See more, do less?—resident-reported training trends in reconstructive urology

Abstract

Background

Urologic surgical training has been dramatically affected by numerous practice changes including a significant increase in robotic surgery, rise of subspecialty fellows, and even the coronavirus disease 2019 (COVID-19) pandemic, among others. How resident training has been affected is not well understood. In this study, we aim to describe the changes in resident-reported case log data for reconstructive urology surgeries, specifically for female reconstructive cases.

Methods

Data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) reporting system, which compiles resident-submitted case reports of procedures performed and resident role. Submitted surgeries are categorized by type using Current Procedural Terminology (CPT) codes as well as resident-reported role in the procedure—“surgeon”, “assistant”, “teaching assistant”, or “all roles”. Data from graduating urologic residents from 2010 to 2022 were reviewed.

Results

From 2010 to 2022, we observed an increase in “all roles” reconstructive urologic cases logged by residents (0.82 cases per year, P=0.06). Reconstructive cases logged as “surgeon” decreased by 0.77 cases per year (P=0.057), while “assistant” cases increased by 1.48 cases per year (P<0.001). For female reconstructive cases, “surgeon” reported cases declined by 1.1 cases annually (P<0.001) while “assistant” role increased by 0.32 (P<0.001).

Conclusions

Over the last decade, we observed a decrease in resident-reported role as “surgeon” in female reconstructive cases while the overall volume of reconstructive urologic cases simultaneously increased. Understanding these trends is essential for resident educators, while further research is necessary to identify potential causes

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Key findings

• Resident-reported case logs designated as “surgeon” have declined for female reconstructive urologic cases.

What is known and what is new?

• Case logs have long been used as a proxy for surgical experience, and prior studies in urology have demonstrated case-dependent learning curves.

• This manuscript describes trends in urology resident case logs over a decade, specifically in regards to reconstructive urology.

What is the implication, and what should change now?

• Program directors and teaching surgeons should be aware of this trend and monitor the potential impact on their trainees.

Introduction

Urologic training has undergone significant change in the past decade. The following have all been proposed factors on the changing resident experience: dramatic rise of minimally invasive/robotic procedures, increasing numbers of subspecialty fellows, changes in teaching philosophy, concurrent surgery policy, case overlap between specialties, and the coronavirus disease 2019 (COVID-19) pandemic (1). The Accreditation Council for Graduate Medical Education (ACGME) requires that residents document their operative experience as a means of monitoring adequacy of a residency training program’s surgical opportunities for residents (2). While it does not directly determine the adequacy of any individual resident, case volume during residency has been widely used as a surrogate for experience, comfort, and proficiency in the operating room. Despite the introduction of ACGME-mandated case minimums, many urology residents feel unprepared for the transition to independent practice (2,3).

Prior studies focusing on quantifying surgical experience have identified steep learning curves where mastery in independent practice is dependent on the number of cases performed, a finding which has been corroborated for urology-specific procedures (4-6). Operative experience consists of more than just case numbers. Other factors include degree of resident involvement, institutional practice, resident investment in overall care of the patient, case specific-educational value, and attending interest and ability in teaching. Nevertheless, analysis of case logs can identify trends and areas for improvement in urology training (7,8). Because case logs require the resident to document their degree of involvement in the operation (or procedure)—namely if they were an “assistant”, “surgeon”, or “teaching assistant”—these logs can lend insight into the quality and quantity of exposure, and the perceived level of resident proficiency.

In particular, reconstructive urologic procedures have demonstrated volume-dependent surgical proficiency with generally lower perceived aptitude as reported by graduating residents (6,9). Even with fellowship training, a significant proportion of trainees still do not feel they had adequate exposure to female reconstructive surgery (2,10,11). In this study, we retrospectively utilized national-level ACGME case log data in order to describe national trends in graduating resident case log data from 2010 to 2022 for reconstructive urologic procedures. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-55/rc).

Methods

Data collection

Case log data were obtained from the ACGME for urology residency graduates from 2010 to 2022. The ACGME National Data Report of Urology Case Logs is presented as an aggregation of all programs submitted data and does not distinguish individual or program-level data, but instead presents a national-level summary. Current Procedural Terminology (CPT) codes are used to classify cases into categories, which include general urology, endoscopic (stone disease), reconstructive surgery, oncology, and pediatric minor/major cases (Table 1). Within the “reconstructive cases” category, cases include male penile/incontinence, urethral, intestinal diversion, and female-specific urologic procedures. Each case is classified by the resident in terms of their self-professed involvement in the case as “surgeon”, “assistant”, or “teaching assistant”. In addition to the three specific roles, an “all roles” is the sum of the three categories, serving to represent the total number of cases in which residents participated or observed. This report addresses the “reconstructive cases” category.

Table 1. Example ACGME procedure groupings as defined by CPT codes with graduating cases minimums (12).

Reconstructive sub-category	Minimum graduating case requirement	Commonly tracked cases [CPT code]
Male penis/incontinence	10	Penile plication [54360]
		Male sling [53440]
		Artificial sphincter [53445]
Male urethra	5	Urethroplasty [53400, 53410, 53415, 53420]
Female	15	Sling [57288]
		Vesicovaginal fistula repair [57320]
		Prolapse repair [57240]
		Diverticulectomy [53230]
		Dilation of female urethra [53660]
Intestinal diversion	8	Augment [51960]
		Ileal conduit [50820]

ACGME, Accreditation Council for Graduate Medical Education; CPT, Current Procedural Terminology.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. No ethical approval was required for this retrospective study as the data set does not involve any patient information. Similarly, the data set does not provide program nor resident-level data.

Statistical analysis

Descriptive statistics were used to identify mean, median, minimum, maximum, and percentile data for each category to describe the graduating case logs at the start of the study. These numbers were then compared across graduating years during the study period using Spearman’s correlation. Subgroup analysis was performed by separating cases specific to male procedures (penis/incontinence, urethra), female, and intestinal diversion, and again comparing trends in resident-reported role across the years of the study.

Results

All cases

Marking the beginning of the study period, residents graduating in 2010 logged an average of 169.1 [standard deviation (SD), 54]. “All roles” reconstructive cases over the course of their residency. Graduating residents in 2010 were designated “surgeon” role in 139.3 (SD, 9) cases, “assistant” in 27.8 (SD, 32) cases, and “teaching assistant” in 4.3 (SD, 9) cases for reconstructive urologic procedures. Over the next decade, there was an overall increase in the annual mean number of “all roles” reconstructive cases logged (0.82 cases per year, P=0.06) (Figure 1, Table 2). The number of cases logged as “assistant” increased by 1.48 cases per year (P<0.001) while the number of cases logged as “surgeon” decreased by 0.77 cases per year (P=0.057). The increase in “teaching assistant” cases was 0.08 cases per year (P=0.16) (Table 2).

Figure 1.

Resident-reported role in reconstructive urologic cases by year. Mean is representative of total cases performed during residency at time of graduation.

Table 2. Average annual changes in resident submitted case log data by self-reported role for 2010–2022.

Case category	All roles, mean				Surgeon, mean				Assistant, mean				Teaching assistant, mean
	rs	P value	Δ/year		rs	P value	Δ/year		rs	P value	Δ/year		rs	P value	Δ/year
Reconstructive surgery	0.533	0.06	0.82		−0.539	0.057	−0.77		0.923	<0.001	1.48		0.414	0.16	0.08
Male	0.945	<0.001	1.20		0.797	0.001	0.53		0.945	<0.001	0.58		0.435	0.14	0.05
Penis/incontinence	0.750	0.001	0.55		0.278	0.36	0.09		0.952	<0.001	0.41		0.402	0.17	0.05
Urethra	0.978	<0.001	0.65		0.911	<0.001	0.44		0.861	<0.001	0.18		0.615	0.03	0.03
Female	−0.919	<0.001	−0.80		−0.923	<0.001	−1.12		0.817	<0.001	0.32		0.122	0.69	0.00
Intestinal diversion	−0.984	<0.001	−0.39		−0.997	<0.001	−0.67		0.880	<0.001	0.28		−0.141	0.65	−0.01

Surgical categories are ACGME reported designations based on CPT coding used for case log submission. ACGME, Accreditation Council for Graduate Medical Education; CPT, Current Procedural Terminology.

Male-specific reconstructive cases

Across all male reconstructive procedures (Table 2), the mean number of cases logged designated as “all roles” increased (1.20 cases per year, P<0.001). “Surgeon” and “assistant” cases increased by 0.53 and 0.58 cases per year, respectively (P=0.001, P<0.001). Again, the increase noted for “teaching assistant” cases was small, 0.05 cases per year (P=0.14).

For penis/incontinence procedures (Table 2), an increase of 0.55 cases per year was noted for “all roles” (P=0.001), an increase in “surgeon” of 0.09 cases per year (P=0.36), and an increase in those logged as “assistant” (0.41 cases per year, P<0.001). Small increases were noted in both “surgeon” (0.44 cases per year, P<0.001) and “assistant” (0.18 cases per year, P<0.001) categories for male urethra cases.

Female-specific reconstructive cases

Female reconstructive cases declined by 0.80 cases per year (P<0.001) for “all roles” and by 1.12 cases for those logged as “surgeon” (P<0.001) (Table 2, Figure 2). Cases logged as “assistant” increased by 0.32 cases per year (P<0.001). Intestinal diversion cases similarly declined by 0.39 and 0.67 cases per year for “all roles” and “surgeon”, respectively (P<0.001), while the number of “assistant” cases increased by 0.28 cases per year (P<0.001).

Figure 2.

Resident-reported role in female reconstructive urologic cases only by year. Mean is representative of total cases performed during residency at time of graduation.

Discussion

From 2010 to 2022, there has been a gradual increase in logged reconstructive cases for graduating urology residents. For the most part, this trend is explained by an increase in cases logged as “assistant” rather than “surgeon”. Female reconstructive cases demonstrated a decrease in both “all roles” and “surgeon” designations. While one fewer case annually is unlikely to significantly affect training experience, the national trend of less operating and more assisting may portend future implications for resident comfort and ability when transitioning to independent practice (9). Over the course of a residency, this trend can be extrapolated to a total of five fewer cases as “surgeon” at time compared to their older colleagues. While the raw number of cases has unclear clinical significance, this data supports a prior study showing decreases in resident exposure to reconstructive urology (2).

Critical to the development of future autonomous practice is the ability of residents to perform cases in the lead role. While there was an overall increase in exposure to reconstructive urologic cases, the observed decline in “surgeon” and increase in “assistant” cases has potential future ramifications for graduating residents. Unfortunately, the data do not designate nor assign value to cases that may be of greater education value, which also affect the quality of resident education significantly. Taken in combination with low resident-reported confidence metrics at time of graduation (9), a decline in “surgeon” role merits additional attention and exploration to its effect on education. The increase in robotic surgery, the effect of the COVID-19 epidemic, and the overlap between urology and urogynecology are all possible influences that may explain this decline. Potential cross over of cases from academic to private practice settings presents another potential source of case decline, however practice trends from the American Urologic Association (AUA) Census which showed a decrease in Urologists working in private practice over the timeframe of our study (13). The AUA Census did not designate the proportion of reconstructive urologists within private practice.

Robotic surgery continues to grow in influence and scope across all urologic subspecialties. Though the robotic platform has been used for urologic oncology for 20 years, the uptake of this technology by reconstructive urologists accelerated in the mid-2000s (14). Robotic surgery, unlike open procedures, requires only one operating surgeon at a time, with residents commonly participating as bedside assistants or observing rather than working at the console. Teaching consoles, where control of the robot can be passed between multiple console users quickly, alleviate this problem but are not widely available (15).

The rise in robotic surgery has coincided with heightened negative public perception of the practice of concurrent surgery, where one attending surgeon runs multiple operating rooms simultaneously (16). While limiting attendings to a single active procedure at any one time may have important patient safety ramifications, inevitably the opportunity for residents to operate independently, even for short periods, declines. Further, the role of the COVID pandemic in resident experience has been incompletely elucidated. In the height of the pandemic, many centers temporarily halted “non-urgent” procedures, a substantial portion of which fall into the reconstructive category within the ACGME case log system (17,18). A study looking at case logs for reconstructive urology fellows demonstrated no changes compared to mean case volume for pre- vs. post-COVID levels (19).

Specific to female reconstructive experience, urogynecology and urology have significant overlap in cases related to incontinence, prolapse, and pelvic floor procedures, resulting in an escalation in competition among learners for adequate exposure. Female cases are increasingly performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS; now called Urogynecology and Reconstructive Pelvic Surgery) specialists, as opposed to general urologists, limiting opportunities for trainee exposure (20). Using available data from fellowship programs, Genitourinary Reconstructive Surgeons (GURS) Fellowship case logs have shown a decrease in logged female reconstructive urologic cases since 2013 (21). Over the same time frame number of GURS programs increased, match rate remained stable, and male reconstructive cases increased, which suggests against pool dilution as an explanation. Indeed, while differences in exposure exist, exploring case logs of gynecology-based urogynecology and reconstructive pelvic surgery Fellowships has shown considerable overlap with urology-based programs and inevitably would affect resident-level exposure. Further, in 2023, 25% of urology residents had neither a FPMRS fellowship nor a FPMRS-trained faculty member at their institutions (22). As this intersection grows, how residents will continue to develop necessary independent skills remains unclear.

It is important to note that the ACGME has recently shifted to an anatomic classification rather than gender classification for tracking case minimums. Future studies using ACGME data will not be able to distinguish between, for example, a gender affirming vaginoplasty vs. a prolapse repair in a cis woman as both would be counted under the same anatomic category. When tracking future case log data, program-specific data will be required to make these distinctions.

The strengths of this study include its use of nationwide data, encompassing the full spectrum of resident experience. This data includes resident-reported involvement, which has significant implications for perceived level of practice readiness. The large volume of data reduces case volume bias that can be seen at the institution level, such as centers with highly specific operative programs. Further, academic centers produce disproportionately more research related to resident training relative to other programs, and the nature of this data helps to minimize this potential source bias.

Our study also has limitations. First, the classification of resident role is subjective, and based on the interpretation and recollection of the case by the resident. Additionally, this data does not contain program-level data, meaning programs with and without fellowship programs cannot be differentiated, nor can regional variations. The retrospective nature of the study further limits direct comparison of possible etiologies leading to the changes observed in operative trends.

Conclusions

Over the last decade, urology residents have gained more exposure to male reconstructive surgeries. This trend, however, is largely due to an increase in cases logged as assistant, with a decrease in those logged as surgeon. Female urology case exposure and involvement have decreased overall. It is important for leaders in urologic education to understand and address this trend. Future studies are needed to clarify the long-term effects of these changing trends, as well as the driving causes.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.