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Practice of endoscopic gynecologic surgery: a survey of Spanish gynecologists
European Journal of Obstetrics & Gynecology and Reproductive Biology, 1, 169, pages 64 - 68
To evaluate the implementation of endoscopic gynecologic surgery in Spanish hospitals.
In January 2011, a questionnaire was sent to 198 gynecology departments to determine the diffusion and acceptance of specific endoscopic procedures (hysteroscopy and laparoscopy) in each hospital.
The response rate was 52% (103/198). The practice of basic laparoscopy in Spain is high (90% of the hospitals surveyed reported that >50% of their specialists use this technique). Although advanced laparoscopic procedures are used in 83.4% of hospitals, 59.2% of these hospitals reported that <25% of gynecologists knew how to perform these techniques. In the case of adnexal masses, the approach used depends on the characteristics of the mass. Most hospitals (96.1%) reported routine use of a laparoscopic approach for benign adnexal masses measuring <10 cm, while 42% of hospitals reported routine use of a laparoscopic approach for masses that appear to be suspicious on ultrasound. Regarding hysterectomy, 38 hospitals (36.9%) reported that an abdominal approach was used in <25% of hysterectomies, 53 hospitals (51.5%) reported that a vaginal approach was used in 25–50% of hysterectomies, and 53 hospitals (52%) reported that a laparoscopic approach was used in <25% of hysterectomies. For the treatment of gynecological cancers, 53 hospitals (52%) reported that a laparoscopic approach was used in <25% of cases; this approach was reported more commonly by teaching hospitals (81.9% vs. 46.75; p < 0.001) and hospitals with >200 beds (84.3% vs. 45.5%; p < 0.001). In teaching hospitals, the concordance between what the respondents felt residents should be able to do, in terms of laparoscopic techniques, and what residents were actually able to do upon finishing their residency training was quite high, with the degree of concordance varying between 84.3% (adnexal mass approach) and 100% (diagnostic laparoscopy and tubal sterilization).
More than 90% of the Spanish hospitals surveyed perform basic endoscopic techniques, and 83.4% are able to perform advanced endoscopic procedures.
Keywords: Survey, Gynecological endoscopy, Practice, Implementation.
The advent of endoscopic surgery (ES) has been one of the most important advances in contemporary surgery, and has reached high levels of development in a very short time. Nowadays there is general consensus about the clinical application of ES in all fields of gynecology, including uterine pathology, benign adnexal masses, pelvic floor defects, oncology, and gynecological and obstetric emergencies.
Development of ES techniques has not been uniform across the various gynecological fields, a fact made manifest by the publications and presentations of diverse research groups. Unfortunately, precise data on how these techniques are actually used throughout Spain are lacking, including information about the availability of technical equipment, the degree of implementation in various hospitals, how many gynecologists routinely use these techniques, etc.
Despite their limitations, surveys and questionnaires enable data to be obtained and analyzed quickly and effectively, as they can be sent out to a large sample and can encompass a broad array of questions  and . Interestingly, very few initiatives of this type have been undertaken in Spain  and  or Europe. Most studies that have been undertaken have evaluated specific aspects of ES  and , with none of them including hysteroscopy on the questionnaire.
2. Materials and methods
In 2011, the authors emailed an introductory letter and the questionnaire to 198 obstetrics and gynecology health providers in Spain (public and private sectors) from the database of the Spanish Ministry of Health. The questionnaire consisted of 39 questions covering demographic characteristics, availability of equipment, implementation of ES, training procedures, etc.
To facilitate questionnaire completion, absolute numbers were avoided in questions with quantitative data, and percentages and descriptive terms were used instead (<25%, 25–50%, 50–75%, >75%; never, sporadically, 25% of cases, 50% of cases, routinely).
A reminder (second mailing or email) was sent to those who did not respond within 6 weeks, in order to maximize the response rate.
Results were entered into a Microsoft Access database. The different variables were summarized using absolute and relative frequencies, expressed as percentages. Differences between explanatory variables and ES activity indicators were examined using Chi-squared test or Fisher's exact test. The level of statistical significance was set at 5% (p < 0.05). Calculations were performed using PASW Version 18.0 (SPSS, Inc., Chicago, IL, USA).
Of the 198 hospitals contacted, 103 (52.02%) returned the questionnaire. Seventy responses (68%) were received from teaching hospitals. With regard to the size of the hospitals that responded to the survey, 11 (10.8%) had <100 beds, 19 (18.6%) had 100–200 beds, 41 (40.2%) had 200–600 beds and 31 (30.4%) had >600 beds.
Seventy-eight hospitals (76.5%) reported that diagnostic hysteroscopy is performed as an outpatient procedure in >75% of cases. Fifty-six hospitals (54.4%) reported that polypectomies are routinely performed as an outpatient procedure.
A clear association was found between the availability of a bipolar generator and a higher rate of outpatient polypectomies (performed routinely in 35.7% of hospitals with a bipolar generator vs. 6.1% of hospitals without a bipolar generator; p < 0.001). Nevertheless, 36% of hospitals with this equipment reported that it was only used sporadically, in <25% of cases or never.
The reported percentage of specialists in any given hospital who perform surgical hysteroscopies was similar to the percentage of specialists who perform diagnostic hysteroscopies. Ninety-four hospitals (92.2%) reported that surgical hysteroscopy is routinely performed as a major outpatient surgical procedure. The data for hysteroscopy are shown in Table 1 .
|Percentage of specialists who perform diagnostic hysteroscopies|
|Diagnostic hysteroscopies performed as outpatient procedures|
|Polypectomies performed as outpatient procedures in the hysteroscopy office|
|25% of cases||7 (6.8)|
|50% of cases||16 (15.5)|
|Is a bipolar generator available in the hysteroscopy office?|
|Percentage of specialists in your hospital who can perform surgical hysteroscopy|
Fifty-eight hospitals (56.3%) reported that >75% of their specialists perform basic laparoscopic surgery, but 61 hospitals (59.2%) reported that <25% of their specialists were able to perform advanced laparoscopic procedures.
Eighty hospitals (77.7%) reported that they had adequate equipment to perform laparoscopic surgery. There were no differences in the availability of materials with regard to the type of hospital (teaching hospital or not) or size of hospital (number of beds) ( Table 2 ).
|Percentage of specialists in your hospital who can perform basic laparoscopic surgery|
|Percentage of specialists in your hospital who can perform advanced laparoscopic surgery|
|Do you think that the laparoscopic equipment available at your hospital is adequate?|
The degree of acceptance and evolution of laparoscopic surgery was judged to be adequate in 62 hospitals (65.3%), and 32 hospitals (33.7%) reported that it needs to be developed. Upon analysing the response rate for the latter, neither differences were found between teaching hospitals and other hospitals, nor between hospitals of different sizes.
Ninety-eight hospitals (95.1%) reported that they had the capability to perform emergency laparoscopic surgery. Within this category of emergency surgery, 93 hospitals (91.2) reported that a laparoscopic approach was used routinely in surgically managed ectopic pregnancies.
The frequency of laparoscopic procedures in the treatment of adnexal masses varied depending on the characteristics of the mass. Most hospitals (96.1%) reported that laparoscopic treatment was used routinely for masses that were found to be benign and which measured <10 cm, and 57 of these hospitals (57%) reported that laparoscopic treatment was also routine for benign adnexal masses >10 cm. Forty-two of the hospitals (42%) reported that a laparoscopic approach was used routinely for masses that were suspicious on ultrasound, but 30 hospitals (30%) reported that a laparoscopic approach was used sporadically or never for these types of masses ( Fig. 1 ).
With regard to the approach used in hysterectomies, 38 hospitals (36.9%) reported that they used an abdominal approach for <25% of hysterectomies, 53 hospitals (51.5%) reported the use of a vaginal approach for 25–50% of hysterectomies, and 53 hospitals (52%) reported using a laparoscopic approach for <25% of hysterectomies. The median frequency of abdominal and vaginal hysterectomy (AH and VH, respectively) was 25–50%, and a laparoscopic approach was used in <25% of cases. If VH candidates with genital prolapse are excluded, 32% and 21% of hospitals reported sporadic and routine use of a laparoscopic approach, respectively. The different approaches to hysterectomy are detailed in Fig. 2 .
Of the hospitals that responded, 74% reported that they treat at least one type of oncological pathology laparoscopically. The rates were found to be higher in teaching hospitals (81.9% vs. 46.7%; p < 0.001) and in hospitals with >200 beds (84.3% vs. 45.5%; p < 0.001). The use of a laparoscopic approach for different oncological procedures is shown in Table 3 .
|Laparoscopic approach in oncological pathologies|
|Endometrial cancer staging surgery|
|25% of cases||3 (4.1)|
|50% of cases||8 (11.0)|
|Ovarian cancer staging surgery|
|25% of cases||7 (9.5)|
|50% of cases||9 (12.2)|
|Diagnostic laparoscopy in cases of clinical suspicion of advanced-stage ovarian cancer to assess the possibility of optimal surgery|
|25% of cases||5 (6.8)|
|50% of cases||8 (10.8)|
|Diagnostic laparoscopy in cases of clinical suspicion of advanced-stage ovarian cancer to perform a biopsy of the tumour prior to administering neoadjuvant chemotherapy|
|25% of cases||2 (2.7)|
|50% of cases||7 (9.5)|
|Radical hysterectomy in cervical cancer|
|50% of cases||2 (2.7)|
Thirty-eight hospitals (36.9%) reported the use of laparoscopic techniques to treat pelvic floor pathologies. Of these, seventeen hospitals (44.7%) reported that sacrocolpopexy is performed routinely, and 12 hospitals (31.5%) reported that it is performed sporadically or never. Thirty hospitals (78.9) reported that the Burch technique for the treatment of urinary incontinence is performed sporadically or never.
Finally, in teaching hospitals, the concordance between the respondents’ views on what residents should be able to do, in terms of laparoscopic techniques, and what they can actually do when they finish their residency training was very high, with the degree of agreement varying between 84.3% (laparoscopic approach for adnexal masses) and 100% (diagnostic laparoscopy and tubal sterilization) ( Table 4 ).
|Need not know||Should know|
|Does not know n||Does know n (%)||Does not know n (%)||Does know n|
|Diagnostic hysteroscopy||7||0||1 (1.6)||62|
|Myomectomy||23||1 (4.2%)||5 (10.9)||41|
|Endometrial resection||38||0||7 (21.9)||25|
|Ectopic pregnancy||7||0||5 (7.9)||58|
|Adnexal masses||9||0||11 (18)||50|
|Advanced laparoscopic surgery||62||0||3 (27.5)||5|
The rapid diffusion of ES means that most gynecological procedures can now be performed laparoscopically. Nevertheless, factors such as the inherent difficulty of ES, the learning curve involved, the higher cost of the necessary equipment, etc., have prevented uniform spread of this technique. It was therefore considered opportune to undertaken a survey to obtain information on the diffusion and implementation of ES in Spanish hospitals.
The survey response rate was adequate (52%), especially given the moderate response generally obtained when surveying medical professionals. It is possible that physicians who were more interested in minimally invasive gynecological procedures may have been more likely to respond to the survey, but the tendencies found in the survey are more important than the absolute values obtained  and .
Hysteroscopy has become a basic technique in all gynecological departments. Of the hospitals surveyed, 17.6% reported that they perform <25% of diagnostic hysteroscopies as outpatient procedures. Likewise, only 54.4% of the hospitals reported that they routinely perform polypectomies as an outpatient procedure in hysteroscopy visits. This may be related to the lack of appropriate equipment or office space for this procedure. Although there is a clear association between the availability of a bipolar generator and a higher rate of outpatient polypectomies, 36% of the clinics equipped with this technology reported that it was used in <25% of cases, sporadically or never. Increasing the number of diagnostic hysteroscopies performed as an outpatient procedure may constitute an area where improvements should be made.
The implementation of basic laparoscopy into Spanish gynecological practice is high. Ninety percent of hospitals reported that >50% of their staff perform basic laparoscopic surgery. As laparoscopic surgery constitutes a daily surgical procedure in both emergency and programmed healthcare services, it would be desirable if >75% of the staff at all hospitals could perform this basic procedure, but only 56.3% of hospitals gave this answer. If the majority of hospitals believe that a resident should be able to perform laparoscopic surgery upon finishing his/her residency training, perhaps the teach-the-teacher phase for basic procedures must be accomplished first.
In this survey, 83.4% of hospitals reported the ability to perform advanced laparoscopic procedures, but 59.2% of these hospitals reported that <25% of gynecologists knew how to perform these procedures. One goal should be to increase this figure to 25–50% so that candidates for laparoscopic surgery do not receive open surgery simply due to the lack of a trained specialist. A major advance in the last few years is that the majority of hospitals now have access to the technology necessary for performing laparoscopy, and 77.6% of the hospitals reported satisfaction with the equipment and means available. In this regard, no differences were found between teaching and other hospitals, nor between small and large hospitals. It is the authors’ belief that the 22.3% of hospitals that reported inadequate materials reflects a lack of compromise from some hospital managers. This problem will be solved progressively as ES expands.
Another advance is the generalized use of laparoscopic techniques in emergency treatments, with 95.1% of hospitals reporting the capability to perform emergency laparoscopic surgery. For example, 91.2% of hospitals reported routine use of a laparoscopic approach for surgically managed ectopic pregnancies. This figure is comparable to that observed in other European countries  and .
Nowadays, a laparoscopic approach is the standard therapeutic option for adnexal masses with a benign appearance after postoperative study. For suspicious adnexal masses, there is broad consensus for the use of an initial laparoscopic approach as a high percentage of these masses are benign; an initial laparotomic approach may thus constitute overtreatment , , and . Nevertheless, in this study, 42% of hospitals reported that laparoscopic treatment was used routinely for suspicious adnexal masses, whereas 39% of hospitals reported laparoscopic treatment was used sporadically, never or in <25% of cases.
VH is the method of choice for performing hysterectomies for benign indications  . This study found that the methods used to perform this type of hysterectomy do not seem to follow evidence-based recommendations, as a slight prevalence for use of an abdominal approach was found, followed by a vaginal approach and then a laparoscopic approach.
In 2002 in the Netherlands  , the distribution of approaches in hospitals that performed laparoscopic hysterectomy (LH) was: AH, 62.6%; VH, 28.9%; and LH, 8.5%. In 2007, however, the distribution was similar to that observed in the present study: AH, 55.4%; VH, 30.8%; and LH, 13.8%. In Finland  , LH and VH have become more common than AH (AH, 26%; VH, 45%; LH, 29%).
Integration of minimal access surgery in the treatment of gynecological cancers has been extremely rapid over the past few years. Currently, minimal access surgery for endometrial cancer is a safe, effective and feasible way to manage this disease  ; a fact reflected in the study findings as 65.8% of the hospitals reported routine use of a laparoscopic approach for this type of surgery.
Currently, the most common approach in the surgical treatment of ovarian cancer is laparotomic, although several authors have defended the possibility of achieving similar results with a laparoscopic approach in the early stages of the cancer  . In Spain, 27.1% of hospitals reported that they used a laparoscopic approach for the surgical treatment of ovarian cancer either routinely or in 50% of cases.
Incorporation of basic laparoscopic procedures into residency training has been largely successful in Spain, but more emphasis should be placed on laparoscopic training for advanced procedures during residency and for practising gynecologists.
Of the gynecological teaching hospitals in Spain, 58.21% are able to perform simulator training. This type of practice is important with regard to performance in the operating theatre, and should be mandatory during residency.
In contrast to countries such as Finland  , gynecologists in Spain do not have a national standardized registration system for operative procedures. As no prospective national registration system is currently available, performing serialized surveys such as those performed in the Netherlands , , and  provides information on implementation tendencies. This information should be a starting point from which to begin a discussion and adopt common resolutions which, when presented to healthcare managers and authorities, will lead to improvements in the training and the implementation and development of ES.
The authors wish to thank their fellow gynecologists for co-operation in completing the questionnaire, and J.M. Tenías for his supervision and for performing the statistical analysis.
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a Hospital General La Mancha-Centro, Alcázar de San Juan, Ciudad Real, Spain
b Hospital Universitario Puerta de Hierro, Madrid, Spain
c Hospital de Cruces, Bilbao, Spain
d Hospital Virgen de las Nieves, Granada, Spain
e Hospital Universitario Lozano Blesa, Zaragoza, Spain
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