Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy

Assessment of socioeconomic and racial differences in patients undergoing concurrent gynecologic oncology and urogynecology surgeries: a National Inpatient Sample (NIS) database study

OBJECTIVE

To assess social determinants of health impacting patients undergoing gynecologic oncology versus combined gynecologic oncology and urogynecology surgeries.

METHODS

We identified patients who underwent gynecologic oncology surgeries from 2016 to 2019 in the National Inpatient Sample using the International Classification of Diseases-10 codes. Demographics, including race and insurance status, were compared for patients who underwent gynecologic oncology procedures only (Oncologic) and those who underwent concurrent incontinence or pelvic organ prolapse procedures (Urogynecologic-Oncologic). A logistic regression model assessed variables of interest after adjustment for other relevant variables.

RESULTS

From 2016 to 2019 the National Inpatient Sample database contained 389 (1.14%) Urogynecologic-Oncologic cases and 33 796 (98.9%) Oncologic cases. Urogynecologic-Oncologic patients were less likely to be white (62.1% vs 68.8%, p=0.02) and were older (median 67 vs 62 years, p<0.001) than Oncologic patients. The Urogynecologic-Oncologic cohort was less likely to have private insurance as their primary insurance (31.9% vs 38.9%, p=0.01) and was more likely to have Medicare (52.2% vs 42.8%, p=0.01). After multivariable analysis, black (adjusted odds ratio (aOR) 1.41, 95% CI 1.05 to 1.89, p=0.02) and Hispanic patients (aOR 1.53, 95% CI 1.11 to 2.10, p=0.02) remained more likely to undergo Urogynecologic-Oncologic surgeries but the primary expected payer no longer differed significantly between the two groups (p=0.95). Age at admission, patient residence, and teaching location remained significantly different between the groups.

CONCLUSIONS

In this analysis of a large inpatient database we identified notable racial and geographical differences between the cohorts of patients who underwent Urogynecologic-Oncologic and Oncologic procedures.

Short-Term Outcomes After Hysterectomy for Endometrial Cancer/EIN With Concomitant Pelvic Floor Disorder Surgery

IMPORTANCE

Endometrial cancer and precancer are common gynecologic problems for many women. A majority of these patients require surgery as the mainstay of treatment. Many of these patients often have concurrent pelvic floor disorders. Despite the prevalence and shared risk, fewer than 3% of women undergo concomitant surgery for PFDs at the time of surgery for endometrial cancer or endometrial intraepithelial neoplasia/hyperplasia.

OBJECTIVE

This study aimed to evaluate postoperative morbidity of concomitant pelvic organ prolapse (POP) and/or urinary incontinence (UI) procedures at the time of hysterectomy for endometrial cancer (EC) or endometrial intraepithelial neoplasia/endometrial hyperplasia (EIN/EH).

METHODS

This retrospective analysis of women undergoing hysterectomy for EC or EIN/EH between 2017 and 2022 used the American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome was any major complication within 30 days of surgery. Comparisons were made between 2 cohorts: hysterectomy with concomitant pelvic organ prolapse/urinary incontinence procedures (POPUI) versus hysterectomy without concomitant POP or UI procedures (HYSTAlone). A subgroup analysis was performed in patients with EC. A propensity score matching cohort was also created.

RESULTS

A total of 23,144 patients underwent hysterectomy for EC or EIN/EH: 1.9% (n = 432) had POP and/or UI procedures. Patients with POPUI were older, were predominantly White, had higher parity, and had lower body mass index with lower American Society of Anesthesiologists class. Patients with POPUI were less likely to have EC (65.7% vs 78.3%, P < 0.0001) and more likely to have their hysterectomy performed by a general obstetrician- gynecologists or urogynecologists. Major complications were low and not significantly different between POPUI and HYSTAlone (3.7% vs 3.6%, P = 0.094). A subgroup analysis of EC alone found that the HYSTAlone subset did not have more advanced cancers, yet the surgeon was more likely a gynecologic oncologist (87.1% vs 68.0%, P < 0.0001). There were no statistically significant differences between the 2 cohorts for the primary and secondary outcomes using propensity score matching analysis.

CONCLUSIONS

Concomitant prolapse and/or incontinence procedures were uncommon and did not increase the rate of 30-day major complications for women undergoing hysterectomy for EC/EH.

Assessment of Adverse Events in a Matched Cohort of Women Undergoing Concurrent Midurethral Sling at the Time of Minimally Invasive Benign Gynecologic Surgery

IMPORTANCE

Procedures for stress urinary incontinence and benign gynecologic surgery are often performed concurrently, and associated complication rates have previously been unexplored.

OBJECTIVE

The aim of this study was to compare postoperative complication rates between women undergoing midurethral sling (MUS) placement at the time of benign gynecologic surgery and those undergoing MUS alone.

STUDY DESIGN

This was a retrospective matched cohort study of women undergoing MUS with or without concurrent minimally invasive benign gynecologic surgery from January 2010 through December 2020. Eligible women undergoing concurrent surgery were matched to a cohort of women undergoing MUS placement alone. The electronic medical record was queried for demographic and perioperative/postoperative data up to 12 months after surgery.

RESULTS

Thirty-eight women met inclusion criteria for the concurrent group, and 152 women were matched accordingly. The overall adverse event rate was 39.5% (95% confidence interval [CI], 0.25-0.55) for the concurrent group and 24.3% (95% CI, 0.18-0.32) for the MUS-only group ( P = 0.05). Adverse events with Clavien-Dindo grade ≤ 2 were higher in the concurrent group (Clavien-Dindo Grade 1: 5% vs 0%, P = 0.04; Clavien-Dindo Grade 2: 16% vs 6%, P = 0.04), as was composite postoperative resource utilization (76% vs 49%, P = 0.003). Mesh exposure ( P = 0.03) and sling lysis/excision rates ( P = 0.02) were higher in the concurrent group. On logistic regression, concurrent surgery cases remained significantly associated with sling mesh erosion (adjusted odds ratio, 12.6; 95% CI, 1.4-116.4).

CONCLUSIONS

Midurethral sling placement at the time of minimally invasive benign gynecologic surgery is safe but is associated with a higher incidence of postoperative hospital resource utilization and sling mesh extrusion, and a need for revision.

Surgeon Attitudes Toward Concurrent Urogynecologic and Gynecologic Oncology Procedures: A Cross-sectional Survey

IMPORTANCE

There is increasing overlap in the urogynecologic and gynecologic oncologic patient populations. To improve patient advocacy and access to care, a collaborative surgical approach may benefit this cohort.

OBJECTIVE

The aim of the study was to evaluate surgeon attitudes toward performing concurrent urogynecologic and gynecologic oncology procedures. We hypothesized that most surgeons are amenable to collaboration.

STUDY DESIGN

We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Oncology and the American Urogynecologic Society from August to November 2020. A 23-item online survey was created to assess surgeon demographics, practice and screening patterns, and attitudes toward surgical collaboration. We also evaluated obstacles to performing joint procedures and assessed whether attitudes could be influenced by new information.

RESULTS

A total of 338 surveys were included in the analysis, including 158 urogynecologists and 226 gynecologic oncologists (GOs). Most surgeons (77.8%) will recommend concurrent procedures with another specialty, and 97.8% of urogynecologists and 95.7% of oncologists currently perform joint surgical procedures. Male surgeons, regardless of specialty, were more likely to recommend staged procedures (44% vs 31%, P < 0.001), as were GOs (28% vs 10.1%, P < 0.001). However, oncologists were more likely than urogynecologists to initiate referrals for surgical collaboration (33.3% vs 14.4%, P < 0.001).

CONCLUSIONS

A total of 22.2% of urogynecologists and oncologists prefer staging surgical procedures. The most common barrier to a combined procedure was logistics. Urogynecologists were more concerned about the effects of cancer treatments on healing, the use of mesh implants, and financial reimbursements as compared with GOs. Treatment delay was a significantly greater concern for the oncologists.