The Impact of MIGS Subspecialty Training on Surgical Care for Endometriosis

INTRODUCTION: Minimally invasive gynecologic surgery (MIGS) fellowship provides comprehensive training in the management of complex benign gynecologic pathology, including endometriosis. Data are currently lacking regarding the impact of MIGS fellowship training on surgical care for endometriosis. OBJECTIVE: This study aims to compare surgical management techniques and outcomes of endometriosis surgery between surgeons with or without subspecialty training in MIGS. METHODS: This was a retrospective cohort study performed at a quaternary care institution in the United States. We included all patients who underwent surgery for endometriosis with a fellowship-trained MIGS surgeon, general obstetrician/gynecologist (OB/GYN), or gynecologic oncologist from 11/1/2013 to 10/31/2023, and had surgical or pathologic documentation of endometriosis. Patients with gynecologic malignancies or patients who underwent urgent surgeries for non-endometriosis indications were excluded. Cases performed by gynecologic oncologists were grouped with general OB/GYN cases as “non-MIGS.” The primary outcome was the rate of fulguration for treatment of endometriosis rather than excision. Secondary outcomes included rates of residual endometriosis left untreated, repeat endometriosis surgery during the study period, definitive management for endometriosis with hysterectomy or oophorectomy, perioperative complications, and need for intraoperative consultation. Outcomes were compared by surgeon type, and logistic regression was used to adjust for possible confounders. RESULTS: A total of 1,481 patients underwent surgery for management of endometriosis during the study period, 1,311 (88.5%) by MIGS surgeons and 170 (11.5%) by non-MIGS surgeons. Rates of stage III/IV endometriosis were higher among MIGS vs. non-MIGS cases (41.8% vs. 30.6%, p=.006), and surgical complexity level was higher among MIGS cases (p<.001). Fulguration was performed at significantly higher rates in the non-MIGS group compared to the MIGS group (70.6% vs. 0.7%; adjusted odds ratio [aOR] 353.3, 95% confidence interval [CI] 168.2–742.2). Residual, untreated endometriosis was documented at higher rates in surgeries performed by non-MIGS surgeons when compared to MIGS surgeons (33.5% vs. 0.6%; aOR 197.7, 95% CI 81.9–477.2). Patients who underwent surgery with a non-MIGS surgeon were more likely to undergo repeat surgery for endometriosis within the study period compared to those whose surgeon was MIGS-trained (23.5% vs. 6.4%; aOR 4.03, 95% CI 2.44–6.67). Rates of oophorectomy did not differ significantly between non-MIGS cases and MIGS cases (3.5% vs. 7.0%; aOR 0.55, 95% CI 0.21–1.45); however, patients were less likely to undergo definitive management with a hysterectomy in surgeries performed by non-MIGS surgeons compared to their MIGS counterparts (1.8% vs. 17.1%; aOR 0.09, 95% CI 0.03–0.29). Rate of composite perioperative complications did not differ between the non-MIGS and MIGS groups (5.9% vs. 7.2%; aOR 1.03, 95% CI 0.51–2.04). Unplanned intraoperative consultation occurred more frequently in surgeries performed by non-MIGS compared to MIGS surgeons (4.7% vs. 1.3%, p=.001). CONCLUSIONS: At a quaternary care institution, MIGS surgeons were more likely to provide optimal surgical treatment of endometriosis with excision rather than fulguration compared to non-MIGS surgeons. Their patients also needed fewer re-operations, and despite the increased complexity of the surgical procedures, did not have increased perioperative complications. These findings highlight the value of MIGS fellowship training and emphasize the need for increased patient access to MIGS subspecialists (Tables 1 and 2).