Factors influencing the outcome of surgery for pelvic organ prolapse

Obesity and Native Tissue Repairs: A Secondary Analysis of the OPTIMAL Trial

IMPORTANCE

The Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) Trial compared sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) surgical outcomes. Increasing body mass index (BMI) is associated with an increased risk of pelvic organ prolapse, and the prevalence of obesity is increasing worldwide.

OBJECTIVE

The purpose of this study was to better understand the effect of obesity on the results of native tissue vaginal apical suspension procedures.

STUDY DESIGN

This was a secondary analysis of the OPTIMAL Trial data set. Subgroup analysis was performed to compare surgical failure rates between SSLF and ULS across BMI subgroups after 2 years.

RESULTS

There were 75, 120, 63, and 39 patients in the normal, overweight, class 1 obesity, and class 2 obesity or greater BMI subgroups, respectively. There were no statistically significant differences in surgical failure rates between SSLF and ULS within BMI subgroups; however, failure rates increased in the ULS group between the nonobese and obese groups (normal, 35.9% SSLF vs 30.6% ULS [ P = 0.81]; overweight, 38.6% vs 30.2% [ P = 0.44]; class 1 obesity, 38.7% vs 40.6% [ P = 0.92]; class 2 obesity or greater, 21.1% vs 45% [ P = 0.21]).

CONCLUSIONS

The risk of surgical failure between SSLF and ULS was not significant across BMI subgroups. Additional investigation is required to further elucidate whether SSLF or ULS is a more reliable option for obese patients.

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.

Menopause and stress urinary incontinence: The risk factors of stress urinary incontinence in perimenopausal and postmenopausal women

OBJECTIVE

The prevalence of stress urinary incontinence (SUI) increases around menopause. The quality of life of perimenopausal and postmenopausal women with SUI is significantly affected. This study aimed to investigate the prevalence of SUI and the associated risk factors in a population of Chinese perimenopausal and postmenopausal women.

METHODS

A total of 273 perimenopausal and postmenopausal women were enrolled, and a cross-sectional study was conducted. SUI was defined as an involuntary loss of urine with increases in abdominal pressure. Data including personal characteristics, menopause information, estrogen levels, and pelvic floor muscle strength levels were statistically analyzed.

RESULTS

The study enrolled 158 (57.9%) perimenopausal and 115 (42.1%) postmenopausal women. Sixty-six (41.8%) perimenopausal women and 56 (48.7%) postmenopausal women complained of SUI. The mean age was 49.42 ± 5.58 years. Body mass index over 24 kg/m2 (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.07-3.81), vaginal delivery (OR 2.47, 95% CI 1.33-4.58), and diabetes (OR 4.65, 95% CI 1.23-17.62) were high-risk factors for SUI. Climacteric symptoms (evaluated by Kupperman index scores) were statistically related to SUI, and among the 13 symptoms, insomnia, nervousness, weakness and fatigue, arthralgia and myalgia, headache, palpitation, and sexual complaints were all correlated with SUI in perimenopausal and postmenopausal women.

CONCLUSIONS

Several factors are associated with SUI in Chinese perimenopausal and postmenopausal women. Obesity, vaginal delivery, climacteric symptoms, and diabetes were identified as the most notable risk factors. The management strategy could focus on the prevention and management of risk factors.

Measurement of extraction forces of non-absorbable suture and different anchoring systems used for pelvic organ prolapse surgery using soft-embalmed cadavers: A feasibility study

OBJECTIVE

Success of pelvic organ prolapse (POP) mesh procedures also depends on reliable anchoring systems (AS). Our primary aim was to assess the use of soft-embalmed cadavers in testing of different AS and our secondary aim was to compare extraction forces (EF) of different AS and non-absorbable suture (NAS).

STUDY DESIGN

IRB approval was obtained. NAS (Ti-cron®) and different AS were attached to force-measuring instrument (Dynamometer SS25LA) and anchored to anterior longitudinal (ALL) and pectineal ligament (PL) (Protack®, Uplift®, NAS), and sacrospinous ligament (SSL) (Surelift®, Elevate PC®, NAS) of Thiel soft-embalmed cadavers. EF were measured 2-4 times in each cadaver. Data were compared using non-parametric tests. Statistical significance was set at p < 0.05.

RESULTS

Three female cadavers (age 59, 77 and 87) were used. NAS EF were significantly higher than AS EF for ALL and SSL, but not PL. Thiel soft-embalmed cadavers proved to be useful in testing of different AS.

CONCLUSIONS

Use of soft-embalmed cadavers in testing of different AS is feasible. According to our results, the NAS provides most reliable intra-corporeal fixation. However, significant inter- and intra-subject variability indicates that results may also be dependent on the tissue properties and anchoring procedure. Further testing using soft-embalmed cadavers could help optimise mesh procedures and establish a threshold EF necessary for reliable fixation.

Rate of Postoperative Urinary Retention after Anterior Compartment Prolapse Surgery: A Randomized Controlled Trial Comparing Early versus Conventional Transurethral Catheter Removal

BACKGROUND

Pelvic organ prolapse is a common condition of pelvic floor dysfunction in women, especially in adult vaginally parous and elderly women. Because of its anatomy, the anterior compartment has a significant effect on urinary symptoms. Anterior colporrhaphy and colpocleisis are major anterior compartment prolapse-related surgeries. As we know, postoperative urinary retention (POUR) is one of the most common complications following pelvic floor surgery. To prevent this complication, indwelling bladder catheterization is routinely applied. In contrast, to minimize risk of infection and the patient's discomfort, the catheter should be removed as soon as possible. However, there is a lack of clarity regarding the optimal timing for catheter removal. Therefore, the aim of this trial is to compare the rate of POUR after anterior prolapse surgery between early transurethral catheter removal (24 h postoperatively) and our standard practice (on postoperative day 3).

METHODS

We conducted a randomized controlled trial among patients undergoing anterior compartment prolapse surgery between 2020 and 2021 at a university hospital. Women were randomized into two groups. After removal, if the second void residual urine volume exceeded 150 mL, POUR was diagnosed, and intermittent catheterization was performed. The primary outcome was the POUR rate. The secondary outcomes included urinary tract infection, asymptomatic bacteriuria, time to ambulation, time to spontaneous voiding, length of hospitalization, and patient satisfaction. Analysis was performed according to the intention to treat principle. The calculated sample size was 68 patients (34 patients in each group) for a 95% confidence interval, 80% power, 5% probability of type I error, and 10% data loss.

DISCUSSION

This study demonstrated that early catheter removal was comparable in POUR rate to conventional treatment with shorter hospitalization among patients undergoing anterior compartment prolapse surgery. Additionally, we observed no re-hospitalization owing to POUR. Therefore, early transurethral catheter removal is preferable following anterior compartment prolapse-related surgery.

Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension

BACKGROUND

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years.

OBJECTIVE

This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse.

STUDY DESIGN

This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors.

RESULTS

In the final multivariable model, body mass index (increase of 5 kg/m2: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3-2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0-1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5-5.8 and 0.9-3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8-5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2-0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5-2.1).

CONCLUSION

Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.

Long-Term Assessment of Pelvic Organ Prolapse Reoperation Risk in Obese Women: Vaginal and Laparoscopic Approaches

The aim of this study was to compare reoperation risks after pelvic organ prolapse repair at 5-year follow-up between obese, overweight, and normal-weight women and to assess these risks accounting for the surgical procedure. We performed a retrospective chart review of all the women who underwent POP repair by transvaginal mesh surgery between January 2005 and January 2009 or laparoscopic sacrocolpopexy between January 2003 and December 2013 at the Gynecologic Surgery Department of the Lille University Hospital. During the study period, 744 women who underwent POP repair were divided into three groups: 382 (51%), 240 (32%), and 122 (16%) in the nonobese group (BMI < 25 kg/m²), overweight group (25 kg/m² ≤ BMI < 30 kg/m²), and obese group (BMI ≥ 30 kg/m²), respectively. The primary outcome was global reoperation. The median duration of follow-up was 87 months. The risks of global reoperation did not significantly differ between the three BMI groups (adjusted HR (95% CI): 1.12 (0.69 to 1.82) for overweight women and 0.90 (0.46 to 1.74) for obese women compared to normal-weight women, adjusted p = 0.80), nor among the women who underwent transvaginal mesh surgery or laparoscopic sacrocolpopexy. The risks of reoperation for POP recurrence, stress urinary incontinence, or mesh-related complications did not significantly differ between the three BMI groups in the overall population nor accounting for the surgical procedure. In conclusion, obesity does not seem to be a risk factor of reoperation for POP recurrence, SUI, or mesh-related complications in the long term regardless of the surgical approach.

Perianal abscess as a manifestation of vaginocutaneous fistula after pelvic floor reconstruction

We present a case of vaginocutaneous fistula 10 years after pelvic floor reconstruction using transvaginal mesh implantation. The female patient in her mid-60s presented with typical symptoms of perianal abscess. After undergoing three surgical operations, the perianal infection was shown to be due to the implanted mesh as a late complication of the reconstruction. The patient was successfully managed with limited removal of the mesh tails. The case highlights one of the late complications of pelvic floor reconstruction using synthetic meshes.

Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension

BACKGROUND

Given that the number of surgeries for pelvic organ prolapse is expected to increase worldwide, knowledge on risk factors for prolapse recurrence is of importance for developing preventive strategies and shared decision-making.

OBJECTIVE

To identify risk factors for subjective and objective failure after either sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension over a period of 5 years after surgery.

STUDY DESIGN

This was a secondary analysis of the 5-year follow-up of the SAVE-U trial. The SAVE-U trial was conducted in 4 Dutch hospitals. A total of 208 women with uterine prolapse stage ≥2 were randomized to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. For the current analysis, available annual 5-year follow-up data of 207 women were analyzed. Without missing values this analysis would have included 1035 measurements in total over the 5-year follow-up. Recurrences were analyzed as "events" using generalized linear mixed models because recurrences of anatomic failure and bothersome vaginal bulge symptoms fluctuated over time. The primary outcome was the composite outcome of failure defined as prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse. Secondary outcome measures were bothersome vaginal bulge symptoms, overall anatomic failure (Pelvic Organ Prolapse Quantification stage ≥2 in any compartment), apical compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), anterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), and posterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2).

RESULTS

For the composite outcome of failure (164 events in 66 different women), statistically significant risk factors were: body mass index (odds ratio, 1.10 [per 1 kg/m²]; 95% confidence interval, 1.02-1.19; P=.02), smoking (odds ratio, 2.88; 95% confidence interval, 1.12-7.40; P=.03), and preoperative Pelvic Organ Prolapse Quantification point Ba (odds ratio, 1.23 [per 1 cm]; 95% confidence interval, 1.01-1.50; P=.04). When analyzing each surgical outcome measure separately, body mass index and Pelvic Organ Prolapse Quantification point Ba were risk factors for overall anatomic failure (462 events in 147 women; odds ratio, 1.15; 95% confidence interval, 1.07-1.25; P<.01 and odds ratio, 1.14; 95% confidence interval, 1.00-1.30; P=.05, respectively) and anterior compartment recurrence (385 events in 128 women; odds ratio, 1.11; 95% confidence interval, 1.02-1.22; P=.02 and odds ratio, 1.17; 95% confidence interval, 1.02-1.34; P=.02, respectively). Vaginal hysterectomy was a risk factor for posterior compartment recurrence when compared with sacrospinous hysteropexy (93 events in 40 women; odds ratio, 5.21; 95% confidence interval, 2.05-13.27; P<.01). Smoking was a risk factor for bothersome vaginal bulge symptoms (70 events in 41 women; odds ratio, 3.80; 95% confidence interval, 1.48-9.75; P=.01), and preoperative Pelvic Organ Prolapse Quantification stage 3 or 4 was significantly protective against bothersome bulge symptoms (odds ratio, 0.32; 95% confidence interval, 0.11-0.89; P=.03).

CONCLUSION

Body mass index, smoking, and Pelvic Organ Prolapse Quantification point Ba were statistically significant risk factors for the composite outcome of failure (prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse) in the period of 5 years after surgery.

The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery

Introduction and hypothesis

The objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery.

Methods

Prospective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis.

Results

A total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1–4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5–2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1–0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8–2.9), p = 0.223).

Conclusions

Levator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.

Outcomes collected in female pelvic floor surgical procedure registries and databases: a scoping review

INTRODUCTION AND HYPOTHESIS

The objective was to overview the literature on the existing pelvic floor procedure registries and databases and to identify patient demographic, clinical and/or patient-reported data items for inclusion in the Australasian Pelvic Floor Procedure Registry (APFPR) Minimum Data Set (MDS).

METHODS

We conducted a literature search on the MEDLINE, Embase, CINAHL and PsycINFO databases in addition to Google Scholar and grey literature to identify studies in the period January 2008 to January 2020. All were English studies of registries and databases on female adults undergoing surgery for pelvic floor disorders including stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Studies were assessed on demographic and clinical patient characteristics, procedure or treatment type, health-related quality of life, adverse events and safety outcomes, captured by pelvic floor procedure registries or databases that have been established to date.

RESULTS

From 1662 studies, 29 publications describing 22 different pelvic floor registries and databases were included for analysis, 12 (55%) of which were multicentre. Six (27%) registries and databases involved solely SUI, eight (36%) were regarding POP, and the remaining eight (36%) focussed on both conditions. The majority of registries and databases captured similar details on patient characteristics, comorbidities and other clinical features, procedure or treatment type, health-related quality of life, adverse events, safety and efficacy.

CONCLUSION

The findings of this scoping review will assist in determining the MDS for the APFPR, an initiative of the Australian government, to improve health and quality of life outcomes of women who undergo pelvic floor reconstructive procedures.

Body mass index and adverse outcomes among singletons with cerclage

OBJECTIVE

To compare the neonatal and maternal adverse outcomes among women with cerclage and prepregnancy body mass index (BMI) < versus > 30 kg/m² STUDY DESIGN: This retrospective cohort study utilized the U.S. Vital Statistics Datasets from 2011-2013. Inclusion criteria were women with non-anomalous singletons, with cerclage placement, without diabetes or hypertensive disorders, and who delivered at 20-41 weeks. The primary outcome was the composite neonatal adverse outcome (Apgar score below 5 at 5 min, birth injury, assisted ventilation for more than 6 h, neonatal seizure, or neonatal death). The secondary outcomes included the composite maternal adverse outcome (admission to intensive care unit, maternal transfusion, ruptured uterus, unplanned hysterectomy, or unplanned operating room procedure), chorioamnionitis, and cesarean delivery. Multivariable Poisson regression models with robust error variance were used, while adjusting for confounders. Adjusted relative risk with 95 % confidence intervals were calculated.

RESULTS

Of the 22,466 live births that met the inclusion criteria during the study period, 6427 (28.6 %) had cerclage and prepregnancy BMI ≥ 30 kg/m². The composite neonatal adverse outcome was significantly increased (aRR 1.45; 95 % CI 1.33-1.60) among women with cerclage and BMI ≥ 30 kg/m² when compared to those with BMI < 30 kg/m². The composite maternal adverse outcome was similar (aRR 0.93; 95 % CI 0.72-1.20) among the two groups. Chorioamnionitis (aRR 1.46; 95 % CI 1.24-1.72) and cesarean delivery (aRR 1.24; 95 % CI 1.19-1.29) were higher in women with cerclage and BMI ≥ 30 kg/m².

CONCLUSION

Among pregnancies with cerclage and delivery at 20-41 weeks, the risk of the composite neonatal adverse outcome was modestly increased in newborns delivered by women with BMI ≥ 30 kg/m² than those delivered by women with BMI < 30 kg/m². No significant difference was found in the risk of the composite maternal adverse outcome.

Opioid prescribing and risks among commercially insured women undergoing pelvic organ prolapse repair

PURPOSE

Opioid use after surgical repair for pelvic organ prolapse (POP) is intended for short-term post-operative pain. This study compared the incidence of opioid prescribing in women undergoing POP transabdominal repair with mesh and transvaginal native tissue repair.

METHODS

A retrospective cohort of women undergoing POP transabdominal repair with mesh or transvaginal native tissue repair, was derived from a 10% random sample of enrollees from 2007 to 2015 within the IQVIA PharMetrics® Plus Database. Primary outcomes were any prescription of opioids and cumulative days of opioids prescribed in the 14- 180 days following surgical intervention. Inverse probability of treatment weights controlled for observed baseline confounders. Any opioid prescription was estimated using logistic regression and generalized linear regression for cumulative days of opioids prescribed.

RESULTS

The cohort of 49 052 women who underwent POP surgical repair included 46 813 women with transvaginal native tissue repair and 2239 women with transabdominal repair with mesh. Women with a transabdominal repair with mesh had a 1.19 (95%CI: 1.09-1.31) significantly higher odds of receiving an opioid prescription than women with transvaginal native tissue repair. Post-operatively, over 29% of women received opioid prescriptions. Mean cumulative days of post-surgical opioid prescribing was 32.2 (SD = 43.1), and was not statistically different between groups. Thirteen percent of women were prescribed opioids for 90 days or more.

CONCLUSIONS

Women undergoing POP with transabdominal mesh are more likely to receive prescriptions for opioids after surgery compared to transvaginal native tissue repair. Treatment plans that address pain while mitigating the risks associated with prolonged opioid prescribing should be employed.

Surgical management of pelvic organ prolapse in a high-volume resource-limited setting

OBJECTIVE

To describe the care pathway of patients with pelvic organ prolapse in a high-volume resource-limited setting and characterize patients undergoing surgery.

METHODS

The patient care pathway at a large referral hospital in eastern Democratic Republic of Congo was determined through interviews with key personnel. Patients with apical prolapse (with or without anterior/posterior prolapse) who underwent surgery between January and December 2018 were included. Demographics and outcomes were characterized. Data were presented as means (standard deviation [SD]), medians (interquartile range), or number (percentages).

RESULTS

A holistic care model was described. During the study period, 772 patients underwent prolapse repairs, 235 met inclusion criteria. Mean age was 55 (±14) years, and 75% (176/235) were postmenopausal. Median parity was 7 (5-9). A majority (56%, 131/233) had body mass index <18.5 (calculated as weight in kilograms divided by the square of height in meters). Most were farmers (77%, 182/235) and had no formal education (76%, 178/235). Postmenopausal patients underwent hysterectomy, whereas premenopausal patients were treated with uterine-preserving techniques. Most repairs were performed vaginally (96%, 225/235), and 40% (94/234) had concurrent multicompartment repairs. Most common complications were hemorrhage (4%, 9/235, intraoperative) and urinary tract infection (5%, 11/235, postoperative).

CONCLUSION

High-volume surgical services for treating prolapse can be integrated into existing healthcare delivery models. Our demographic of patients differs from studies in high-income countries. The degree to which these studies can be generalized to patients in settings similar to ours represents an opportunity for further research.

The effect of women's body mass index on pelvic organ prolapse: a systematic review and meta analysis

BACKGROUND

Pelvic organ prolapse remains the public health challenge globally. Existing evidences report the effect of woman's weight on the pelvic organ prolapse inconsistently and this urges the need of pooled body weight effect on the pelvic organ prolapse. Although there was a previous work on this regard, it included papers reported before June 18/2015. Thus, updated and comprehensive evidence in this aspect is essential to devise strategies for interventions.

OBJECTIVE

This review aimed at synthesizing evidence regarding the pooled effect of body weight on the pelvic organ prolapsed.

METHODS

For this review, we searched all available articles through databases including PubMed, Web of Sciences, CINAHL, JBI library, Cochran library, PsycInfo and EMBASE as well as grey literature including Mednar, worldwide science, PschEXTRA and Google scholar. We included cohort, case-control, cross-sectional and experimental studies which had been reported between March 30, 2005 to March 30, 2020. In the effect analysis, we utilized random model. The heterogeneity of the studies was determined by I2 statistic and the publication bias was checked by Egger's regression test. Searching was limited to studies reported in the English language.

RESULTS

A total of 14 articles with 53,797 study participants were included in this systematic review (SR) and meta analysis (MA). The pooled result of this Meta analyses depict that body mass index (BMI) doesn't have statistical significant association with pelvic organ prolapse.

CONCLUSION

This review point out that women's body mass index has no significant effect on the development of pelvic organ prolapse. However, the readers should interpret the result with cautions due to the presence of considerable limitations in this work. Trial registration The protocol of this systematic review (SR) and meta analysis (MA) has been registered in PROSPERO databases with the Registration number of CRD42020186951.

Complications of Pelvic Organ Prolapse Surgery in the 2015 Finnish Pelvic Organ Prolapse Surgery Survey Study

OBJECTIVE

To describe the major complications of pelvic organ prolapse (POP) surgery in Finland.

METHODS

The Finnish Pelvic Organ Prolapse Surgery Survey 2015 study is a prospective cohort of POP surgeries performed in Finland in 2015. Perioperative, postoperative, and late complications during 1 year of follow-up were compared among native tissue repair, transvaginal mesh, and abdominal mesh surgery. Major complications were assessed using the Clavien-Dindo grading system. Predictive factors for major complications were studied with logistic regression analysis.

RESULTS

Within 1 year after POP surgery, 396 (11.2%) of 3,515 women had at least one complication: 10.9% after native tissue, 11.7% after transvaginal mesh, and 13.5% after abdominal mesh repair. The majority of complications occurred within 2 months after surgery and postoperative infection (4.3%) and bleeding or hematoma (2.6%) were the most frequent. The incidence of organ injuries was low. Mesh-augmented surgery was associated with significantly higher rates of bladder and bowel injuries than native tissue surgery. Complication-related reoperations occurred significantly more often after abdominal mesh repair than native tissue surgery (5.2% vs 1.8%, P=.001). Mesh-related complications were diagnosed more often after transvaginal mesh repair. The overall rate of major complications (Clavien-Dindo grades III-V) was 3.3%. Abdominal mesh surgery was associated with the highest rate of major adverse events (8.8% vs native tissue repair 2.6% and transvaginal mesh 4.9%). The incidence of Clavien-Dindo grade IV or V complications was rare (less than 0.6%). Mesh surgery (transvaginal mesh adjusted odds ratio [aOR] 2.23, 95% CI 1.31-3.80, and abdominal mesh aOR 3.02, 95% CI 1.67-5.46), longer operating time (aOR 2.84, 95% CI 1.78-4.53), prior POP surgery (aOR 1.68, 95% CI 1.00-2.81) and difficult surgery (aOR 2.75, 95% CI 1.63-4.62) were associated with an increased risk for occurrence of major complications.

CONCLUSION

Serious adverse events were rare regardless of the operative approach. However, mesh-augmented surgery was associated with higher risk for major complications.

The Effect of Follow-Up Contact on Recovery After Benign Hysterectomy: A Randomized, Single-Blinded, Four-Arm, Controlled Multicenter Trial

Background: The objective of this trial was to analyze the effect of follow-up programs using standard follow-up protocol and structured coaching on recovery after hysterectomy in an enhanced recovery after surgery setting. Materials and Methods: A randomized, four-armed, single-blinded, controlled multicenter trial comprising 487 women was conducted at five hospitals in the southeast region of Sweden. The women were allocated (1:1:1:1) to Group A: no planned follow-up contact; Group B: a single, planned, structured, broadly kept, follow-up telephone contact with the research nurse the day after discharge; Group C: planned, structured, broadly kept follow-up telephone contact with the research nurse the day after discharge and then once weekly for 6 weeks; and Group D: as Group C, but with planned, structured, coaching telephone contact. Recovery was assessed by the health-related quality of life (HRQoL) questionnaires EuroQoL-5 Dimension with three levels (EQ-5D-3L) and Short-Form-Health Survey with 36 items (SF-36) and duration of sick leave. Results: Neither the recovery of HRQoL as measured by the EQ-5D-3L and the SF-36 nor the duration of sick leave (mean 26.8-28.1 days) differed significantly between the four intervention groups. Irrespective of mode of follow-up contact used, the women had recovered to their baseline EQ-5D-3L health index 4 weeks after surgery. The occurrence of unplanned telephone contact was significantly lower (by nearly 30%) in the women who had structured coaching. Conclusion: Follow-up contact, including coaching, did not seem to expedite the postoperative recovery in HRQoL or reduce the sick leave after hysterectomy, but the coaching seemed to reduce unplanned telephone contact with the health care services. ClinicalTrial.gov (NCT01526668).

Obesity and postoperative outcomes of the patients with laparoscopic adrenalectomy: a systematic review and meta-analysis

Background

Studies have suggested differences in postoperative outcomes between patients with obesity and those without following adrenalectomy, but these remained to be ascertained with synthesis of available evidence. The aim of this systematic review and meta-analysis was to investigate the association between obesity and outcomes of patients after laparoscopic adrenalectomy.

Methods

We searched EMBASE, PubMed, Global Index Medicus, and Web of Science, without language restriction, to identify cohort studies published between January 1, 2000 and November 6, 2019. We considered studies with data comparing outcomes of adults with and without obesity after laparoscopic adrenalectomy. Random-effects meta-analysis was used to pool study-specific estimates. This review was registered with PROSPERO, CRD42018117070.

Results

Five studies with data on a pooled sample of 353 patients with obesity and 828 without were included in the meta-analysis. The risk of bias was moderate to low. We found no association between obesity and the various stages of postoperative complications: Clavien-Dindo grade 1 (OR = 1.57; 95%CI = 0.55–4.48; I² = 44.6%), grade 2 (OR = 1.12; 95%CI = 0.54–2.32; I² = 0.0%), grade 3 (OR = 1.79; 95%CI = 0.58–5.47; I² = 0.0%;), grade 4 (OR = 0.43; 95%CI = 0.05–3.71; I² = 0.0%), and grade 5 (death) (OR = 0.43; 95% CI = 0.02–14.31). Furthermore, no association was found between obesity and readmission rates (OR = 0.7; 95% CI = 0.13–3.62) and conversion of laparoscopic to open surgery (OR = 0.62; 95% CI = 0.16–2.34; I² = 19.5%).

Conclusions

This study suggests that obesity is not associated with complications following laparoscopic adrenalectomy. This meta-analysis might have been underpowered to detect a true association between obesity and patient outcome after laparoscopic adrenalectomy due to the small number of included studies. Larger studies are needed to clarify the role of obesity in patients undergoing laparoscopic adrenalectomy.

Body mass index influences the risk of reoperation after first-time surgery for pelvic organ prolapse. A Danish cohort study, 2010-2016

INTRODUCTION AND HYPOTHESIS

The aims of this study were to evaluate the impact of body mass index (BMI) on the risk of reoperation for pelvic organ prolapse (POP) up to 5 years after first-time surgery.

MATERIALS AND METHODS

This nationwide register-based study includes first-time POP surgery in 2010 through 2016. The cumulative incidence proportions of reoperation were analyzed in a Cox regression model and described using Kaplan-Meier plots stratified in BMI categories.

RESULTS

A total of 28,533 first-time procedures were performed in 22,624 women; 76.6% had single-compartment repair. The 1- and 5-year reoperation rate within the same compartment was 2.6% and 6.1% respectively for women with BMI < 25, and for women with BMI > 35 it was 3.7% and 11.2 respectively. In the anterior compartment there was a significantly increased adjusted hazard ratio for reoperation in the same compartment with increasing BMI (reference group BMI < 25), BMI 30-34.9 with an aHR = 1.34 (CI 95% 1.04-1.71) and BMI ≥ 35 aHR = 1.77 (CI 95% 1.17-2.67). The 1- and 5-year reoperation rate in an adjacent compartment was 0.6% and 1.6% respectively for women with BMI < 25, and for women with BMI > 35 it was 1.0% and 4.4 respectively. For reoperation in an adjacent compartment the adjusted results were BMI 30-34.9 aHR = 1.64 (95% CI 1.05-2.56) and BMI > 35 aHR = 2.64 (95% CI 1.36-5.14) when the first-time operation was in the anterior compartment.

CONCLUSIONS

If the woman had BMI > 35 and first-time surgery was in the anterior compartment, she had an almost doubled risk of reoperation within 5 years both in the same compartment and in an adjacent compartment compared to women with BMI < 35. In the apical and posterior compartment there was a trend towards increasing risk of reoperation with increasing BMI, although with a broad confidence interval.

Reoperation rate and outcomes following the placement of polypropylene mesh by the vaginal route for cystocele: very long-term follow-up

INTRODUCTION AND HYPOTHESIS

The aim was to evaluate the reoperation rate and outcomes in women who underwent transvaginal non-absorbable monofilament polypropylene mesh placement for the treatment of cystocele.

METHODS

The retrospective cohort study included 63 patients who underwent transvaginal surgery using a synthetic polypropylene mesh (Gynemesh™) for cystocele. Patients were evaluated using a clinical examination (POP-Q) and validated questionnaires (PGI-I, PFDI-20, PFIQ-7) at 18 years of follow-up (median 18 years [IQR 16-19]). Cumulative death rate was 13 out of 63 (20%) and rate of total loss to follow-up was 21 out of 50 (42%). Finally, among the 63 women who underwent surgery, 29 completed maximum follow-up and 21 underwent a clinical examination.

RESULTS

The cumulative reoperation rate was 35% (22 out of 63). Three patients were reoperated on because of recurrence of pelvic organ prolapse. Among the 63 patients initially operated, vaginal mesh exposure occurred in 16 (25%) during follow-up and 11 women (17%) needed a reintervention for vaginal mesh exposure. One patient was reoperated on for bladder mesh exposure. Among the 29 women who completed follow-up, the overall postoperative improvement rate was 93% after 18 years (PGI-I: 1-3). Mean overall satisfaction rate was 80 out of 100. Functional success rate was 76% (22 out of 29) and anatomical success rate was 62% (13 out of 21). The median score of the POP-DI-6 was 4.1 (IQR: 0-11) and the median score of the PFDI-20 was 30.7 (IQR: 13-60) in the 29 women who completed maximum follow-up.

CONCLUSION

At very long-term follow-up, the recurrence rate of cystocele following polypropylene mesh placement by the vaginal route remained low and the satisfaction rate was high. However, we found high cumulative reoperation and mesh exposure rates.

Evaluation of 30-day complication rates following vaginal anterior compartment repair with and without graft augmentation in a propensity score matched cohort

OBJECTIVE

To determine if graft augmentation with anterior colporrhaphy (AC+G) is associated with higher complication rates compared to native tissue repair (AC).

MATERIALS AND METHODS

Retrospective cohort study using data from the ACS-NSQIP database between 2010 and 2017. CPT codes were used to identify women undergoing AC+G and AC. Propensity scores for the likelihood of undergoing AC+G were calculated and were used to match to women undergoing native tissue repair at a ratio of 1:2. The primary outcome was the composite complication rate. Descriptive statistics are reported as means with standard deviations for parametric data and as medians and interquartile ranges for non-parametric data. Pairwise comparisons were performed using Fisher's exact test, Wilcoxon rank-sum and Student's t test as appropriate. Multivariable logistic regression was then used to adjust for confounders to identify statistically significant factors associated with the likelihood of experiencing a complication after prolapse repair.

RESULTS

582 women met inclusion criteria for AC+G and were matched with 1164 women undergoing AC. There were no differences in preoperative characteristics between groups. There was no difference in the composite complication rate, (10.8% vs. 8.5%, p = 0.13) between groups. Dependent functional status (aOR 4.31, 95% CI 1.96-13.58) was the strongest predictor of the likelihood of a complication: other significant predictors were operating time greater than 20 min (aOR 1.68, 95% CI 1.19-2.38) and ASA class greater than 2 (aOR 1.44, 95% CI 1.01-2.05).

CONCLUSION

There is no increase in 30-day complication rates in women undergoing AC+G compared to a matched cohort of those undergoing AC alone.

Smoking cessation prior to gynecological surgery-A registry-based randomized trial

INTRODUCTION

Smoking cessation, both pre- and postoperatively, is important to reduce complications associated with surgery. Identifying feasible and effective means of alerting the patient before surgery to the importance of perioperative smoking cessation is a challenge to healthcare systems.

MATERIAL AND METHODS

A randomized registry-based trial using the web-version of the Swedish national quality register for gynecological surgery, GynOp, was performed (ClinicalTrials.gov NCT03942146). Current smokers scheduled for gynecological surgery were randomly assigned before surgery to group 1 (control group, no specific information), group 2 (web-based written information), group 3 (information to doctor that the woman was a smoker and should be recommended smoking cessation or group 4 (a combination of groups 2 and 3). Perioperative smoking habits were evaluated in a postoperative questionnaire 2 months after surgery. The treatment effect was estimated to be a 15% reduction in the number of smokers at the time of surgery. Thus, 94 women in each group were required, in total 376 women, using a one-sided test with an alpha level of 0.001 and a statistical power of 80%.

RESULTS

Participants (n = 1427) were recruited between 5 November 2015 and 6 December 2017. A total of 1137 smokers responded to the follow-up questionnaire (80%), with 486 women declining to participate, leaving 651 women eligible for analysis. Women who received both web-based information prior to surgery and information from a doctor, reported smoking cessation more often from 1 to 3 weeks preoperatively (Odds ratio [OR] 1.8, 95% confidence interval [CI] 1.0-3.3) and 1 to 3 weeks after surgery (OR 1.9, 95% CI 1.1-3.3) compared with the control group who received no specific information.

CONCLUSIONS

A combination of written information in the health declaration and a recommendation from a doctor regarding smoking cessation may be associated with higher odds of smoking cessation at 1-3 weeks pre- and postoperatively.

Pelvic, anorectal and urinary symptoms according to the nutritional status of adult women: A cross-sectional study

ABSTRACT To review the occurrence of pelvic, anorectal and urinary symptoms according to the nutritional status of adultwomen. Methods This is a cross-sectional study with 54 women, aged 18 to 35 years, divided into normal weight (<25kg/m2), overweight (25kg/m2 to 29.99kg/m2) and obesity (≥30kg/m2) according to the body mass index. The presence of pelvic floor muscle dysfunction symptoms was assessed by the Pelvic Floor Distress Inventory and the impact of these symptoms by the Pelvic Floor Impact Questionnaire. Descriptive and inferential statistics were used, with a significance level of 5%. Results Pelvic Floor Distress Inventory total score was 22.95 (SD=26.11) in the eutrophic group and 59.67 (SD=47.80) in the obesity group (p=0.01). Considering the scales, urinary symptoms were higher in obese women than in the eutrophic group (p=0.01). In the assessment of patients with each symptom, a difference (p<0.01) was observed in incomplete bowel emptying, in which the highest frequency occurred in overweight women (47.4%) compared to eutrophic and obese women (both 26.3%). Urinary incontinence symptoms (18.2% in eutrophic women, 27.3% overweight and 54.5% obese), stress urinary incontinence (8.3% eutrophic, 41.7% overweight and 50.0%, obese) and difficulty in emptying the bladder (0.0% eutrophic, 33.3% overweight and 66.7% obese) exhibited higher frequencies (p=0.03; p<0,01 and p=0.02, respectively) in obese women. Conclusion Symptoms of pelvic floor muscles dysfunction, especially urinary tract muscles, occur more frequently in obese adult women when compared to eutrophic women.