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 ...