Prevalence and risk factors for cardiac arrest and myocardial infarction after pelvic reconstructive surgery: a national, multi-institutional, surgical database study

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared.

METHODS OF STUDY SELECTION

In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39).

CONCLUSION

Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022326255.

Pelvic Organ Prolapse Surgery in the Elderly and Frail: Safety of a Reconstructive Versus Obliterative Approach

OBJECTIVES

The aim of this study was to compare the risk of complications associated with obliterative surgery versus reconstructive surgery in elderly and frail patients undergoing surgery for pelvic organ prolapse.

METHODS

We performed a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2017. We compared characteristics and perioperative complications in patients aged 80 years or older who underwent obliterative surgery versus reconstructive surgery. Multivariate logistic regression and propensity score matching were used to control for confounding. A subanalysis was performed that included patients who were considered frail as defined by the National Surgical Quality Improvement Program Modified Frailty Index 5.

RESULTS

Of 1,654 total patients, reconstructive surgery was performed in 56.9% of patients, and obliterative surgery was performed in 43.1%. The respective composite complication rates were 9.2% and 9.8% (P = 0.69), whereas severe complications were experienced by 1.9% in the reconstructive group versus 0.8% in the obliterative group (P = 0.07). On multivariate logistic regression, reconstructive surgery was not significantly associated with the composite complication rate (adjusted odds ratio, 1.0; 95% confidence interval, 0.7-1.4; P = 0.80). After propensity score matching, composite complications did not differ between groups, but the rate of severe complications was significantly higher in patients who underwent reconstructive surgery compared with obliterative surgery (2.1% vs 0.8%; odds ratio, 2.53; 95% confidence interval, 1.01-6.36; P = 0.05). In frail patients only, complication rates did not differ between groups.

CONCLUSIONS

In patients aged 80 years or older, the overall rate of complications did not differ between those who underwent reconstructive surgery versus obliterative surgery. However, propensity score matching identified an increased risk of the most severe complications in patients who underwent reconstructive surgery.

Evaluating Postoperative Morbidity in Patients Undergoing Pelvic Reconstructive Surgery Using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator

OBJECTIVE

The aim of this study was to evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict surgical morbidity in patients undergoing pelvic reconstructive surgery.

METHODS

This was a retrospective study of patients who underwent pelvic reconstructive surgery from 2014 to 2017. Preoperative risk factors were abstracted from medical records and entered into the ACS NSQIP surgical risk calculator. The Current Procedural Terminology code that produced the largest risk was used and compared with actual patient outcomes. Demographic, clinical, and surgical characteristics were analyzed descriptively. Logistic regression evaluated significant factors associated with each outcome; prediction capability of the risk calculator was assessed.

RESULTS

Seven hundred thirty-one surgical cases were reviewed. The cohort was predominantly younger than 65 years (58.7%), white (77.4%), multiparous (81.1%), and overweight (64.7%); 76.3% were American Society of Anesthesiologists class 2, and 70.2% had vaginal surgery. There was no difference in median risk scores between those with and without postoperative event. Two hundred twenty-one (30.3%) experienced "any serious complication," with 89% of these due to urinary tract infection. Incidence of urinary tract infection was 27%; readmission was 3.2%, and 3.6% returned to the operating room. Decreasing age was predictive of return to the operating room (P < 0.001), and increasingly worse functional status predicted discharge to nursing or skilled rehabilitation facility (P < 0.001).

CONCLUSIONS

The ACS NSQIP surgical risk calculator is an overall poor predictor of actual outcomes in a sample of patients who underwent pelvic reconstructive surgery, perhaps because of low prevalence of serious events. A more accurate surgical risk calculator is needed for this patient population.

Perioperative Safety of Surgery for Pelvic Organ Prolapse in Elderly and Frail Patients

OBJECTIVE

To evaluate the effects of old age and frailty on complication rates after surgery for pelvic organ prolapse.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for prolapse from 2010 to 2017. We compared our control group (45-64 years, index population) to those aged 65-79 years (elderly) and 80 years and older (very elderly). Frailty was assessed using the National Surgical Quality Improvement Program Modified Frailty Index-5. The primary outcome was the composite rate of serious complications and mortality.

RESULTS

We analyzed 27,403 patients in the index population, 20,567 in the elderly group, and 3,088 in the very elderly group. The composite rate of serious complications in the index population was 4.5%, compared with 4.7% in the elderly group (odds ratio [OR] 1.0, 95% CI 0.9-1.1) and 9.0% in the very elderly group (OR 2.1, 95% CI 1.8-2.4). Compared with the index group, the very elderly group had notably elevated risks of cardiac complications (OR 11.9, 95% CI 6.2-23.0), stroke (OR 26.6, 95% CI 5.4-131.8), and mortality (OR 39.9, 95% CI 8.6-184.7). On multivariate logistic regression, the only age group independently associated with serious complications was the very elderly group (adjusted odds ratio [aOR] 2.01, 95% CI 1.8-2.3). The Modified Frailty Index-5 score was independently predictive of complications (aOR 1.4, 95% CI 1.1-2.0). Stratified analysis using interaction terms revealed the Modified Frailty Index-5 score to be predictive of complications in the elderly age group (aOR 2.5, 95% CI 1.3-4.6), but not in the very elderly group.

CONCLUSION

Serious complications surrounding prolapse surgery increase substantially in the cohort of patients older than 80 years of age, independent of frailty and medical or surgical risk factors.

Adverse Cardiovascular Events Associated With Female Pelvic Reconstructive Surgery

OBJECTIVE

To evaluate national trends in major adverse cardiovascular and cerebrovascular events (MACCE) in female pelvic reconstructive surgery (FPRS).

METHODS

Data from the National Inpatient Sample was used to identify women undergoing FPRS between 2012 and 2016. Demographic, procedural, and comorbidity data were collected. Patients were stratified into those with and without MACCE (defined as all-cause mortality, cardiac arrest, myocardial infarction (MI) and acute ischemic stroke). Descriptive statistics are expressed as medians and interquartile ranges. Pairwise analysis was performed using Wilcoxon rank-sum or Fisher exact test as appropriate. Multivariable logistic regression was used to identify independent risk factors for MACCE.

RESULTS

During the study period, 53,540 patients underwent FPRS. The rate of MACCE was 4.8 per 1000 surgeries; MI, 3.7; acute ischemic stroke, 0.6; cardiac arrest, 0.4; and all-cause mortality, 0.3. Patients experiencing MACCE were more likely to have major preexisting cardiovascular comorbidities, coagulopathy, neurologic disease (ND), and diabetes and were more likely to undergo robotic colpopexy (20.7% vs 9.6%, P < 0.001), vaginal colpopexy (32.0% vs 28.5%, P = 0.04), and to receive a blood transfusion (8.2% vs 2.5%, P < 0.001).On logistic regression, preexisting coagulopathy was the strongest predictor of MACCE (adjusted odds ratio [aOR], 5.53; 95% confidence interval [CI], 2.39-12.78), followed by blood transfusion (aOR, 4.84; 95% CI, 1.89-12.45), congestive heart failure (aOR, 3.61; 95% CI, 1.56-8.37), ND (aOR, 3.14; 95% CI, 1.23-8.06), and electrolyte abnormalities (aOR, 1.99; 95% CI, 1.05-3.99).

CONCLUSION

Major adverse cardiovascular and cerebrovascular events after FPRS is a rare event, with MI being the most common manifestation. Preexisting ND, congestive heart failure, coagulopathy, electrolyte disturbances, and perioperative transfusions are strongly associated with MACCE.

Perioperative cardiovascular complications following urogynecological operations

INTRODUCTION

The risk of perioperative cardiovascular complications following operations for urinary incontinence and pelvic organ prolapse (POP) must be taken into consideration during surgical planning. The literature on the cardiovascular risk following urinary incontinence and POP operations shows conflicting results. Our aims were to provide an estimate of the mortality and the risk of cardiovascular complications following urinary incontinence and POP operations considering women's preoperative cardiovascular comorbidity.

MATERIAL AND METHODS

This nationwide register-based study includes a total of 13 992 operations for urinary incontinence and 35 765 for POP from 2007 to 2017. The risk was estimated as an incidence/rate ratio for women with and without former cardiovascular comorbidity adjusted for relevant confounders by using a case-crossover study design.

RESULTS

A total of 7677 patients were at high risk, with a cardiovascular comorbidity prior to the operation, and 42 076 patients were at low risk, with no cardiovascular comorbidity. Overall, 11 patients died within 30 days following an operation, of whom five were in the high-risk group and six in the low-risk group. Of the women at high risk, 0.59% had cardiovascular complications from 0 to 6 days following an operation, corresponding to an incidence/rate ratio of 3.64 (95% CI; 2.67-4.97), compared with women at low risk where no complications were registered in the first week.

CONCLUSIONS

We found an increased risk of cardiovascular complications following urogynecological operations in women with preoperative cardiovascular comorbidity, and no increased risk in women without prior cardiovascular comorbidity. In general, the risk of cardiovascular complications was lower than that found in previous studies.