispadias | 0 (0%) |
| Inguinal orchiopexy | 74 (100%) | Open Nephroureterectomy* | 1 (1.4%) |
| Inguinal hernia age <5 yrs | 74 (100%) | PCNL < 2 cm | 2 (2.7%) |
| Inguinal hernia age >5 yrs | 68 (91.9%) | PCNL > 2 cm | 4 (5.4%) |
| Circumcision revision | 65 (87.8%) | Radical nephrectomy | 4 (5.4%) |
* One incision or two incisions (50234 or 50236)
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