Objectives To describe how learning curves are measured and what procedural variables are used to establish a ‘learning curve’ (LC). To assess whether LCs are a valuable measure of competency. Patients and Methods A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases. Results Variables should be fully defined and when possible, patient‐specific variables should be used. Trainee's prior experience and level of supervision should be quantified; the case mix and complexity should ideally be constant. Logistic regression may be used to control for confounding variables. Ideally, a learning plateau should reach a predefined/expert‐derived competency level, which should be fully defined. When the group splitting method is used, smaller cohorts should be used in order to narrow the range of the LC. Simulation technology and competence‐based objective assessments may be used in training and assessment in LC studies. Conclusions Measuring the surgical LC has potential benefits for patient safety and surgical education. However, standardisation in the methods and variables used to measure LCs is required. Confounding variables, such as participant's prior experience, case mix, difficulty of procedures and level of supervision, should be controlled. Competency and expert performance should be fully defined.

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.• 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.

Although ureteric injury is relatively uncommon, it is a serious event that can result in intra-abdominal sepsis, renal failure, and loss of the ipsilateral renal unit. Most injuries are iatrogenic and remain undiagnosed until the patient presents with symptoms postoperatively. In addition to compromising patient safety, missed ureteric injuries frequently result in litigation. Over the past 20 years, there has been a rapid uptake of laparoscopic and robotic techniques within urology and other surgical specialties. This trend, coupled with increased use of ureteroscopy, has increased the risk of injury to the ureter. The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence. Diagnosis can be achieved using retrograde pyelography, ureteroscopy, CT, or intravenous urography. Initial management should involve ureteric stent placement or percutaneous nephrostomy drainage. In selected patients, surgical reconstruction might be the optimal approach. Decisions regarding surgical technique (open, laparoscopic, or robotic) are guided by the clinical situation and surgical expertise available.

Ureteropelvic junction obstruction (UPJO) is characterized by impaired flow of urine from the renal pelvis to the ureter. Untreated disease can result in renal impairment making effective management crucial. A combination of CT imaging and diuretic renography is typically used for diagnosis. CT is the investigation of choice for obtaining anatomical information about UPJO and can help to identify potential causes. Diuretic renography is best for providing functional information about UPJO. A variety of open and minimally invasive surgical techniques are available for treatment of UPJO. Traditionally open pyeloplasty has been the standard of care but minimally invasive surgical techniques have become increasingly popular. Endopyelotomy has a lower success rate than other modalities (42-90% depending on the approach), but is associated with reduced pain and shorter convalescence. Laparoscopic pyeloplasty and robot-assisted pyeloplasty have similar success rates to open pyeloplasty (>90%), with the additional advantages of significantly reduced morbidity and shorter convalescence. More long-term outcome data for minimally invasive surgical techniques are awaited.

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OBJECTIVE To report the largest single series of renal transplant patients (adults and children) with urolithiasis, assess the risk factors associated with urolithiasis in renal transplant recipients, and report the outcome of the multimodal management by endourological and open procedures. PATIENTS AND METHODS The records of all patients undergoing renal transplantation between 1977 and 2003 were reviewed. In all, 2085 patients had a renal transplant at our centre and 21 (17 adults and four children) developed urinary tract calculi. Their mode of presentation, investigations, treatments, complications and outcomes were recorded. Investigations included one or more of the following; ultrasonography (US), plain abdominal X‐ray, intravenous urography, nephrostogram and computed tomography. Management of these calculi involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. RESULTS Thirteen patients had renal calculi, seven had ureteric calculi and one had bladder calculi. The incidence of urolithiasis was 21/2085 (1.01%) in the series. Urolithiasis was incidentally discovered on routine US in six patients, six presented with oliguria or anuria, including one with acute renal failure, four with a painful graft, three with haematuria, one with sepsis secondary to obstruction and infection and in one, urolithiasis was found after failure to remove a stent. Ten patients (63%) had an identifiable metabolic cause for urolithiasis, two by obstruction, two stent‐related, one secondary to infection and in six no cause was identifiable. Thirteen required more than one treatment method; 13 (69%) were treated by ESWL, eight of whom required multiple sessions; eight required ureteric stent insertion before a second procedure and four required a nephrostomy tube to relieve obstruction. Two patients had flexible ureteroscopy and stone extraction, three had a PCNL and one had open cystolithotomy. PCNL failed in one patient who subsequently had successful open pyelolithotomy. All patients were rendered stone‐free when different treatments were combined. CONCLUSIONS The incidence of urolithiasis in renal transplant patients is low. There is a high incidence of metabolic causes and therefore renal transplant patients with urolithiasis should undergo comprehensive metabolic screening. Management of these patients requires a multidisciplinary approach by renal physicians, transplant surgeons and urologists.

Analysis 1.4. Comparison 1 Robotic-assisted laparoscopic versus open radical cystectomy, Outcome 4 Transfusion rate. Analysis 1.5. Comparison 1 Robotic-assisted laparoscopic versus open radical cystectomy, Outcome 5 Hospital stay.. Analysis 1.6. Comparison 1 Robotic-assisted laparoscopic versus open radical cystectomy, Outcome 6 Quality of life. Analysis 1.7. Comparison 1 Robotic-assisted laparoscopic versus open radical cystectomy, Outcome 7 Positive margin.

Urology has increasingly become a technology-driven specialty. The advent of robotic surgical systems in the past 10 years has led to urologists becoming the world leaders in the use of such technology. In this paper, we review the history and current status of robotic technology in urology. From the earliest uses of robots for transurethral resection of the prostate, to robotic devices for manipulating laparoscopes and to the current crop of master–slave devices for robotic-assisted laparoscopic surgery, the evolution of robotics in the urology operating theatre is presented. Future possibilities, including the prospects for nanotechnology in urology, are awaited.