Introduction

Systematic reviews in gynaecology and outside of gynaecology have demonstrated that higher surgical volume may be associated with better post operative outcomes. As surgical experience increases in relation to number of operations undertaken, technical proficiency also increases. High-volume surgeons may also be exposed to processes of care that positively impact surgical outcomes The relationship between surgical case volume and myomectomy longer term outcomes has hitherto not been investigated.

Aims

To investigate the impact of surgical case-volume on rates of readmission, laparoscopic approach and reintervention after myomectomy. 

Methods

Retrospective, national population-based, cohort study utilising Hospital Episode Statistics(HES) data

Cohort determined based on HES dataset extract

Inclusion criteria: Patients were identified in the HES Admitted Patient Care dataset between 2010 and 2015 that underwent myomectomy in England under the NHS

Exclusion criteria: Women who were aged less than 18 years; underwent a non-elective procedure; were coded as having a hysterectomy during the encounter of their index procedure or cases without a valid consultant code  

All encounters linked relating to an individual cohort member using HESID until end of study. After the index treatment, all subsequent encounters scrutinised for the presence of reintervention OPCS4 procedural codes until the end of study.  Patients undergoing hysterectomy or Uterine-preserving procedure (UPP) reinterventions contributed person-time to the study until first occurrence of either hysterectomy or UPP reintervention, death, or end of study (31st March 2020). 

Primary outcome(s): UPP and hysterectomy reinterventions rates after index myomectomy

UPP reintervention included only myomectomy, uterine artery embolization, endometrial ablation, or MR guided focused ultrasound procedures

High-volume determined as >12 myomectomies performed annually per surgeon

Around the 95th centile

Similar threshold used in other studies

Chi-squared test was used to compare categorical variables. Binary logistic regression was used to provide an estimate of the crude risk for readmission and for laparoscopic approach after myomectomy. Cox’s proportional-hazards regression model was used to provide an estimate of the crude risk for hysterectomy or UPP reintervention after index treatment for myomectomy.

Results

536 gynaecologists performed >= myomectomy in 1 year. Median annual case volume per surgeon = 6 +/- 6.5. Range: 1-80

27 gynaecologists (5%) were defined as high volume surgeons (>12 myomectomies/year)

There were 9443 myomectomies undertaken over 5 years