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Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery

      Background

      Although several different apical suspension procedures are available to women with pelvic organ prolapse, data on long-term efficacy and safety profiles are limited.

      Objective

      The primary aim of this study was to analyze longitudinal reoperation risk for recurrent prolapse among the 4 apical suspension procedures over 2 to 15 years. Secondary aims included evaluation of all-cause reoperation, defined as a repeated surgery for the indications of recurrent prolapse and adverse events, and total retreatment rate, which included a repeated treatment with another surgery or a pessary.

      Study Design

      This was a multicenter, retrospective cohort study within Kaiser Permanente Southern California that included women who underwent sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation, or colpocleisis from January 2006 through December 2018. Women who underwent concomitant rectal prolapse repair or vaginal prolapse repair with mesh augmentation were excluded. Data were abstracted using procedural and diagnostic codes through July 2021, with manual review of 10% of each variable. Patient demographics and pessary use were compared using analysis of variance or chi square tests for continuous and categorical variables, respectively. Time-to-event analysis was used to contrast reoperation rates. A Cox regression model was used to perform an adjusted multivariate analysis of the following predictors of reoperation for recurrence: index surgery, concomitant procedures, patient demographics, baseline comorbidities, and year of index surgery. Censoring events included exit from the health maintenance organization and death.

      Results

      The cohort included 9681 women with maximum follow-up of 14.8 years. The overall incidence of reoperation for recurrent prolapse was 7.4 reoperations per 1000 patient-years, which differed significantly by type of apical suspension (P<.0001). The incidence of reoperation was lower after colpocleisis (1.4 events per 1000 patient-years) and sacrocolpopexy (4.8 events per 1000 patient-years) when compared with uterosacral ligament suspension (9 events per 1000 patient-years) and sacrospinous ligament fixation (13.9 events per 1000 patient-years). All pairwise comparisons between procedures were significant (P=.0003–.0018) after correction for multiplicity, except for uterosacral ligament suspension or uterosacral ligament hysteropexy vs sacrospinous ligament fixation or sacrospinous ligament hysteropexy (P=.05). The index procedure was the only significant predictor of reoperation for recurrence (P=.0003–.0024) on multivariate regression analysis.
      Reoperations for complications or sequelae (overall 2.9 events per 1000 patient-years) also differed by index procedure (P<.0001) and were highest after sacrocolpopexy (4.4 events per 1000 patient-years). The incidence of all-cause reoperation for recurrence and adverse events after sacrocolpopexy, however, was comparable to that of the other reconstructive procedures (P=.1–.4) in pairwise comparisons with Bonferroni correction. Similarly, frequency of pessary use differed by index procedure (P<.0001) and was highest after sacrospinous ligament fixation at 9.3% (43/464).

      Conclusion

      Among nearly 10,000 patients undergoing prolapse surgery within a large managed care organization, colpocleisis and sacrocolpopexy offered the most durable obliterative and reconstructive prolapse repairs, respectively. All-cause reoperation rates were lowest after colpocleisis by a large margin, but similar among reconstructive apical suspension procedures.

      Key words

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      References

        • Maher C.
        • Feiner B.
        • Baessler K.
        • Haya N.
        • Brown J.
        Surgery for women with apical vaginal prolapse.
        Cochrane Database Syst Rev. 2016; 10: CD012376
        • Siddiqui N.Y.
        • Grimes C.L.
        • Casiano E.R.
        • et al.
        Mesh sacrocolpopexy compared With native tissue vaginal repair: a systematic review and meta-analysis.
        Obstet Gynecol. 2015; 125: 44-55
        • Weber A.M.
        • Abrams P.
        • Brubaker L.
        • et al.
        The standardization of terminology for researchers in female pelvic floor disorders.
        Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12: 178-186
        • Barber M.D.
        • Brubaker L.
        • Nygaard I.
        • et al.
        Defining success after prolapse surgery for pelvic organ prolapse.
        Obstet Gynecol. 2009; 114: 600-609
        • Jelovsek J.E.
        • Barber M.D.
        • Brubaker L.
        • et al.
        Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the OPTIMAL randomized clinical trial.
        JAMA. 2018; 319: 1554-1565
        • Nygaard I.
        • Brubaker L.
        • Zyczynski H.M.
        • et al.
        Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse.
        JAMA. 2013; 309: 2016-2024
        • Nager C.W.
        • Visco A.G.
        • Richter H.E.
        • et al.
        Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial.
        Am J Obstet Gynecol. 2021; 225: 153.e1-153.e31
        • Grzybowska M.E.
        • Futyma K.
        • Kusiak A.
        • Wydra D.G.
        Colpocleisis as an obliterative surgery for pelvic organ prolapse: is it still a viable option in the twenty-first century? Narrative review.
        Int Urogynecol J. 2021; : 1-16
        • FitzGerald M.P.
        • Richter H.E.
        • Siddique S.
        • Thompson P.
        • Zyczynski H.
        Ann Weber for the Pelvic Floor Disorders Network. Colpocleisis: a review.
        Int Urogynecol J Pelvic Floor Dysfunct. 2006; 17: 261-271
        • Geller E.J.
        • Siddiqui N.Y.
        • Wu J.M.
        • Visco A.G.
        Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy.
        Obstet Gynecol. 2008; 112: 1201-1206
        • Siddiqui N.Y.
        • Geller E.J.
        • Visco A.G.
        Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy.
        Am J Obstet Gynecol. 2012; 206: 435.e1-435.e5
        • Dunivan G.C.
        • Sussman A.L.
        • Jelovsek J.E.
        • et al.
        Gaining the patient perspective on pelvic floor disorders’ surgical adverse events.
        Am J Obstet Gynecol. 2019; 220: 185.e1-185.e10
        • Fitzgerald J.
        • Siddique M.
        • Miranne J.M.
        • Saunders P.
        • Gutman R.
        Development of a patient-centered pelvic floor complication scale.
        Female Pelvic Med Reconstr Surg. 2020; 26: 244-248
        • Heinze G.
        • Schemper M.
        A solution to the problem of monotone likelihood in Cox regression.
        Biometrics. 2001; 57: 114-119
        • Kenton K.
        • Mueller E.R.
        • Tarney C.
        • Bresee C.
        • Anger J.T.
        One-year outcomes after minimally invasive sacrocolpopexy.
        Female Pelvic Med Reconstr Surg. 2016; 22: 382-384
        • Elliott D.S.
        • Krambeck A.E.
        • Chow G.K.
        Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse.
        J Urol. 2006; 176: 655-659
        • Diwadkar G.B.
        • Barber M.D.
        • Feiner B.
        • Maher C.
        • Jelovsek J.E.
        Complication and reoperation rates after apical vaginal prolapse surgical repair: a systematic review.
        Obstet Gynecol. 2009; 113: 367-373
        • Milani R.
        • Frigerio M.
        • Cola A.
        • Beretta C.
        • Spelzini F.
        • Manodoro S.
        Outcomes of transvaginal high uterosacral ligaments suspension: over 500-patient single-center study.
        Female Pelvic Med Reconstr Surg. 2018; 24: 203-206
        • Maher C.F.
        • Qatawneh A.M.
        • Dwyer P.L.
        • Carey M.P.
        • Cornish A.
        • Schluter P.J.
        Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study.
        Am J Obstet Gynecol. 2004; 190: 20-26
        • Benson J.T.
        • Lucente V.
        • McClellan E.
        Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation.
        Am J Obstet Gynecol. 1996; 175: 1418-1422
        • Marcickiewicz J.
        • Kjöllesdal M.
        • Engh M.E.
        • et al.
        Vaginal sacrospinous colpopexy and laparoscopic sacral colpopexy for vaginal vault prolapse.
        Acta Obstet Gynecol Scand. 2007; 86: 733-738
        • Zebede S.
        • Smith A.L.
        • Plowright L.N.
        • Hegde A.
        • Aguilar V.C.
        • Davila G.W.
        Obliterative LeFort colpocleisis in a large group of elderly women.
        Obstet Gynecol. 2013; 121: 279-284
        • Moore R.D.
        • Miklos J.R.
        Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia.
        J Am Assoc Gynecol Laparosc. 2003; 10: 276-280
        • Kato K.
        • Hayashi Y.
        • Adachi M.
        • et al.
        Razor-type dermatomes enable quick and thin vaginal dissection with less bleeding in colpocleisis.
        Int Urogynecol J. 2020; 31: 1959-1964
        • Dessie S.G.
        • Shapiro A.
        • Haviland M.J.
        • Hacker M.R.
        • Elkadry E.A.
        Obliterative versus reconstructive prolapse repair for women older than 70: is there an optimal approach?.
        Female Pelvic Med Reconstr Surg. 2017; 23: 23-26
        • Mueller M.G.
        • Jacobs K.M.
        • Mueller E.R.
        • Abernethy M.G.
        • Kenton K.S.
        Outcomes in 450 women after minimally invasive abdominal sacrocolpopexy for pelvic organ prolapse.
        Female Pelvic Med Reconstr Surg. 2016; 22: 267-271
        • Yadav G.S.
        • Gaddam N.
        • Rahn D.D.
        A comparison of perioperative outcomes, readmission, and reoperation for sacrospinous ligament fixation, uterosacral ligament suspension, and minimally invasive sacrocolpopexy.
        Female Pelvic Med Reconstr Surg. 2021; 27: 133-139
        • Bradley C.S.
        • Kenton K.S.
        • Richter H.E.
        • et al.
        Obesity and outcomes after sacrocolpopexy.
        Am J Obstet Gynecol. 2008; 199: 690.e1-690.e8
        • Kenton K.
        • Pham T.
        • Mueller E.
        • Brubaker L.
        Patient preparedness: an important predictor of surgical outcome.
        Am J Obstet Gynecol. 2007; 197: 654.e1-654.e6