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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Article info
Publication history
Published online: May 30, 2022
Accepted:
May 24,
2022
Received in revised form:
May 19,
2022
Received:
January 4,
2022
Footnotes
The authors report no conflict of interest.
Funding was provided by the Kaiser Permanente Southern California Regional Research Committee (RRC). The RRC provided a programmer for data collection and a statistician for analysis. Study design, data interpretation, and reporting of findings were performed independently of the RRC.
The study was presented at the 48th annual scientific meeting of the Society of Gynecologic Surgeons, San Antonio, TX, March 27–30, 2022.
Cite this article as: Shah NM, Berger AA, Zhuang Z, et al. Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery. Am J Obstet Gynecol 2022;227:306.e1-16.
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