Gynecologic oncologists in surgery for placenta accreta spectrum: a survey for practice, experience, and interest

WHAT IS ALREADY KNOWN ON THIS TOPICHOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Gynecologic oncologists are encouraged to be proactively involved in the management of patients with placenta accreta spectrum, not only for intraoperative surgical consultation, but also in protocol and guideline development.

Introduction

Surgical treatment of placenta accreta spectrum disorder—a broad term used to describe abnormal attachment of the placenta to the myometrium of the gravid uterus including placenta accreta, increta, and percreta—is associated with significant maternal morbidity and mortality.1 2 Cesarean hysterectomy, which is commonly performed in placenta accreta spectrum, can result in surgical blood loss of 3000–5000 mL3 4 and a mortality rate of approximately 1–7% in the perioperative period.5 Additionally, the incidence rate of placenta accreta spectrum is increasing, likely due to an increasing rate of Cesarean deliveries.6 Thus, there is an urgent need to explore any treatment approaches that may reduce morbidity and mortality associated with surgical treatment of placenta accreta spectrum.

A recent study across five US institutions showed that inclusion of gynecologic oncologists as part of a multidisciplinary approach reduced surgical blood loss.7 Another study showed that outcomes improved with the early presence of a gynecologic oncologist and that a ‘call as needed’ approach was not acceptable because of the complexity of placenta accreta spectrum cases.8 Other studies have outlined criteria for hospitals to be centers-of-excellence for placenta accreta spectrum, including a multidisciplinary team approach with gynecologic oncologists,9 and surgical techniques to improve outcomes.10 A few studies have evaluated single-center experiences with multidisciplinary teams.11 12 It is not clear, however, how often these recommendations are implemented at hospitals across the USA.

To date, no study has surveyed gynecologic oncologists about their experience and interests in placenta accreta spectrum surgery. The objective of our study was to examine the practice, experience, and interests in placenta accreta spectrum surgery of current gynecologic oncologists.

MethodsSurvey Concept

The survey items are displayed in online supplemental table S1. The questions for this survey study were created by the authors and developed based on a recent consensus related to surgical treatment for placenta accreta spectrum. To assess the gynecologic oncologist’s role in the surgical management of placenta accreta spectrum, three elements were explored in the survey: the surgeon’s practice, the surgeon’s experience, and their interest in placenta accreta spectrum cases. The University of Southern California Institutional Review Board exempted this survey study. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines were consulted to outline the study content.

Study Population

The target population of this closed, cross-sectional, confidential survey study was gynecologic oncologists who practice medicine in the USA. In the USA, following a 4-year specialty training in obstetrics and gynecology, an additional 3–4-year subspecialty training in gynecologic oncology is required to be board-eligible in this subspecialty.

The Society of Gynecologic Oncology (SGO) members list was filtered using the following criteria: (1) members categorized as gynecologic oncologists in the USA, (2) members listed as full/associate status, and (3) members practicing in the USA. The survey was administered only to gynecologic oncologists as they are most likely to be the key surgeons for placenta accreta spectrum surgery. Gynecologic oncologists listed as full or associate members were included as they are most likely to be involved in the decision-making process. The survey was limited to surgeons practicing in the USA to make the study population homogenous. A total of 1084 members met the inclusion criteria for survey eligibility.

Survey Strategy

The completely anonymous questionnaire was formatted as a web-based survey through SurveyMonkey Inc,13 a commonly utilized survey platform. On July 8, 2021, an email with a direct weblink for the survey was distributed to SGO members who met the study criteria above. The member was voluntarily allowed to have a one-time entry without incentives, and the program used cookies to prevent the second/duplicated entries. Reminder emails were sent twice. The survey period was closed after 4 weeks.

Statistical Consideration

The first step of our analysis was to perform descriptive statistics for the surgeon’s practice, experience, and interest related to placenta accreta spectrum surgical management. The number and frequency per cohort were reported in each questionnaire item. The second step of analysis was to examine the survey results stratified by the gynecologic oncologist’s parameters (number of years after the completion of fellowship training, and hospital region), practice, experience, and interest. The last step was to assess the survey results stratified by the placenta accreta spectrum treatment parameters (multidisciplinary approach, center-of-excellence criteria, and surgeon’s surgical volume), practice, experience, and interest.

A χ2 test or Fisher’s exact test was used to assess differences and a p value <0.05 was interpreted as being statistically significant (two-tailed hypothesis). Replies with missing information were not utilized for statistical analysis. Statistical Package for the Social Sciences (SPSS) version 27.0 (International Business Machines Corp (IBM), Armonk, NY) was used for analysis.

ResultsCohort Characteristics

A total of 184 of 1084 members replied to the survey, corresponding to the total response rate of 17.0%. The baseline demographics are shown in Table 1. Over half (53.2%) of the responding gynecologic oncologists completed their fellowship training >10 years ago. The majority are practicing in urban-teaching hospitals (84.8%) that have delivery volumes of ≥3000/year (54.3%) and have a multidisciplinary approach for placenta accreta spectrum (82.5%). Awareness of the center-of-excellence criteria for placenta accreta spectrum management was modest, as only 42.1% of gynecologic oncologists recognize this criteria.

Table 1

Study demographics.

The majority felt that the number of placenta accreta spectrum surgeries has been increasing over the past 5 years (78.7%). In terms of placenta accreta spectrum hysterectomy volume, 16.8% of respondents performed two cases per year on average, one-third (38.7%) performed 3–5 hysterectomies per year, and another one-third (35.5%) performed ≥6 cases per year (Figure 1). Approximately half performed hysterectomy for placenta accreta spectrum in the main operating room (59.4%), rather than a labor and delivery operating room, and were involved from the beginning of surgery (49.7%).

Figure 1Figure 1Figure 1

Surgeon’s hysterectomy volume for placenta accreta spectrum per year on average. Percentages represent among answered for the survey item 9 (online supplemental table S1).

Total hysterectomy is the preferred mode of placenta accreta spectrum hysterectomy (71.0%), and the responding gynecologic oncologists do not place ureteral stents or an intra-arterial balloon routinely (Table 1). Three-quarters (71.6%) of those surveyed have experienced surgical blood loss >5 L and one-third (36.6%) experienced cases with blood loss >10 L. Less than half practice non-hysterectomy conservative management (45.5%) or delayed hysterectomy (43.2%) for placenta accreta spectrum management. About half (50.3%) of respondents are interested in placenta accreta spectrum surgery as part of their future practice.

Stratification per Surgeon/Hospital Factors

When surveyed items were stratified by number of years from completion of subspecialty training (Table 2), those who are >10 years after fellowship were more likely to offer conservative management (57.8% vs 28.9–33.3%) or delayed hysterectomy (56.0% vs 26.3–30.3%) compared with those ≤10 years post-fellowship (both p<0.05).

Table 2

Placenta accreta spectrum hysterectomy per post-training period

When analyzed by region of practice (Supplemental Table S2), responding gynecologic oncologists in the Southern region are more likely to offer conservative management (65.4% vs 26.7–45.7%) or delayed hysterectomy (59.6% vs 30.0–40.5%) compared with those in other regions (both p<0.05). Moreover, gynecologic oncologists in the Southern region are more likely to be located in hospitals that do not have a multidisciplinary approach (71.2% vs 85.0–92.5%, p=0.049) compared with those in other regions.

When stratified by the hospital’s multidisciplinary approach for placenta accreta spectrum (Table 3), gynecologic oncologists practicing in hospitals with a multidisciplinary approach are more likely to be in an urban teaching setting (89.4% vs 65.1%), perform hysterectomy for placenta accreta spectrum (98.6% vs 65.4%), have high surgeon’s surgical volume for placenta accreta spectrum hysterectomy (≥6 cases a year, 38.4% vs 12.5%), be involved from the beginning of surgery (52.2% vs 31.3%), and be interested in placenta accreta spectrum surgery for future practice (55.0% vs 28.0%) compared with those who practice in hospitals that do not a have multidisciplinary approach for placenta accreta spectrum (all p≤0.05). Similar associations were observed for gynecologic oncologists who practice in hospitals meeting the center-of-excellence criteria for placenta accreta spectrum management (Table S4).

Table 3

Placenta accreta spectrum hysterectomy per multidisciplinary approach

When stratified by gynecologic oncologist’s placenta accreta spectrum hysterectomy volume (Table 4), higher surgical volume gynecologic oncologists are more likely to practice in urban teaching hospital settings, hospitals that meet the center-of-excellence criteria, settings with larger delivery volumes, and have experience of surgical blood loss >10 L (all p<0.05).

Table 4

Placenta accreta spectrum hysterectomy per annual surgeon’s surgical volume

Lastly, gynecologic oncologists who are interested in placenta accreta spectrum surgery for future practice are more likely to work in hospitals that have a multidisciplinary approach for placenta accreta spectrum (90.6% vs 70.4%) or meet the center-of-excellence criteria for placenta accreta spectrum management (42.4% vs 14.1%) and perform placenta accreta spectrum hysterectomy (98.8% vs 81.7%) compared with those who are not interested (all p<0.05; online supplemental table S3).

DiscussionSummary of Main Results

The results of this survey found that gynecologic oncologists involved in surgical care of patients with placenta accreta spectrum are at urban teaching hospitals with large bed capacity and use a multidisciplinary approach for placenta accreta spectrum meeting the center-of-excellence criteria. While many gynecologic oncologists perform few cases of placenta accreta spectrum hysterectomy per year, they are actively involved in the case from the beginning.

Results in the Context of Published Literature

Our study suggests that gynecologic oncologists are actively involved in the surgical management of placenta accreta spectrum in the USA. Previous research found that a gynecologic oncologist was involved in approximately 60% of cases of placenta accreta spectrum in the University of California Fetal Consortium.7 Another study found that gynecologic oncologists were the primary surgeons in 88% of placenta accreta spectrum cases that were diagnosed antenatally compared with 33% of unanticipated cases.14

We found that survey respondents in urban teaching hospitals and settings that meet center-of-excellence criteria for placenta accreta spectrum management were more likely to be involved in placenta accreta spectrum cases.9 This is clinically significant because previous research has demonstrated the importance of gynecologic oncology involvement in these cases.7 These settings may be more likely to have specialized care, including access to expert pelvic surgeons including gynecologic oncologist and urologists, interventional radiology, and trauma surgeons. Gynecologic oncologists practicing in these settings may have more cases of placenta accreta spectrum per year and therefore have more experience in best practices for surgical management. Furthermore, urban teaching hospitals are likely to be higher resource settings in which multidisciplinary care can be undertaken and the center-of-excellence criteria for placenta accreta spectrum management are more easily implemented.

For those survey respondents who did participate in hysterectomies for placenta accreta spectrum, about half (49.7%) were present at the beginning of the case, while only 5% were just available on call as needed. This is encouraging because active involvement of a gynecologist oncologist at the beginning of the case has been linked to improved surgical outcomes and lower intraoperative blood loss.8 12 It is unknown whether the complexity of the case, the resource constraints of the workplace setting, or local practices influence when the gynecologic oncologist becomes involved.

Finally, an interesting finding of this survey is that half of respondents are interested in performing placenta accreta spectrum surgeries in the future. This is clinically meaningful because gynecologic oncologists traditionally deal with malignant pathology rather than placenta accreta spectrum, and these surgeries have an obstetrics component that they do not routinely encounter. Previous research supports the evolution of gynecologic oncologists beyond their traditional role.15 However, no other research to our knowledge has explored interests of current gynecologic oncologists in placenta accreta spectrum surgery. It is therefore encouraging that half of respondents are interested in using their technical skills in placenta accreta spectrum surgery.

Strengths and Limitations

A strength of the current study is that this is likely the first SGO survey regarding surgical practice for placenta accreta spectrum.

There are several major limitations in this study. First, the response rate of the study is low. This low response rate limits the generalizability of this study and results in selection bias. It is important to note that those who were interested in responding to this survey may also be more likely to be interested in placenta accreta spectrum surgery in general, and therefore the data may be skewed. It is also unknown exactly what barriers exist for those who indicated they are not interested in participating in placenta accreta spectrum cases in the future. Second, the results of this survey are qualitative (yes vs no), but not quantitative, and the true incidence of surgical morbidity is unknown. Lastly, the survey items were created by the authors as there is no validated survey assessing the role of gynecologic oncologists in placenta accreta spectrum surgery.

Implications for Practice and Future Research

This society survey confirms previous studies showing that gynecologic oncologists in the USA are actively involved in the management of placenta accreta spectrum. Most are involved from the beginning of the case. These findings are encouraging for improved outcomes in placenta accreta spectrum surgeries. Future studies need to evaluate barriers to gynecologic oncology interest and involvement, including personal interest, level of institutional support for multidisciplinary care, and availability of resources. Likewise, re-evaluation and standardization of surgical training for gynecologic oncologists to include placenta accreta spectrum surgery may be necessary as suggested by the expert panel.16 Developing a surgical technique for placenta accreta spectrum is another unmet need.10 17 18

Conclusion

Despite these study limitations, the findings of current study suggest that gynecologic oncologists are actively involved and express an interest in placenta accreta spectrum surgery in the USA. A 2022 expert review stated that gynecologic oncologists are encouraged to be proactively involved in the management of patients with placenta accreta spectrum.19 Their recommendations address not only the area of intraoperative surgical consultation, but also clinical protocol and guideline development. Given the projected increase in the incidence of placenta accreta spectrum in the future,20 active involvement of gynecologic oncologists in placenta accreta spectrum at the society level would be of value.

Data availability statement

Data are available upon reasonable request. Completely deidentified data are available upon reasonable request and approval by the University of Southern California Institutional Review Board and obtained Data Use Agreement.

Ethics statementsPatient consent for publication

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