For isolated anterior or posterior vaginal wall surgery, increasing surgical experience appears to save hospital resources. However, individual surgeon volume seems to have no measurable effect on the cure rate of routine colporrhaphy operations among healthy, low-risk patients. A plausible explanation would be that the high recurrence rate is not due to insufficient surgical training or practice, but is inherent in the method. The dated Manchester–Fothergill technique uses the existing degraded, torn connective tissue, and has in principle not undergone any fundamental change over 100 years [26]. In the last decade, mesh, reinforcing native tissue, has improved the success rate, but not without drawbacks [18, 27]. Further research aiming to improve cure rates for anterior and posterior colporrhaphy should therefore focus on improvement of the surgical method.
We studied isolated anterior or posterior colporrhaphy in healthy patients, as they are the simplest to operate on, and therefore complicated cases in this group are rare. Making a comparison without complicated cases minimizes fluctuations in operation complexity, and makes it possible to compare across experience groups, and to evaluate whether surgical experience (or lack thereof) explains the high recurrence rate.
Postoperative complication rates in our study population were comparable across all experience groups. In our analysis, we included all types of surgeon-reported complications. As this opens up the possibility of overlooking a particular type of complication related to surgical experience, we stratified all reported complications. No specific complication was more prevalent in any of the groups, regardless of surgical experience. Also, there were so few instances of organ damage that a valid statistical analysis was not possible. These results are not surprising, as we investigated a relatively simple surgical procedure performed in otherwise generally healthy patients, where major complications were not expected to occur.
Our definition of experience could precipitate a subgroup of surgeons who play a more “observing” role than that of an active surgeon, performing only very few operations as the main surgeon, and assisting or observing most of the time. A group such as this, arguably, would be hard to define in relation to their actual experience of the operations. We have analyzed our material with regard to such a subgroup, and found no such cases, as most surgeons all operate primarily by themselves, or assist in an assistant/trainee situation.
Another possible bias is that experience could influence the threshold for reporting complications. Assuming that less experienced surgeons are more prone to reporting surgical complications than their more experienced colleagues, the uniformity of the reported complication rates confirms the conclusion that experience had no impact on our cohort. The most experienced surgeons, in general, treated patients who were less likely to have taken preoperative estrogen. Estrogen is supposed to have a beneficial effect on the tissue quality, and therefore enhances the chances of success of the operation. Even though the absolute difference between groups is only 8.5%, this could represent a slight bias toward no difference in this study.
Highly experienced surgeons also treated older patients. As the mean age difference is only around 2.5 years, this seems highly unlikely to have influenced the results of the study.
We found resource parameters to be dependent on the surgeons’ experience. The mean operation time was reduced by 31.4% (about 13 min) in favor of the more experienced surgeons, which, in proportional terms, seems considerable.
The hospital stay was significantly shorter for patients who were operated on by surgeons with more experience. This may reflect that patients recovered faster and were able to return home sooner, but it may also simply have been a consequence of different practices in the different experience groups. Less experienced surgeons are, presumably, more cautious, and the difference in duration of hospital stay may have been a product of surgeons’ caution, rather than of the patients’ health.
Differences in perioperative bleeding, although statistically detectable because of the large amount of data, can arguably be dismissed as clinically irrelevant, as the absolute divergence was around 3.5 ml.
The only symptom specific to prolapse is the awareness of a vaginal bulge or protrusion [28]. This is regarded as being a valid way of measuring the existence of prolapse [22,23,24], and is used in our material as the conclusive parameter to ascertain if the operation has been successful.
Patient-reported cure rates have the inherent problem of not having been objectively verified by a physician. De novo prolapse in a new compartment, therefore, would be reported as a failed operation, even though it may be unrelated to the surgical procedure. This would overestimate the total amount of failure, but it would not influence the differences between experience groups. “Objective verification” by a surgeon would also risk being biased, particularly as in most cases, it would be the operating surgeon carrying out an evaluation of his/her own work.
Our study procedure did not include any randomization, and possible confounding factors must be considered. In this study, we analyzed the difference between surgeon groups of similar experience, thus reducing the variation due to individuals. Our patient groups were comparable concerning health status, body mass index (BMI), parity, and smoking, which are established risk factors associated with POP [28,29,30].
Degree of prolapse, which affects the complexity of the operation, is possibly a major confounding factor in our study. The most experienced surgeon group (surprisingly) operated on less advanced prolapses. We measured the position of the anterior or posterior vaginal wall in relation to the hymen, in centimeters for each group. Although statistically significant, the largest absolute difference between groups was around 8 mm. Consequently, it seems highly unlikely that such a minimal discrepancy would affect the complexity of the operation or have clinical consequences.
Patients reported less postoperative pain with increasing surgeon experience. We used “patient-reported days of using painkillers” as a quantitative measurement. This method has the disadvantage of not necessarily being correlated with actual pain, as the use of painkillers may be the result of the instructions regarding pain management that the patient has received from the clinic.
It seems logical to assume that an inexperienced surgeon’s results will be improved if she or he is supervised by a highly experienced colleague. Our results contradict this assumption, but are consistent with the finding that the results of surgeons operating alone did not improve with surgical experience.