Learning curve of hysteroscopic placement of tubal sterilization microinserts in 15 gynecologists in the Netherlands.

OBJECTIVE: To evaluate the learning curve of hysteroscopic placement of tubal sterilization microinserts by gynecologists in the Netherlands. DESIGN: Prospective multicenter study (Canadian Task Force II-2). SETTING: Ten community (teaching) hospitals in the Netherlands. PATIENT(S): A total of 631 women who underwent permanent sterilization by tubal microinserts. INTERVENTION(S): Hysteroscopic placement of tubal sterilization microinserts performed by 15 gynecologists experienced in performing operative hysteroscopy, starting from their very first placement. MAIN OUTCOME MEASURE(S): Effect of increasing experience in time on procedure time, pain score, successful bilateral placement, and complications. RESULT(S): Bilateral successful placement with confirmation of adequate positioning at follow-up evaluation was achieved in 480 (76.1%) patients at first attempt and in 44 (7.0%) at second attempt. Median procedure time was 8.0 minutes (range: 3-40), and 31 (4.9%) patients were lost to follow-up evaluation. Gravidity showed to be a confounding factor and was consequently adjusted for. A learning curve was seen in a statistically significant decrease of procedure time with increasing experience. The decrease in procedure time extended to 11 to 15 cases and was followed by a plateau phase of the subsequent 60 cases. In contrast, pain scores, successful placement, and complication rate appeared not to improve with increasing experience. CONCLUSION(S): A learning curve for hysteroscopic tubal sterilization was seen for procedure time, but successful placement, pain score, and complication rate were not clearly influenced by increasing experience.

Increasing experience in laparoscopic staging of early ovarian cancer.

We assessed the effect of increasing experience of a single surgeon (learning curve) in the laparoscopic staging procedure for women with early ovarian cancer and compared the results with the literature. We retrospectively analysed a total of 25 women with apparent early-stage ovarian cancer who underwent a laparoscopic staging procedure by the same surgeon. Three time periods, based on date of surgery, were compared with respect to operating time, amount of lymph nodes harvested and surgical outcome. There was no significant difference in operation time, estimated blood loss and hospital stay between the three periods. There was, however, a significant increase in the median number of pelvic and para-aortal lymph nodes harvested (group1 = 6.5, group 2 = 8.0 and group 3 = 21.0; P < 0.005). For the total period, median operation time was 235 min and median estimated blood loss was 100 ml. The median length of hospital stay was 4.0 days. Two intraoperative and two postoperative complications occurred. The upstaging rate was 32%. The mean interval between initial surgery and laparoscopic staging was 51.2 days. Mean duration of follow-up was 43 months, range (1-116 months). Five (20%) patients had recurrences, and two (8%) patients died of the disease. In conclusion, there is a significant learning curve for the laparoscopic full staging procedure in ovarian cancer. In our study this is mainly reflected in the amount of lymph nodes harvested and not in the total operating time.