Association Between Obesity and Perioperative Morbidity in Open Versus Laparoscopic Sacrocolpopexy:

Effect of body mass index on surgical outcomes in patients undergoing laparoscopic sacrohysteropexy and sacrocolpopexy

INTRODUCTION

Laparoscopic promontofixation is often considered the preferred approach for the treatment of significant apical pelvic organ prolapse (POP). Obesity is an established risk factor for pelvic organ prolapse (POP), and obese patients may constitute a substantial portion of those seeking care for uterovaginal prolapse. Our aim was to evaluate the impact of body mass index on perioperative complications and long-term outcomes of this procedure.

METHODS

This is a single center retrospective cohort study. All patients who underwent laparoscopic sacrohysteropexy/sacrocolpopexy, between July 2011 and December 2021 were evaluated. The study population was divided into three groups, according to Body mass index (BMI) at time of surgery.

RESULTS

Altogether 246 patients were included: 145 in group 1 (mean BMI 21.9 ± 2), 88 patients in group 2 (mean BMI 27.1 ± 1), and 13 patients in group 3 (mean BMI 33.0 ± 3). LSH was more frequent than LSC in all groups. The overall perioperative complications rate was 6.3 %. There were no differences in operative details and rates of perioperative complications between the groups. During follow-up period, 30 patients (12.2 %) presented with prolapse recurrence (objective and/or subjective). The rates of prolapse recurrence, as well as long-term complications, were similar between the groups. Similarly, the groups did not differ in postoperative functional results except for postoperative constipation (group 1--14.5 %, group 2--23.8 %, group 3--25 %, p = 0.001).

CONCLUSION

Laparoscopic sacrohysteropexy/sacrocolpopexy is associated with low rates of perioperative and long- term complications. We did not find a difference in rates of complications and/ or long-term outcomes, between different weights groups.

Impact of Age and Body Mass Index on the Outcomes of Laparoscopic Mesh Sacrocolpopexy

Background: Pelvic organ prolapse (POP) is a benign condition that can adversely affect women's quality of life. Mesh sacrocolpopexy is an effective surgical treatment for POP, but is considered a complex and risky surgery for obese and elderly women. The objective of this study was to assess the impact of age and obesity on the outcomes of minimally invasive sacrocolpopexy. Methods: We performed a retrospective cohort study reviewing all minimally invasive sacrocolpopexy cases performed between 2003 and 2021. Data on operative time, hospital stay, conversion rate, perioperative injuries, early and late postoperative complications were collected. Surgical success was evaluated by gynecological examination at each follow-up visit. Results: One hundred seventy subjects were included, of whom 44% were older than 65 years and 58% had a body mass index (BMI) above 25 kg/m2. Seventy percent presented stage III uterovaginal prolapse. All patients achieved a good subjective outcome with no reported prolapse with a mean follow-up of 6 years. The rate of de novo stress urinary incontinence was 3.2%. Vaginal implant exposure was found in 4% of cases. A bivariate analysis studying the impact of older age (≥ 65 vs. < 65 years) and higher BMI (≥ 25 vs. < 25) on surgical and postoperative outcomes did not show any significant differences between the subgroups (p > 0.05). Conclusion: In experienced hands, laparoscopic sacrocolpopexy can be used as a safe and effective procedure for operable patients with POP, even when patients are between 65 and 80 years or have a BMI of 25 kg/m2 and above.

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.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database

IMPORTANCE

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population.

OBJECTIVE

The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression.

RESULTS

Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches.

CONCLUSIONS

Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Impact of obesity on operative complications and outcome after sacrocolpopexy: A systematic review and meta-analysis

OBJECTIVE

Surgery is required by many obese women with pelvic organ prolapse, and sacrocolpopexy is considered to be an effective method to correct apical prolapse. However, to the authors' knowledge, epidemiological studies have not been summarized formally.

STUDY DESIGN

A systematic literature search of Pubmed, Medline (Ovid) and Embase databases was undertaken for articles written in English. Statistical analysis was performed using Revman 5.3.

RESULTS

In total, 7315 patients in 12 studies were included in this meta-analysis. No significant differences were found between obese women and non-obese women in terms of re-operation rate [risk ratio (RR) 1.19, 95 % confidence interval (CI) 0.88-1.59; p = 0.25], postoperative Pelvic Organ Prolapse Quantification System stage ≥2 (RR 0.86, 95 % CI 0.64-1.16; p = 0.33), transfusion rate (RR 0.91, 95 % CI 0.57-1.44; p = 0.68), mesh erosion rate (RR 1.62, 95 % CI 0.74-3.51; p = 0.23), overall rate of surgical complications (RR 1.17, 95 % CI 0.91-1.50; p = 0.23) and length of hospital stay [mean difference (MD) 0.13 days, 95 % CI -0.05 to 0.31; p = 0.15). Additionally, no differences were found in the rates of bladder injury, ileus and urinary incontinence between obese women and non-obese women. However, obese women were associated with a higher laparoconversion rate (RR 3.00, 95 % CI 1.71-5.31; p = 0.0002), higher rate of infection (RR 1.65, 95 % CI 1.25-2.20; p = 0.0005), longer operative duration (MD 14.93 min, 95 % CI 10.14-19.73; p < 0.00001) and higher estimated blood loss (MD 18.01 ml, 95 % CI 8.22-27.80; p = 0.0003) compared with non-obese women.

CONCLUSIONS

The complications and curative effects of sacrocolpopexy for obese women are similar to those of non-obese women, except for the higher laparoconversion rate, higher rate of infection, longer operative duration and higher estimated blood loss in obese women. Obesity increases the operational difficulty of sacrocolpopexy to a certain extent, although it does not increase the mesh erosion rate or prolapse recurrence rate. Gynaecologists need to be aware of the possibility of the abovementioned risks when choosing sacrocolpopexy for obese patients with middle pelvic defects.

A Survey of Operative Techniques Used by Female Pelvic Medicine and Reconstructive Surgeons Performing Minimally Invasive Sacral Colpopexy

Objective

Assess variability of surgical technique for minimally invasive sacral colpopexy (MISC) among Female Pelvic Medicine and Reconstructive Surgery (FPMRS).

Methods

A voluntary anonymous questionnaire was given to the 2018 American Urogynecologic Society (AUGS) annual meeting attendees. Comparisons were made by age, gender, experience (years), practice setting, and U.S. region.

Results

There were 59 responses from 671 physician conference attendees. Most were male (64.4%), U.S. physicians (94.6%), completed Obstetrics and Gynecology residencies (91.5%), practicing in University settings (66.1%). The mean age was 47.4±8.6 years, practicing>15 years (47.5%). Predominant routes were 53.8% robotic, 42.2% laparoscopic, and 4.0% open. Surgeons used 3-4 ports (both 50.0%), with 0-degree (46.0%) or 0 and 30 degree laparoscopes (36%). For sacral mesh attachment, 83.1% used suture as opposed to tacking devices, most often Gortex (56.3%). Anterior (48.1%) and posterior (50.0%) vaginal attachment used 5-6 sutures.

Concomitant procedures included anterior repair (83.4% “not usually”/“not at all”), posterior repair/perineorrhaphy (77.8% “yes, often”/“yes, sometimes”), midurethral sling (42.6% “yes, often”/51.9% “yes, sometimes”), and hysteropexy (86.5% “not usually”/“not at all”). Post void residual (PVR) was assessed after surgery by 89.8%, 75.5% via retrograde fill voiding trial. Most patients were discharged post-operative day 1 (POD1) (47.6% AM, 29.1% PM) or day of surgery (15.2%). 

Females more commonly performed hysteropexy (p=0.028) with no other significant differences by age, gender, experience, practice setting or region. 

Conclusion

Most FPMRS surgeons perform MISC, equally robotic and laparoscopic. Concomitant posterior wall procedures and midurethral slings are common. Other than more hysteropexies performed by females, no other variables predicted technique variations, suggesting technique homogeneity.

Feasibility and safety of laparoscopic approach in obese patients with endometriosis: a multivariable regression analysis

PURPOSE

To evaluate the feasibility and safety of laparoscopic excision of endometriotic lesions in obese women.

METHODS

Retrospective analysis of prospectively collected data involving consecutive women scheduled for complete laparoscopic removal of macroscopic endometriotic lesions between January 2012 and November 2018. Operative time, laparotomic conversion rates, complication rates, and length of hospital stay were recorded.

RESULTS

One thousand two hundred thirty women were enrolled and divided into two main groups, according to the World Health Organization classification of obesity, obese (body mass index ≥ 30 kg/m²) and non-obese (body mass index < 30 kg/m²). During the study period, 91 (7.4% of overall study cohort) obese women underwent surgery. At univariate analyses, significant differences between the two groups were found in terms of age, rates of severe endometriosis, American Society of Anesthesiologists physical status classification ≥ III, and different surgical procedures. Significant differences in terms of median operative time [125 (interquartile range (IQR) 85-165) in obese group vs 110 min (IQR 75-155) in non-obese group, P = 0.04] were observed. There were no significant differences between the obese and non-obese groups with respect to the other variables of interest. After adjusted multivariable regression models for potential confounders, difference in operating time (coefficient of 13.389; 95% CI 1.716, 25.060) was still found to be significant.

CONCLUSION

In our tertiary care referral center, laparoscopic removal of endometriosis is feasible and safe, except for a slight increase of operative time and conversion rate.

Obesity and its long-term impact on sacrocolpopexy key outcomes (OBELISK)

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is the preferred contemporary approach to managing significant apical pelvic organ prolapse. Obesity is an established risk factor for several surgical procedures and can have a negative impact on outcomes. Our goal was to evaluate the impact of BMI on the safety and efficacy of laparoscopic sacrocolpopexy in women with pelvic organ prolapse.

METHODS

A single-center retrospective observational study of women undergoing laparoscopic sacrocolpopexy between January 1, 2015, and December 31, 2017.

RESULTS

We found 299 procedures: 82 (27.4%), 147 (49.2%) and 70 (23.4%) in women with BMI <25 (normal weight), BMI ≥ 25 - < 30 (overweight) and BMI ≥ 30 (obese), respectively. Perioperative and early postoperative complications were generally low and not statistically significantly different between the groups. At 12 months postoperatively, 81 (98.8%), 136 (92.5%) and 62 (88.6%) normal-weight, overweight and obese women attended their follow-up, respectively. All obese women attending the follow-up scored an overall Patient Global Impression of Improvement (PGI-I) of ≤ 3. The Pelvic Floor Distress Inventory (PFDI) scores showed a significant improvement in all domains and were similar between the study groups. In total, there was one (0.4%) anatomical apical compartment failure, three (1.1%) anterior compartment failures and two (0.7%) posterior compartment failures with no significant differences between the groups. Similarly, there were no differences in functional outcomes or mesh position as assessed by ultrasound.

CONCLUSIONS

There were no differences in surgical, short- and long-term outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse in obese compared with non-obese women.

Laparoscopic sacrocolpopexy posthysterectomy: intraoperative feasibility and safety in obese women compared with women of normal weight

Introduction and hypothesis

Our aim was to determine the intraoperative feasibility and complication rate of laparoscopic sacrocolpopexy (LSC) in overweight and obese women compared with women of normal weight.

Methods

This was a retrospective observational cohort study (Canadian Task Force classification II-2) conducted at a tertiary urogyaenocology unit evaluating 119 women who underwent LSC between March 2005 and January 2013.

Results

Body mass index (BMI) was classified as normal (22.89 ± 1.55), overweight (27.12 ± 1.40) and obese (33.47 ± 3.26) according to the World Health Organisation (WHO) classification. There was no difference in intraoperative complication rates for bladder, bowel, ureteric or vascular injury; haemorrhage; conversion to laparotomy; or anaesthetic complications for normal weight, overweight or obese women. Similarly there was no difference in operating time, duration of anaesthetic or hospital stay between BMI class (p = 0.070, p = 0.464, p = 0.898, respectively) postoperative or mesh complication rates. At 6-months’ follow-up, there was no difference in Patient Global Impression of Improvement scale (PGI-I) (defined as very much better or much better) between normal weight, overweight and obese women (76.9, 72 and 65.4%, p = .669) or objective cure using the Pelvic Organ Prolapse Quantification (POP-Q) examination (p = 0.402).

Conclusions

LSC is feasible, with equivalent intraoperative complication rates for normal weight, overweight and obese women when performed by experienced laparoscopic urogynaecologists. Given the benefits of a laparoscopic approach in obese women, the authors suggest they should be offered LSC as an option to treat vault prolapse when surgical management is being considered.

Surgery for Apical Vaginal Prolapse After Hysterectomy: Abdominal Sacrocolpopexy

The number of surgeries for pelvic organ prolapse in the United States is increasing. Abdominal sacrocolpopexy has become the gold standard for women desiring a restorative repair of their apical pelvic organ prolapse. Despite the associated morbidity of abdominal sacrocolpopexy, advances in minimally invasive approaches have safely increased the number of these surgeries performed, especially among urologists. Moreover, a number of studies have demonstrated superior objective outcomes after abdominal sacrocolpopexy when compared with vaginal approaches. Variations in the technique are described, but no consensus exists on a standard approach.