Hysterectomies in Finland in : comparison of outcomes between trainees and specialists

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1 A C TA Obstetricia et Gynecologica AOGS MAIN RESEARCH ARTICLE Hysterectomies in Finland in : comparison of outcomes between trainees and specialists EWA JOKINEN 1, TEA BRUMMER 2, JYRKI JALKANEN 3, JAANA FRASER 4, ANNA-MARI HEIKKINEN 5, JUHA M AKINEN 6, JARI SJ OBERG 7, EIJA TOM AS 8, TOMI S. MIKKOLA 7 &P AIVI H ARKKI 7 1 Department of Obstetrics and Gynecology, Hospital District of Helsinki and Uusimaa/Hyvink a a Hospital, Hyvink a a, Finland, 2 Department of Obstetrics and Gynecology, Østfold Central Hospital, Fredrikstad, Norway, 3 Department of Obstetrics and Gynecology, Central Finland Central Hospital, Jyv askyl a, 4 Department of Obstetrics and Gynecology, North Karelia Central Hospital, Joensuu, 5 Terveystalo Private Healthcare Service, Kuopio, 6 Department of Obstetrics and Gynecology, Turku University Hospital, Turku, 7 Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, and 8 Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland Key words Hysterectomy, trainee, laparoscopic hysterectomy, complications, surgical training Correspondence Ewa Jokinen, Department of Obstetrics and Gynecology, Hospital District of Helsinki and Uusimaa/Hyvink a a Hospital. Sairaalankatu 1, Hyvink a a, Finland. ewa.jokinen@hus.fi. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Jokinen E, Brummer T, Jalkanen J, Fraser J, Heikkinen A-M, M akinen J, et al. Hysterectomies in Finland in : comparison of outcomes between trainees and specialists. Acta Obstet Gynecol Scand 2015; 94: Received: 2 November 2014 Accepted: 8 April 2015 DOI: /aogs Abstract Objective. To assess trends for hysterectomy methods in the Nordic countries and to compare outcomes of hysterectomies in Finland done by trainees with those done by specialists. Design. Register-based study. Setting. NOMESCO database for the Nordic countries and the Finnish Hospital Discharge Register. Population. National prospective cohort of 5279 hysterectomies in Finland. Methods. Numbers of hysterectomies in the Nordic countries were collected in and in Finland in The Finhyst study to collect data on hysterectomies for benign indications was carried out in Finland in Information concerning patients, surgeons, and hysterectomy outcome was analysed. Main outcome measures. Hysterectomy numbers and methods. Operating time, blood loss, and complications in hysterectomies done by trainees and specialists. Results. In Finland, the rate of hysterectomies has been reduced by approximately 50% since the 1990s and is now similar to that in the other Nordic countries. The laparoscopic method is twice as common in Finland as in other Nordic countries, constituting 35 40% of all hysterectomies. The operating time for all hysterectomy methods was 16 25% longer among trainees than specialists. For the abdominal or laparoscopic methods there were no significant differences in the complication rates between the groups. In the vaginal approach, blood loss of 1000 ml was slightly more common in operations done by trainees (1.3% vs. 2.6%, p = 0.037). Conclusions. Laparoscopic hysterectomy is more common in Finland than in the other Nordic countries. Although trainees need more time to operate, there were no differences between the trainees and the specialists with regard to major complication rates. Abbreviations: AH, abdominal hysterectomy; LH, laparoscopic hysterectomy; NOMESCO, Nordic Medico-Statistical Committee; VH, vaginal hysterectomy. Introduction Hysterectomy remains the most common major gynecological operation (1), although total hysterectomy rates have declined in several countries. Abdominal hysterectomy (AH) is the traditional procedure, but vaginal, laparoscopic, and also robotic methods have become more Key Message Although the hysterectomy rate in Finland has halved in the past 10 years, the proportion of these dealt with by laparoscopic methods has risen. The major complication rate is similar for trainees and specialists, although trainees need more time to operate. ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

2 Hysterectomy trends and outcomes in Finland E. Jokinen et al. common since they are considered less invasive (2 4). Many residency programs in the USA and Canada include all types of hysterectomies (5 7) but that is not yet the case in all European countries. Residency programs vary considerably between the different European countries (8). In Finland, universities are responsible for residency programs, whereas in many other countries, national societies or private hospitals provide training. In Finland, completion of a residency program in obstetrics and gynecology takes 6 years, including surgical training by an apprentice-model. Laparoscopic surgery was introduced in Finland in the 1990s and thus for the past decade, laparoscopic hysterectomies (LH) have also been taught to trainees during their residency programs. The laparoscopic approach has become a basic method of gynecological surgery when treating benign adnexal pathology and ectopic pregnancies (9). This is due to the benefits of a less invasive technique, shorter hospital stay, more rapid recovery, less pain, and better cosmetic outcomes (10 12). However, the laparoscopic approach has also been associated with longer operation times and an increased complication level, especially in the early stage of the learning curve (13 15). In addition to the apprenticeship model used in surgical training, virtual reality training (16) and specific mentorship programs (17) are used to overcome these problems. In this study, we analysed and compared the hysterectomy numbers and proportions of the different methods in the Nordic countries. Furthermore, we compared outcomes of different hysterectomy techniques between trainees and specialists in Finland. Material and methods The numbers of hysterectomies in the Nordic countries were collected from the NOMESCO database (Nordic Medico-Statistical Committee. Health Statistics for the Nordic Countries Available at: The Faroe Islands and Aland were excluded because for every yearly report, only an average number for the last 5-year period was available. The numbers represent the surgical procedures due to both benign and malignant causes (per women). Numbers until 2007 also include the radical gynecological cancer operations (pelvic exenterations) and colpoperineoplasties with vaginal hysterectomy (code LEF-13 according to NOMESCO Classification of Surgical Procedures). In Finland, open radical hysterectomy due to ovarian malignancy is coded separately (code LAF-16), and was excluded from our study. Proportions of LH in the NOMESCO database can be found separately only for the years The numbers of hysterectomies from 2007 to 2012 for benign indications in Finland were collected from the Hospital Discharge Register of the National Institute for Health and Welfare. The respective numbers for have been published previously (15,18,19). The abdominal group (AH) also includes supracervical hysterectomies. The vaginal group comprises all vaginal hysterectomies (VH) with or without colpoperineoplasty. The LH group comprises all LHs: laparoscopic hysterectomy with uterine artery ligation laparoscopically, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy and laparoscopic subtotal hysterectomy. Data concerning differences in hysterectomies between specialists and trainees were collected from the FINHYST 2006 survey (19). Data from hysterectomies for benign indications operated from 1 January to 31 December in all 46 public hospitals and in seven private clinics in Finland were collected for this survey. The data consist of 5279 hysterectomies representing 79.4% of all hysterectomies for benign indications in Finland in Of the 5279 hysterectomies, 1255 were done abdominally, 1679 laparoscopically and 2345 vaginally. For each patient, the surgeon filled in a detailed questionnaire concerning intra- and postoperative surgical data. Data were also collected concerning the surgeon status (specialist or trainee position) and experience in the hysterectomy method used. Patient-related variables included height, weight, and age. Procedure-related data included the method for hysterectomy, indication, operation time (min), blood loss (ml), weight of the uterus (g), antibiotic prophylaxis, and intra- or postoperative complications. Complications were defined as intra-operative bleeding ( 1000 ml), postoperative hemorrhage or hematomas, infections (febrile events, urinary tract infections, wound and pelvic infections), and major complications comprising organ injuries (bladder, ureter, bowel and vascular), deep vein thrombosis, pulmonary embolism, and other situations requiring re-operation. In this study, one LH in the specialist group was excluded as an outlier because of massive bleeding (25 L). The FINHYST 2006 study plan was approved by the Ministry of Social Affairs and Health in Finland, and the Helsinki University Hospital Ethics Committee (Dnro 457/E8/04). The study was included in the ClinicalTrials.gov protocol (NCT ). The statistical analysis was done with the SPSS 17.0 statistical software (SPSS Inc., Chicago, IL, USA) using the independent sample t-test for the normally distributed continuous variables, and the chi-square test or Fisher s exact probability test when needed for categorical data. Results The hysterectomy rates were similar in Denmark, Norway, and Sweden for the whole evaluation period, being 702 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

3 E. Jokinen et al. Hysterectomy trends and outcomes in Finland Operations per women Finland Iceland Denmark Norway Sweden Figure 1. Hysterectomy numbers in Nordic countries between 1995 and From Iceland data are not available. Year Percent Year Finland Iceland Denmark Norway Sweden Figure 2. Proportions of laparoscopic hysterectomies of all hysterectomies in Nordic countries in From Iceland data are not available. around 200 hysterectomies per women annually (Figure 1). Sweden had the lowest rate for hysterectomies, 169 operations per women in In Finland, the hysterectomy rate was the highest for almost the entire period, with up to 408 operations per women in 2001 and Since then, the rate has declined steeply, reaching that of the other Nordic countries in In Iceland, a similar pattern is seen. The laparoscopic approach is considerably more common in Finland than in the other Nordic countries, 36% in 2008 and 43% in 2011 (Figure 2). In Norway and Denmark in 2011, approximately 20% of the hysterectomies were done laparoscopically, whereas in Sweden the proportion for LHs is under 10%. In Finland in the beginning of 1990s, more than 90% of the hysterectomies were done abdominally, whereas since 2002 the vaginal route has been the most common method (Figure 3). In 2002 the vaginal and in 2005 the laparoscopic approach exceeded the abdominal route. In the period , the AH rate declined from 38 to 25%, while the VH rate rose from 37 to 43% and the LH rate from 25 to 32%. By 2012, of the 5926 operations 42% were vaginal, 35% laparoscopic, and only 22% abdominal. In the FINHYST study the surgeon status was known in 94% of the operations. The main surgeon was a specialist in 3832 cases (77.0%) and a trainee in 1145 (23.0%) cases (Figure 4). The abdominal route was as common in both groups (24%), but the trainees did VHs more frequently than the specialists (51 and 42%, respectively). Of the laparoscopic operations, 76.8% were Number of hysterectomies Year Total Abdominal hysterectomy Vaginal hysterectomy Laparoscopic hysterectomy Figure 3. Number of hysterectomies for benign disease in Finland in ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

4 Hysterectomy trends and outcomes in Finland E. Jokinen et al. Surgeon status Abdominal hysterectomy Vaginal hysterectomy Laparoscopic hysterectomy % 20% 40% 60% 80% 100% Figure 4. Distribution of different hysterectomy methods by surgeon status. operated as laparoscopic hysterectomy with uterine artery ligation laparoscopically, 17.9% as laparoscopically assisted VH, and 0.2% as laparoscopic subtotal hysterectomy. Conversions to laparotomy occurred in 5.2% of the LH and in 0.6% of the VH cases. There was no statistical difference in the conversion rates between the specialists and trainees. In over 90% of the cases in all hysterectomy approaches, specialists had used the method more than 30 times, whereas only in 10 30% of the trainees operations had the Table 1. Patient, surgeon and procedure-related characteristics by surgeon status and hysterectomy approach. Mean Range SD Mean Range SD p 95% CI Abdominal hysterectomies Total (n) Patient characteristics BMI (kg/m 2 ) Age (year) Hysterectomies done by surgeon (%) < > Surgery characteristics Operation time (min) < Blood loss (ml) Uterus weight (g) Vaginal hysterectomies Total (n) Patient characteristics BMI (kg/m 2 ) Age (year) Hysterectomies done by surgeon (%) < > Surgery characteristics Operation time (min) < Blood loss (ml) Uterus weight (g) < Laparoscopic hysterectomies Total (n) 1295 a 285 Patient characteristics BMI (kg/m 2 ) Age (year) Hysterectomies done by surgeon (%) < > Surgery characteristics Operation time (min) < Blood loss (ml) Uterus weight (g) BMI, body mass index. a One laparoscopic hysterectomy in the specialist group is excluded as an outlier because of massive bleeding 25 L. 704 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

5 E. Jokinen et al. Hysterectomy trends and outcomes in Finland Table 2. Complication rates by surgeon status and hysterectomy approach. Abdominal hysterectomy Vaginal hysterectomy Laparoscopic hysterectomy n % n % p n % n % p n % n % p Blood loss 1000 ml Postoperative hemorrhage or hematoma Infections Organ injury total Bladder injury Ureteric injury Bowel injury Major complication a Total complications a Major complications comprise organ injuries, deep vein thrombosis, pulmonary embolism, and other situations requiring re-operation. surgeon used the method (Table 1). In all hysterectomy types the operation time was longer for the trainees; 16% longer (p < 0.001) in the abdominal, 26% longer (p < 0.001) in the vaginal, and 25% longer (p < 0.001) in the laparoscopic approach. However, no differences were observed in blood loss or uterus weight in AH and LH groups. In the VH group the mean blood loss was higher in operations done by trainees, while the mean size of the uterus was higher in operations done by specialists. As regards complication rates between the specialists and trainees, there were no statistical differences in abdominal and laparoscopic procedures (Table 2). In the VH group a blood loss of 1000 ml was more common in operations done by the trainees (2.6% vs. 1.3%, p = 0.037). Among both specialists and trainees, the total complication rate was the highest with the abdominal approach. However, the total complication rate or the major complication rate did not differ in any hysterectomy types for the specialists compared with trainees. Discussion In this study we show that during the past 10 years the total number of hysterectomies in Finland has declined significantly, now being more equivalent to the numbers in the other Nordic countries. The Finnish guidelines introduced in 2005 for operative treatment of abnormal uterine bleeding, leiomyomas and prolapse (20) could explain at least part of the descending trend. Furthermore, in 1990 the levonorgestrel-releasing intrauterine system received marketing authorization in Finland, and its effective use thereafter for abnormal uterine bleeding (21) likely reduced the need for hysterectomies. The increasing use of uterus-preserving surgery [National Institute for Health and Welfare, Finland. Episodes of care procedures and interventions ; available at: (in Finnish)], such as operative hysteroscopies, myoma embolizations, and endometrial ablations, may also have decreased the numbers. In Finland, LH are more common than in the other Nordic countries. The NOMESCO database does not include the operation colpoperineoplasty and vaginal hysterectomy (the code LEF-13 according to the NOME- SCO Classification of Surgical Procedures, NCSP-E) after 2008, but only the code for vaginal hysterectomy (LCD- 10). Since VH is the most common method in Finland and both operations (LCD-10 and LEF-13) are done, the proportion operations using the laparoscopic method may be overestimated in the NOMESCO database; however, this would be the case for all the Nordic countries. Implementation of LH has often been slow (22). Both in the USA in 2003 (1) and in Germany in (23) only about 12% of hysterectomies were laparoscopic. In the Netherlands, 10% of hysterectomies were laparoscopic in 2007 (22). However, in many countries the proportion of LH has constantly been growing (24). The wide use in Finland of the laparoscopic method may be partly due to the way laparoscopic surgery was initially introduced in the 1990s; it was not centralized to specific clinics, as in many other European countries. In Finland, 81% of all adnexal surgery, 34% of myomectomies, and 34% of all hysterectomies, including for malignant tumors, were done laparoscopically in 2010 [National Institute for Health and Welfare, Finland. Episodes of care procedures and interventions 2010; available at: (in Finnish)]. In 2012, 42% of all hysterectomies for benign conditions were vaginal and 35% laparoscopic. Furthermore, in our study the LH outcomes among the specialists are similar to what has been reported from other countries (4,25). Thus, the Cochrane recommendation that Vaginal hysterectomy should be preferred over AH. Where this is not possible, a laparoscopic hysterectomy ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

6 Hysterectomy trends and outcomes in Finland E. Jokinen et al. should be used to avoid the need for the abdominal approach (4), appears to be well executed in Finland. The trainees did VHs more often than the specialists. This is an expected finding, because VH is a most common method and is also taught at an earlier stage of the residency program. Furthermore, the vaginal route is often used due to concomitant prolapse, when VH is considered an easier operation than LH or AH (19). We may also assume that, overall, the trainees operated on the easier cases. Although trainees needed more time than the specialists to do any type of hysterectomy, we did not notice an increased risk for complications. According to the Cochrane review, AH is associated with higher intraoperative blood loss than LH, and substantial bleeding is higher for LH than for VH (4). The mean blood loss in this study was also the highest in AHs and the lowest in VHs. However, we detected a higher mean and more often 1000 ml blood loss in VHs done by the trainees as compared with specialists. The reason for this finding is not clear, but together with the slightly longer operating time, it may represent the possible effect of limited experience. The body mass index was higher in the patients operated by specialists, indicating potentially more difficult operations. As expected, the specialists were more experienced in the laparoscopic method than were the trainees. It should be noted that we had information only on the number of hysterectomies, but not the number of different gynecologists who did the operations. Thus, we cannot deduce how many of the trainees had the experience of more than 30 LH, and this can potentially distort our results. Already at the time of the study the apprenticeship model was used to teach surgical skills for trainees, and this model has been continued. In our study the status of the assisting doctor was not registered, but in Finnish clinical practice a junior trainee always operates with a specialist, who mentors and is also in charge of the procedure. Only at the end of the training, when appropriate skills are acquired, may a senior trainee operate with another trainee or even alone. Thus, in the majority of the trainee operations, the assistant most likely was a senior doctor. Only few studies have assessed the outcomes of hysterectomies done by trainees (5,26). It has been shown that supervised hysterectomies take more time but incur less bleeding (5). Since the majority (60%) of these operations were abdominal, the outcomes according to hysterectomy type were not reported. In another study of chief trainees doing supracervical hysterectomies it was reported that the first two operations took more time than the last two, but there were no differences in the complication rates (26). In publications with different types of hysterectomies, the expectations of surgical training (6), self-confidence (27), and comfort (28,29) were evaluated. However, to our knowledge there are no previous European studies reporting the outcomes of hysterectomies done by trainees. To conclude, even though the total hysterectomy rate in Finland has declined significantly in the past 10 years, the laparoscopic method has become more common. With the Finnish apprenticeship training model, trainees seem to learn LH as safely as the other hysterectomy methods. In future, with declining case load and more demanding mini-invasive techniques, simulators and virtual reality training should be part of surgical training. Funding The study was supported by grants from the Finnish Medical Association and the Finnish Medical Society Duodecim. References 1. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. 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