Variation in Surgical Technique (VaST): How and why do surgical techniques to perform native tissue pelvic organ prolapse repairs vary between UK based surgeons and does this affect the outcome of surgery?

Abstract

Overall AbstractIntroductionSurgical techniques used to perform native tissue pelvic organ prolapse (POP) repair vary between surgeons in the UK and other countries. There is a lack of evidence exploring whether this variation in practice influences the outcomes of surgery.ObjectiveTo evaluate how and why a cohort of UK surgeons use particular surgical techniques when performing native tissue POP surgery and whether this influences the outcome of surgery.MethodA mixed methods study. A questionnaire survey was conducted to detail current surgical techniques for native tissue and graft/mesh POP repairs performed by a cohort of UK surgeons recruiting to a large multicentre prolapse trial (PROSPECT).This informed qualitative research (video observations of surgery, audio taped interviews with surgeons and fieldwork) to categorise how surgeons operate and why surgeons use certain surgical techniques when performing native tissue POP surgery. The influence of different aspects of the surgical technique on patient outcomes following native tissue anterior repair in women recruited to the PROSPECT trial were then investigated using the themes from the qualitative part of the study.ResultsSurgical techniques used to perform POP surgery vary between surgeons who recruited to the PROSPECT and VaST studies. The techniques used varied between surgeons in each step of the procedure and themes were derived from these steps rather than the procedure in its entirety. Categorisation of themes was challenging due to the subjective elements of surgery and the lack of standard terminology to describe techniques. Four themes were identified to explain why variation in surgical practice exists; The surgical journey; Rationalising practice; Contextual factors; And, Concepts of success. Although surgeons expressed a willingness to incorporate evidence based medicine into practice there was a reported lack of evidence on which to base practice. Certain aspects of technique (depth of dissection, method of repair, fascia suture material and skin suture method) were observed to influence the subjective and anatomical outcomes of surgery.ConclusionNative tissue anterior repair surgery has been categorised and the reasons for practice variation identified. Aspects of surgical technique were found to influence the outcomes of POP surgery. Standardisation of surgical terminology is required. These results should raise awareness of the influence of surgical technique on outcomes and should inform future RCT in this area to identify if a change in practice is required.

Date of Award	1 Aug 2017
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Fiona Reid (Supervisor), Jenny Myers (Supervisor) & Anne Segar (Supervisor)