Impact of the COVID-19 pandemic on surgery for benign diseases in gynecology: A nationwide survey by the Japan Society of Obstetrics and Gynecology.

Aim This study aimed to clarify the impact of coronavirus disease 2019 on gynecology practice in Japan, in particular, on surgeries for benign gynecological diseases.

An online questionnaire was distributed to 966 facilities in Japan, including core facilities, facilities participating in perinatal and gynecologic oncology registries, and facilities certified for training by the Japanese Society of Obstetrics and Gynecology Endoscopy. The number of surgeries performed was compared between 2019 and 2020, when the novel coronavirus disease was prevalent.

Five hundred and eighty (58.2%) facilities responded. The total number of surgeries decreased from 129 648 in 2019 to 118 565 in 2020, by 8.5%, for all surgical procedures. However, there was a clear increase in the number of robotic surgeries performed in 2020 compared to that in 2019 for all populations. The number of total hysterectomies decreased markedly from 15 385 in 2019 to 12 531 in 2020, a fall of 10.1%.

The number of surgeries for benign gynecological diseases decreased by 8.5% in 2020 compared to that in 2019. This value is among the lowest in the world.

benign neoplasm, COVID‐19, gynecologic surgery, gynecology, survey

As a result of the global spread of the novel coronavirus disease 2019 (COVID‐19) in 2020, the number of patients with this disease increased markedly in Japan. This was expected to have extensive ramifications on the treatment of diseases other than respiratory illnesses; however, there exists no clarity on the actual practice. During the COVID‐19 pandemic, national and local governments in Japan declared a state of emergency and adopted measures to prevent the spread of the disease, which led to restraints on patients' consultation behaviors, including those in the obstetrics and gynecology (OBG) department. As the future of COVID‐19 infection remains unclear, the possibility of the infection spreading again cannot be denied, and there is an urgent need to review the OBG treatment system in the likelihood that the infection spreads. For patients with cancer, delays in consultation and diagnosis affect the timing of therapeutic interventions and may also contribute to the occurrence of advanced disease. In fact, systematic reviews have already been reported overseas. 1 Therefore, the Japanese Society of Gynecologic Oncology studied the effects of new coronavirus infections in patients with malignant tumors. 2 , 3 The Japanese Society of Obstetrics and Gynecology (JSOG) Endoscopy manages cases of endoscopic surgeries including laparoscopic and hysteroscopic surgeries. Meanwhile, the JSOG maintains a gynecological tumor registry that collects information on malignant tumors, but such a database does not exist for benign tumors. The purpose of this study was to clarify the impact of the COVID‐19 infection on OBG practice in Japan and in particular, on surgery for benign gynecological diseases.

Study design and participants The answers were obtained from the online questionnaires distributed to 966 facilities falling under the following categories: (1) core facilities and affiliated facilities of the specialized training program in OBGa, (2) facilities participating in the perinatal registryb, (3) facilities participating in the Gynecologic oncology registryc, (4) affiliated facilities certified for training by the JSOG Endoscopyd, (5) the number of surgeries performed in 2019 and 2020, when COVID‐19 was highly prevalent, were compared. aThe following requirements were to be met. Core facilities are (a) The number of deliveries after 22 gestation weeks (including cesarean section) was at least 150 during the period from January to December of the previous year of application, (b) At least 150 laparotomies other than cesarean section were performed during the period from January to December in the year preceding the year of application (this number may include laparoscopic surgeries, but not vaginal surgery), (c) At least 15 cases of first‐line treatment for gynecological malignancies (invasive cancer only) were treated in the year from January to December of the previous year of application and (d) The facility had a proven record of expertise in reproductive/endocrine and women's health care. Affiliated facilities For this category, in addition to women's health care facilities, the following criteria were met from January to December in the year preceding the year of application: (a) More than 30 cycles of in vitro fertilization (including IntraCytoplasmic Sperm Injection), (b) More than 100 surgeries for benign gynecological tumors (including similar tumors), (c) At least 15 cases of initial treatment for gynecological malignancies (invasive cancer only), (d) At least 100 deliveries (including cesarean section) after 22 weeks of pregnancy. However, if the JSOG Central Medical Specialist System Committee judged that it was necessary for regional medical care, the facility may have been recognized as a collaborating facility (regional medical care) based on a comprehensive evaluation of the above conditions even if it did not meet these requirements. bRefers to facilities to which members of the JSOG belong. These are the facilities that enter relevant medical information of the mother, fetus, and peripartum period into the prescribed computerized registration form in the relevant year. The purpose of this project is to understand the epidemiological and medical trends in perinatal care in Japan and to build a comprehensive database that can be used for secondary purposes by members of the society. This is a registration database project. cRefers to facilities to which members of the JSOG belong. The purpose of this project is to analyze and publicize the actual status of advanced stages, diagnosis, and treatment of gynecological cancers, as well as treatment outcomes, and to compare the characteristics prevalent in Japan with those in other countries. dThe purpose of this project is to analyze and publish the results of treatments and compare the characteristics in Japan with those in other countries: (a) The person in charge of the training facility is a member of this organization, (b) The training facility is either for the guidance of major physicians of the JSOG, a core hospital of the Japan Medical Specialists Organization, or a partner facility, (c) At least one technically certified physician (laparoscopy) designated by this organization is on duty. A technically certified physician who works at the facility at least 32 h per week or 5 days per week is considered full‐time, (d) Laparoscopic surgery is performed in at least 50 cases per year (for the time being). If robot‐assisted surgery is included, up to 10 cases are included. The procedures must be covered by insurance, (e) There should be a backup system of other departments in the hospital or a hospital with which close cooperation can be established, (f) various guidelines are followed, and insurance is used appropriately. Measures Survey period: October 25, 2021–November 30, 2021 (37 days) Survey items: (1) attributes of hospitals, (2) total number of hospital beds, (3) number of deliveries per year, (4) number of full‐time obstetricians and gynecologists, (5) number of full‐time residents for obstetricians and gynecologists, (6) number of specialists (obstetricians and gynecologists of the JSOG, gynecologic oncologists of the Japanese Society of Gynecologic Oncology, maternal‐fetal specialists of the Japanese Society of Perinatology and Neonatology, reproductive medicine specialists [OBG] of the Japanese Society for Reproductive Medicine), (7) number of certified endoscopists (laparoscopists or hysteroscopists) of the JSOG Endoscopy, and (8) number of surgeries performed for benign disease between January–December 2019 and January–December 2020. The total number of surgeries (open, laparoscopic, robotic), including total hysterectomy ± bilateral adnexal hysterectomy (open, laparoscopic, robotic), myomectomy (open, laparoscopic), ovarian cystectomy for benign tumors (open, laparoscopic), adnexal hysterectomy for benign tumors (open, laparoscopic), endometriosis lesion ablation and adhesiolysis (open, laparoscopic) hysteroscopic surgery, endometrial curettage, cervical conization resection, cervical evisceration, and ectopic pregnancy surgery.

A total of 580 (58.2%) facilities responded. Of these, 82 (14.1%) were medical and educational institutions (including university hospitals), 213 (36.7%) were public hospitals, and 149 (25.6%) were private hospitals. There was not much difference in the decrease in the number of surgeries by facility. The total number of surgeries is shown in Table 1. The total number of surgeries decreased from 129 648 in 2019 to 118 565 in 2020, by 8.5% for all surgical procedures. However, there was a clear increase in the number of robotic surgeries in 2020 compared to that in 2019 for all populations. Table 1. | 2019 | 2020 | Change | ||||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | a. Total | b. University | c. Non‐university | d. COVID‐19 patient handling facility | e. Non‐COVID‐19 patient handling facility | f. Special precautionary area | g. Nonspecial precautionary area | a′. Total | b′. University | c′. Non‐university | d′. COVID‐19 patient handling facility | e′. Non‐COVID‐19 patient handling facility | f′. Special precautionary area | g′. Non‐special precautionary area | a versus a′ | b versus b′ | c versus c′ | d versus d′ | e versus e′ | f versus f′ | g versus g′ | | | Open | 31 648 | 7108 | 24 988 | 26 081 | 5086 | 18 811 | 13 285 | 26 951 | 6149 | 22 341 | 22 341 | 4243 | 15 589 | 11 701 | −14.8 | −13.5 | −15.4 | −14.3 | −16.6 | −17.1 | −11.9 | | Laparoscopic | 55 356 | 14 234 | 41 472 | 45848 | 8323 | 37310 | 18 396 | 51 844 | 12 854 | 42802 | 42 802 | 7943 | 34 210 | 18 006 | −6.3 | −9.7 | −5.1 | −6.6 | −4.6 | −8.3 | −2.1 | | Robotic | 1026 | 479 | 547 | 712 | 197 | 644 | 382 | 1818 | 697 | 1296 | 1 296 | 319 | 1184 | 634 | 77.2 | 45.5 | 104.9 | 82 | 61.9 | 83.9 | 66 | | Vaginal | 28 799 | 5805 | 23 236 | 22502 | 6045 | 19115 | 9926 | 26118 | 5446 | 20300 | 20 300 | 5529 | 17147 | 9157 | −9.3 | −6.2 | −10.2 | −9.8 | −8.5 | −10.3 | −7.7 | | Others | 12 819 | 2524 | 10 364 | 9034 | 3538 | 8154 | 4734 | 11834 | 2247 | 8437 | 8437 | 3236 | 7241 | 4644 | −7.7 | −11.0 | −7.0 | −6.6 | −8.5 | −11.2 | −1.9 | | Total | 129 648 | 30 150 | 100 607 | 104 177 | 23 189 | 84 034 | 46 723 | 118565 | 27 393 | 95176 | 95 176 | 21 270 | 75371 | 44 142 | −8.5 | −9.1 | −8.4 | −8.6 | −8.3 | −10.3 | −5.5 | The number of total hysterectomies decreased markedly from 15 385 in 2019 to 12 531 in 2020, by 10.1% compared to that in 2019 (Table 2). By disease, the number of surgeries for precancerous lesions (CIN3/AIS + EIN/AEH) did not change much for each procedure (2019 vs. 2020: 4676 vs. 4206), while the number of surgeries other than robotic surgery for benign disease decreased (2019 vs. 2020: 35245 vs. 30 930). Compared to the number of laparoscopic plus robotic surgeries, there was only a 2.6% decrease, from 22 954 in 2019 to 22 348 in 2020 (Table 3). Especially in precancerous lesions (CIN3/AIS + EIN/AEH), it is performed without decrease in 2020 compared to 2019. Table 2. | 2019 | 2020 | Total | Rate (%) | | |---|---|---|---|---| | Open | |||| | Benign disease | 15 385 | 12 531 | 27 916 | −18.6 | | CIN3/AIS | 705 | 562 | 1267 | −20.3 | | EIN/AEH | 345 | 297 | 642 | −13.9 | | Others | 505 | 602 | 1107 | 19.2 | | Laparoscopic | |||| | Benign disease | 17 117 | 15 892 | 33 009 | −7.2 | | CIN3/AIS | 1479 | 1475 | 2954 | −0.3 | | EIN/AEH | 512 | 535 | 1047 | 4.5 | | Others | 898 | 753 | 1651 | −16.1 | | Robotic | |||| | Benign disease | 745 | 1315 | 2060 | 76.5 | | CIN3/AIS | 114 | 189 | 303 | 65.8 | | EIN/AEH | 58 | 88 | 146 | 51.7 | | Others | 12 | 81 | 93 | 57.5 | | Vaginal | |||| | Benign disease | 2743 | 2507 | 5250 | −8.6 | | CIN3/AIS | 1398 | 952 | 2350 | −31.9 | | EIN/AEH | 65 | 108 | 173 | 66.2 | | Others | 1296 | 1093 | 2389 | −15.7 | | Total | 43 377 | 38 980 | 82 357 | −10.1 | Abbreviations: AEH, atypical endometrial hyperplasia; AIS, adenocarcinoma in situ; CIN3, cervical intraepithelial neoplasia; EIN, endometrial intraepithelial neoplasia. Table 3. | 2019 | 2020 | Rate (%) | | |---|---|---|---| | Benign disease | 17 862 | 17 207 | −3.6 | | CIN3/AIS | 1593 | 1664 | 4.4 | | EIN/AEH | 570 | 623 | 9.2 | | Others | 910 | 834 | −8.3 | | Total | 22 954 | 22 348 | −2.6 | Abbreviations: AEH, atypical endometrial hyperplasia; AIS, adenocarcinoma in situ; CIN3, cervical intraepithelial neoplasia; EIN, endometrial intraepithelial neoplasia. The number of surgeries for benign diseases for which robotic surgery was not indicated, such as myomectomy, ovarian cystectomy and oophorectomy, declined across the board, with the fall ranging from 10% to 17% (Table 4). Similarly, there was a decrease in the number of procedures such as removal of endometriosis, which can be performed on a waiting list. On the other hand, the rate of decrease was lower for conization and endometrial curettage (−6.1% to −9.0%) than that for other benign procedures. A slight decrease from 3446 to 3197 (7.2%) in the number of surgeries for ectopic pregnancy was also observed. Table 4. | 2019 | 2020 | Total | Rate (%) | | |---|---|---|---|---| | Myomectomy | |||| | Open | 3903 | 3269 | 7172 | −16.2 | | Laparoscopic | 7194 | 6375 | 13 569 | −11.4 | | Total | 11 097 | 9644 | 20 741 | −13.1 | | Ovarian cystectomy | |||| | Open | 2206 | 1851 | 4057 | −16.1 | | Laparoscopic | 14 027 | 12 674 | 26 701 | −9.6 | | Total | 16 233 | 14 525 | 30 758 | −10.5 | | Oophorectomy | |||| | Open | 4723 | 3868 | 8591 | −18.1 | | Laparoscopic | 11 695 | 10 909 | 22 604 | −6.7 | | Total | 16 418 | 14 777 | 31 195 | −10.0 | | Removal of endometriosis | |||| | Open | 324 | 123 | 447 | −62.0 | | Laparoscopic | 1834 | 1668 | 3502 | −9.1 | | Total | 2158 | 1791 | 3949 | −17.0 | | Endometrial curettage | |||| | Endometrial polyp | 3283 | 3103 | 6386 | −5.5 | | Hyperplasia | 3001 | 2873 | 5874 | −4.3 | | EIN/AEH | 1877 | 1891 | 3768 | 0.7 | | Others | 2570 | 1997 | 4567 | −22.3 | | Total | 10 731 | 9864 | 20 595 | −8.1 | | Conization (including LEEP) | |||| | Conization | 14 443 | 13 203 | 27 646 | −8.6 | | LEEP | 2541 | 2254 | 4795 | −11.3 | | Laser ablation | 2086 | 1988 | 4074 | −4.7 | | Total | 19 070 | 17 445 | 36 515 | −8.5 | Abbreviations: AEH, Atypical endometrial hyperplasia; EIN, endometrial intraepithelial neoplasia; LEEP, loop electrosurgical excision procedure.

In this study, we investigated the impact of the COVID‐19 pandemic on the number of surgeries for benign gynecological conditions at core and training facilities accredited by the JSOG in Japan. The number of surgeries for benign diseases decreased by 8.5% in 2020 compared to that in 2019, but it is difficult to determine from the results of this study how much of an impact this figure had on the society. For reference, more than 40% of non‐cancer surgeries were canceled in the United States. 4 Public access to health services was limited and poor during the pandemic. Limited access to health services and the fear of COVID‐19 infection can possibly explain the lower number of elective surgical procedures for cancer in 2020 compared to those in the same period in 2019 in Italy. 5 South Africa also reported a 44% decrease in general surgical procedures. 6 Furthermore, a large survey conducted in Spain reported that 20.9% of rectal cancer surgeries could not be performed. 7 A study investigating the impact of COVID‐19 on gynecologic cancer surgery in Japan found only a 3.9% decrease. 2 These results suggest that gynecologists in Japan have managed to maintain the conventional medical care system while taking adequate infection control measures, even under pandemic circumstances. This may be due to the fact that we as medical professionals have tried to be patient‐centered despite our fear of COVID‐19. In the case of total hysterectomies, the number of robotic surgeries apparently increased, but this may be due to the fact that laparoscopic surgeries are now being considered an indication of robotic surgery. In fact, the number of laparoscopic plus robotic surgeries decreased by only 2.6% compared to that in 2019. Robotic surgery is currently being widely incorporated in hospitals across Japan. Thus, we may have managed to maintain the robotic surgery system in order to maintain the learning curve. In addition, an across‐the‐board decline in uterine myomectomy and ovarian surgery was observed, which can clearly be attributed to the impact of COVID‐19. The decrease in diagnostic and therapeutic procedures such as cervical conization and total endometrial curettage for precancerous lesions was less than 10%, suggesting that these procedures may have been handled flexibly at each institution, though they were affected to a small extent. Surgeries for benign diseases do not necessarily have to be performed in an emergency setting, but laparoscopic procedures in COVID‐19 patients must be performed with caution, as aerosols may be present. 8 , 9 A decrease in the number of surgeries has a significant impact on the training of young physicians. While Italy and the United States reported a shortage of cases for their surgical education programs, some states experienced delays of about 1 month, but stated that there have been no issues thereafter. 10 , 11 , 12 , 13 In this study, the decrease in surgeries for benign diseases was small compared to that in other countries; thus, there seems to have been no impact on the practicing surgeons so far. The impact on hospital revenues is also important from the perspective of maintaining the health care system. 14 However, since less than 10% of both benign and malignant surgeries were not being performed in Japan, there may not have been a significant loss in revenue. Since we did not examine the detailed changes by facility, it is possible that the actual changes differ significantly depending on whether the facility handled new‐type coronavirus‐positive patients, and whether it was a university hospital or not. We would like to conduct further analysis of these aspects through additional studies in the future. There are several limitations to this study. First, responses were not obtained from all facilities in Japan. However, the facilities that responded include both core facilities and training facilities that handle a large number of cases; thus, the data may be considered representative of Japan as a whole. Second, because this was a questionnaire survey, there may have been limitations in interpretation. Third, it was only a single‐year comparison and lacks certainty in comparison with the 2019 data alone. However, the fact that the results are from a large‐scale registry in Japan is a strength, as it directly compares data from 2019 and 2020, which were collected from more than half of the facilities. In conclusion, it is difficult to determine whether the impact of COVID‐19 infection was limited or whether it decreased the rate of surgical procedures for benign diseases significantly; nevertheless, it is necessary to maintain the number of surgeries in the future given the various factors at stake, such as the hospital structure, profitability, and surgeon training. In the future, in the event of a similar infectious disease pandemic, it will be possible to respond suitably by making use of our experience this time. Funding Information This work was supported by Ministry of Health, Labour and Welfare (MHLW) Special Research Program Grant Number JPMH20CA2046. Conflict of interest The authors declare no conflict of interests for this article. Acknowledgments The authors are deeply grateful to all facilities that responded to this survey. Hiroaki Komatsu and Satoshi Nakagawa contributed equally to this study. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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