Hysterectomy Volume Among Recent Obstetrics and Gynecology Residency Graduates

OBJECTIVE: Although guidelines recommend hysterectomy be performed vaginally whenever possible, recent trainees have decreased exposure to vaginal hysterectomy given the availability of laparoscopic hysterectomy, nonsurgical management, and falling volume nationwide. We sought to estimate hysterectomy volume in the 5 years after residency. Our secondary objective was to compare vaginal hysterectomy utilization between recent graduates and senior surgeons. METHODS: Retrospective, statewide data from 2005 to 2014 was obtained from the Massachusetts Center for Health Information Analysis. All hysterectomies performed in Massachusetts, regardless of payer type, were included. Surgeon identifiers were cross-referenced to another data set with provider demographics. Hysterectomies performed in the first 5 years after graduation were compared with a group 21 to 25 years after residency. RESULTS: Data from inpatient and outpatient databases revealed 87,846 hysterectomies performed by 1967 physicians, including 3146 simple hysterectomies by 192 recent graduates. Recent graduates chose abdominal hysterectomy (44.2%) most commonly, followed by laparoscopic (29.4%), vaginal (16.1%), and laparoscopically assisted vaginal (10.4%). Recent graduates performed a median of 3 to 4 hysterectomies in each of the first 5 years with no increase over time (P = 1). The median number of vaginal or laparoscopic hysterectomies was 0 in these 5 years (interquartile ranges, 0-1 and 0-2, respectively). Members of the senior cohort performed a median of 8 to 9 hysterectomies annually, completing them vaginally more often (24.7% vs 16.1%, P \u3c 0.01). When controlling for patient age and hysterectomy indication, this effect dissipated. CONCLUSIONS: Recent graduates perform 3 to 4 (interquartile range, 1-7) hysterectomies annually, predominantly by laparotomy. Although senior surgeons perform vaginal hysterectomy more often, this is explained by patient characteristics

Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis.

BACKGROUND: Fallopian tubes are commonly removed during laparoscopic and open hysterectomy to prevent ovarian and tubal cancer but are not routinely removed during vaginal hysterectomy because of perceptions of increased morbidity, difficulty, or inadequate surgical training. OBJECTIVE: We sought to quantify complications and costs associated with a strategy of planned salpingectomy during vaginal hysterectomy. STUDY DESIGN: We created a decision analysis model using TreeAgePro. Effectiveness outcomes included ovarian cancer incidence and mortality as well as major surgical complications. Modeled complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. We also modeled subsequent benign adnexal surgery beyond the postoperative window. Those whose procedures were converted from a vaginal route were assumed to undergo bilateral salpingectomy, regardless of treatment group, following American College of Obstetricians and Gynecologists guidelines. Costs were gathered from published literature and Medicare reimbursement data, with internal cost data from 892 hysterectomies at a single institution used to estimate costs when necessary. Complication rates were determined from published literature and from 13,397 vaginal hysterectomies recorded in the National Surgical Quality Improvement Program database from 2008 through 2013. RESULTS: Switching from a policy of vaginal hysterectomy alone to a policy of routine planned salpingectomy prevents a diagnosis of ovarian cancer in 1 of every 225 women having surgery and prevents death from ovarian cancer in 1 of every 450 women having surgery. Overall, salpingectomy was a less expensive strategy than not performing salpingectomy ($7350.62 vs$8113.45). Sensitivity analysis demonstrated the driving force behind increased costs was the increased risk of subsequent benign adnexal surgery among women retaining their tubes. Planned opportunistic salpingectomy had more major complications than hysterectomy alone (7.95% vs 7.68%). Major complications included transfusion, conversion to laparotomy or laparoscopy, abscess/hematoma requiring intervention, ileus, readmission, and reoperation within 30 days. Therefore, routine salpingectomy results in 0.61 additional complications per case of cancer prevented and 1.21 additional complications per death prevented. A surgeon therefore must withstand an additional ∼3 complications to prevent 5 cancer diagnoses and ∼6 additional complications to prevent 5 cancer deaths. CONCLUSION: Salpingectomy should routinely be performed with vaginal hysterectomy because it was the dominant and therefore cost-effective strategy. Complications are minimally increased, but the trade-off with cancer prevention is highly favorable

Hysterectomy Versus Hysteropexy at the Time of Native Tissue Pelvic Organ Prolapse Repair: A Cost-Effectiveness Analysis.

OBJECTIVE: The aim of the study was to determine whether a hysterectomy at the time of native tissue pelvic organ prolapse repair is cost-effective for the prevention of endometrial cancer. METHODS: We created a decision analysis model using TreeAge Pro. We modeled prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension (TVH-USLS) versus sacrospinous ligament fixation hysteropexy (SSLF-HPXY). We modeled incidence and diagnostic evaluation of postmenopausal bleeding, including risk of endometrial pathology and diagnosis or death from endometrial cancer. Modeled costs included those associated with the index procedure, subsequent prolapse repair, endometrial biopsy, pelvic ultrasound, hysteroscopy, dilation and curettage, and treatment of endometrial cancer. RESULTS: TVH-USLS costs US $587.61 more than SSLF-HPXY per case of prolapse. TVH-USLS prevents 1.1$2,698,677 to prevent one cancer death by performing TVH-USLS. As this is lower than the value of a statistical life, it is cost-effective to perform TVH-USLS for cancer prevention. Multiple 1-way sensitivity analyses showed that changes to input variables would not significantly change outcomes. CONCLUSIONS: TVH-USLS increased costs but reduced postmenopausal bleeding and subsequent major surgery compared with SSLF-HPXY. Accounting for these differences, TVH-USLS was a cost-effective approach for the prevention of endometrial cancer. Uterine preservation/removal at the time of prolapse repair should be based on the woman\u27s history and treatment priorities, but cancer prevention should be one aspect of this decision

Mortality and Reoperation Following Midurethral Sling versus Urethral Bulking In Older Women.

OBJECTIVE: To examine differences in mortality, retreatment rates, and comorbidities that may be risk factors for retreatment among Medicare beneficiaries (age 65+) undergoing midurethral sling versus urethral bulking. MATERIALS AND METHODS: This was a retrospective cohort study using the 5% limited data set from the Center for Medicare and Medicaid Services between 2010 and 2018. Beneficiaries age 65 or older who underwent sling or bulking without concomitant surgery from 2011 to 2014 were included and followed until reoperation or retreatment, loss of Medicare, death, or December 31, 2018. Repeat procedures for ongoing stress incontinence or complication were included. Associations between index treatment and need for a secondary procedure were evaluated using Cox proportional hazards models. RESULTS: Median follow-up time was 5.7 years for 1,700 patients undergoing sling and 5.2 years for 875 patients undergoing bulking. Within 5 years, 10.2% of sling patients and 23.2% of bulking patients had died. When controlling for age, race, and comorbidities, bulking patients were 1.73 times more likely than sling patients to die during the study period. Bulking patients were significantly more likely to have 12 of the 16 of the medical comorbidities evaluated. By 5 years, 6.7% of sling patients had been retreated for SUI compared with 24.6% of bulking patients. Apart from hypertension, none of the comorbidities evaluated was associated with a difference in the risk of a subsequent surgical procedure. Members of racial and ethnic minority groups were less likely to be retreated. CONCLUSIONS: Older adults undergoing bulking are notably sicker and have shorter life expectancy as compared with those undergoing sling, suggesting these factors heavily guide patient selection. Comorbidities do not predispose patients to reoperation or retreatment