How Surgeon Volume Predicts Rates of Minimally Invasive Myomectomy

INTRODUCTION: Creating high-volume surgeons improves perioperative outcomes and encourages surgeons to perform more minimally invasive gynecological procedures. Compared to open abdominal myomectomies (AM), minimally invasive myomectomies (MIM) for benign uterine leiomyomas have lower complication rates, costs, and recovery time. Despite this, approximately 40% of myomectomies nationally are performed via an abdominal approach. In 2011, Kaiser Permanente Northern California (KPNC) introduced a quality improvement initiative to increase the proportion of MIMs by developing a streamlined high-volume surgeon pool. This study examines the interplay between surgeon volume and route for myomectomy. METHODS: This was an institutional review board (IRB)-approved retrospective observational data-only cohort study of patients who received an AM or MIM for benign uterine leiomyomas between 2009 and 2019 within KPNC. Surgeon volume was categorized as low (20 cases/year). RESULTS: Over the 11-year study period, 4,033 adult women underwent a myomectomy. The proportion of MIMs went from 6.0% to 89.5%, a 15-fold increase. The number of MIM surgeons increased over time but remained below 50, even as MIM rates increased. Medium and high volume surgeons were significantly more likely to perform MIMs compared to their low volume peers. As the MIM surgeon pool decreased in size and experience increased, the likelihood of having a MIM increased significantly. CONCLUSION: Decreasing the number of obstetricians/gynecologists performing surgery by limiting the number of MIM-privileged surgeons effectively increased individual surgeon case volume and increased the rate of MIM over an 11-year period, even with a rise in overall myomectomy incidence.