Trainee participation and perioperative complications in benign hysterectomy: the effect of route of surgery

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy

BACKGROUND

To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications.

METHODS

A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2).

RESULTS

Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications.

CONCLUSION

Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

Inpatient Hospital Costs and Route of Hysterectomy for Management of Benign Uterine Disease in the 90-Day Global Billing Period

OBJECTIVE

To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy.

METHODS

The Premier Healthcare Database was used to identify patients who underwent hysterectomy between 2000 and 2020. Current Procedural Terminology codes were used to group patients based on route of hysterectomy. Comorbidities and complications were identified using International Classification of Diseases codes. Fixed, variable, and total costs for inpatient care were compared. Fixed costs consist of costs that are set for the case, such as operating room time or surgeon costs. Variable costs include disposable and reusable items that are billed additionally. Total costs equal fixed and variable costs combined. Data were analyzed using analysis of variance, t test, and χ 2 test, as appropriate. Factors independently associated with increased total costs were assessed using linear mixed effects models. Multivariate logistic regression was performed to evaluate associations between the route of surgery and complication rates.

RESULTS

A cohort of 400,977 patients were identified and grouped by route of hysterectomy. Vaginal hysterectomy demonstrated the lowest inpatient total cost ($6,524.00 [interquartile range $4,831.60, $8,785.70]), and robotic-assisted laparoscopic hysterectomy had the highest total cost ($9,386.80 [interquartile range $6,912.40, $12,506.90]). These differences persisted with fixed and variable costs. High-volume laparoscopic and robotic surgeons (more than 50 cases per year) had a decrease in the cost difference when compared with costs of vaginal hysterectomy. Abdominal hysterectomy had a higher rate of complications relative to vaginal hysterectomy (adjusted odds ratio [aOR] 1.52, 95% CI, 1.39-1.67), whereas laparoscopic (aOR 0.85, 95% CI, 0.80-0.89) and robotic-assisted (aOR 0.92, 95% CI, 0.84-1.00) hysterectomy had lower rates of complications compared with vaginal hysterectomy.

CONCLUSION

Robotic-assisted hysterectomy is associated with higher surgical costs compared with other approaches, even when accounting for surgeon volume. Complication rates are low for minimally invasive surgery, and it is unlikely that the robotic-assisted approach provides an appreciable improvement in perioperative outcomes.

Does the experience of the first assistant affect organ injuries in laparoscopic hysterectomy for benign diseases?

PURPOSE

This study sought to explore whether the experience level of the first assistant surgeon influences perioperative organ injuries (ureteral, bladder, and intestinal injuries) in patients undergoing total laparoscopic hysterectomy (TLH) for benign diseases. We defined an experienced surgeon as a surgeon certified by the Skill Qualification Committee of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy or a surgeon with equivalent surgical skills.

METHODS

We reviewed our surgical registry database of TLH for benign indications between 2014 and 2020 and only selected cases performed by an experienced primary surgeon. Patients were divided into two groups based on the experience level of the first assistant. Inverse probability of treatment weighting by propensity score, which was adjusted for patient and procedure characteristics, was used to examine differences in perioperative organ injuries according to the experience level of the first assistant.

RESULTS

Among 1682 patients who underwent TLH, 18 organ injuries were found (0.83%). In the propensity score inverse probability of treatment weighting models, less experience of the first assistant had no significant impact on the occurrence of perioperative organ injuries (p = 0.348).

CONCLUSION

In TLH for benign indications at our hospital, given an experienced primary surgeon, the inclusion of a less experienced first assistant does not negatively affect the occurrence of perioperative organ injuries.

Factors influencing treatment decisions in HIFU treatment of adenomyosis: A retrospective study

Objective

To explore the influencing factors of decision-making in patients with adenomyosis, who are receiving high-intensity focused ultrasound (HIFU) treatment.

Methods

A total of 776 patients with adenomyosis were enrolled into HIFU group (241 cases) and hysterectomy group (535 cases) according to the treatment methods. The general data, clinical symptoms, marital and childbearing history, and economic status were compared between the two groups, and factors with P < 0.05 were introduced into multivariate logistic regression analysis to determine the determinants of patients choosing HIFU.

Results

The average age of the patients in the HIFU group was 39.1 ± 5.2 years, which was lower than that in the hysterectomy group, which was 45.1 ± 3.9 years (P < 0.05). The basic medical insurance for urban workers in the HIFU group was more than the hysterectomy group (P < 0.05). 95.9% of the hysterectomy group had no desire to have children, compared to 60.6% of the HIFU group, the difference was significant (P < 0.05). The treatment costs of HIFU group were significantly lower than that of hysterectomy group (P < 0.05). The main symptoms of the two groups were dysmenorrhea, menorrhagia, and secondary anemia. The results of multivariate logistic regression analysis showed that 31–40 years old, fertility desire, dysmenorrhea, menorrhagia, anemia and dizziness and fatigue were the influencing factors for the decision-making of HIFU for patients with adenomyosis.

Conclusion

31–40 years old, fertility desire, dysmenorrhea, menorrhagia, anemia and dizziness and fatigue were the influencing factors for patients to choose HIFU treatment. HIFU therapy has emerged as a new option for patients with adenomyosis as an alternative to hysterectomy.

Trends in operative time and outcomes in minimally invasive hysterectomy from 2008 to 2018

BACKGROUND

There is a national shift toward laparoscopic hysterectomy as the predominant form of minimally invasive hysterectomy. Previous research suggests that vaginal hysterectomy is associated with lower operative time and improved outcomes; however, this has not been validated in a modern cohort of women.

OBJECTIVE

This analysis aims to evaluate whether total vaginal hysterectomy remains associated with lower operative times and fewer postoperative complications than total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, given recent shifts in clinical practice patterns and training experience.

STUDY DESIGN

A secondary analysis of the National Surgical Quality Improvement Program database was performed. Three primary outcomes were defined for the analysis: operative time, rate of major complications, and rate of minor complications. Secondary outcomes included changes in route of surgery over time. Descriptive analyses were performed for all outcomes of interest. Operative time, rate of major complications, and rate of minor complications were compared for each of the 3 forms of minimally invasive hysterectomy: total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and total vaginal hysterectomy. Bivariate analyses were performed using analysis of variance, Kruskal-Wallis, Pearson chi-square, or Fisher exact tests where appropriate. Multivariable ordinary least squares and logistic regression were used to assess for overall differences in outcomes and trends over time, controlling for sociodemographic factors and medical comorbidities. Sensitivity analyses were performed using a propensity score-matched cohort created to balance groups across time.

RESULTS

A total of 161,626 women met criteria for inclusion. Rates of total vaginal hysterectomy dropped from 51% to 13% between 2008 and 2018, whereas rates of total laparoscopic hysterectomy increased from 12% to 68% (P<.001). In multivariable analyses, total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy were associated with lower odds of major complications (adjusted odds ratio [95% confidence interval]: 0.813 [0.750-0.881] and 0.873 [0.797-0.957], respectively) and minor complications (adjusted odds ratio [95% confidence interval]: 0.723 [0.676-0.772] and 0.896 [0.832-0.964], respectively) than total vaginal hysterectomy. Temporal trends show an increase in total vaginal hysterectomy operative time and decreases in total laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy operative times over the 11-year analysis period (P<.001), although total vaginal hysterectomy continues to have the shortest median operative time overall. No temporal trends were observed in rates of complications.

CONCLUSION

This analysis highlights recent shifts in rates of minimally invasive hysterectomy. Alongside this change in practice pattern, this study also brings to light a resultant shift in the complication rates associated with each surgical approach, as laparoscopic hysterectomy has lower rates of complications than vaginal hysterectomy despite longer operative times.

Association of Race/Ethnicity with Surgical Route and Perioperative Outcomes of Hysterectomy for Leiomyomas

STUDY OBJECTIVE

To evaluate the associations among race/ethnicity, route of surgery, and perioperative outcomes for women undergoing hysterectomy for uterine leiomyomas.

DESIGN

Retrospective cohort study.

SETTING

Multistate.

PATIENTS

Women who underwent hysterectomies for leiomyomas from the American College of Surgeons National Surgical Quality Improvement Program database, 2014 to 2017.

INTERVENTIONS

None. Exposures of interest were race/ethnicity and route of surgery.

MEASUREMENTS AND MAIN RESULTS

Racial/ethnic variation in route of surgery and perioperative outcomes. Propensity score matching was employed to control for possible confounders. We identified 20 133 women who underwent nonemergent abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or vaginal hysterectomy (VH) for leiomyomas. We defined minimally invasive hysterectomy (MIH) as LH or VH. Black women were more likely to have open surgery (AH vs MIH adjusted odds ratio [aOR], 2.22; 95% confidence interval [CI], 2.07-2.38; AH vs VH aOR, 1.79; 95% CI, 1.54-2.08; AH vs LH aOR, 2.27; 95% CI, 2.13-2.44) than white women. Likewise, Hispanic women were more likely to have open surgery (AH vs MIH aOR, 1.76; 95% CI, 1.58-1.96; AH vs LH aOR, 1.82; 95% CI, 1.61-2.00) than white women. Black women were more likely to experience any complication after hysterectomy (AH aOR, 1.54; 95% CI, 1.31-1.80; VH aOR, 1.65; 95% CI, 1.02-2.68; LH aOR, 1.37; 95% CI, 1.13-1.66) than white women. Hispanic women were less likely than white women to experience major complications after VH (aOR, 0.28; 95% CI, 0.08-0.98). Compared with white women, the mean length of stay was longer for black women who underwent AH or LH. The mean total operation time was higher for all minority groups (except for Asian/other undergoing AH) regardless of surgical approach.

CONCLUSION

Women of minority race/ethnicity were more likely to undergo abdominal rather than MIH for leiomyomas. Even when controlling for route of surgery, they were more likely to experience perioperative complications.

[Safety of total laparoscopic hysterectomy in a high complexity Hospital in Pereira, Colombia, between 2007 and 2017. Cohort study]

OBJECTIVE

To describe intra and postoperative complications of total laparoscopic hysterectomy (TLH) for benign uterine pathology and to compare with other hospitals with large volumes of laparoscopic hysterectomies.

METHODS

Retrospective cohort study of women who underwent TLH for benign gynecological pathology between 2007 and 2017 in a private high complexity institution that serves populations covered by contributive and state-subsidized insurance in Pereira, Colombia. The procedures were performed by the group of surgeons of the ALGIA training center. Consecutive sampling was used. Sociodemographic and baseline clinical characteristics, intra-operative findings and intra- and post-operative complications are described. Descriptive statistics were used.

RESULTS

A total of 1.350 patients were included during the study period. Surgical time was 95 minutes (SD ± 31), blood loss 88 cc (SD ± 66), and average uterine weight was 236 g (SD ± 133); 96.5% of the patients were assessed within the next 30 to 45 days; 3.48% had minor complications and 2.5% had major complications; 3 patients were converted to laparotomy. There were no deaths in the study sample.

CONCLUSIONS

TLH is a safe procedure and the rate of complications is similar to the best international standards. Further prospective studies using objective criteria are important in order to compare the performance of different groups and institutions offering surgical procedures and training.

<p>Effect of Time Interval Between LEEP and Subsequent Hysterectomy on Postoperative Infectious Morbidity</p>

Objective

This study aimed to provide insight into the effect of time interval between loop electrosurgical excision procedure (LEEP) and subsequent hysterectomy on postoperative infectious morbidity in cervical neoplasia patients.

Methods

In this retrospective cohort study, a total of 1172 medical records of patients who were diagnosed with high grade cervical intraepithelial neoplasia (HSIL) or invasive cancer underwent a subsequent hysterectomy after LEEP at the International Peace Maternity and Child Health Hospital (IPMCH) in Shanghai, China from January 2008 to December 2019 were collected. The study outcome was postoperative infectious morbidity within 30 days after a hysterectomy. Overall and surgical approach specific effect of time interval on infectious morbidity was estimated using logistic regression in crude and adjusted models.

Results

There was an inverse association between time interval and postoperative infectious morbidity in HSIL or invasive cancer patients (OR=0.99, 95% CI: 0.98–1.00, p=0.0079). When trisecting time interval into three parts, the top tertile time interval (34–90 days) was also inversely associated with infectious morbidity compared with bottom tertile (0–16 days), independent of stage, surgical approach, operative time and estimated blood loss (OR=0.66,95% CI: 0.43–1.00, P=0.0487). A test for interaction between time interval and surgical approach on infectious morbidity was significant (P values for interaction= 0.0352). Longer time interval significantly reduced the risk of infectious morbidity in the laparoscopic group (OR = 0.37, 95% CI: 0.17–0.78), while no statistically significant effects were observed in patients who underwent vaginal or open abdominal hysterectomy.

Conclusion

The time interval and surgical approach can interactively affect the risk of postoperative infectious morbidity in cervical neoplasia patients who underwent a hysterectomy after LEEP. Our data suggest that compared with vaginal or open abdominal hysterectomy, laparoscopic hysterectomy required a longer time interval (34–90 days) to reduce the risk of infectious morbidity.

Operating Room Efficiency: Examining the Impact of Personnel Handoffs

OBJECTIVES

This study aimed to determine if personnel handoffs or number of learners in the operating room (OR) are associated with longer OR times in women having pelvic organ prolapse surgery.

METHODS

A retrospective review of women undergoing prolapse surgery in 2016 was conducted. Demographics; procedure; OR, anesthetic, and surgical time; number of handoffs between anesthesia members, circulators, and surgical technologies; and number of learners were abstracted.

RESULTS

One hundred forty-eight women underwent pelvic organ prolapse surgery. Mean age was 54 ± 14 years, and most women were healthy and white. Procedures performed were as follows: 31% laparoscopic sacrocolpoexies (LASCs), 28% robotic sacrocolpopexies (RASCs), 19% colpocleises, and 22% native tissue reconstructions. For minimally invasive sacrocolpopexies (LASC + RASC), mean OR time was 270 ± 65 minutes. Median anesthesia, surgical technology, and circulator handoffs for sacrocolpopexies were 2 (interquartile range, 0-4), 1 (0-3), and 2 (2-6). Median number of learners in the OR for sacrocolpopexies was 4 (interquartile range, 1-7). Patient comorbidities and American Society of Anesthesiologists class were not associated with longer OR times (P = 0.9 and P = 0.4). Longer OR times were positively correlated with increasing numbers of anesthesia, surgical technology, and circulator handoffs, but not with the number of learners (Spearman ρ = 0.34, P = 0.001; ρ = 0.34, P < 0.001; ρ = 0.59, P < 0.001, and ρ = 0.16, P = 0.43). For LASC, every technology handoff was associated with 23 additional minutes of OR time (P = 0.004). For RASC, every technology handoff was associated with 31 additional minutes of OR time (P = 0.007), and each circulator handoff was associated with 15 additional minutes (P = 0.05).

CONCLUSION

Handoffs between OR personnel are associated with longer OR times, independent of patient factors.

Examining Disparities in Route of Surgery and Postoperative Complications in Black Race and Hysterectomy

OBJECTIVE

To estimate the associations among race, route of hysterectomy, and postoperative complications among women undergoing hysterectomy for benign indications.

METHODS

A cohort study was performed. All patients undergoing hysterectomy for benign indications, recorded in the National Surgical Quality Improvement Program and its targeted hysterectomy file in 2015, were identified. The primary exposure was patient race. The primary outcome was route of hysterectomy and the secondary outcome was postoperative complication. Associations were examined using both bivariable tests and logistic regression.

RESULTS

Of 15,136 women who underwent hysterectomy for benign indications, 75% were white and 25% were black. Black women were more likely to undergo an open hysterectomy than white women (50.1% vs 22.9%; odds ratio [OR] 3.36, 95% CI 3.11-3.64). Black women had larger uteri (median 262 g vs 123 g; 60.7% vs 25.6% with uterus greater than 250 g), more prior pelvic surgery (58.5% vs 53.2%), and higher body mass indices (32.7 vs 30.4). After adjusting for these and other clinical factors, black women remained more likely to undergo an open hysterectomy (adjusted OR 2.02, 95% CI 1.85-2.20). Black women experienced more major complications than white women (4.1% vs 2.3%; P<.001) and more minor complications (11.4% vs 6.7%; OR 1.78, P<.001). Again these disparities persisted with adjustment (major adjusted OR 1.56, 95% CI 1.25-1.95; minor adjusted OR 1.27, 95% CI 1.11-1.47).

CONCLUSIONS

Black women undergo a higher proportion of open hysterectomy and experience more major and minor postoperative complications. These differences persisted even after adjusting for confounding medical, surgical, and gynecologic factors.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes

STUDY OBJECTIVE

Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications.

DESIGN

Retrospective, multicenter, cohort study (Canadian Task Force classification II-2).

SETTING

Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites.

PATIENTS

Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012.

INTERVENTION

ACS-NSQIP database.

MEASUREMENTS AND MAIN RESULTS

Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality.

CONCLUSION

Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Characteristics associated with prolonged length of stay after hysterectomy for benign gynecologic conditions

BACKGROUND

Length of stay after surgery has become an important quality measure for many common surgical procedures and is now also tied to reimbursement. Currently, little is known about the perioperative factors that contribute to prolonged hospital length of stay in women who undergo hysterectomy for benign conditions.

OBJECTIVE

We performed a population-based analysis to investigate the association between perioperative factors and prolonged length of stay in women who undergo minimally invasive, abdominal, and vaginal hysterectomy.

STUDY DESIGN

We used the National Surgical Quality Improvement Program database to identify women from 2006-2015 who underwent benign hysterectomy. The primary outcome was length of stay >75th percentile. Demographic, preoperative, intraoperative, and postoperative factors were analyzed to determine individual predictors of prolonged length of stay. Model fit statistics were used to assess the importance of each group of perioperative factors on prolonged length of stay.

RESULTS

We identified a total of 157,589 women, including 83,172 (52.8%) of whom underwent minimally invasive hysterectomy, 45,149 (28.6%) of whom underwent abdominal hysterectomy, and 29,268 (18.6%) of whom underwent vaginal hysterectomy. The 75th percentile for length of stay was 1 day for minimally invasive, 3 days for abdominal, and 2 days for vaginal hysterectomy. The measured factors accounted for 11.0% of the ability to predict a prolonged length of stay for minimally invasive, 20.3% for abdominal, and 16.2% for vaginal hysterectomy. Intraoperative factors were the most important contributors to length of stay for minimally invasive and abdominal hysterectomy; demographic factors dominated for vaginal hysterectomy.

CONCLUSION

The most important perioperative factors that contributed to prolonged length of stay for hysterectomy were, in large part, not modifiable and suggest that targeted interventions to reduce length of stay will be challenging.

Blood transfusion after vaginal hysterectomy for pelvic organ prolapse

BACKGROUND AND AIMS

Hysterectomy is a commonly performed gynaecological procedure, and vaginal hysterectomy for the treatment of pelvic organ prolapse will become more common as our population ages. Red cell transfusion after hysterectomy has been reported in the literature as between 2.5 and 4.3%. This paper aimed to review the rate of red cell transfusion after vaginal hysterectomy for pelvic organ prolapse in three university-affiliated teaching hospitals.

METHODS

We reviewed 108 vaginal hysterectomies performed across three teaching hospitals to determine the rate of post-operative blood transfusion.

RESULTS

A total of 1.9% (2/108) of women received at least one unit of red cells after their vaginal hysterectomy in our cohort. The mean drop in haemoglobin was 2.0 (95% CI, 1.8-2.3, P < 0.001).

CONCLUSIONS

Red cell transfusion remains lower than international figures. This may form part of patient counselling when discussing the route of hysterectomy in the future.

Is There a Difference in the Outcome of Mid-Urethral Sling Operations Performed by Urogynecologists Compared with Supervised Residents?

STUDY OBJECTIVE

To compare the operative results of midurethral sling (MUS) surgeries for stress urinary incontinence (SUI) performed by residents under the guidance of an attending specialist in urogynecology and those performed by attendings.

DESIGN

Retrospective chart review (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

A retrospective analysis of all MUS surgeries performed at a single public tertiary medical center between January 2009 and December 2013 was carried out. A total of 257 patients underwent transobturator tape (TOT) placement during the study period, including 136 (52.9%) placed by an attending specialist in urogynecology (group A) and 121 (47.1%) placed by a resident, under the guidance of an attending (group B).

MEASUREMENTS

The efficacy of treatment was evaluated in terms of early postoperative course, reoperation, and symptom improvement, as based on the Pelvic Floor Distress Inventory short form (PFDI-20) questionnaire. The primary outcome was patient-reported symptoms of SUI, as assessed with the PFDI-20 questionnaire, as well as absence of surgical retreatment for SUI.

RESULTS

Immediate postoperative complications were comparable in the 2 groups, as were subjective failure and self-reported SUI. The primary outcome-moderate and severe symptoms of SUI-were reported by 23.7% of the patients in group A and 23.6% of those in group B (p = .91). At a mean follow-up of 40 months in both groups, symptoms, as assessed using the urinary scale and prolapse scale of the PFDI-20, were also similar in the 2 groups. The rate of reoperation with repeated sling for SUI was 5% in both groups.

CONCLUSION

The operative results of TOT surgery for SUI performed by residents under the guidance of an attending specialist in urogynecology did not differ significantly from those performed by the attendings themselves.

Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity

BACKGROUND

Surgical trainee association with operative outcomes is controversial. Studies are conflicting, possibly due to insufficient control of confounding variables such as operative time, case complexity, and heterogeneous patient populations. As operative complications worsen long-term outcomes in oncologic patients, understanding effect of trainee involvement during laparoscopic colectomy for cancer is of utmost importance. Here, we hypothesized that resident involvement was associated with worsened 30-day mortality and 30-day overall morbidity in this patient population.

METHODS

Patients undergoing laparoscopic colectomy for oncologic diagnosis from 2005 to 2012 were assessed using the American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score matching accounted for demographics, comorbidities, case complexity, and operative time. Attending only cases were compared to junior, middle, chief resident, and fellow level cohorts to assess primary outcomes of 30-day mortality and 30-day overall morbidity.

RESULTS

A total of 13,211 patients met inclusion criteria, with 4075 (30.8%) cases lacking trainee involvement and 9136 (69.2%) involving a trainee. Following propensity matching, junior (PGY 1-2) and middle level (PGY 3-4) resident involvement was not associated with worsened outcomes. Chief (PGY 5) resident involvement was associated with worsened 30-day overall morbidity (15.5 vs. 18.6%, p = 0.01). Fellow (PGY > 5) involvement was associated with worsened 30-day overall morbidity (16.0 vs. 21.0%, p < 0.001), serious morbidity (9.3 vs. 13.5%, p < 0.001), minor morbidity (9.8 vs. 13.1%, p = 0.002), and surgical site infection (7.9 vs. 10.5%, p = 0.006). No differences were seen in 30-day mortality for any resident level.

CONCLUSION

Following propensity-matched analysis of cancer patients undergoing laparoscopic colectomy, chief residents, and fellows were associated with worsened operative outcomes compared to attending along cases, while junior and mid-level resident outcomes were no different. Further study is necessary to determine what effect the PGY surgical trainee level has on post-operative morbidity in cancer patients undergoing laparoscopic colectomy in the context of multiple collinear factors.