The role of minimally invasive gynecologic surgeons in the era of subspecialties: when to refer and consult

Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications

OBJECTIVE

To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes.

METHODS

This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification.

RESULTS

A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery.

CONCLUSION

For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.

Shifting trends and sicker patients: Reassessing hysterectomy performed for benign indications by gynecologic oncologists

OBJECTIVE

To assess trends and differences in patient characteristics, complications, and distributions of hysterectomy for benign indications by benign gynecologists (BG) and gynecologic oncologists (GO).

METHODS

This retrospective cohort study identified patients undergoing hysterectomy for benign indications using the National Surgical Quality Improvement Program data from 2014 to 2021. Exclusions were made for gynecologic or disseminated cancers, ascites, non-gynecologic surgeons, and cesarean hysterectomies. Primary outcome was major (≥Grade 3) 30-day complications, categorized into any complications, wound, cardiovascular and pulmonary, renal, infectious, andthromboembolic complications. Thirty-day readmissions, reoperations, and mortality were also analyzed. Propensity score matching was performed in a 1:1 match of GO to BG patients and was compared. Linear regressions assessed trends.

RESULTS

Among 198,767 patients, 18% (n = 37,707) underwent hysterectomy for benign indications with GO. GO patients exhibited more risk factors for complications and differed significantly from BG patients in comorbidities and perioperative characteristics. Overall, GO patients had higher major complication rates (3.1% vs 2.2%, p < 0.001) and for several other composite complications. After matching, compared to BG, GO-performed hysterectomies had similar rates of major complications (3.0% vs 3.0%, p = 0.55) and no differences in other composite complications, except fewer reoperations (1.2 % vs 1.5%, p < 0.01) and wound complications (0.4% vs 0.5%, p = 0.02) in GO patients. Over the eight years, the percentage of GO-performed hysterectomy (β = 0.41, R2 = 0.71,p < 0.01) increased significantly whereas BG-performed surgeries decreased by the same magnitude. BG had a significant decrease in frail patients (β = -0.47, R2 = 0.90, p < 0.01), but GO did not (β = -0.36, R2 = 0.38, p = 0.10).

CONCLUSIONS

GO are performing more hysterectomies for benign indications on higher-risk patients. However, on a matched cohort, risks of major complications were similar between GO and BG.