The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Myomectomy: A Retrospective Cohort Study

Study Objective: To compare surgical outcomes among patients undergoing minimally invasive myomectomy (MIM) or abdominal myomectomy (AM) with MIGS subspecialists versus general obstetrician/gynecologists (OB/GYNs), and to characterize the complexity of myomectomies by surgeon type. Design: Retrospective cohort study. Setting: Quaternary care institution. Participants: Patients who underwent MIM (laparoscopic or robotic) or AM with a fellowship-trained MIGS subspecialist or general OB/GYN from March 15, 2015 to March 14, 2020. Interventions: Myomectomy. Results: Of 609 myomectomies, 460 (75.5%) were MIM, 404 (87.8%) of which were performed by MIGS subspecialists. The remaining 149 (24.5%) cases were AM, 36 (24.1%) of which were performed by MIGS subspecialists. Compared to general OB/GYNs, MIGS subspecialists excised a greater number of fibroids for both MIM (median 3.0 [range 1.0–30.0] vs 2.0 [1.0–9.0], p <.001) and AM (21.0 [10.0–60.0] vs 6.0 [1.0–42.0], p <.001), and had a greater proportion of uteri >20 weeks size for AM (22.2% vs 3.5%, p = .003). Composite perioperative complication rates were significantly higher for general OB/GYNs than for MIGS subspecialists (29.0% vs 11.8%, adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 1.48–4.92). In a subgroup analysis of MIM only, general OB/GYNs had higher rates of composite perioperative complications (28.6% vs 9.9%, aOR 4.51, 95% CI 2.27–8.97), excessive blood loss and/or transfusion (10.7% vs 3.0%, unadjusted odds ratio [OR] 3.92, 95% CI 1.41–10.91), surgery time ≥ 90th percentile (25.0% vs 8.9%, aOR 5.05, 95% CI 2.39–10.64), and conversions to laparotomy (10.7% vs 0.2%, unadjusted OR 48.36, 95% CI 5.71–409.93). For AM only, there were no significant differences in perioperative complication rates between groups. Conclusion: Fellowship-trained MIGS subspecialists had improved surgical outcomes for MIM compared to general OB/GYNs, with fewer conversions to laparotomy, reduced surgery time, and less blood loss, while outcomes for AM were similar by surgeon type. MIGS subspecialists excised a greater number of fibroids regardless of surgical approach, highlighting a level of comfort in complex benign gynecology beyond endoscopic surgery at our institution.