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Differences in Patterns of Preoperative Assessment Between High, Intermediate, and Low Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse

Pulliam, Samantha J. MD*; Morgan, Daniel M. MD; Guaderrama, Noelani MD; Guire, Kenneth MS§; Adam, Rony A. MD

Female Pelvic Medicine & Reconstructive Surgery: January/February 2016 - Volume 22 - Issue 1 - p 7–10
doi: 10.1097/SPV.0000000000000204
AUGS Conference
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Objective The aim of the study was to determine whether surgeon case volume is associated with preoperative evaluation of pelvic organ prolapse before a hysterectomy for uterovaginal prolapse including a complete objective evaluation of prolapse (Baden-Walker or Pelvic Organ Prolapse Quantification), an offer of nonsurgical options for therapy (pessary), and a preoperative assessment of urinary incontinence

Methods We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008 and December 31, 2011. The number of hysterectomies per surgeon for 4 years was evaluated to establish low-volume (≤10 cases), intermediate-volume (11–49 cases), and high-volume (≥50 cases) groups. Rates of preoperative standardized prolapse evaluations, offer of pessary, and evaluation of stress urinary incontinence were determined by chart review of 15% of the hysterectomy cases. Adjustment was made in a logistic regression model for age, race, insurance status, and prolapse size.

Results Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Rates of preoperative assessment by standardized pelvic examination differed between high-, intermediate-, and low-volume surgeons (91.2% vs 61.3% vs 48.8%, respectively), as did offer of a pessary (86.5% vs 71.9% vs 69.9%, respectively) and preoperative stress test for urinary incontinence (93.5% vs 72.8% vs 63.5%, respectively). Regression analysis revealed that high-volume surgeons were more likely than intermediate- or low-volume surgeons to perform a standardized pelvic examination, offer a pessary, or perform preoperative evaluation for urinary incontinence.

Conclusions High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and evaluate stress urinary incontinence.

When evaluating a patient before hysterectomy for pelvic organ prolapse, high-volume surgeons are more likely than low-volume surgeons to perform a standardized pelvic examination, offer a pessary, and perform a stress test to evaluate urinary incontinence.

From the *Division of Urogynecology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; †Division of Urogynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; ‡Division of Urogynecology, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Irvine, CA; §Division of Statistics, School of Public Health, University of Michigan, Ann Arbor, MI; and ∥Division of Urogynecology, Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, TN.

Reprints: Samantha J. Pulliam, MD, Massachusetts General Hospital Boston, 55 Fruit St, Founders 540C, MA 02114. E-mail: spulliam@mgh.harvard.edu.

The authors have declared they have no conflicts of interest.

Supported by American Urogynecologic Society Foundation Grant.

Use of REDCap is made possible by Michigan Institute for Clinical and Health Research grant support (CTSA: UL1RR024986).

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