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Copyright of Contemporary Accounting Research is the property of Canadian Academic Accounting Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Training in diagnostic colonoscopy is one of the criteria for good training in gastroenterology. However, there is no curriculum that deals strictly with the purely technical aspects of colonoscopy. Our aim is to carry out a review of the literature focusing on the number of colonoscopies required to acquire autonomy in diagnostic colonoscopy and also the different means used to improve technical success in endoscopy. Materials and methods: this is a review of the literature over the last 30 years, looking at observational studies and clinical trials that have looked at residents in digestive endoscopy, their success rate in performing an endoscopy, and the different technical means used to improve their success in diagnostic endoscopy. We used the PRISMA recommendations to carry out the literature review and the Cochrane register of clinical trials to determine the quality of the clinical trial used. In addition, this literature review was carried out using the key words: trainees , colonoscopy , competence , evaluation , learning curve on the various search bases: Pubmed and medline. All articles were analysed on the basis of title and abstract. Results: After reviewing the literature and excluding articles based on title and abstract, we retained 32 articles for analysis. The number of colonoscopies required to achieve autonomy in diagnostic endoscopy varies between 50 and 400, although the majority of authors seem to agree on 200 colonoscopies. Video feedback is validated by all the studies as the best means of improving the learning curve in colonoscopy. The colonoscopy simulator shows satisfactory results in the technical success of colonoscopy. Virtual reality, however, has contradictory results as a predictor of colonoscopy success. An objective means of evaluating endoscopy training is the adenoma detection rate. There are factors that appear to predict a successful examination: loop-free progression of the sigmoid, rapid progression to the right colon and the us e of long colonoscopes. Conclusion: After this review of the literature, we can conclude that 200 diagnostic colonoscopies are necessary to obtain a technical success rate of cæcal intubation of 90%. Simulators and video feedback play an important role at the start of training and help to improve this technical success rate at the beginning of medical training. [ABSTRACT FROM AUTHOR]

Objective: To assess the learning curve and evaluate the impact of surgical experience related to the outcomes of flexible ureteroscopy (fURS) for upper urinary tract stones., Method: We evaluated retrospectively lithiasis fURS performed in our institution between January 2004 and December 2020. Patients were divided into two groups by the number of procedures performed by surgeon. Group 1 (G1) included the first 50 procedures, and group 2 (G2) the next cases. These groups were matched on baseline characteristics by a propensity score. Stones free rate (SFR) and complication rate (CR) were compared. Learning curves were realized using logistic curve with 95% confidence interval., Results: After criteria exclusion and propensity score matching, 1548 procedures were analyzed (1:1, G1 and G2, n=774 procedures). A total of 29 surgeons were evaluated. The overall SFR was 68.4% without statistical difference between the two groups (G1=67.9% vs. G2=68.8%, P=0.72). The surgeon's experience was not associated with SFR (OR=1.15, 95% CI: 0.90-1.47), except in subgroup stones>2cm (OR=2.89, 95% CI: 1.29-6.46). The overall CR was 12.5%, mainly Clavien-Dindo grade I-II complications (96.2%). Surgical experience was not associated with CR (OR=1.06, 95% CI: 0.77-1.45). The overall logistic curves for probability of stone clearance and complication tended to be a flat slope., Conclusion: Impact of surgical experience on fURS for UUTS was not associated with SFR and CR. However, for stones larger than 2cm, surgeon's experience tended to be associated with SFR, but without impact on overall complications., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

The combination of complex surgeries, in particular within the field of oncology, and the man–machine interface requiring new surgical techniques means that training in robotic surgery must be well structured. With this challenge in mind, the ideal form of teaching should focus on meeting three requirements: limiting the number of errors, reducing the learning curve on the patient and finally certifying each of the surgeon’s and team’s skills. There has been much debate in both France and the USA regarding the rapid development of robotic surgery and the lack of adequate and appropriate training for surgeons. In this paper, we are proposing a four-stage plan to meet these robotic surgery training needs. Initially, a list of skills specific to robotic surgery needs to be created. The Fundamentals of Robotic Surgery consensus conference has defined 25 basic training areas, however the list will be adapted, based on the previous experience of the surgeon. The second stage will be to select the pre-clinical (theory courses, model exercises, training on tissue samples, training on animals and/or cadavers and virtual reality simulation) and clinical (observations, surgical-assistant practice and mentor-observed surgical practice) training tools. Next, there will need to be standardisation of the assessment and certification methods for healthcare professionals; numerous tools are currently available: R-OSATS, GEARS, checklists, simulator-based automated assessment, movement analysis, robot data analysis, Markov statistical models, etc. Finally, a training programme will need to be organised, adapted to meet the objectives of each surgical team, drawing on multiple methods and including standardised assessments. The final objective being the safe introduction of this new technology into operating theatres. [ABSTRACT FROM AUTHOR]

Background: Holmium laser enucleation of the prostate (HoLEP) is a proven surgical technique for the treatment of benign prostatic hyperplasia (BPH). However, its challenging learning curve prevents its widespread adoption by urologists. The aim of this study was to analyse the learning curve of HoLEP and to determine the factors accelerating it., Methods: This was a retrospective, monocentric cohort study of the first 60 cases of HoLEP performed by three operators. The primary outcome measure was operative efficiency, defined as the ratio of preoperative prostate volume estimated by trans-abdominal ultrasound (TAUS)to total surgical time in minutes. The studied learning curve parameters included the number of previously performed cases (NPPCs) and monthly case density (CD) (number of monthly performed cases before the studied one)., Results: Overall, 180 patients with a mean age of 71 (±9) years and a mean prostate volume (g) of 80.4 (±41) were included. The mean operative efficiency in the population was 0.74 (±0.37) g/min. Operative efficiency was increased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 0.66 (±0.27) g/min vs. CD ≥3: 0.79 (±0.43) g/min; P=0.012). At 3months, 46 patients (29%) developed stress urinary incontinence (SUI). Early SUI was significantly decreased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 37%, (n=26) vs CD ≥3: 22%, (n=20); P=0.045)., Conclusions: A high frequency HoLEP procedures, set as one case per week, appeared to accelerate learning curves by improving operative efficiency. A high CD was also associated with reduced rates of early SUI., Level of Proof: 5., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Summary Purpose The deep inferior epigastric perforator (DIEP) flap provides excellent results when performed by a trained surgical team. However, the beginning of the procedure is often complicated. To date, few authors have published their initial experiences. This study presents our team's experience using a DIEP flap in breast reconstruction. Methods From June 2008 until December 2013, the same leading operator performed 132 consecutive DIEP flaps. Breast reconstructions were immediate ( n = 18) or delayed ( n = 114), unilateral ( n = 110) or bilateral ( n = 11). The learning curve was assessed using the operating time, ischemic time, postoperative hospital stay, and complications. For statistical comparisons, unilateral reconstructions were divided into five chronologic groups of 22 consecutive DIEP flaps and two chronologic groups of 55 flaps. Results The average time of surgery was 291 min (range, 185–645) for unilateral breast reconstruction and 513 min (range, 400–790) for bilateral breast reconstruction. The global complication rate was 24.5%. In the unilateral series, the time of surgery decreased progressively from 415 min to 233 min ( P = 4.8 × 10 −8 ). The mean postoperative hospital stay was reduced from 7.14 days to 6.32 days ( P = 0.042). The complications and flap failure rates had regular time distributions. Initially, the revision rate reached 50% for the first ten unilateral cases but decreased rapidly and remained steady at 6% for the following cases ( P = 0.0012). Conclusions Our initial experience of DIEP flap breast reconstruction showed a significant improvement of surgical performances exceeding 50 cases, with a critical ten first case period. [ABSTRACT FROM AUTHOR]

Résumé Objectif Définir les phases composant la courbe d’apprentissage de l’hystérectomie totale (HT) et de l’hystérectomie élargie avec curage pelvien (HECP) robot-assistée d’un unique opérateur sans expérience préalable en cœliochirurgie. Méthodes Nous avons analysé de façon rétrospective 72 procédures (HT, n = 34 et HECP, n = 38) réalisées entre 2002 et 2011. L’utilisation de la méthode CUSUM a permis l’analyse de la courbe d’apprentissage de l’HT et de l’HECP à partir du temps à la console (TC). Les données épidémiologiques, périopératoires et les complications opératoires ont été comparées à partir des différentes phases composant la courbe d’apprentissage. Résultats L’analyse CUSUM du temps à la console (CUSUM TC ) a permis d’identifier 2 phases d’apprentissage pour le groupe HT (phase 1 : apprentissage initial, phase 2 : augmentation des performances). Pour le groupe HECP, trois phases d’apprentissage ont été identifiées (phase 1 : apprentissage initial, phase 2 : extension des indications, phase 3 : maîtrise technique). Les données périopératoires ainsi que le taux de complications postopératoires ne différaient pas de façon significative entre les phases d’apprentissage. Le TC diminuait dès le 9 e cas ( p = 0,01) pour le groupe HT et dès le 13 e cas ( p = 0,04) pour le groupe HECP. Conclusion L’étude de la courbe d’apprentissage par la méthode CUSUM en chirurgie oncogynécologique robot-assistée a permis de définir deux phases d’apprentissage pour des procédures simples comme l’hystérectomie totale et trois phases d’apprentissage pour des procédures plus complexes comme l’hystérectomie élargie avec curage pelvien. Objectives Define the phases composing the learning curve of total hysterectomy (TH) and radical hysterectomy with pelvic lymphadenectomy (RHPL) robot-assisted performed by a single surgeon with no prior experience in laparoscopic surgery. Methods We retrospectively analyzed 72 procedures (TH, n = 34 and RHPL, n = 38) conducted between 2002 and 2011. The surgeon console time (CT) was used to determine the learning curve of TH and RHPL using CUSUM analysis. Epidemiological data, perioperative and postoperative complications were compared from the different phases of the learning curve. Results CUSUM analysis of surgeon console time (CUSUM CT ) identified two learning phases for the TH group (phase 1: initial learning, phase 2: surgical skill increase). For the RHPL group, three learning phases were identified (phase 1: initial learning, phase 2: extending surgical indications, phase 3: control of surgical skills). Perioperative and postoperative complication rates did not differ significantly between the learning phases. Surgeon CT decreased from the 9th case ( P = 0.01) for the TH group and from the 13th case ( P = 0.04) for the RHPL group. Discussion CUSUM analysis of the learning curve in robotic-assisted gynecologic oncology surgery identified two phases of learning curve for simple procedures such as total hysterectomy and three phases for more complex procedures as radical hysterectomy with pelvic lymphadenectomy. [ABSTRACT FROM AUTHOR]

Delay is one of the major factors in the cost overruns that affect construction projects. Furthermore, delay may cause a cumulative impact or ripple effect on productivity. Even though there are various methods proposed in previous researches that are considered applicable for analyzing the damages resulting from delay, there are some limitations to previous approaches. Notably, they do not consider the realistic production rates of activities over time. Moreover, they do not reflect the ripple effects on the performance of the work remaining, after the completion of delay events. This paper, therefore, proposes a method, which is referred to as the COME method (combination of measured mile analysis and earned value management (EVM) incorporating probable production rates) that can reasonably calculate the cumulative damages due to delay, considering the feasible rates of production over time, and the ripple effects on productivity. The COME method includes the 'learning curve', and the 'earned value analysis' as research methodologies. Earned value management was utilized, to demonstrate and calculate the effects of the cumulative loss of productivity on the remaining work, as well as on the impacted work due to delay. An example analysis showed that the COME method is a feasible choice for damages calculation, considering probable production rates over activity progress, and indirect impacts on performance changes, after the completion of delay events. It is noted, however, that the COME method relies on the use of a subjective or availability of an estimated production rate for the estimate to complete calculations. [ABSTRACT FROM AUTHOR]

Résumé Objectif Déterminer la courbe d’apprentissage des internes pour les extractions fœtales par spatules de Thierry. Patientes et méthodes Étude prospective monocentrique suivant la progression de 6 internes en gynécologie obstétrique dans l’apprentissage des extractions fœtales par spatules de Thierry. Les procédures d’extractions instrumentales réalisées par les internes étaient évaluées par l’obstétricien senior de garde selon une échelle d’évaluation validée. En parallèle, l’interne remplissait un questionnaire sur sa propre perception de ses capacités au moment de la procédure. Résultats Les 6 internes ont participé à 160 extractions par spatules de Thierry entre novembre 2010 et mai 2012, dont 63 (39,6 %) ont été évalués, soit un nombre moyen de 12 ± 6 extractions par interne. Après avoir validé respectivement 0, 1, 2 ou 3 semestres, les moyennes des scores globaux d’évaluation (notés sur 5) obtenus par les internes étaient 3,54, 3,18, 4,43 et 4,61. Le score global moyen était significativement supérieur lorsque l’interne avait participé à plus de 20 extractions avant l’extraction étudiée (4,0 vs 3,7 ; p < 0,001). Après avoir participé à plus de 20 extractions, aucun interne n’a obtenu le score maximal d’évaluation de 5/5 ni n’a été jugé capable de réaliser des extractions sans supervision. Discussion et conclusion L’apprentissage des extractions par spatules de Thierry, englobant une évaluation objective effectuée par des médecins seniors et une auto-évaluation des internes, est constant au cours des premiers semestres de formation. Un apprentissage spécifique sur simulateur devrait être développé afin de permettre aux étudiants de réaliser un nombre seuil d’extractions, garant de la sécurité de la procédure dans les salles de naissance. Objectives To determine the learning curve of fetal extractions with Thierry's spatulas. Patients and methods Single-center prospective study following the progress of six residents in obstetrics and gynecology in learning fetal extractions by Thierry's spatulas. The instrumental extractions procedures performed by the residents were evaluated by the senior obstetrician on call according to a validated scoring rubric. In parallel, the residents would fill out a questionnaire on their own perception of their abilities at the time of the procedure. Results The six residents participated in 160 extractions using Thierry's spatulas between November and May 2011. Sixty-three (39.6%) were evaluated, i.e. an average number of 12 ± 6 extractions per resident. After validating respectively 0, 1, 2 or 3 semesters, the mean global assessment scores (graded out of 5) obtained by the residents were 3.54, 3.18, 4.43 and 4.61. The overall average score was significantly higher when the resident participated in more than 20 extractions before the studied extraction (4.0 vs. 3.7, P < 0.001). After attending more than 20 extractions, no resident had obtained the maximum evaluation score of 5/5 nor was deemed capable of performing extractions without supervision. Discussion and conclusions Learning extractions with Thierry's spatulas, including an objective assessment by senior doctors and a self-assessment by the residents, is a constant process over the first six months of training. Specific training simulator should be developed to enable students to achieve a threshold number of extractions, ensuring the safety of the procedure in the birthing rooms. [ABSTRACT FROM AUTHOR]

Résumé Objectifs Évaluer l’impact de la courbe d’apprentissage sur la qualité dosimétrique d’une curiethérapie prostatique de haut débit de dose après une radiothérapie externe. Matériel et méthodes Entre février 2009 et mai 2012, 124 patients ont bénéficié d’une curiethérapie de haut débit de dose après une radiothérapie externe de 46 Gy en 23 fractions en utilisant le logiciel Plato™ (Nucletron, an Elekta company, Elekta AB, Stockholm, Suède). L’impact de la courbe d’apprentissage sur la qualité dosimétrique de l’implant prostatique a été évalué. Les valeurs dosimétriques suivantes ont été comparées : D90 (dose délivrée à 90 % du volume cible anatomoclinique), D100 (dose dans 100 % du volume cible anatomoclinique), V100 (V x : volume cible anatomoclinique recevant x % de la dose prescrite) V150, V200 et indice d’homogénéité de dose (IDH). Les doses délivrées à 0,1, 1 et 2 cm 3 (01, D1, D2) du volume urétral et rectal ont été calculées. Résultats Au cours de la période d’étude de 39 mois, une diminution significative du V150 ( p < 0,001), du V200 ( p < 0,001), de la D0,1rectum ( p < 0,001), de la D1rectum ( p < 0,001), de la D2rectum ( p < 0,001), de la D0,1urètre ( p < 0,001), et de la D1urètre ( p < 0,002) a été observée au prix d’une dégradation significative de la D90 ( p < 0,001) mais non significative du V100 ( p = 0,29) et de la D100 ( p = 0,3). Conclusion Cette étude confirme que la qualité dosimétrique de l’implant prostatique est significativement améliorée durant la période d’apprentissage de la technique de curiethérapie de prostate de haut débit de dose. Purpose To analyse the influence of the learning curve on dosimetric data for high-dose-rate brachytherapy prostate cancer boost. Patients and methods From February 2009 to May 2012, after a first course of external beam radiation therapy (46 Gy/23 fractions), 124 patients underwent high-dose-rate brachytherapy boost using Plato™ (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden). The impact of the learning curve on the dosimetric quality of the prostate implant was assessed. The dosimetric data have been analysed: clinical target volume (CTV), D90 (dose to 90 % of CTV), D100, V100 (part on the CTV receiving 100 % of the dose), V150, V200 and DHI (dose non-homogeneity index). The doses delivered to 0.1, 1 and 2 cm 3 of the rectum and urethra were calculated. Results During the study period (39 months), a significant reduction of V150 ( P < 0.001), V200 ( P < 0.001), D0.1rectum ( P < 0.001), D1rectum ( P < 0.001), D2rectum ( P < 0.001), D0.1urethra ( P < 0.001), and D1urethra ( P < 0.002) was observed associated with a significant degradation of the D90 ( P < 0.001) but not significant for the V100 ( P = 0.29) and the D100 ( P = 0.3). Conclusion This study confirms that the dosimetric quality of high-dose-rate brachytherapy prostate implant is significantly improved during the learning curve period. [ABSTRACT FROM AUTHOR]

Résumé: Introduction: Les techniques de reconstruction mammaire autologue obtiennent les meilleurs résultats cosmétiques. La satisfaction esthétique est un critère d’évaluation important. L’indication repose sur des critères techniques (morphologiques, antécédents médicaux) et sur les souhaits de la patiente. Une évaluation rigoureuse des résultats est nécessaire afin d’aider les patientes dans leur choix de reconstruction. Méthodes: Cette étude a concerné 33 DIEP et 27 grands dorsaux. Un questionnaire de satisfaction a été envoyé aux patientes afin de recueillir l’évaluation esthétique de leur poitrine reconstruite, les séquelles au niveau du site donneur, ainsi que leur satisfaction générale. Les photographies postopératoires des patientes ont bénéficié d’une évaluation esthétique par deux groupes d’observateurs. Les complications ont été analysées. Résultats: Le DIEP tend à obtenir une meilleure satisfaction esthétique en ce qui concerne la symétrie de la poitrine et le volume du sein reconstruit (p =0,05), ainsi qu’une meilleure satisfaction générale (p =0,02). L’homogénéité de couleur du sein reconstruit a été jugée supérieure par les observateurs dans le groupe grand dorsal (p =0,005). La cicatrice du prélèvement du DIEP a été jugée plus inesthétique, tandis que celle du grand dorsal a été jugée plus douloureuse (p = 0,04) et gênante, avec plus fréquemment des anomalies de contour (p =0,03). Nous avons déploré deux nécroses totales et trois partielles dans le groupe DIEP, ainsi que deux nécroses partielles dans le groupe grand dorsal. Conclusion: Cette étude apporte des éléments pouvant orienter la patiente et le chirurgien dans le processus complexe de décision thérapeutique, sans dispenser ce dernier d’une sélection rigoureuse des indications. [ABSTRACT FROM AUTHOR]

Copyright of Obésité is the property of Lavoisier and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: Objective: This survey evaluated if residents felt a benefit to their participation in robot-assisted procedures and highlights the interest of robot in the initial surgical training. Patients and methods: A questionnaire was submitted to 33 residents participating as assistants in robot-assisted surgical procedures in our department and to seven residents of the Chapel Hill hospital, North Carolina, USA. Items rated their experience with the robot, their feeling during the surgical procedures and whether they thought they improved their technical skills. Results: The majority of French residents felt passive during the procedures (97%) or bored (75%); most of them found an immediate interest to learn anatomy (72.7%) and surgical procedures (66.7%). Then, a minority of them reported an improvement of their knowledge in anatomy (39.4%), in surgical procedures (24.2%), and conventional laparoscopy (9.1%). Most of French residents are not willing to repeat the experience as an assistant (81.8%), whereas they showed great interest in practicing robot-assisted surgery later. The oldest residents benefited more than younger in learning anatomy and surgical procedures. US resident’ ratings concerning the contribution of the robot in their training were generally more positive. They were all convinced they made progress in anatomy, as in surgical techniques and they all wanted to repeat such procedures. Discussion and conclusion: This work demonstrates the pedagogical value of using the robot for teaching surgical procedures and anatomy. It also suggests the establishment of training programs dedicated to the learning of robot-assisted surgery in gynaecology, in parallel with training in conventional laparoscopy. [Copyright &y& Elsevier]

Résumé: Objectifs: Les objectifs étaient d’évaluer l’amélioration de la mesure du pincement de l’interligne articulaire (PIA) dans la coxarthrose, en fonction de l’expérience du lecteur. Méthodes: Cinquante radiographies de patients atteints de coxarthrose ont été extraites de la base de données de l’étude randomisée et contrôlée ECHODIAH. Chacune d’entre elles a été lue par deux lecteurs n’ayant pas le même degré d’expérience dans l’interprétation radiologique. Les reproductibilités intra-observateur et interobservateur ont été évaluées par le calcul de la plus petite différence détectable (SDD) et le coefficient de corrélation intraclasse (ICC). Résultats: Reproductibilité interobservateur : pour le lecteur expérimenté, il n’a pas été observé de changement significatif dans la SDD avec la répétition des mesures de PIA. Pour le lecteur junior, la SDD a diminué significativement de 0,90 à 0,65mm (p =0,002). Un plateau a été obtenu après lecture de 200 à 300 radiographies, avec une SDD proche de la SDD moyenne du lecteur expérimenté (0,67mm). Les ICCs étaient élevés (>0,88) pour les deux lecteurs. Reproductibilité interobservateur : aucune amélioration de la reproductibilité interobservateur n’a été observée avec la répétition des lectures du PIA (SDD=0,81mm). Les ICCs étaient élevés (>0,85). Conclusion: Cette étude démontre pour la première fois l’effet de l’apprentissage de la lecture du PIA dans la coxarthrose pour un lecteur inexpérimenté. Après avoir lu 200 à 300 radiographies, la reproductibilité intra observateur du lecteur inexpérimenté est équivalente à celle d’un lecteur entraîné. Cette étude suggère en outre que la SDD et l’ICC devraient être systématiquement rapportés dans les études (l’ICC seul étant insuffisant) sur la progression radiologique dans l’arthrose pour faciliter l’interprétation des résultats. [Copyright &y& Elsevier]

Abstract: The transradial approach is the main route in France to perform percutaneous coronary intervention, reaching nearly 60% of the cases in 2008. Its proven benefit in reducing bleeding complications and therefore its impact on morbidity and mortality are now well documented. However, a definite learning curve is necessary in relation with specifics challenges. Radial spasm and anatomical variations are the main reasons to explain failures encountered during its implementation. In order to increase success procedure, these difficulties and the ways to overcome them must be well-known. Finally, success rate is now comparable to the classical femoral approach. [Copyright &y& Elsevier]

Abstract: Objective: Since 2002, Conceptus company markets in France and Europe the Essure® microinsert as permanent hysteroscopic intratubal sterilization, and organizes a meeting, a training and an assistance on a few cases. The data from this interview and the results of the first cases done with assistance of Conceptus instructors were collected prospectively between January 2004 to December 2006. The purpose is to make a state of the art about teaching hysteroscopy to gynaecologist surgeons in France and in Europe. Patients and methods: According to their statements about their knowledge of hysteroscopy practice, surgeons were classified in four groups. Group 1 included those who had a bad knowledge and a sporadic practice, group 2 those who had no formation and an empirical practice, group 3 those who had a regular practice and an incomplete formation or whose formation was in progress and group 4 those with fully-formed surgeons with a regular practice. Results: One thousand one hundred and fourty-four women underwent hysteroscopic sterilisation with a global success rate of 92.13%. Were included 536 surgeons and 498 were evaluated. There were 80 (16.06%) surgeons in group 1, 149 (29.92%) in group 2, 121 (24.30%) in group 3 and 148 (29.72%) in group 4. Failure rates for each group were respectively 16.25%, 10.07%, 9.10% and 4.73% (p ≤ 0.01). The presence of an instructor was associated with a fast improvement judging from the classification in a higher level group in 47.83%, 28.21% and 25% respectively for the groups 1 to 3 after the second visit and in 75%, 58.33% and 20% after the third visit. Discussion and conclusion: It seems important to establish a modern and low-cost teaching program to improve surgeon''s theoretical and practical formation in hysteroscopy in order to increase success rates and reduce possible complications. Theoretical formation has to include a good knowledge of the material and its use: diameter and form of the operative channel, obliquity of the scope, liquid of distension and kind of current used. Practical formation could be done at once with virtual models to get used with the manipulation of the scope and thanks to the use of different currents with the assistance of a trained surgeon. [Copyright &y& Elsevier]

Abstract: Introduction: Few information are available regarding the learning curve in ultrasonography and even less for ultrasound-guided regional anesthesia. This study aimed to evaluate in a training program the learning curve on a phantom of 12 residents novice in ultrasonography. Material and methods: Twelve trainees inexperienced in ultrasonography were given introductory training consisting of didactic formation on the various components of the portable ultrasound machine (i.e. on/off button, gain, depth, resolution, and image storage). Then, students performed three trials, in two sets of increased difficulty, at executing these predefined tasks: adjustments of the machine, then localization of a small plastic piece introduced into roasting pork (3cm below the surface). At the end of the evaluation, the residents were asked to insert a 22 G needle into an exact predetermined target (i.e. point of fascia intersection). The progression of the needle was continuously controlled by ultrasound visualization using injection of a small volume of water (needle perpendicular to the longitudinal plane of the ultrasound beam). Two groups of two different examiners evaluated for each three trials the skill of the residents (quality, time to perform the machine adjustments, to localize the plastic target, and to hydrolocalize, and volume used for hydrolocalization). After each trial, residents evaluated their performance using a difficulty scale (0: easy to 10: difficult). Results: All residents performed the adjustments from the last trial of each set, with a learning curve observed in terms of duration. Localization of the plastic piece was achieved by all residents at the 6th trial, with a shorter duration of localization. Hydrolocalization was achieved after the 4th trial by all subjects. Difficulty scale was correlated to the number of trials. All these results were independent of the experience of residents in regional anesthesia. Discussion: Four trials were necessary to adjust correctly the machine, to localize a target, and to complete hydrolocalization. Ultrasonography in regional anesthesia seems to be a fast-learning technique, using this kind of practical training. [Copyright &y& Elsevier]

Abstract: Kidney transplantation is the therapeutic option of choice for patients with end-stage renal disease. With the advent of safer harvesting techniques and immunosuppression, both donor and recipient outcomes have markedly improved in recent years. Kidney donation from living donors remains the single most important factor responsible for improving patient and graft survival. The laparoscopic donor nephrectomy has revolutionized renal transplantation, allowing expansion of the donor pool by diminishing surgical morbidity while maintaining equivalent recipient outcome. This technique is now becoming the gold-standard harvesting procedure in transplant centres worldwide, despite its technical challenge and ongoing procedural maturation, especially early in the learning curve. Previous contraindications to laparoscopic donor nephrectomy are no longer absolute. In the following analysis, the procedural aspects of the laparoscopic donor nephrectomy are detailed including pre-operative assessment, operative technique and a review of the current literature delineating aspects of both donor and recipient morbidity and mortality compared with open harvesting techniques. [Copyright &y& Elsevier]

Introduction: We aimed to assess the impact of antiplatelet and anticoagulation therapy for patients undergoing HoLEP., Methods: We performed a study during the learning curve on a consecutive series of patients who underwent HoLEP surgery from 2015 to 2018. The patients were divided into 3 groups: a control group, patients with antiplatelet therapy and patients with anticoagulation therapy., Results: A total of 223 patients underwent HoLEP surgery during this period: 124 in the control group, 63 in the antiplatelet group and 36 in the anticoagulant group. In the anticoagulant group, we observe significant differences with the control group for the catheterization time (2.05 days vs 5.17 days; P<0.001), the hospital length of stay (1.5 nights vs 4.49 nights; P<0.001) and complications (8.9% vs 58%; P<0.001). No difference between the control and antiplatelet groups in terms of catheterization time, hospital length of stay and complications (2.05 days vs 2.68 days; 1.5 nights vs 1.6 nights) but variation in terms of complications and bleeding complications (8.9% vs 21%; P<0,001; 8.1% vs 19%; P<0,001) CONCLUSION: Our study shows that HoLEP is therefore associated with a higher risk of bleeding for patients treated with anticoagulation therapy. Complications increase morbidity with longer catheterization time, hospitalization times and higher transfusion's rates, revision surgery and readmission., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Inflatable penile prosthesis surgery is relatively rare in France, and around ten surgeons perform most of this surgery. The objective of this study was to define the learning curve concerning this surgery., Methods: This study is a retrospective monocentric cohort of first time implantation of inflatable penile prosthesis between 2008 and 2016 in a university hospital. 68 consecutive patients underwent this procedure performed by a single surgeon. These patients were dispatched into two groups: a group of the first 20 patients and a group of the 48 last patients. For each patient, multiple parameters were measured including: duration of surgery, per operative complications, post operative morbidity according to Clavien classification, length of stay, and functional satisfaction. Parameters were compared using Fisher or Wilcoxon tests., Results: Patients were on average 58.2 year old and average operating time was 87.7minutes. The average complication rate was 16.2%. Five patients from the first group and 3 patients from the second group presented a grade 3 post operative complication according to Clavien classification. The complications included 5 infections, one erosion, one irreductible paraphimosis and a prosthesis dysfunction. This difference was statistically significative (P=0.043). The average duration of hospitalization was significantly shorter in the second group (P=0.004). There was no significative difference concerning the satisfaction using the EDITS score (P=0.52) or a Likert scale (P=0.72)., Conclusion: In this monocentric and retrospective study, the learning curve for first time implantation of inflatable penile prosthesis is acquired after 20 surgeries. Specific training could lower this number, but needs further evaluation., Level of Evidence: 3., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Résumé Objectif Comparer les phases d’apprentissage des deux techniques d’énucléation de l’adénome de prostate au laser : HoLEP et GreenLEP. Méthode L’auteur fait part de son expérience d’apprentissage de l’énucléation de l’adénome de prostate successivement par la technique d’HoLEP puis de GreenLEP. Résultat Cette expérience permet de comparer les phases d’apprentissage et les difficultés techniques rencontrées par un opérateur débutant ces deux méthodes. La technique monobloc du GreenLEP semble plus rapide à acquérir mais la technique en trois lobes de l’HoLEP semble plus sécurisante en début d’expérience. Conclusion Il semble envisageable de développer une méthode d’apprentissage commune s’inspirant des avantages de chacune de ces techniques afin de faciliter l’enseignement de l’énucléation de l’adénome de prostate au laser. Summary Objective Compare the learning phase of two techniques of laser enucleation of the prostate: HoLEP and GreenLEP. Method The author shares his learning experience of the laser enucleation of the prostate successively by HoLEP and GreenLEP. Results This experience allows to compare learning curves and technical difficulties encountered by a beginner operator with both methods. GreenLEP En-bloc method appears to be faster to learn, but HoLEP three-lobar method gives a safer feeling for beginner. Conclusion It seems possible to develop a common learning method based on the benefits of both techniques to facilitate education of the laser enucleation of the prostate. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this work was to evaluate the impact of the laparoscopic radical cystectomy learning curve on perioperative and oncological outcomes., Patient and Methods: This is a retrospective and single-center study of all patients who underwent laparoscopic radical cystectomy for bladder cancer from February 2007 to March 2016, (93 patients) Perioperative and oncological data were collected. We used mixed statistical models to predict the number of patients needed in the learning phase. We compared the perioperative parameters of the patients in the learning phase with those of the rest of the patients. Overall survival was estimated using the Kaplan-Meier method., Results: Thirty-six patients are required for the learning phase (P1). The expertise phase begins after the 36th LRC (P2). In both phases, there was no significant difference in age, ASA score, and tumor stage (P=0.237, P=0.577, P=0.998). Mean operative time was 328.3min and 262.4min in P1 and P2 (P=0.0001), mean blood loss was 333.7mL and 194.3mL in P1 and P2 respectively (P=0.0003). The rate of major complications was high in the learning phase (P=0.042). There was no significant difference in lymph node yield, positive surgical margins and overall survival (P=0.068, P=0.194, P=0.703)., Conclusion: This learning experience was evaluated without compromising oncological results, but with a significantly higher rate of major complications., Level of Evidence: 3., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: Holmium laser enucleation of the prostate (HoLEP) has been shown to be effective in treating large prostates compared to prostate transurethral resection (TURP). There are no published data evaluating specifically the impact of the learning curve on the direct costs of HoLEP. The objective of this study was to evaluate the direct costs generated by the use of HoLEP laser during the learning curve period., Method: The costs of all medical devices (DM) and drugs used, pre- and post-operative parameters during surgery have been prospectively collected between March and October 2016., Results: A total of 32 patients were included in the study with a mean age of 70.8 years and a mean prostate volume of 68.6 cm 3 . The mean cost of anesthesia was 39.0 € and that of drugs and DM used for surgery was 257.95 € but could reach 470.76 € in case of conversion to bipolar resection. The mean duration of enucleation and morcellation was 150minutes with a mean weight of enucleated specimens of 40.4g. The total mean duration of patient care was 197minutes at an estimated hourly cost of € 636., Conclusions: Despite some limitations, this study makes it possible to analyze the direct costs of the management of benign prostatic hypertrophy using HoLEP, an innovative surgical technique, and to specify that these costs are more related to bipolar conversion and voluminous adenomas especially during the learning curve., Level of Evidence: 5., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: Morcellation of intravesical adenoma (MIA) is an important part of the endoscopic enucleation procedure. The aim of this study was to analyse the learning curve of the MIA during endoscopic enucleation of the prostate., Material: We conducted a prospective study of the first 90 patients treated by endoscopic enucleation of the prostate by a single surgeon without previous experience of MIA. The population was divided into 3 consecutive groups of 30 patients. MIA was performed with the morcellator Pinranha (Wolf) and disposable blades (V max © ). The criteria selected to assess the progress of MIA over time were: duration of MIA (min), the intraoperative complications encountered during MIA and weight morcelleted tissue. The efficacy of MIA was assessed with the ratio weight specimen/MIA duration (min/g) over time., Results: The three groups were comparable in terms of age, ASA score of prostate volume. A significant decrease in the duration of MIA was found between groups 1 and 2 (12 versus 5.5min, P<0.0001), to reach a plateau in the group 3 (3min). A significant increase in the efficiency of MIA was found between group 1 and 2 (5.5 versus 11g/min, P<0.0001), to reach a plateau in the group 3 (20g/min). Bladder injuries were limited (7.7%), superficial and encountered in the early learning phase., Conclusion: In our experience, the MIA required a learning curve estimated between 30 and 60 procedures., Level of Evidence: IV., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Aim: Holmium laser enucleation of prostate (HoLEP) is renowned for the difficulty of its learning curve. Our aim was to evaluate the interest of a three-step tutorial in the HoLEP learning curve, in a university center., Methods: It is a retrospective, monocentric study of the 82 first procedures done consecutively by the same operator with a proctoring in early experience and after 40 procedures. For all patients were noted: enucleation efficiency (g/min), morcellation efficiency (g/min), percentage of enucleated tissue (enucleated tissue/adenome weigth evaluated by ultrasonography. g/g), perioperative morbidity (Clavien), length of hospital stay, length of urinary drainage, functional outcomes at short and middle term (Qmax, post-void residual volume [PVR], QOL scores and IPSS at 3 and 6months)., Results: Enucleation and morcellation efficiency were significantly higher after the second proctoring (0.87 vs 0.44g/min; P<0.0001 and 4.2 vs 3.37g/min, P=0.038, respectively) so as the prostatic volume (43.5 vs 68.1mL, P=0.0001). Percentage of enucleated tissue was higher in the second group, however, the difference was not significant (69.5% vs 80.4%, P=0.03). Per- and postoperative complications, hospital length of stay, urinary drainage length and functional results at 3 and 6months were not significantly different., Conclusion: The learning curve did not interfere with functional results. The second proctoring was essential to us in order to grasp the technique. These data underlined the necessity of a pedagogic reflexion in order to built a standardized formation technique to the HoLEP., Level of Evidence: 4., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Objectives: Renal transplantation is performed only in university hospital centres, in accredited transplanting centres. The aim of this study is to analyse the learning curve of this operation and its impact on the graft survival., Patients-Methods: Monocentric retrospective study in which 3 groups have been defined: Juniors 1, Juniors 2 and Seniors corresponding respectively to the first thirty transplantations and to the last thirty transplantations of 5 clinical leaders, and 30 transplantation graft of referent seniors. Data have been registered in a database. Operation times, lukewarm ischemic times and postoperative complications have been compared within the 3 groups., Results: A clear difference of operation time has been noted within the 3 groups with an average time of 202 minutes for Juniors 1, 173 minutes for Juniors 2 and 140 minutes for Seniors (P<0.0001). Likewise, concerning lukewarm ischemic time and vascular anastomosis time respectively with an average time of 72, 59 and 40 min (P<0.0001). Vascular complications occurred in 20% of cases in Juniors 1, 44.3% of cases in Juniors 2 and 17% of cases in Seniors (P=0.65). There were no significant differences of survival without urinary complications: 20% of complications for Juniors 1, 10% for Juniors 2 and 17% for Seniors (P=0.63). Similarly results have been obtained with analysing complications following Clavien's order., Conclusion: This study reveals that renal transplantations operated by young surgeons require longer operation and lukeward ischemic time but without significant repercussions on the surgical complication rate and the global survival. This stresses on the importance of surgical training during medicine internship., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: The aim of this study was to analyze the XPS laser learning curve of one single surgeon with no previous experience of PVP and the impact of the use of reel time transrectal ultrasound (TRUS) monitoring., Materials and Methods: Retrospective analysis of the first 100 patients: group 1 (1st-49th patient without TRUS) and group 2 (50th-100th with TRUS). The learning curve was analyzed through technical variables: vaporization time/intervention time (VT/IT) (%), energy delivered (J)/prostate volume (J/mL) and delivered energy (J/s or Watt), peroperative conversion into monopolar transurethral resection, postoperative complication, duration of catheterization and hospitalization and evolution of International Prostate Symptom Score (IPSS), PSA level, prostate residual volume and Qmax. Relationships between variables were evaluated by analysing the covariance (R 2 software. 14.2)., Results: A significant increase in VT/IT (P=0.0001) and the energy delivered per mL prostate (P=0.043) was reported in group 1. The average energy delivered per second was significantly higher in group 2 (P=0.0016). No difference was observed in terms of intra- or postoperative complication and catheterization time. The duration of hospitalization was significantly shorter in group 2 (P=0.03). The use of TRUS was associated with a gain of energy delivered by prostate volume at the end of learning curve (P=0.018). Prostate residual volume was significantly lower in the group 2 (P=0.0004)., Conclusion: In our experience, 50 procedures are required to achieve the learning curve of PVP. The use of reel time TRUS would increase the energy delivered by prostate volume., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)