Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database

Systematic review and meta-analysis of the pelvic organ prolapse and vaginal prolapse among the global population

Background

Pelvic organ prolapse (POP) occurs when one or more pelvic organs (uterus, bowel, bladder or top of the vagina) descend from their normal position and bulge into the vagina. Symptoms include pelvic discomfort, fullness, and changes in bladder or bowel function. Treatment ranges from conservative approaches to surgery, depending on symptom severity. Surgical methods include vaginal wall repair, with or without hysterectomy, or via laparoscopic, robotic or open techniques. Common complications include bleeding, infection, and urinary or bowel dysfunction.

Methods

A systematic review was conducted, and a protocol was registered with PROSPERO (CRD42022346051). Publications from 30 April 1980 to 30 April 2023 were retrieved from multiple databases. Data were analysed using random-effects and common-effects models with subgroup and sensitivity analyses.

Findings

Forty-four studies met the inclusion criteria, with 29 studies used for meta-analysis of vaginal prolapse surgery outcomes. Sixteen studies focused on patients who had undergone hysterectomy alongside prolapse repair.

Interpretation

Patients who underwent vaginal prolapse surgery with hysterectomy experienced higher operative and postoperative complication rates than those without hysterectomy. Increased risks included hospital readmission, POP recurrence and re-operation. The review highlighted a lack of diversity in terms of ethnicity, age and comorbidity status, which are essential to fully understanding the impact of POP. Future research should focus on these underrepresented factors.

Associations Between Short-Term Postoperative Outcomes and Immunocompromised Status in Patients Undergoing Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Few data exist on the impact of immunosuppression on perioperative outcomes in women undergoing sacrocolpopexy. The objective of this study was to compare differences in 30-day perioperative morbidity in immunocompromised versus non-immunocompromised women undergoing sacrocolpopexy (SCP). We hypothesize that compared with the non-immunocompromised group, immunocompromised women undergoing SCP experience worse composite 30-day postoperative outcomes.

METHODS

Retrospective cohort of female patients aged 18 years or older who underwent sacrocolpopexy from 2012 to 2017. Current procedural terminology (CPT) codes 57280 and 57425 identified sacrocolpopexy in the American College of Surgeons-National Surgical Quality Improvement Project database. The primary exposure was a binary indicator of immunocompromised status, and the primary outcome was a composite indicator of readmission, reoperation, or a severe adverse event 30 days after surgery. Marginal standardization, a G-computation method, was used to estimate risk ratios (RR) and 95% confidence intervals (CI) representing the association between exposure and outcome.

RESULTS

A total of 13,505 women underwent SCP between 2012 and 2017. Of those, 2,625 (19.4%) had an indicator of immunocompromised status, with diabetes and smoking being most common. The risk of the composite adverse outcome in immunocompromised women was 7.3% versus 4.6% in non-immunocompromised women. After adjusting for age, race, ethnicity, and body mass index, immunocompromised women experienced 54% increased relative risk of an adverse outcome, compared with non-immunocompromised women (RR = 1.54; 95% CI: 1.31, 1.82).

CONCLUSIONS

Immunocompromised status, most commonly caused by diabetes and smoking, increases the risk of readmission, reoperation, and a severe adverse event within 30 days of sacrocolpopexy.

Perioperative Outcomes for Same- Versus Next-Day Discharge After Benign Vaginal Hysterectomy

IMPORTANCE

While same-day discharge (SDD) after laparoscopic hysterectomy is well supported, studies for vaginal hysterectomy (VH) are lacking.

OBJECTIVE

The aim of the study was to compare 30-day complications for SDD versus next-day discharge (NDD) after benign VH.

STUDY DESIGN

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Vaginal hysterectomy with or without urogynecology procedures was identified by Current Procedural Terminology codes. The primary outcome was 30-day composite complications of SDD versus NDD after VH. Secondary outcomes compared reoperations rates, time to and reasons for reoperation, and complications between the groups. Composite complications included death, major infection or wound complication, thromboembolism, transfusion, cardiopulmonary complication, renal insufficiency/failure, stroke, or reoperation. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analysis.

RESULTS

Of 24,277 people included, 4,073 (16.8%) were SDD, which were more likely to be younger ( P < 0.001), less likely to have hypertension (23.4 vs 18.3%, P < 0.0001) or diabetes (4.5 vs 3.3%, P = 0.001), and had shorter surgical procedures (100.7 ± 47.5 vs 111.2 ±57.5 minutes, P < 0.0001). There was no difference in composite complications after SDD versus NDD and this remained true in multivariate analysis (2.0 vs 2.3%, P = 0.30, SDD; adjusted odds ratio, 0.9; 95% confidence interval, 0.7-1.1). There was no difference in reoperation rates (0.9 vs 0.9%, P = 0.94) or reasons for reoperation. Time to first complication was shorter for SDD versus NDD (11 vs 13 days, P = 0.47).

CONCLUSION

In our cohort of low-risk patients, SDD after VH with or without urogynecology procedures did not have an increased odds of 30-day composite complications.

Mesh Exposure and Prolapse Recurrence Following Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: Over 24 Months of Follow-up Data

STUDY OBJECTIVE

To describe the results of mesh exposure and prolapse recurrence of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for sacrocolpopexy after more than 24 months of postoperative follow-up.

DESIGN

A retrospective cohort study.

SETTING

A university hospital.

PATIENTS

Women with uterine prolapse who underwent vNOTES sacrocolpopexy with an ultralightweight polypropylene mesh between May 2018 and March 2020.

INTERVENTIONS

vNOTES sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

Of 57 women, 55 women (96.5%) were included in the final analysis. The mean follow-up duration was 35.5 ± 7.6 (24-46) months. The total incidence of mesh exposure was 3 of 55 (5.5%). The total incidence of prolapse recurrence was 3 of 55 (5.5%). The changes in the Pelvic Organ Prolapse Quantification System scores, including Aa, Ba, C, Ap, Bp, and total vaginal length values, showed significant improvement after surgery (p <.05 for all).

CONCLUSION

The study demonstrates that vNOTES sacrocolpopexy appears to be an effective option with low risks of mesh exposure and prolapse recurrence. Studies including more patients and longer follow-up periods should be performed before a clear conclusion can be reached.

Mesh complications after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Our objective was to compare mesh exposure rates (4 months and 1 year) after total (TLH) vs supracervical (SLH) laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy (SCP). Secondary outcomes included 30-day complications and midurethral mesh exposure rates.

METHODS

This a retrospective cohort study at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes. Demographics, operative characteristics, and perioperative complications were abstracted from medical records.

RESULTS

Four hundred three women met the inclusion criteria: 91 SLH+SCP and 312 TLH+SCP. Median follow-up was 52 weeks with an overall mesh exposure rate of 1.5%. Follow-up was available for 90% of patients at 4 months and 51% at 1 year. Half of patients had lightweight mesh (n = 203), and half had ultralightweight mesh (n = 200). Vaginal mesh fixation was performed with permanent suture in 86% (n = 344) and delayed absorbable suture in 14% (n = 56) of patients. At 4 months, vaginal mesh exposure rates did not differ between groups (0% SLH vs 1% TLH, p = 1.00). All mesh exposures in the study period occurred with lightweight mesh in the TLH arm. No differences were noted in 1-year mesh exposure rates, 30-day perioperative complications (p = 0.57), or midurethral mesh exposure rates at 4 months (p = 0.35) and 1 year (p = 1.00) between groups.

CONCLUSIONS

Short-term mesh exposure following SCP with ultralightweight and lightweight polypropylene mesh is rare regardless of type of hysterectomy and much lower than reported in earlier studies with heavier weight mesh. These data suggest TLH at the time of SCP is a safe option in appropriately counseled patients.

Pelvic Organ Prolapse: Controversies in Surgical Treatment

This article discusses a few of the most prominent controversies currently confronting providers and patients when planning for surgical repair of pelvic organ prolapse including preoperative counseling and patient preparedness, preoperative urodynamics and concomitant anti-incontinence procedures, uterine preservation, total versus supracervical hysterectomy at the time of sacrocolpopexy, same-day discharge, and use of telemedicine for routine postoperative care. These current controversies reflect some of the larger questions and themes confronting the field at this time, and this discussion serves to highlight opportunities for further research and stimulate the constructive debate that moves the field forward.

Route of Hysterectomy at the Time of Sacrocolpopexy: A Multicenter Retrospective Cohort Study

OBJECTIVES

This study aimed to compare the incidence of mesh exposure based on route of hysterectomy at the time of minimally invasive sacrocolpopexy. Secondary outcomes included perioperative outcomes and prolapse recurrence.

METHODS

This was a multicenter, retrospective cohort study. Patients who underwent sacrocolpopexy between 2007 and 2017 were stratified by hysterectomy approach: total vaginal hysterectomy (TVH), total laparoscopic or robotic hysterectomy (TLH), and laparoscopic or robotic supracervical hysterectomy (LSH). Total vaginal hysterectomy was subdivided into vaginal and laparoscopic mesh attachment to the cuff. Statistical analyses were performed, with P < 0.05 denoting statistical significance.

RESULTS

Seven institutions participated, and 502 minimally invasive sacrocolpopexies with concomitant hysterectomy were performed by 23 surgeons: 263 TVH, 128 TLH, and 111 LSH. The median follow-up interval was 10 months, and this was significantly different between the groups (months): TVH, 11 (3-13); TLH, 2 (2-9); and LSH, 12 (5-24; P < 0.01). The overall incidence of vaginal mesh exposure was 4.0% (20/502). There were no significant differences in vaginal mesh exposure based on hysterectomy route: TVH, 5.7% (15/263); TLH, 1.6% (2/128); and LSH, 2.7% (3/111; P = 0.11). Within the TVH group, there was no significant difference in vaginal mesh exposure comparing vaginal and laparoscopic mesh attachment: 1.9% (1/52) versus 6.6% (14/211; P = 0.48). Laparoscopic supracervical hysterectomy demonstrated a significantly higher incidence of recurrence compared with TVH and TLH: 10.8% (12/111) versus 3.4% (9/263) and 2.3% (3/128; P < 0.01).

CONCLUSIONS

The incidence of sacrocolpopexy mesh exposure was not significantly different based on route of hysterectomy or mode of mesh attachment to the vagina. There was a significant increase in prolapse recurrence with supracervical hysterectomy.

New "Wrinkle Method" for Intracorporeal Anterior Vaginal Wall Plication during Sacrocolpopexy

In this study, we introduce a new wrinkle method for intracorporeal anterior vaginal wall plication during sacrocolpopexy for pelvic organ prolapse (POP) aiming to decrease POP recurrence and postoperative vaginal wall mesh erosion. The wrinkle method was performed using robotic sacrocolpopexy (RSC) on 57 symptomatic POP patients. Sixty-six patients underwent conventional RSC before the development of the wrinkle method. Feasibility and perioperative outcomes were compared. The wrinkle method is not time consuming. The total operative time was shorter in the wrinkle group than in the non-wrinkle group; however, this was attributed to lower adhesiolysis in the wrinkle group. No differences were recorded in the mean estimated blood loss and complication rates between the two groups. In conclusion, although we were unable to confirm that the wrinkle method decreased POP recurrence and vaginal wall mesh erosion after RSC because of the short follow-up period, our preliminary findings are positive in terms of safety. Further long-term well designed randomized controlled trials are required to elucidate the benefits of the wrinkle method.

Perioperative outcomes of laparoscopic sacrocolpopexy with and without hysterectomy: a secondary analysis of the National Surgical Quality Improvement Program Database

INTRODUCTION AND HYPOTHESIS

The objective was to compare 30-day perioperative complications in women undergoing minimally invasive sacrocolpopexy with and without a concomitant hysterectomy.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified women undergoing minimally invasive sacrocolpopexy between 2014 and 2018. Women were then stratified into two groups: sacrocolpopexy only and sacrocolpopexy + hysterectomy. The primary outcome was the occurrence of any 30-day postoperative complication. Group comparisons were performed using Student's t test, Mann-Whitney U test, and Chi-squared test. Multivariate logistic regression was used to identify independent factors associated with the occurrence of any complication.

RESULTS

A total of 8,553 women underwent laparoscopic sacrocolpopexy, 5,123 (59.9%) of whom had a concomitant hysterectomy. Median operative time was longer in women who had sacrocolpopexy + hysterectomy compared with sacrocolpopexy alone (185 [129-241] versus 172 [130-224] min, p < 0.001). The rate of any 30-day postoperative complication did not differ between groups (sacrocolpopexy + hysterectomy 5.5% versus sacrocolpopexy alone 5.8%, p = 0.34). Likewise, organ space, deep, and superficial surgical site infections did not differ between groups. There was also no difference in reoperation or readmission rates between groups. On multivariate logistic regression, sacrocolpopexy + hysterectomy were not associated with increased odds of 30-day postoperative complications relative to women who underwent sacrocolpopexy alone.

CONCLUSIONS

Complication rates during the first 30 days after minimally invasive sacrocolpopexy are low and concomitant hysterectomy is not associated with increased risks of 30-day complications after surgery.

Pelvic organ prolapse and uterine preservation: a cohort study (POP-UP study)

Background

Abdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH + LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH + LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures.

Methods

A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH + LSC or TLH + LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic.

Results

In total, 294 women were included in this analysis (LSH n = 43, LSCH + LSC n = 208 and TLH + LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p = 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006).

Conclusion

LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01208-5.

Unanticipated Uterine and Cervical Malignancy in Women Undergoing Hysterectomy for Uterovaginal Prolapse

OBJECTIVE

This study aimed to determine the prevalence of unanticipated uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse.

METHODS

Using data from the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program, we identified adult women who underwent a hysterectomy with a concurrent procedure for uterovaginal prolapse. Patients who underwent a radical hysterectomy or had other procedures or diagnoses suggestive of preoperatively suspected or known gynecologic cancer were excluded. Our outcome measures were pathology-confirmed diagnoses of uterine cancer and cervical cancer. Bivariate statistical tests and multivariable logistic regression were used to identify patient characteristics associated with the likelihood of having unanticipated uterine cancer.

RESULTS

Among 9,687 patients meeting the sample eligibility criteria (median age, 60 years), 51 (0.53%; 95% confidence interval, 0.39%-0.69%) had a diagnosis of uterine cancer. Forty-three (84.3%) were stage I-IB. Multivariable logistic regression showed that older age (adjusted odds ratio, 2.75; 95% confidence interval, 1.47-5.51, for age >60 vs 41-60 years) and uterine weight greater than 250 g (adjusted odds ratio, 4.34; 95% confidence interval, 1.48-10.79) were associated with a significantly higher likelihood of having unexpected uterine malignancy. In addition, in a subsample of 7,908 patients who underwent a total hysterectomy, 7 (0.09%; 95% confidence interval, 0.04%-0.18%) had a diagnosis of cervical cancer.

CONCLUSIONS

The risk of unexpected uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse was relatively low but should be appropriately considered when counseling patients desiring uterine- or cervix-sparing procedures.

Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA

STUDY OBJECTIVE

The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication.

DESIGN

Retrospective chart review.

SETTING

Tertiary care referral center in the United States.

PATIENTS

A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018.

INTERVENTIONS

All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication.

MEASUREMENTS AND MAIN RESULTS

Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001).

CONCLUSION

In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.