The laparoscopic myomectomy: a survey of Canadian gynaecologists.

Abstract

To survey all gynaecologists in Canada to determine the number who perform or offer the laparoscopic myomectomy (LM) procedure, the barriers that deter gynaecologists from performing or offering LM, and to understand the perceptions and attitudes of Canadian gynaecologists with respect to LM.
A survey was developed, pre-tested, and distributed to all 1279 obstetrician-gynaecologists on the SOGC mailing list in April 2007.
A total of 529 obstetrician-gynaecologists participated in the survey a response rate of 41.4%. Of the 485 respondents who practised gynaecology, 119 (24.5%) performed LM, but only 15 (3.1%) stated that more than 50% of their myomectomies were performed laparoscopically. Two hundred twelve gynaecologists (44.3%) admitted to having referred a patient to another gynaecologist for LM. Laparoscopic surgeons felt the principal barrier to performing LM was lack of training in the procedure (70.7%). Gynaecologists felt the principal barrier to referring to another gynaecologist for LM was their uncertainty about who offered the procedure (33%). The majority of gynaecologists believed that LM has faster recovery time. The majority of respondents, however, were unsure which procedure is superior with respect to blood loss, adhesion formation, fertility rate post-procedure, uterine rupture rate in subsequent pregnancy, and cost-effectiveness.
Despite existing evidence that indicates that LM is comparable to abdominal myomectomy with respect to complication rates and fertility, only one quarter of Canadian gynaecologists who responded to this survey performed the procedure. Barriers to performing LM included lack of training and barriers to referral included uncertainty about who offered the procedure.

Full text

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GYNAECOLOGY
The Laparoscopic Myomectomy:
A Survey of Canadian Gynaecologists
Grace Liu, MD, MSc, FRCSC, FACOG,1Lynne Zolis, MD,1Rose Kung, MD, MSc, FRCSC, FACOG,1
Mary Melchior, MD, FRCSC,2Sukhbir Singh, MD, FRCSC,2E. Francis Cook, ScD3
1Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON
2St. Joseph’s Health Sciences Centre, Toronto ON
3Division of General Medicine, Brigham and Women’s Hospital, Harvard University, Boston MA
Abstract
Objective: To survey all gynaecologists in Canada to determine the
number who perform or offer the laparoscopic myomectomy (LM)
procedure, the barriers that deter gynaecologists from performing
or offering LM, and to understand the perceptions and attitudes of
Canadian gynaecologists with respect to LM.
Methods: A survey was developed, pre-tested, and distributed to
all 1279 obstetrician-gynaecologists on the SOGC mailing list in
April 2007.
Results: A total of 529 obstetrician-gynaecologists participated in the
survey a response rate of 41.4%. Of the 485 respondents who
practised gynaecology, 119 (24.5%) performed LM, but only
15 (3.1%) stated that more than 50% of their myomectomies were
performed laparoscopically. Two hundred twelve gynaecologists
(44.3%) admitted to having referred a patient to another
gynaecologist for LM. Laparoscopic surgeons felt the principal
barrier to performing LM was lack of training in the procedure
(70.7%). Gynaecologists felt the principal barrier to referring to
another gynaecologist for LM was their uncertainty about who
offered the procedure (33%). The majority of gynaecologists
believed that LM has faster recovery time. The majority of
respondents, however, were unsure which procedure is superior
with respect to blood loss, adhesion formation, fertility rate
post-procedure, uterine rupture rate in subsequent pregnancy, and
cost-effectiveness.
Conclusion: Despite existing evidence that indicates that LM is
comparable to abdominal myomectomy with respect to
complication rates and fertility, only one quarter of Canadian
gynaecologists who responded to this survey performed the
procedure. Barriers to performing LM included lack of training and
barriers to referral included uncertainty about who offered the
procedure.
Résumé
Objectif : Sonder tous les gynécologues du Canada afin de
déterminer le nombre de ceux d’entre eux qui mènent ou offrent
des myomectomies laparoscopiques (ML), d’identifier les
obstacles qui dissuadent les gynécologues de mener ou d’offrir
des ML et de comprendre les points de vue et les attitudes des
gynécologues canadiens en ce qui concerne la ML.
Méthodes : Un sondage a été conçu, prétesté et distribué aux
1 279 obstétriciens-gynécologues de la liste d’envoi de la SOGC,
en avril 2007.
Résultats : Au total, 529 obstétriciens-gynécologues ont participé au
sondage, soit un taux de réponse de 41,4 %. Chez les
485 répondants qui pratiquaient la gynécologie, 119 (24,5 %)
menaient des ML; toutefois, seulement 15 d’entre eux (3,1 %) ont
affirmé que plus de 50 % de leurs myomectomies étaient menées
par voie laparoscopique. Deux cent douze gynécologues (44,3 %)
ont admis avoir orienté une patiente vers un autre gynécologue
aux fins de l’exécution d’une ML. Les chirurgiens laparoscopiques
étaient d’avis que le principal obstacle à l’exécution d’une ML était
le manque de formation quant à cette intervention (70,7 %). Les
gynécologues étaient d’avis que le principal obstacle à
l’orientation des patientes vers un autre gynécologue aux fins de
l’exécution d’une ML était l’incertitude quant à l’identité de ceux
qui offraient cette intervention (33 %). La majorité des
gynécologues estimaient que la ML comptait un temps de
récupération accéléré. Cependant, la majorité des répondants
demeuraient incertains quant à la détermination de l’intervention
qui s’avérait supérieure en matière de perte sanguine, de
formation d’adhérences, de taux de fertilité post-intervention, de
taux de rupture utérine dans le cadre d’une grossesse
subséquente et de rentabilité.
Conclusion : Malgré les données disponibles qui indiquent que la
ML est comparable à la MA en ce qui concerne les taux de
complication et de fertilité, seul le quart des gynécologues
canadiens qui ont répondu à ce sondage effectuaient cette
intervention. Parmi les obstacles à l’exécution d’une ML, on
trouvait le manque de formation, tandis que parmi les obstacles à
l’orientation, on trouvait l’incertitude quant à l’identité des
professionnels qui offraient cette intervention.
J Obstet Gynaecol Can 2010;32(2):139–148
INTRODUCTION
U
ing from smooth muscle cells of the uterus. They are
the most common gynaecologicalneoplasm. They are clini-
cally apparent in approximately 25% of reproductive aged
women and noted on pathological examination in approxi-
mately 80% of surgically excised uteri.1,2Most leiomyomata
terine leiomyomata (fibroids) are benign tumours aris-
FEBRUARY JOGC FÉVRIER 2010 ?
139
GYNAECOLOGY
Key Words: Fibroids, laparoscopic, myomectomy, surgery, survey
Competing Interests: None declared.
Received on May 27, 2009Accepted on July 20, 2009

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areasymptomaticandrequirenotreatment.However,these
tumours have the potential to cause menorraghia,
dysmenorrhea, pelvic pressure, and infertility.
Treatment for symptomatic fibroids must be individual-
ized; surgical management is an option for some patients.
According to the 2000 American College of Obstetricians
and Gynecologists practice bulletin, indications for surgical
management include (1) abnormal uterine bleeding not
responsive to conservative therapy, (2) iron deficiency
anemia related to abnormal uterine bleeding, (3) pain or
pressure that interferes with quality of life, (4) urinary tract
frequency or obstruction, (5) infertility with distortion of
the endometrial cavity or tubal occlusion, (6) high level of
suspicionofmalignancy,and(7)growthaftermenopause.3
Surgical options for removal of fibroids include hysterec-
tomy and myomectomy. Myomectomy is an option for
women who wish to preserve their uterus.4Myomectomies
may be performed by laparotomy, laparoscopy, or
hysteroscopy. Hysteroscopic myomectomy is considered
first-lineconservativetreatment
submucosalfibroids. Symptomatic
subserosal fibroids require removal by laparotomy or lapa-
roscopy. The traditional surgery for uterine preservation
has been the abdominal myomectomy. The laparoscopic
myomectomy is a minimal access approach that was first
reported in 1979 by Semm and colleagues.5Since that time,
it has been increasing in popularity. It affords women wish-
ing to retain their uterus and childbearing potential an
opportunity to undergo a minimal access procedure. There
is good evidence that LM is a safe and effective surgical
option. Three prospective randomized trials comparing
abdominal and laparoscopic myomectomy have been
reported.6–8Each of these studies has shown that LM pro-
vides the advantages of shorter hospitalization stays and a
fasterrecovery.Inaddition,LMresultsinlesspostoperative
pain, analgesic use, fever, and anemia than AM when per-
formed by skilled surgeons. Pregnancyrates and recurrence
ratesappeartobecomparablebetweenthetwogroups.The
only randomized controlled trial to date assessing preg-
nancy outcome after AM and LM was performed by
Seracchioli et al.,7and in this trial, the difference in
cumulative pregnancy rates after each procedure did not
reach statistical significance.
forsymptomatic
intramuraland
In Canada, surgical trainees appear to be anticipating an
increaseinthedemandforthisprocedure.Whengraduating
Canadian residents in obstetrics and gynaecology were sur-
veyed, none felt that they would “always” be expected to
perform LM upon graduation, but 93% felt thattheywould
“sometimes” be expected to perform LM.9Only 6%, how-
ever,feltthattheywerecompetenttoperformthesurgery.
Currently, there are no published data on the number of
providers of the procedure in Canada. Because this is a
potentially useful surgical option in certain patients, all
Canadian gynaecologists were surveyed to determine how
many actually offer LM, under what circumstances they do
so, and how they perceive the procedure.
METHODS
With input from staff at both Sunnybrook and Women’s
College Health Sciences Centre and St. Joseph’s Health
Centre, a four-part questionnaire was developed. The first
partofthequestionnaireaddressed demographiccharacter-
istics. The second part addressed current practice patterns
of the respondents with respect to surgical management of
uterine myomas. The third part addressed the respondents’
perceptionsregardingthedifferencesbetweenLMandAM,
and the fourth part asked the physicians if they would allow
their patients to be part of a future trial regarding LM. Ten
staff gynaecologists from three different academic institu-
tionspre-testedandcriticallyreviewedthequestionnairefor
content, relevance, and ease of use. Revisions were made
accordingly. The questionnaire was then translated into
French, and an online version (SurveyMonkey.com) and a
paper version (Teleform) created.
The survey was distributed in April 2007 to all obstetrician-
gynaecologists who were members of the SOGC; this
included a total of 1279 obstetrician-gynaecologists.A total
of 962 members had an email address registered with the
SOGC and therefore received an email that included the
study objectives and a link to the survey website. If they did
not have an email address registered, they received the sur-
vey by mail, including a cover letter describing the study
objectives. In total, 317 members were sent the survey by
regular mail. These responders had the option to return the
survey by mail or by fax to a research assistant involved in
the study. All 1279 obstetrician-gynaecologists were sent
two reminders (via email or regular mail), two and four
weeks after the initial mailing. In an attempt to maximize
the response rate, surveys were made available at the
Annual General Meeting of the SOGC in Ottawa in June
2007 to SOGC members who had not participated. Finally,
to encourage involvement, an incentive was offered. Those
who completed the questionnaire were eligible to enter a
draw to win their annual SOGC membership fee.
GYNAECOLOGY
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ABBREVIATIONS
AM abdominal myomectomy
GnRHgonadotropin-releasing hormone
LM laparoscopic myomectomy

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No personal or unique identifiers were used during the col-
lection or analysis process. The online survey results were
collected and collated using SurveyMonkey, an online sur-
vey development and management tool. Results were
enteredintoa Microsoft Access database.Thepapersurvey
used forms created by Cardiff Teleform (Teleform, Vista,
CA) software elite version 8, facilitating data collection and
collation by scanning directly into a Microsoft Access data-
base. The two databases were then combined and the data
were checked for any missing information. Results from
both versions were analyzed using SPSS (SPSS Inc., Chi-
cago, IL) statistical software version 17.0. Frequencies of
responses were compared between appropriate pairs of
variables.
Ethics approval for the survey was obtained from the
Research Ethics Board of both Sunnybrook and Women’s
College Health Sciences Centre and St. Joseph’s Health
Centre.
RESULTS
Of the 1279 obstetrician-gynaecologists who were sent a
survey, a total of 529 responded, a response rate of 41.4%.
Two respondents did not give their consent to participate,
and 17 respondents either failed to answer the primary
questions or left large areas of their survey incomplete;
thesesurveys werenotincluded intheanalysis.Twenty-five
respondents practised obstetrics only, leaving a total of 485
respondentswhopractisedgynaecology.Oftheresponding
gynaecologists, 462 (95.2%) performed surgery, 444
(91.5%) performed laparoscopic surgery, and 119 (24.5%)
performed laparoscopic myomectomy (Figure). Baseline
demographic characteristics of all responding gynaecolo-
gists and those who performed laparoscopic myomectomy
are shown in Table 1.
Within the group of 462 surgeons who performed surgery,
385 performed myomectomy in general. As previously
stated,119surgeons
myomectomy. Therefore, 30.9% of surgeons who per-
formed myomectomy would do so using the laparoscope.
The majority, however, stated that less than 10% of their
myomectomies were completed using the laparoscopic
approach (68 surgeons, 57.6%). Only 15 surgeons (12.7%)
stated that more than 50% of their myomectomies were
performed laparoscopically.
performedlaparoscopic
ThemajordeterrentstoperformingLM,forthosewhoper-
formed this procedure, were the presence of more than
three fibroids (53.4% of respondents), fibroids > 5 cm in
diameter (53.9% of respondents), and intramural fibroids
The Laparoscopic Myomectomy: A Survey of Canadian Gynaecologists
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Survey Responses

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(81.3%ofrespondents).Thepresenceofaposteriorfibroid
would dissuade 29.2% of surgeons from attempting the
minimalaccessapproach.
laparotomy (12.3% of respondents) or laparoscopy (1.8%
of respondents), was not seen as a significant deterrent
(Table 2).
Previoussurgery, either
Gynaecologists were also asked what factors they believed
to be barriers to performing LM. Laparoscopic surgeons
felt that lack of training in the procedure was the biggest
barrier (70.7%). This was followed by operative time con-
straints (53.2%) and lack of appropriateequipment (52.3%)
(Table 3). Other barriers specified included poor financial
compensation, few indications or lack of evidence for the
procedure, lack of trained assistants and operating room
nurses, a higher associated complication rate, and long
operating wait times.
Despitethesebarriers, 246 (51.4%) stated thattheyhad had
patients inquire about LM and 212 (44.3%) had referred
patients to another gynaecologist for LM. The principal
barriertoreferralwasthatgynaecologistswerenotsurewho
was currently performing the procedure (33%). Of sur-
veyed gynaecologists, 30.2% did not refer because they
thought there was insufficient evidence to support the lap-
aroscopic approach, and 21.2% believed that the complica-
tion rate is higher. Approximately 18% of respondents did
not refer patients because they prefer to operate on their
own patients. Thirteen percent identified geographical rea-
sons as a barrier to referral (Table 4). Other barriers cited
included long referral wait times and lack of interest in the
procedure on the part of the surgeon.
Understanding the views of respondents who performed
LM was another secondary objective of the survey. Their
perceptionsofthesurgicaloutcomeofLMversusAMwere
compared with those of respondents who did not perform
the procedure (Table 5). Surgeons who performed LM
believed the procedure resulted in faster recovery times,
and less adhesion formation than AM (94.0% and 56.0%).
Gynaecologists who did not perform LM also believed that
the LM had faster recovery times, but the majority did not
GYNAECOLOGY
142
? FEBRUARY JOGC FÉVRIER 2010
Table 1. Characteristics of respondents
Characteristics
Gynaecologists who
performed LM
(n = 119), n (%)
Gynaecologists who did
not perform LM
(n = 366), n (%)
Total gynaecologists
(N = 485), n (%)
Year of graduation from residency
Before 1960
1960–1969
1970–1979
1980–1989
1990–1999
2000 and later
Post-residency laparoscopic training
Yes
No
Province of current practice
BC
AB/SK/MB
ON
QC
NS/PEI/NB/NL
NU/NWT/YT
Other
Current practice setting
Academic
Community
Other
0 (0)
1 (0.8)
13 (10.9)
42 (35.3)
38 (31.9)
25 (21.0)
3 (0.8)
7 (1.9)
58 (15.8)
87 (23.8)
119 (32.5)
92 (25.1)
3 (0.6)
8 (1.6)
71 (14.6)
129 (26.6)
157 (32.4)
117 (24.1)
30 (25.2)
89 (74.8)
32 (8.8)*
331 (91.2)*
62 (12.9)*
420 (87.1)*
13 (10.9)
14 (11.8)
43 (36.1)
32 (26.9)
6 (5.0)
2 (1.7)
9 (7.6)
38 (10.4)
53 (14.5)
152 (41.5)
82 (22.4)
32 (8.7)
1 (0.3)
8 (2.1)
51 (10.5)
67 (13.8)
195 (40.2)
114 (23.5)
38 (7.8)
3 (0.6)
17 (3.5)
49 (41.2)
49 (41.2)
171 (46.8)†
168 (46.0)†
26 (7.1)†
220 (45.5)†
217 (44.8)†
47 (9.7)†
21 (17.6)
*3 respondents did not answer
†1 respondent did not answer

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feel that it resulted in less adhesion formation (84.2% and
44.3%, respectively). Both groups believed that the proce-
dures yielded no difference with respect to myoma recur-
rence rate, and the preponderance of both groups were
unsure which procedure led to a higher subsequent fertility
rate. The majority of LM surgeons either thought that LM
did not differ from AM with respect to risk of uterine rup-
ture during subsequent pregnancy (37.1%) or were unsure
whether there was a difference (33.6%). The results were
similar among those who did not perform the procedure
(36.9% and 40.0%, respectively).
Regarding to treatment options for fibroids offered by
Canadian gynaecologists, 85.7% of respondents offered
patients uterine artery embolization, 77.2% performed or
offered their patients hysteroscopic myomectomies, and
281 (58.5% of respondents) performed or offered their
patients mini-laparotomy myomectomies (Table 6). Most
respondents (57.1%) indicated their willingness to partici-
pate in a randomized controlled trial investigating patient
outcome and satisfaction following LM compared to AM.
DISCUSSION
With the current trend of women choosing to delay child-
bearing coupled with the increasing incidence and size of
fibroids associated with advancing age,10LM is likely to
become a more requested procedure. Women might
enquire about uterine-preserving surgery for symptomatic
leiomyomata as an alternative to hysterectomy, regardless
of their desire for fertility. Myomectomy has traditionally
been performed via laparotomy, and in 1875, W. H. Byford
stated that AM was “dangerous and difficult as not to be
thoughtofexceptindesperateconditions.”11Withprogress
towards minimal access surgery, advances in surgical tech-
nique have made LM possible. However, its feasibility and
indications are still debated. Most reports concerning LM
have originated from Europe and the United States, and
very little Canadianexperiencewith the procedure has been
published.
Of the 485 Canadian gynaecologists who responded to our
survey, only 119 (24.5%) perform LM, and 385 (79.3%)
perform AM. Only 15 respondents (12.7%) stated that they
performed the procedure routinely, i.e., performing more
than 50% of myomectomies laparoscopically. This appears
to be largely due to lack of training in the procedure, which
was reportedas thebiggestbarrier(70.7%) forlaparoscopic
surgeons. Interestingly, however, when respondents were
asked about post-residency training in minimal access sur-
gery, 46.4% who had had training still did not perform LM.
Conversely, the majority of surgeons who performed LM
(74.8%)statedthattheyhadnothadpost-residencytraining
in laparoscopic surgery. LM is a technically challenging
surgical procedure, requiring
laparoscopicallytoclosethemyometrialdefect.TheAmeri-
can College of Obstetricians and Gynecologists guidelines
published in May 2000 state “the two major concerns with
LM versus hysterectomy are the removal of large myomas
through small abdominal incisions and the repair of the
uterus . . . there is controversy as to whether the closure
techniques available are equal to those achieved at
laparotomy.”3Similarly, theSOGC ClinicalPracticeGuide-
line published in May 2003 mentions LM briefly, and indi-
cates that the “choice of surgical approach is largely
dependent on surgical expertise.”4
the ability to suture
No matterhow experiencedthesurgeon, however,LM car-
ries the risk of requiring conversion to an open abdominal
procedure. With any procedure, patient selection criteria
identifycasesinwhichsuccessfulcompletionofthesurgery
can be reasonably anticipated. Several authors have
attempted to establish these standards for LM.12–15Using
multiple logistic regression, Dubuisson et al.12developed a
predictionmodelbaseduponpreoperativeinformationcol-
lected prior to LM. Of 426 patients undergoing LM, 48
(11.3%) had to have their surgery converted to a
laparotomy.Fourfactorswerefoundtopredictconversion:
size of fibroid ? 5 cm, intramural fibroid, anterior location
of fibroid on the uterus, and preoperative use of GnRH
agonists. Marret et al.13also examined preoperative factors
predicting conversion from LM to an open procedure.
Thirty-three (28%) conversions were reported in 116 pro-
cedures that began laparoscopically. In their model, the
authorsalsofoundthatmyomasizeandintramurallocation
The Laparoscopic Myomectomy: A Survey of Canadian Gynaecologists
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143
Table 2. Deterrents to performing laparoscopic
myomectomy, n = 119*
Fibroid/patient characteristic
n (%)
Intramural fibroid†52 (81.3)
62 (53.9)
? 5 cm fibroid‡
? 3 fibroids§
62 (53.4)
Posterior fibroid?
Obese patient¶
Previous laparotomy¶
Previous laparoscopy¶
33 (29.2)
29 (25.4)
14 (12.3)
2 (1.8)
*number of gynaecologists who performed laparoscopic myomectomy
†55 missing (all online English responses to this question are missing
because of an error on the Survey Monkey site.This question was not
included in the survey sent to this group. Therefore, the responses are from
physicians who received the English and French paper survey and the
physicians who received the online French survey).
‡4 respondents did not answer
§3 respondents did not answer
?6 respondents did not answer
¶5 respondents did not answer