The Impact of Surgeon Training on Endometrioma Management

INTRODUCTION: Endometrioma management balances age, fertility, symptoms, and ovarian reserve with recurrence and surgical complexity. When indicated, surgery improves pain, decreases recurrence, and improves spontaneous pregnancy. Although debate exists about management, major societies (ACOG, ESHRE, and ASRM) recommend optimal surgical techniques: 1) minimally invasive route is preferred; 2) cystectomy with removal of cyst is preferred; 3) oophorectomy is acceptable for pain and history of prior cystectomy. Patients are managed by general obstetrician-gynecologists (OBG) and fellowship-trained gynecologists (REI, MIGS, GO) leading to potential management variability. Thus, we sought to evaluate adherence to recommendations based on surgeon training. OBJECTIVE: To evaluate the impact of surgeon training, patient characteristics, and surgical factors on endometrioma surgical management and to assess adherence to society recommendations. METHODS: This is a retrospective cohort of patients >18 years old who underwent surgery for a histologically confirmed endometrioma at an academic center between January 2012 and December 2022. The electronic medical record system was used to collect patient demographics, surgeon training, surgical procedures, and outcomes. Patients were grouped into MIGS/REI and OBG/GO. (Our REI division comprises surgeons providing complete endometriosis care.) Descriptive statistics were used to compare the groups. Multivariable logistic regression was used to determine the impact of surgeon training while controlling for confounders. RESULTS: Two hundred eighty-one patients underwent surgery: 231 (82%) by MIGS/REI and 50 (18%) by OBG/GO. There were no differences in age, BMI, race, parity, medical comorbidities, infertility history, prior surgeries, or endometrioma size. MIGS/REI patients desired pregnancy more (55%, 24%, p<.001); however, 26% were unknown in OBG/GO. Most patients (96%) had a minimally invasive surgery. MIGS/REI were more likely to do a cystectomy (76%, 38%, p<.001). Of the patients who had an oophorectomy by MIGS/REI, 80% had a history of cystectomy on the same ovary. MIGS/REI were more likely to complete an excision of endometriosis (82%, 24%, p<.001) and/or ureterolysis (64%, 36%, p<.001). MIGS/REI had longer operative times (2.8 hours, 1.7 hours, p<.001) and higher EBL (75 ml, 25 ml, p<.001). There were no differences in complication or readmission rates. Overall, 220 patients had a minimally invasive cystectomy, demonstrating complete adherence to society recommendations, MIGS/REI (90%), OBG/GO (10%). MIGS/REI performed a laparotomy/cystectomy on 4 patients with 2/4 starting laparoscopic. The OBG/GO group performed 3 laparotomy/oophorectomies, and the MIGS/REI group did 2 laparotomy/oophorectomies, both conversions. When comparing groups based on cystectomy vs oophorectomy, age (32 vs 39, p<.001) and prior or concurrent hysterectomy (26 vs 48, p<.001) were significantly associated with oophorectomy. In a multivariable logistic regression model controlling for age and hysterectomy, patients undergoing surgery by GO had 7 times the odds of having an oophorectomy (Figure 1). CONCLUSIONS: Fellowship-trained MIGS and REI surgeons were more likely to adhere to society recommendations for endometrioma surgical management. Future studies are needed to better understand quality of life and fertility outcomes, improve the standard of care, and give endometriosis patients the care they deserve (Tables 1 and 2).