The Impact of Resident Involvement on Surgery for Pelvic Organ Prolapse

Objectives: Prior research has shown that when urogynecologists operate with fellows, operative time increases, without an increase in adverse events or prolapse recurrence. Outside of fellowship training programs, urogynecologists often operate with the assistance of an OB/GYN resident (RES) or with a physician assistant (PA). We sought to explore the impact on operative time and complications of prolapse surgery when urogynecologists operate with a RES versus PA.

Methods: This is a retrospective cohort study of all apical pelvic organ prolapse (POP) repairs performed between June 2016 to July 2020 by a single fellowship-trained urogynecologist at two community hospitals. The surgeon operated with a 3rd or 4th year RES at one hospital, and with a PA without RES involvement at the other hospital. Demographic information, history, exam findings, and intra- and postoperative details up to 6 weeks after surgery were compared between RES vs. PA cases. Along with descriptive statistics, operative time and perioperative complications were compared using linear and logistic regression, adjusting for potential confounders.

Results: We identified 108 POP repairs, of which 77 (71.3%) were assisted by a RES and 31 (28.7%) by a PA . Patients were predominantly White (n=80, 78.4%), with mean age 60.4±13.7 years and mean BMI of 28.6±6.2 kg/m2. Most were ASA Class 2 (n=78, 72.2%) and 12 (11.2%) were tobacco users. No significant differences in demographic characteristics existed between cohorts. Procedures were performed vaginally in 62% (n=67) and laparoscopically in 8% (n=41) of cases. Cohorts had similar rates of concomitant hysterectomy (62.3% RES vs. 64.5% PA, p=1.00) and midurethral sling (5.2% vs. 12.9%, p=.223). RES cases had significantly higher estimated blood loss(64.4 ± 66.4 vs. 33.2 ± 20.6 mL, p < .001).

The average RES operative time was 187.5 ± 80.3 minutes compared to 155.7 ± 53.2 minutes with a PA (p=0.045). After adjusting for surgical route, BMI, concomitant hysterectomy and midurethral slings, cases with residents took 49.0 minutes longer (Table 1). Complications including readmission, reoperation, infection, bowel obstruction, conversion to laparotomy, bladder or bowel injury, and mesh-related complications were seen in 25.0% (n=19) of RES and 9.7% (n=3) of PA cases (p=.112). On logistic regression, complications were 10.84 times more likely in RES cases (95%CI 1.81-64.79) after adjusting for confounders (Table 2).

Conclusions: When an expert surgeon operated with a resident as opposed to a physician assistant, the operative time increased by 49 minutes (~30% longer) with >10 times increased odds of perioperative complications.