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Longitudinal reoperation risk after apical suspension procedures in female pelvic reconstructive surgery

      Objectives

      To analyze longitudinal reoperation risk for recurrent pelvic organ prolapse (POP) among the 4 apical suspension procedures over a period of 2 through 15 years.

      Materials and Methods

      This multicenter, retrospective cohort study included adult women who underwent sacrocolpopexy (SCP), uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF), or colpocleisis (CC) from January 1, 2006 through December 31, 2018, with follow up through July 25, 2021. Women who underwent vaginal prolapse repair with mesh augmentation or concomitant rectopexy were excluded. Data were abstracted using procedural and diagnosis codes with manual review of 10% of each variable. The primary outcome was reoperation for POP in any compartment. Rates were compared using a X2 test with Bonferroni correction. Time to event distributions was contrasted with a log rank test. Multivariate analysis using a Cox proportional hazards model with Firth correction evaluated the following predictors: index surgery, patient characteristics (age, race/ethnicity, body mass index [BMI], smoking status), concomitant procedures (hysterectomy, compartment repairs, incontinence procedures), and year of index surgery. Censoring events included exit from the health maintenance organization and death.

      Results

      This cohort included 9,117 women with mean age of 60.6 (SD ±11.6) years and BMI of 28 kg/m2 (±4.9) at the time of index surgery. Most women were Hispanic (48.3%) or White (40.2%). The overall reoperation rate was 5.1%. Rates by procedure are shown in Table 1. Significant differences were found in the following pairwise comparisons: SCP (3.6%) versus USLS (6.1%; P <0.0006), SCP (3.6%) versus SSLF (9%; P <0.0006), SCP (3.6%) versus CC (0.8%; P <0.0006), USLS (6.1%) versus CC (0.8%; P <0.0006), and SSLF (9%) versus CC (0.8%; P <0.0006). Reoperation rate did not significantly differ between USLS (6.1%) and SSLF (9%; P =0.074) after correction for multiplicity. Similarly, pairwise comparisons of time to event distributions were significant (P =0.0003-0.0018), except for USLS versus SSLF (P =0.05). Index procedure was found to be a significant predictor of reoperation when compared to SCP (Table 1, P =0.0003-0.0024). No other covariates were shown to consistently predict reoperation upon either crude or adjusted analysis.

      Conclusion

      While overall reoperation rate after apical suspension is low, index surgery is a significant predictor of reoperation. CC offers the most durable prolapse repair, followed by SCP. USLS and SSLF appear to be comparable to one another in durability.
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