Learning curve for second-stage laparoscopic Fowler-Stephens orchidopexy: an exploratory CUSUM analysis with prospective ultrasonographic follow-up.

purposeTo characterize the sequential changes in operative time and Doppler-confirmed perfusion across the longitudinal second-stage laparoscopic Fowler-Stephens orchidopexy experience of an early-career academic pediatric urologist within a surgeon-educator practice.

methodsAll consecutive second-stage attempts for laparoscopically confirmed intra-abdominal testes performed and/or supervised by the index surgeon from February 2020 to October 2025 were identified. Ninety completed procedures (106 operated testes) entered the CUSUM analysis and segmented into series phases; two additional attempts that could not be completed as orchidopexies remained visible in the overall experience. Operative-time CUSUM was a descriptive running deviation from the overall mean. A Wald binary CUSUM monitored absent intratesticular flow on protocolized Doppler ultrasonography. Its 7%/16% failure-rate assumptions were borrowed from procedure-level complication data in open pyeloplasty and were not validated for this perfusion endpoint; a 5%/10% sensitivity model was also examined.

resultsThe 90 completed procedures were accumulated over 5.7 years (mean 15.7 per year). Satisfactory postoperative scrotal position was documented in 86/90 cases (95.6%); absent Doppler flow in 4/106 testes (3.8%); and a relative volume deficit of at least 50% in 33/101 evaluable testes (32.7%), underscoring that these outcomes are not interchangeable. CUSUM-OT reached its first fitted landmark at case 26 and plateaued approximately through case 44, although the cubic fit was weak (R2 = 0.14), phases means were similar (p = 0.876). Administrative OR-log review showed that the index surgeon was ecorded as most-responsible/ supervising surgeon in 81/90 cases (90%), increasing across phases 1-4 from 73.1% to 89.5%, 100%, and 100%, respectively (p = 0.002). CUSUM-CR crossed the favourable boundary at case 41 under the 7%/16% model and case 57 under the 5%/10% sensitivity model; later absent-flow events occurred at cases 72 and 78. Four postoperative Clavien-Dindo grade I-II events and one separate intraoperative vasal-vessel injury occurred.

conclusionOperative-time and outcome based CUSUM suggested an early plateau beginning around case 26. This supports approximately 25-30 cases as a hypothesis-generating estimate of the evolution from greater primary-operator participation early on the series toward a consistentlyy supervisory, teaching, and mentoring role in a comparable academic setting, not as a stand-alone test of competence or a credentialing threshold. The model-dependent perfusion signal and later failures support continued multidimensional outcome surveillance after that interval.