The Evolution of Incontinence and Pelvic Floor Surgical Experience in OB/Gyn Trainees

Objectives: It is well-known that the operative case volumes logged by OB/Gyn residents for abdominal and vaginal hysterectomies has been decreasing. As such, there has been significant attention to attaining minimum numbers of cases to assure adequate exposure and competency for these procedures. However, the decrease in incontinence surgery and pelvic floor procedures (ISPF) is less clear relative to other surgical procedures. We hypothesized that ISPF exposure has similarly declined in general OB/Gyn training.

Methods: The Accreditation Council for Graduate Medical Education (ACGME) publishes residency case volumes annually. We evaluated the ISPF case numbers per resident over the last 10 years (2012-2022). We also evaluated other gynecologic surgical procedures during that time frame (e.g., the total number of hysterectomies, the number of vaginal hysterectomies, and the number of invasive cancer cases). All case counts were based on national average per resident as published by the ACGME. We used linear regression to estimate the average change in case type volume per resident per year, with quantification using R2 to evaluate how well this regression estimate captured the trend in the data and slope to determine decline. All analyses were performed using RStudio Version 1.3.1093.

Results: ISPF case volumes have decreased over the last decade, with an average decline of 4.77 cases per resident per year (p=0.00217, Figure 1); from a mean of 114.9 (SD 54) in 2012 to a mean of 44.5 (SD 22.9) in 2022. A linear model was found to be a relatively good fit of this data, as time explains two-thirds of the variation in ISPF case volume (R2 of 0.666). A profound decrease was noted 2012-13, so the analysis was repeated excluding 2012, with an average decline of 2.85 cases per resident per year. In comparison to other case types, ISPF case volume decreased more over the last 10 years compared to invasive cancer procedures (average decrease of 1.7 cases per resident per year), total hysterectomies (average decrease of 1.07 cases per resident per year) and vaginal hysterectomies (average decrease of 0.24 cases per resident per year).

Conclusions: ISPF case volume has declined significantly over the past decade, despite the high prevalence of conditions like pelvic organ prolapse and urinary incontinence. The rate of decreased case exposure for ISPF procedures has been greater than for other surgical procedures, including total hysterectomies and vaginal hysterectomies. In order to prepare OB/Gyn residency graduates for specialist obstetrics and gynecologic practices, it is imperative to maintain ISPF exposure and training.