Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: a systematic review and meta-analysis

Alex Mowat, Christopher Maher, Emma Ballard

The aim of this study was to determine the impact of gynecologic surgeon volumes on patient outcomes. Eligible studies were selected through an electronic literature search from database inception up until September 2015 and references in published studies. Search terms included "surgical volume," "surgeon volume," "low-volume OR high-volume," "gynecology OR hysterectomy OR sling OR pelvic floor repair OR continence procedure". The literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We defined a low volume surgeon (LVS) as one performing the procedure once a month or less and studies were excluded if their definition of LVS was > +/- 33% of our definition. Primary outcomes were total complications, intraoperative complications and postoperative complications. All outcome data for individual studies were entered into Review Manager 5.3 systematic review software. When two or more studies evaluated a designated outcome meta-analysis of the entered data was undertaken as per the Cochrane database methodology. Data analysis was entered into GRADEpro, software, which generated a Summary of Findings (SOF) table that included structured and qualified grading (very low to high) of the quality for the evidence of the individual outcomes and provided a measure of effect. Fourteen peer-reviewed studies with 741 760 patients were included in the systematic review. For gynecology the low volume surgeon (LVS) group had an increased rate of total complications; OR 1.3 95% CI 1.2 to 1.5, intraoperative complications; OR 1.6 95% CI 1.2 to 2.1 and postoperative complications; OR 1.4 95% CI 1.3 to 1.4. In gynecologic oncology the LVS group had higher mortality; OR 1.9 95% CI 1.3 to 2.6. In the urogynecology group a single study reported that the LVS group had a higher rate of any complication; RR 1.4 95% CI 1.2-1.6. Another single study found that LVS had higher rates of reoperation for mesh complications after mid-urethral sling procedures; RR 1.4 95% CI 1.2 to 1.5. The evidence is of moderate to very-low quality. Gynecologists performing procedures approximately once a month or less were found to have higher rates of adverse outcomes in gynecology, gynecologic oncology and urogynecology, with higher mortality in gynecologic oncology.