AAGL 2013: Surgical Volume Affects Risk of Lower Urinary Tract Injury, Evidence Suggests

November 22, 2013

Surgeons who perform a high volume of hysterectomies each year are less likely to injure the lower urinary tract during surgery.

Among surgeons who perform hysterectomies, those who perform a high volume of procedures each year had a lower rate of lower urinary tract injury (LUTI), according to the results of a study presented last week at the 42nd AAGL Global Congress on Minimally Invasive Gynecology, held in National Harbor, Maryland.

In a retrospective chart review, Jorge F. Carrillo, MD, and colleagues examined the results of conventional laparoscopic, robotic-assisted, and laparoscopic hysterectomies performed from January 2009 to June 2012 at the University of Rochester Medical Center. Specifically, they looked at patient and operative characteristics, the nature of the LUTI, and the number of cases per surgeon per year.

A total of 73 surgeons were included, but this group was divided into conventional laparoscopic surgeons (n=53), robotic surgeons (n=23), and open surgeons (n=67). Surgeons who performed 24 or more surgeries in a given surgical category were considered high-volume surgeons. However, an alternate definition of high volume as 12 or more surgeries in a category was created for comparison.

Of 2558 patients included in this review, 57 patients sustained 60 urinary tract injuries. These injuries included 41 cystotomies and 19 ureteral injuries, which represented an overall incidence rate of 2.2%. For specific surgical procedures, the incidence rate of LUTI was 1.8% for conventional laparoscopy, 1.9% for robotic assisted, and 2.6% for laparotomy. No significant differences in incidence rates were found between procedure types.

However, using either definition of high volume, high-volume surgeons had a significantly lower rate of LUTIs than low-volume surgeons. Among surgeons who performed 24 or more hysterectomies per year, there were 9 incidences of LUTI, compared with 48 incidences of LUTI in low-volume surgeons. In comparison, there were 21 cases of LUTI for high-volume surgeons who performed 12 or more hysterectomies per year, compared with 36 cases of LUTI for low-volume surgeons.

When the researchers examined LUTI incidence by surgical type, they found that LUTIs were 7.3 times more likely and 2.7 times more likely to occur during laparotomic hysterectomies performed by low-volume surgeons compared with high-volume surgeons (24 or more procedures vs 12 or more procedures, respectively).

Either way, LUTIs are less likely to occur when surgeons perform a high volume of a specific procedure. Interestingly, these findings are in line with another study presented last week at this same meeting that showed surgeons who maintained surgical proficiency by performing 20 or more of the same procedures each year had fewer complications and better outcomes than surgeons who did not maintain proficiency.