Thromboembolic complications of sling surgery for stress urinary incontinence among female Medicare beneficiaries

The impact of concomitant mid-urethral sling surgery on patients undergoing vaginal prolapse repair

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups.

RESULTS

A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32 days, p = 0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, p = 0.670), perioperative blood transfusion (1.1% versus 1.2%, p = 0.673), readmission (2.7% versus 2.6%, p = 0.884) and postoperative wound infection (0.5% versus 0.7%, p = 0.51). There was a higher rate of reoperation (2.2% versus 1.5%, p = 0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, p = 0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone.

CONCLUSIONS

Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.

Incidence and risk factors for venous thromboembolism events after different routes of pelvic organ prolapse repairs

BACKGROUND

Venous thromboembolism events, including deep venous thrombosis and pulmonary embolism are the most common cause of preventable deaths in hospitalized patients in the United States. Although the risk of venous thromboembolism events in benign gynecologic surgery is generally low, the potential for venous thromboembolism events in urogynecologic population is significant because most patients undergoing the pelvic organ prolapse surgery have increased surgical risk factors.

OBJECTIVE

This study aimed to investigate the incidence and risk factors for venous thromboembolism events within 30 days after different routes of the pelvic organ prolapse surgery in a large cohort population using the American College of Surgeons-National Surgical Quality Improvement Program.

STUDY DESIGN

This retrospective cohort study used Current Procedural Terminology codes to identify pelvic organ prolapse repairs with and without concurrent hysterectomy performed during 2011-2017 in the American College of Surgeons-National Surgical Quality Improvement Program database. Demographics, preoperative length of hospital stay, operative time, preoperative comorbidities, smoking status, American Society of Anesthesiologists classification system scores, along with other variables were collected. Postoperative 30-day complications, including readmission, reoperation, and mortality, were collected. The incidence rates of venous thromboembolism, as defined by American College of Surgeons-National Surgical Quality Improvement Program, were compared among different surgical routes. Descriptive statistics were used, and logistic regression was performed to identify associations.

RESULTS

Among 91,480 pelvic organ prolapse surgeries identified, 63,108 were analyzed: 43,279 (68.6%) were performed vaginally, 16,518 (26.2%) laparoscopically, and 3311 (5.2%) abdominally. A total of 34,698 (55.0%) underwent a concurrent hysterectomy. Of 63,108 subjects, 133 developed venous thromboembolism within 30 days after surgery (0.21%; 95% confidence interval, 0.18-0.25; P<.0001). More than half (60%) of venous thromboembolism events occurred within 10 days after surgery. For all surgical routes, older age (P<.041), higher body mass index (P=.002), race or ethnicity (P=.04), longer operating time (P<.0001), inpatient status (P<.0001), American Society of Anesthesiologists 3 or 4 (P<.0001), having preoperative renal failure (P=.001), and chronic steroid use (P=.02) were significantly associated with venous thromboembolism. In addition, in the vaginal pelvic organ prolapse repair group, concurrent hysterectomy (P=.03) and preoperative dyspnea (P=.01) were associated with development of venous thromboembolism. In the abdominal pelvic organ prolapse repair, concurrent hysterectomy (P=.005) and hypertension requiring medication (P=.04) were also independently associated with venous thromboembolism development (Table 1). The incidence of venous thromboembolism was highest in abdominal repairs (0.72%), followed by laparoscopic repairs (0.25%) and vaginal repairs (0.16%). After adjusting for confounders, abdominal compared with vaginal approach (adjusted odds ratio, 3.27; 95% confidence interval, 1.93-5.41; P<.0001), longer operative time (adjusted odds ratio, 1.005; 95% confidence interval, 1.003-1.006; P<.0001), older age (adjusted odds ratio, 1.020; 95% confidence interval, 1.00-1.037; P=.015), greater body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P=.0006), American Society of Anesthesiologists 3 or 4 (adjusted odds ratio, 1.55; 95% confidence interval, 1.03-2.31; P=.03), and preoperative renal failure (adjusted odds ratio, 8.87; 95% confidence interval, 1.16-44.15; P=.04) remained significantly associated with developing venous thromboembolism. Neither laparoscopic repair (compared with vaginal repair) nor concurrent procedures (hysterectomy, antiincontinence procedure, vaginal mesh insertion) were found to be significantly associated with the development of venous thromboembolism. The abdominal pelvic organ prolapse repairs were associated with an increased hazard of venous thromboembolism (hazard ratio, 3.27; 95% confidence interval, 1.96-5.45; P<.0001). Venous thromboembolism development was associated with 30-day mortality, readmission, and reoperation (all P<.0001).

CONCLUSION

The overall incidence of venous thromboembolism after pelvic organ prolapse repairs based on a recent, large cohort database was very low, confirming the finding in previous smaller cohort studies. The highest venous thromboembolism risk was associated with abdominal route, and more than 60% of venous thromboembolism events occurred within 10 days after surgery. Thus, focus should be placed on risk-reducing strategies in the immediate postoperative period, with greater emphasis on patients undergoing abdominal surgery.

Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients

OBJECTIVE

We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population.

STUDY DESIGN

We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge.

RESULTS

Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8).

CONCLUSION

Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.