The Northeastern Society of Plastic Surgeons

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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 300.820.6 (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 345.730.3 vs 231.117.6, p=0.01). Compared to the bottom quartile, surgeons in the top quartile performed more cases of minimal (110.08.0 vs 66.87.7, p<0.001), moderate (32.53.0 vs 11.11.4, p<0.001) and significant (11.31.7 vs 1.60.3, 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 17.20.5 (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 (94.36.4 vs 73.24.4, p=0.008) and significant (6.51.0 vs 2.8.50, p=0.001) complexity, but there was no difference in cases of moderate complexity (21.71.8 vs 18.02.0, p=0.234). No procedure was performed more frequently by female surgeons. Male surgeons performed more circumcisions (37.34.2 vs 24.92.7, p=0.015), ureteroscopies with stone manipulation (1.50.3 vs 0.60.2, p=0.022), laparoscopic pyeloplasties (2.2+0.42 vs 1.14+0.03, p=0.04), laparoscopic partial nephrectomies (0.130.05 vs 0.0, p=0.013), partial nephrectomies (0.220.08 vs 0.030.03, p=0.03), 1-stage perineal hypospadias repairs (0.200.03 vs 0.0, 0.037), and 2-stage proximal hypospadias repairs (0.180.08 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 ComplexityModerate ComplexitySignificant Complexity
Circumcision/revisionDistal hypospadiasProximal, penoscrotal, and perineal hypospadias
OrchiopexySimple fistula repairComplex fistula repair
Inguinal hernia repairAbdominal orchiopexyRadical nephrectomy
Ureterocele incisionLap orchiopexyLap radical nephrectomy
Valve ablationVaricocelectomyNephroureterectomy
Subureteric injectionLap varicocelectomyLap nephroureterectomy
Ureteroscopic stone treatment
Simple nephrectomyPartial nephrectomy
Lap nephrectomyLap partial nephrectomy
Simple pyeloplastyComplex pyeloplasty
Lap pyeloplastyReimplant with tailoring
Ureteral reimplantationEnterocystoplasty
Lap ureteral reimplantationContinent stoma
Percutaneous nephrolithotomy < 2 cmExstrophy closure
Epispadias repair
PCNL > 2 cm

Table 2: Procedures Performed by the Most and Least Pediatric Urologists
Most Commonly Performed Procedures# Peds Uro who performed at least oneLeast Commonly Performed Procedures# Peds Uro who performed at least one
Circumcision74 (100%)Complete Male Epispadias0 (0%)
Inguinal orchiopexy74 (100%)Open Nephroureterectomy*1 (1.4%)
Inguinal hernia age <5 yrs74 (100%)PCNL < 2 cm2 (2.7%)
Inguinal hernia age >5 yrs68 (91.9%)PCNL > 2 cm4 (5.4%)
Circumcision revision65 (87.8%)Radical nephrectomy4 (5.4%)

* One incision or two incisions (50234 or 50236)

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