Impact of surgeon training and volume on myomectomy route & outcomes Impact of surgeon volume on myomectomy route: A multicenter review from the Minimally Invasive Gynecologic Surgery Fellows’ Pelvic Research Network Patricia J. Mattingly, MD Stacey Scheib, MD Kelly Wright, MD Department of Obstetrics & Gynecology, Division of Gynecologic Specialty Surgery Impact of surgeon training and volume on myomectomy route & outcomes

Disclosures I have no disclosures. How What Why

Background Uterine leiomyomas are the most common benign tumors of the female genital tract and are clinically evident in approximately 25% of women of reproductive age.1,2 In 2010, approximately 37,134 myomectomies were performed in the United States.3 The annual number of myomectomies performed in the United States is projected to increase to 49,154 by the year 2050.3 How What Why

Background Compared to abdominal myomectomy, laparoscopic myomectomy less blood loss, fewer blood transfusions, less postoperative pain, decreased febrile morbidity, shorter hospital stays and a faster recovery. 4,5,6 No significant difference in risk of fibroid recurrence, major complications and pregnancy and perinatal outcomes.4,5,6 Laparoscopic myomectomy requires advanced laparoscopic skills that not all gynecologic surgeons possess. 5,7,8,9 How What Why

Background Surgical outcomes have been shown to be affected by surgeon volume.10,11,12 Surgeon’s hysterectomy volume has been shown to affect surgical approach.11 Laparoscopic hysterectomy complication rates have been directly correlated with surgeon volume.10 There is limited data that examines the association between myomectomy outcomes and surgeon volume and training. Surgical outcomes, including complication rates, operative times, blood loss, length of hospital stay and resource utilization have been shown to be affected by surgeon volume.10,11,12

Objectives Primary Objective Determine if there is an association between myomectomy route and surgeon volume. How What Why

Objectives Secondary Objectives: Determine if there is an association between myomectomy route and training in a fellowship in minimally invasive gynecologic surgery. Determine if there is an association between myomectomy perioperative outcomes and surgeon volume and training. How What Why

Objectives Hypothesis A higher proportion of myomectomies are completed laparoscopically when performed by a high-volume gynecologic surgeon or a gynecologic surgeon who has completed a fellowship in minimally invasive gynecologic surgery. How What Why

Methods Design: Retrospective cohort study Inclusion: women 18 years or older abdominal, laparoscopic or robot-assisted laparoscopic myomectomy for benign indications July 1 2016 – June 30 2017 Exclusion: emergency surgery women younger than 18 years How What Why

Methods Primary outcome: rates of abdominal and laparoscopic myomectomy Secondary outcomes: operative time route of tissue extraction intraoperative complication EBL, blood transfusion conversion rate length of hospital stay pathology diagnosis & size (g) How What Why

Methods Surgeon characteristics major gynecologic surgeries: hysterectomy, myomectomy, endometriosis Fellowship training operative time, route of tissue extraction, intraoperative complication, EBL, blood transfusion, conversion rate, length of hospital stay, pathology diagnosis & size (g) Hospital characteristics Location, region, size, teaching status How What Why

Methods Electronic medical records used to myomectomy by CPT code Sample size: CI 95%, 80% power Assume the proportion of laparoscopic myomectomies by high-volume surgeons is 50% vs 25% for low-volume surgeons the same size needed is 55 How What Why

Methods Statistical analysis Demographic characteristics of the two groups will be analyzed using unpaired Student t tests for continuous variables and X2 or Fisher’s exact test for categorical variables. Results will be expressed as unadjusted relative risks (RRs) with 95% confidence intervals (CIs). How What Why

Timeline & Budget Multicenter Redcap database Recruit sites Obtain IRB approval Retrospective chart review 18 months Budget: $3,000 How What Why

Thank you Items for Discussion Surgeon volume vs fellowship training Define high-volume surgeon Scope of data collection How What Why

References Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol 2013;209:319.e1-20. Stewart EA. Uterine fibroids. Lancet. 2001;357:293–298 Wechter ME, Stewart EA, Myers ER, Kho RM, Wu JM. Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. American Journal of Obstetrics and Gynecology. 2011;205(5). doi:10.1016/j.ajog.2011.07.008. Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD004638. Jin C, Hu Y, Chen X-C, et al. Laparoscopic versus open myomectomy—A meta-analysis of randomized controlled trials. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2009;145(1):14-21. doi:10.1016/j.ejogrb.2009.03.009.  Hurst B, Matthews M, Marshburn P. Laparoscopic myomectomy for symptomatic uterine myomas. Fertility and Sterility. 2005;83(1):1-23. doi:10.1016/j.fertnstert.2004.09.011. Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol 2013;209:319.e1-20. Stewart EA. Uterine fibroids. Lancet. 2001;357:293–298.

References Mikhail E, Scott L, Miladinovic B, Imudia AN, Hart S. Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists. Minimally Invasive Surgery. 2016;2016:1-6. doi:10.1155/2016/5459147. Einarsson J, Young A, Tsien L, Sangi-Haghpeykar H. Perceived Proficiency in Endoscopic Techniques Among Senior Obstetrics and Gynecology Residents. The Journal of the American Association of Gynecologic Laparoscopists. 2002;9(2):158-164. doi:10.1016/s1074-3804(05)60124-7. Magrina JF. Isnt It Time to Separate the O From the G? Journal of Minimally Invasive Gynecology. 2014;21(4):501-503. doi:10.1016/j.jmig.2014.01.022. Wallenstein, Michelle R., et al. “Effect of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Indications.” Obstetrics & Gynecology, vol. 119, no. 4, 2012, pp. 709–716., doi:10.1097/aog.0b013e318248f7a8. Boyd LR, Novetsky AP, Curtin JP. Effect of Surgical Volume on Route of Hysterectomy and Short-Term Morbidity. Obstetrics & Gynecology. 2010;116(4):909-915. doi:10.1097/aog.0b013e3181f395d9. Vree, Florentien E. M. The Impact of Surgeon Volume on Perioperative Outcomes in Hysterectomy.” 1 Jan. 1970, archive.org/details/pubmed-PMC4035626.