The Impact of Race and Ethnicity on Perioperative Complications of Endometriosis Surgery Performed by Minimally Invasive Gynecologic Surgery Subspecialists

INTRODUCTION: There is a large body of evidence demonstrating racial and ethnic disparities in benign gynecologic surgery. Currently, data regarding disparities in surgical care specifically for patients with endometriosis are limited. Prior analyses of a large national database revealed that Black patients undergoing endometriosis surgeries experienced more perioperative complications, had higher rates of undergoing laparotomy, and underwent oophorectomy more frequently and at younger ages. Notably, this database did not stratify results by surgeon volume or subspecialty training. OBJECTIVE: Our primary objective was to evaluate whether perioperative complication rates differed by race or ethnicity among patients undergoing surgery for endometriosis with a MIGS surgeon. Additionally, we sought to evaluate whether rates of definitive procedures for endometriosis varied by race or ethnicity. METHODS: This was a retrospective cohort study conducted at a quaternary care institution in the United States. We included all patients who underwent surgery for endometriosis with a fellowship-trained MIGS subspecialist from 11/1/2013 to 10/31/2023, and had surgical or pathological documentation of endometriosis. Cases were excluded if they involved a gynecologic malignancy, were performed urgently for a non-endometriosis indication, or if race or ethnicity data were not available. The primary outcome consisted of composite perioperative complications within 30 days of surgery. Secondary outcomes included rates of major or minor complications and rates of concomitant hysterectomy or oophorectomy. Intraoperative complications were graded as major or minor using the Classification of Intraoperative Complications scale, while postoperative complications were graded according to the Clavien-Dindo system. Outcomes were compared by race and ethnicity, and logistic regression was performed to adjust for potential confounders. RESULTS: Of 1,297 patients who underwent endometriosis surgery with a MIGS surgeon during the study period, 58.1% were non-Hispanic White (White), 6.5% non-Hispanic Black (Black), 17.7% Hispanic, 12.2% non-Hispanic Asian (Asian), and 5.5% American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, or Other/Multiracial (AI/AN/PI/O/M). More than 95% patients across all racial/ethnic groups were privately insured. Endometriosis severity differed significantly among study groups, with rates of stage III/IV endometriosis highest among Black patients (60.7%) and lowest among White patients (34.2%) (p<.001). There were no significant differences in composite perioperative complication rates between White (6.5%) and non-White patient groups (Black, 8.5%, adjusted odds ratio [aOR] 1.09, 95% confidence interval [CI] 0.47–2.50; Hispanic, 8.7%, aOR 1.18, 95% CI 0.68–2.06; Asian, 8.9%, aOR 0.73, 95% CI 0.59–2.13; AI/AN/PI/O/M, 5.6%, aOR 0.77, 95% CI 0.28–2.23). Similarly, there were no differences in complication rates when stratified by major or minor. Rates of concomitant oophorectomy or hysterectomy did not differ by racial/ethnic group (p=.870 and p=.535, respectively). CONCLUSIONS: Among patients undergoing endometriosis surgery with a MIGS subspecialist, there were no racial or ethnic differences in the rates of perioperative complications or definitive procedures performed. Access to fellowship-trained MIGS surgeons may mitigate disparities for patients seeking surgical management of endometriosis. The generalizability of our findings is limited by the study’s predominantly privately insured patient population (Tables 1 and 2).