Results From the VOICE (Vaginal Surgeon Opinions on Intraoperative Complications and Events) Survey

INTRODUCTION: Standardized systems for classifying and reporting intraoperative complications exist for surgical fields including general surgery, urology, and cardiothoracic surgery. Gynecologic surgery lacks such a system, which would allow for increased accuracy and reliability in outcomes research. OBJECTIVE: Our primary objective was to examine the opinions and practice patterns of gynecologic surgeons regarding the classification and reporting of intraoperative events in vaginal surgery. METHODS: A nationwide, cross-sectional survey of gynecologic surgeons was conducted using the Qualtrics platform, distributed via the Society of Gynecologic Surgeons (SGS) listserv from September 2024 through February 2025. All responses were anonymous. Current SGS members were eligible. The survey consisted of 7 demographic items and 2–32 items related to the classification of intraoperative events as a complication and how to report them (describe in the operative report narrative, directly to patient/proxy, as a complication in the operative report, or none of the above), utilizing adaptive questioning. Comments were solicited. Descriptive statistics were used to characterize responses. RESULTS: The participation rate was 38% (112/291), with a 79% completion rate (89/112) among respondents. Most respondents were urogynecologists (71%), with more than 10 years of experience (67%), practicing in an academic setting (73%), and operating at least once a week (95%). The majority regularly performed vaginal surgery (76%), midurethral slings (MUS) (74%), sacrospinous/uterosacral suspensions (72%), and urethral bulking (58%), while the minority regularly performed vaginal uterine morcellation (32%) and urethral diverticulectomy (25%). Respondents’ experience with each intraoperative event ranged from 31% to 92% (Table 1). Surgeons agreed that some intraoperative events should be classified as a complication, such as bowel injury requiring repair (100%). Some events, such as the use of topical hemostatic agents (2%), were considered a complication by a small minority. The classification of other events was more varied; for example, 59% and 30% of respondents, respectively, deemed bladder perforation during MUS placement and unintentional vaginal laceration requiring repair complications (Figure 1). Opinions regarding appropriate reporting varied. While repair of bladder injury (99%) and urethral perforation during MUS placement (93%) were characterized as complications by most surgeons, fewer (88% and 79%, respectively) agreed that these events should be documented as complications in operative reports. Even fewer surgeons thought bladder perforation during MUS placement (65%) or unplanned temporary stent placement to evaluate ureteral patency (53%) should be reported to the patient; only 49% and 20% of surgeons, respectively, thought these events should be documented in the operative reports as complications (Figure 1). Qualitatively, respondents reported that events that are unexpected or uncommon and cause harm or change patient management should be defined as complications, while common or routine events that do not negatively impact the patient should not (Table 2). Respondents also reported a desire for further discussion regarding what constitutes a complication within the field of gynecologic surgery, as well as which steps should be taken to report them. CONCLUSIONS: Opinions regarding the classification and reporting of intraoperative events during vaginal surgery vary among surgeons.Figure 1Table 1Table 2