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Rise of TVT shifts focus from laparoscopic to vaginal surgery. (Less Emphasis on Laparoscopy Training).

SAN FRANCISCO--Three little initials account for much of the decline in enthusiasm for laparoscopic gynecologic surgery in recent years: TVT, Dr. Mark D. Walters said.

The ease and economy of the Gynecare TVT Tension-Free Support for Incontinence device in treating urinary incontinence led some surgeons who painstakingly acquired the skills for laparoscopic surgery to do more TVT procedures instead. Compared with laparoscopic Burch procedures, for example, "TVTs are easier; they're faster; they seem to work as well, if you believe the data; and you make more money from them," he said at the annual meeting of the American Urogynecologic Society.

Fewer urogynecologists and pelvic surgery residents are being trained in laparoscopy, as the TVT sling and other vaginal procedures compete with laparoscopy for dwindling training time in the operating room. The best laparoscopic surgeons tend to practice privately and many of them don't teach, said Dr. Walters, a paid consultant and speaker for American Medical Systems, which manufactures the SPARC sling.

Operative laparoscopy is difficult and time consuming to learn and perform; requires costly equipment; and may cause more complications, compared with vaginal surgery, he said.

Because of these and other factors, initial enthusiasm for gynecologic laparoscopy has leveled off even while laparoscopy has been embraced as an alternative to open surgery by other specialties, including general surgery and orthopedics, said Dr. Walters, head of urogynecology and pelvic reconstructive surgery at the Cleveland Clinic.

In a recent e-mail poll of directors of fellowships in urogynecology and pelvic reconstructive surgery, 14 of 17 respondents said that their fellows had access to some laparoscopic cases, and 12 provided didactic courses or dry-lab training in laparoscopy.

The number of laparoscopic cases seen by fellows tended to be small: nine programs (53%) handled four or more laparoscopic Burch procedures per year; five programs (29%) performed four or more laparoscopic vaginal suspensions per year; and three programs (18%) did four or more laparoscopic hysterectomies. The other programs handled fewer of each type of surgery, he said.

Some of the comments from the program directors were telling, such as "We're doing more vaginal cases and TVTs," and "TVT has realigned our approach to stress urinary incontinence," he said.

Dr. Walters compared data on 72 patients who underwent a TVT procedure or a laparoscopic Burch procedure at two institutions in an ongoing study. He found that the TVT operation went much faster, 46 minutes vs. 104 minutes.

Each TVT procedure generated 13 relative value units (RVUs) for reimbursement calculations, compared with 12.5 for a Burch procedure. Physicians billed $4,190 for a TVT procedure and $3,797 for a Burch.

In a hypothetical-surgery day at the Cleveland Clinic, assuming a 7:30 a.m. to 5 p.m. workday with 40-minute operating room turnovers, a surgeon who spent the day doing nothing but TVT procedures for incontinence could handle six cases, generate 78 RVUs, and bill for $25,140. A surgeon doing nothing but laparoscopic Burch procedures could handle four cases, generate 50 RVUs, and bill for $15,188, Dr. Walters calculated.

Laparoscopic pelvic surgery does have some advantages: better imaging of the anatomy; smaller incisions, less pain, quicker healing, and better cosmetic results for patients, when compared with laparotomy; plus a marketing advantage for practitioners because patients seek out laparoscopists when facing surgery.

Incontinence cure rates probably are equivalent with laparoscopic Burch procedures, open Burch procedures, or TVT procedures, though more data from randomized controlled trials are needed to be sure, he said.

The barriers to laparoscopic pelvic surgery may outweigh these, however, and data are lacking that would force a shift to operative laparoscopy when compared with vaginal surgery.
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Author:Boschert, Sherry
Publication:OB GYN News
Date:Feb 15, 2003
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