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

How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians

INTRODUCTION

Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients.

METHODS

We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery.

RESULTS

Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively.

CONCLUSION

Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.

Outcomes of a novel modified total colpocleisis for advanced pelvic organ prolapse in elderly women and its efficacy on lower urinary tract symptoms

OBJECTIVES

To evaluate the effectiveness of modified total colpocleisis for advanced pelvic organ prolapse (POP) in elderly women and to assess the improvement in lower urinary tract symptoms (LUTS) of the patients.

METHODS

An observational cohort study was conducted, including 105 POP patients who underwent modified total colpocleisis between April 2020 and December 2022. The study analyzed the patients' demographic characteristics, perioperative outcomes, and follow-up outcomes, including complications, remission of LUTS, satisfaction rates, and regret rates. Confirming the safety, durability, and patient satisfaction of modified total colpocleisis.

RESULTS

Most patients (95/105, 90.5%) had more than one comorbidity. Eighty-six (81.9%) had a concomitant hysterectomy, the average operative time was 112.78 ± 34.92 min, with a median estimated bleeding of 50 mL (10-300 mL). Perioperative changes in hemoglobin and hematocrit were 11.64 ± 10.03 g/L and 3.87% ± 3.05%, respectively. Urinary retention was the most common complication (10/105, 9.5%). With a median follow up of 16 months (3-35 months), 101 patients (96.2%) reported satisfaction with the results of the procedure, with none reporting regret. Both subjective and anatomical recurrence rates were quite low (2.9% and 5.7%, respectively). Twenty-three (21.9%) had de novo urinary incontinence, and the remaining LUTS such as frequent, urgent, hesitation, and difficulty emptying were significantly improved (P < 0.05).

CONCLUSION

Modified total colpocleisis is an effective treatment option for elderly women with severe POP. This procedure can significantly improve several LUTS, and most de novo incontinence is mild and has a limited impact on patients' quality of life.

Risk factors prediction of 6-month mortality after noncardiac surgery of older patients in China: a multicentre retrospective cohort study

BACKGROUND

Identifying the risk factors associated with perioperative mortality is crucial, particularly in older patients. Predicting 6-month mortality risk in older patients based on large datasets can assist patients and surgeons in perioperative clinical decision-making. This study aimed to develop a risk prediction model of mortality within 6 months after noncardiac surgery using the clinical data from 11 894 older patients in China.

MATERIALS AND METHODS

A multicentre, retrospective cohort study was conducted in 20 tertiary hospitals. The authors retrospectively included 11 894 patients (aged ≥65 years) who underwent noncardiac surgery between April 2020 and April 2022. The least absolute shrinkage and selection operator model based on linear regression was used to analyse and select risk factors, and various machine learning methods were used to build predictive models of 6-month mortality.

RESULTS

The authors predicted 12 preoperative risk factors associated with 6-month mortality in older patients after noncardiac surgery. Including laboratory-associated risk factors such as mononuclear cell ratio and total blood cholesterol level, etc. Also including medical history associated risk factors such as stroke, history of chronic diseases, etc. By using a random forest model, the authors constructed a predictive model with a satisfactory accuracy (area under the receiver operating characteristic curve=0.97).

CONCLUSION

The authors identified 12 preoperative risk factors associated with 6-month mortality in noncardiac surgery older patients. These preoperative risk factors may provide evidence for a comprehensive preoperative anaesthesia assessment as well as necessary information for clinical decision-making by anaesthesiologists.

Are older patients with prolapse likely to continue pessary use? A retrospective observational study

INTRODUCTION AND HYPOTHESIS

To review the outcomes and complications of vaginal prolapse management with pessaries in women aged 75 years or older, to ascertain whether pessaries are providing satisfactory long-term outcomes for older women.

METHODS

A retrospective observational study was performed on women aged 75 years or older presenting to a tertiary Urogynaecology service with vaginal prolapse who opted for management with a vaginal pessary. Demographic and clinical data were collected by reviewing clinical files. The primary outcome was the proportion of women who opted for pessary management who later required prolapse surgery. Secondary outcomes included pessary complications and risk factors for failure. Kaplan-Meier survival estimates were performed to analyse pessary failure.

RESULTS

Of the 218 women who presented with prolapse, 78% opted for pessary management, and pessary fitting was successful in 84%. Sixty-nine percent of women who opted for initial pessary management underwent surgery later, with a mean time from pessary insertion to surgery of 21.6 months. Vaginal erosions were reported in 42% of pessary users. Risk factors for pessary failure were younger age and previous history of hysterectomy or prolapse surgery.

CONCLUSIONS

Although vaginal pessary use was the preferred first-line management choice for vaginal prolapse in most older women, surgery for prolapse was ultimately required in two-thirds of those conservatively managed. As three-quarters of older women presenting with prolapse had surgery as either a primary or secondary procedure; patients need to be advised of the high chance of requiring surgery at a later stage if they opt for pessary management.

Nonhome Discharge in Patients Undergoing Pelvic Reconstructive Surgery: A National Analysis

IMPORTANCE

Discharge to home after surgery has been recognized as a determinant of long-term survival and is a common concern in the elderly population.

OBJECTIVE

The aim of the study was to determine the incidence and risk factors for nonhome discharge in patients undergoing major surgery for pelvic organ prolapse.

STUDY DESIGN

We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program Database from 2010 to 2018. We included patients who underwent sacrocolpopexy, vaginal colpopexy, and colpocleisis. We compared perioperative characteristics in patients who were discharged home versus those who were discharged to a nonhome location. Stepwise backward multivariate logistic regression was then used to control for confounding variables and identify independent predictors of nonhome discharge.

RESULTS

A total of 38,012 patients were included in this study, 209 of whom experienced nonhome discharge (0.5%). Independent predictors of nonhome discharge included preoperative weight loss (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 1.3-27.5), dependent health care status (aOR, 5.0; 95% CI, 2.6-9.5), abdominal hysterectomy (aOR, 2.3; 95% CI, 1.4-3.7), American Society of Anesthesiologists class 3 or greater (aOR, 2.0; 95% CI, 1.5-2.7), age (aOR, 1.1; 95% CI, 1.05-1.09), operative time (aOR, 1.005; 95% CI, 1.003-1.006), laparoscopic hysterectomy (aOR, 0.6; 95% CI, 0.4-1.0), and laparoscopic sacrocolpopexy (aOR, 0.5; 95% CI, 0.3-0.8).

CONCLUSIONS

In patients undergoing surgery for pelvic organ prolapse, nonhome discharge is associated with various indicators of frailty, including age, health care dependence, and certain comorbidities. An open surgical approach increases the risk of nonhome discharge, while a laparoscopic approach is associated with lower risk.

Effects of Same-Day Discharge on 30-Day Readmission Rates in Women Aged 65 Years and Older Undergoing Minimally Invasive Pelvic Organ Prolapse Surgery

OBJECTIVE

To compare the effects of same-day discharge on 30-day readmission after minimally invasive pelvic organ prolapse (POP) surgery in older patients.

METHODS

This retrospective cohort study examined all minimally invasive POP surgeries performed and included in the national Centers for Medicare & Medicaid Services 5% Limited Data Set (2011-2018). Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department (ED) visits.

RESULTS

Of the 7,278 patients undergoing surgery, patients who had same-day discharge were older (73.5 years vs 73.1 years, P =.04) and less likely to undergo concomitant hysterectomy (9.5% vs 34.9%, P <.01) or midurethral sling (36.8% vs 40.1%, P =.02). Same-day discharge increased over the study period from 15.7% in 2011 to 25.5% in 2018 ( P <.01). On propensity score-matching multiple logistic regression, the adjusted difference was statistically significant, with same-day discharge increasing the odds of 30-day readmission compared with next-day discharge (adjusted odds ratio [OR] 1.57, 95% CI 1.19-2.08). There was no difference (OR 0.81, 95% CI 0.63-1.05) for 30-day ED visits on propensity score-matching multiple logistic regression.

CONCLUSION

After minimally invasive POP surgery, older women have low rates of readmission and ED visits within 30 days. After propensity score matching and adjustment for perioperative factors, there may be increased odds in readmission and no difference in ED visits risk in those who had same-day discharge. When considering patient factors, same-day discharge after minimally invasive POP surgery may be effective for older patients.

The incidence and risk factors of perioperative cardiac complications in noncardiac major surgery in high-altitude areas: A prospective trial in Tibet autonomous region, China

Background

The risk of perioperative cardiac complications (PCCs) in patients living in high-altitude areas may increase with more adverse clinical outcomes due to the special geographical environment, which has not yet been studied. We aimed to determine the incidence and analyze risk factors for PCCs in adult patients undergoing major noncardiac surgery in the Tibet Autonomous Region.

Methods

This prospective cohort study enrolled resident patients from high-altitude areas receiving major noncardiac surgery in Tibet Autonomous Region People's Hospital in China. Perioperative clinical data were collected, and the patients were followed up until 30 days after surgery. The primary outcome was PCCs during the operation and within 30 days after the surgery. Logistic regression was used to build the prediction models for PCCs. A receiver operating characteristic (ROC) curve was used to evaluate the discrimination. A prognostic nomogram was constructed to generate a numerical probability of PCCs for patients undergoing noncardiac surgery in high-altitude areas.

Results

Among the 196 patients living in high-altitude areas involved in this study, 33 (16.8%) suffered PCCs perioperatively and within 30 days after surgery. Eight clinical factors were identified in the prediction model, including older age (P = 0.028), extremely high altitude above 4,000 m (P = 0.442), preoperative metabolic equivalent (MET) &lt; 4 (P = 0.153), history of angina within 6 months (P = 0.037), history of great vascular disease (P = 0.073), increased preoperative high sensitivity C-reactive protein (hs-CRP) (P = 0.072), intraoperative hypoxemia (P = 0.025) and operation time &gt;3 h (P = 0.043). The area under the curve (AUC) was 0.766 (95% confidence interval: 0.785–0.697). The score calculated from the prognostic nomogram predicted the risk of PCCs in high-altitude areas.

Conclusion

The incidence of PCCs in resident patients living in high-altitude areas who underwent noncardiac surgery was high, and the risk factors included older age, high altitude above 4,000 m, preoperative MET &lt; 4, history of angina within 6 months, history of great vascular disease, increased preoperative hs-CRP, intraoperative hypoxemia, and operation time &gt;3 h. The prognostic nomogram of this study could help to assess the PCCs for patients in high-attitude areas undergoing noncardiac surgery.

Clinical Trial Registration

ClinicalTrials.gov ID: NCT04819698.

Surgical outcomes in patients aged 70 years and older following uterosacral ligament suspension: a comparative study

PURPOSE

The number of elderly patients bothered by pelvic organ prolapse symptoms is growing rapidly. The aim of this study was to evaluate the relationship between age and surgical outcomes in women undergoing uterosacral ligament suspension for treatment of apical prolapse.

METHODS

We performed a retrospective cohort study including women who underwent uterosacral ligament suspension between 2010 and 2020. The cohort was divided into two groups: (1) Patients 70 years or older; (2) Patients under the age of 70. Outcome measures included clinical, anatomical, and composite outcomes as well as patient satisfaction.

RESULTS

A total of 271 patients were included in the final analysis. Of them 209 patients were under age 70 and 62 patients 70 years or older. Mean age was 59 ± 6 vs. 73 ± 3 for the young and elderly age groups, respectively. Clinical success was high for both groups, reaching 94% vs. 89% for elderly and young patients, respectively (p = 0.34). Anatomical and composite outcome success were higher in the young age group (76% vs. 56%, p < 0.01 and 70% vs. 54%, p = 0.02, respectively); however, following multivariate analysis these differences were no longer statistically significant. Following multivariate logistic regression analysis for the dependent parameter of anatomical success, increased pre-operative genital hiatus and vaginal surgical route were associated with anatomical failure while performing a concomitant posterior colporrhaphy increased likelihood for anatomical success.

CONCLUSION

Women over the age of 70 undergoing uterosacral ligament suspension for treatment of apical prolapse have comparable outcomes to younger patients.

Racial and socioeconomic disparities in cost and postoperative complications following sacrocolpopexy in a US National Inpatient Database

PURPOSE

We sought to determine the association between socioeconomic factors, procedural costs, and postoperative complications among patients who underwent sacrocolpopexy.

METHODS

The 2016-2017 US National Inpatient Sample from the Healthcare Cost and Utilization Project was used to identify females > 18 years of age with an ICD10 diagnosis code of apical prolapse who received open or laparoscopic/robotic sacrocolpopexy. We analyzed relationships between socioeconomic factors, procedural costs, and postoperative complications in these patients. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs, respectively.

RESULTS

We identified 4439 women who underwent sacrocolpopexy, of which 10.7% had complications. 34.6% of whites, 29.1% of Blacks, 29% of Hispanics, and 34% of Others underwent a laparoscopic/robotic procedure. Hispanic patients had the highest median charge associated with surgical admission for sacrocolpopexy at $51,768, followed by Other ($44,522), White ($43,471), and Black ($40,634) patients. Procedure being within an urban teaching hospital (+ $2602), laparoscopic/robotic (+ $6790), or in the West (+ $9729) were associated with a significantly higher median cost of surgical management.

CONCLUSIONS

In women undergoing sacrocolpopexy, the protective factors against postoperative complications included private insurance status, a laparoscopic approach, and concurrent hysterectomy. Procedures held within an urban teaching hospital, conducted laparoscopically/robotically or in the West are associated with significantly higher costs of surgical management. Hispanic patients observe significantly higher procedure charges and costs, possibly resulting from the large number of this ethnic group living in the Western United States.

The Effect of Age on Surgical Outcomes Following Uterine Preserving Surgery for Treatment of Apical Prolapse

STUDY OBJECTIVE

The aim of this study was to evaluate the effect of age on outcomes after uterine-preserving surgical treatment for apical prolapse.

DESIGN

Retrospective cohort study.

SETTING

Female pelvic medicine and reconstructive surgery unit at a tertiary, university-affiliated teaching medical center.

PATIENTS

Women who underwent surgical management of apical prolapse with uterine preservation between 2010 and 2020. Excluded were women who had ≤1 month of follow-up and those for whom medical records were substantially incomplete.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Included in the study were 140 women who underwent apical prolapse repair with uterine preservation and who met the inclusion criteria. The cohort was divided into 2 groups: (1) women aged 65 years and older (≥65 group) and (2) women younger than 65 years of age (<65 group). Pre-, intra-, and postoperative data were compared between the groups. A total of 103 women (73.6%) were in the <65 group and 37 women (26.4%) in the ≥65 group. Mean age for the entire cohort was 58 ± 9.8 years, body mass index 25.9 ± 4.8 kg/m2, and duration of follow-up was 25.9 ± 21.0 months. Women in the ≥65 group had more comorbidities, were less sexually active, and were less likely to have a midurethral sling performed during their surgery. Clinical and anatomical success rates were somewhat higher in the ≥65 group; however, these differences did not reach statistical significance (97.3% vs 85.4%, p = .069 and 89.2% vs 81.2%, p = .264, respectively). Composite outcome success was higher in the ≥65 group (89.2% vs 72.5%, p = .039). Patient satisfaction recorded using the Patient Global Impression of Improvement questionnaire was high for both groups. A multivariable logistic regression analysis for the dependent parameter of composite outcome success was performed, during which none of the parameters investigated reached statistical significance. Subgroup analysis was performed including only women who were postmenopausal. This was done to address the possible confounding effect that menopausal status may have had on our results. No differences were found between the groups with regard to clinical, anatomical, and composite outcomes.

CONCLUSION

Uterine-preserving surgery is a safe and effective surgical treatment for women aged ≥65 years.

Quantifying the Added Value of 2 Common Frailty Measures for Predicting Adverse Outcomes After Elective Hysterectomy

IMPORTANCE

Although frailty is predictive of adverse outcomes in predominantly male general and orthopedic surgical populations, the utility of American College of Surgeons National Surgical Quality Improvement Program-based frailty measurement for hysterectomy is unclear.

OBJECTIVES

The objective of this study was to measure the added contribution of the modified frailty index (mFI) and Risk Analysis Index (RAI) for predicting adverse outcomes after hysterectomy.

STUDY DESIGN

A secondary analysis of the 2011 to 2014 American College of Surgeons National Surgical Quality Improvement database was conducted. Benign elective hysterectomy by any route was included. The primary outcome was readmission within 30 days of surgery. Secondary outcomes were major (Clavien-Dindo grade ≥3) and minor (grade 1-2) complications. The fraction of new prognostic information attributable to each frailty measure was estimated by the ratio of model likelihood-ratio χ 2 values compared with a baseline model, including American Society of Anesthesiologists classification, age, body mass index (BMI), smoking status, and surgical route.

RESULTS

Among 70,649 cases, 3.0% (95% confidence interval [CI], 2.9-3.1) were readmitted within 30 days and 2.8% (95% CI, 2.7-2.9) and 5.2% (95% CI, 5.0-5.4) had major and minor complications, respectively. The RAI provided a greater fraction of new prognostic information than the mFI when predicting readmission (4.8 vs 2.7%) and major complications (4.8 vs 2.3%). Interaction analysis showed a stronger association of frailty and outcomes among individuals undergoing abdominal hysterectomy and with BMI of 40 of higher or less than 20.

CONCLUSIONS

The RAI and mFI provided modest improvement in the ability to predict adverse outcomes, which limits its clinical utility. Surgeons may consider selective utilization among those individuals undergoing abdominal hysterectomy or with BMI of 40 of higher or less than 20.

Predictors of prolonged admission after outpatient female pelvic reconstructive surgery

OBJECTIVES

This study aimed to determine factors associated with prolonged hospital admission following outpatient female pelvic reconstructive surgery (FPRS) and associated adverse clinical outcomes.

METHODS

Using the National Surgical Quality Improvement Program database, we identified outpatient FPRS performed 2011-2016. Isolated hysterectomy without concurrent prolapse repair was excluded. Surgeries were classified as major or minor for analysis. The primary outcome was prolonged length of stay (LOS), defined as admission of ≥2 days. Secondary outcomes included complications, readmission and reoperation associated with prolonged LOS. We abstracted data on covariates, and following univariable analysis, performed backward stepwise regression analysis.

RESULTS

A total of 29645 women were included: 12311 (41.5%) major and 17334 (58.5%) minor procedures. A total of 6.9% (2033) had a prolonged LOS. On full cohort multivariable regression analysis, patient characteristics associated with prolonged LOS were older age (odds ratio [OR]: 1.1 per 10 years, confidence interval [CI]: 1.06-1.1, p < 0.001), frailty (OR: 1.8, 95% CI: 1.3-2.6, p = 0.001), and Caucasian race (OR: 1.2, CI: 1.02-1.3, p = 0.024). Associated surgical factors included having a major surgical procedure (OR: 1.3, CI: 1.2-1.4, p < 0.001), use of general anesthesia (OR: 2.0, CI: 1.5-2.6, p < 0.001) and longer operative time (OR: 2.0, CI: 1.8-2.2, p < 0.001). The occurrence of any complication (10.3% vs. 4.7%, p < 0.001), hospital readmission (4.3% vs. 1.7%, p < 0.001), and reoperation (2.7% vs. 1.0%, p < 0.001) were more likely with prolonged LOS.

CONCLUSIONS

After outpatient FPRS, 6.9% of patients experience an admission of ≥2 days. Prolonged LOS is more common in patients who are older, frail and Caucasian, and in those who have major surgery with long operative time and general anesthesia.

Health Care Disparities in Surgical Management of Pelvic Organ Prolapse: A Contemporary Nationwide Analysis

OBJECTIVES

Our objective was to compare the rate of native tissue repair (NTR) versus sacrocolpopexy (SCP) and reconstructive (RECON) versus obliterative repair (OBR) for the treatment of pelvic organ prolapse (POP), evaluating for health care disparities based on race, socioeconomic, and geographic factors.

METHODS

The National Inpatient Sample database was queried for patients older than 18 years undergoing POP surgery from 2008 to 2018. Baseline demographics, comorbidity index, socioeconomic, and hospital variables were extracted. The weighted t test, Wilcoxon test, and χ2 test were used to compare the rate of (1) NTR versus SCP and (2) RECON vs OBR. Multivariate weighted logistic regression was used to compare while controlling for confounders. Reference groups were White race, Medicare patients, northeast region, small hospital size, and rural location.

RESULTS

Of 71,262 patients, 67,382 (94.6%) underwent RECON. Patients undergoing OBR were older and had a higher comorbidity score. Multivariate analysis showed the following: (1) Black, Hispanic, and other races; (2) Medicaid patients; (3) patients at urban teaching hospitals are less likely to receive RECON. Patients in the midwest were more likely to receive RECON. Among 68,401 patients, 23,808 (34.8%), and 44,593 (65.19%) underwent SCP and NTR, respectively. Hysterectomy was more common in the NTR group. Multivariate analysis showed the following:(1) Black, Hispanic, and "other" races; (2) uninsured and Medicaid patients; (3) patients in the midwest, south, and west were at higher odds of receiving NTR. Patients in large and urban hospitals were less likely to undergo NTR.

CONCLUSIONS

Racial, socioeconomic, and geographic disparities exist in surgical management for POP warranting further study to seek to eliminate these disparities.

Predictors of postoperative complications from stress urinary incontinence procedures: a NSQIP database study

INTRODUCTION AND HYPOTHESIS

There are few studies examining patient risk factors for postoperative complications following midurethral sling (MUS) placement for stress urinary incontinence (SUI). The objective of this study was to describe 30-day postoperative complications after MUS using the National Surgical Quality Improvement Program database. Secondary objectives included rates of readmission and patient factors associated with postoperative complications and readmissions following MUS.

METHODS

We identified 16,491 women who underwent MUS for SUI between 2014 and 2018. American Society of Anesthesia (ASA) classification, medical comorbidities, readmission, reoperation, and 30-day postoperative complications were extracted. Outcomes included the 30-day postoperative complications, readmission, and reoperations. Descriptive statistics, univariate analyses, and multivariate logistic regression were used.

RESULTS

The majority of patients were white (66.9%) and had an ASA classification II (60.9%). Postoperative complications occurred in 4.2% of patients; 1.5% required readmission and 1.0% required reoperation. The most common complication was urinary tract infection (3.4%). Using multivariate logistic regression, older age, i.e., ≥80 years of age, was associated with increased odds of complication (aOR 1.77, 95%CI 1.14-2.72) and readmission (aOR 3.84, 95%CI 1.76-8.66). ASA class III and IV were associated with increased odds of complications (aOR 1.55, 95%CI 1.13-2.14, and aOR 3.06, 95% CI 1.48-5.86 respectively) and readmissions. Women of Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander descent ("other") were associated with increased postoperative complications (aOR 1.51, 95%CI 1.07-2.07).

CONCLUSION

Postoperative complications following MUS are rare. Factors associated with complications following MUS for SUI include age, ASA class, and women of "other" race.

Hysterectomy Versus Uterine Preservation at the Time of Pelvic Reconstructive Surgery

OBJECTIVE

To evaluate national trends in apical prolapse surgery with and without uterine preservation using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Based on the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, patients diagnosed with uterovaginal prolapse who underwent apical suspensions between 2013 and 2018 were identified, and procedures involving uterine preservation were differentiated from those with concomitant hysterectomy. Patient characteristics and postoperative complications were analyzed.

RESULTS

A total of 16 427 patients met inclusion criteria, with 2235 (13.6%) undergoing uterine-preservation procedures and 14 192 (86.4%) undergoing hysterectomy. Between 2013 and 2018, the rates of uterine preservation ranged from 12.8% to 15.3%, with the last 2 years having significantly lower rates. Patients in the uterine-preservation group were older (62.8 vs. 60.5 y, P < 0.001), had higher BMI (28.4 vs. 28.1 kg/m², P = 0.018), and were more likely to have diabetes (12.4% vs. 10.5%, P = 0.006) and hypertension (43.4% vs. 38.0%, P < 0.001). These patients also had higher frailty index than hysterectomy patients. Patients in the uterine-preservation group were more likely to have vaginal mesh. There were no differences between the 2 groups in length of stay or postoperative complications. On multivariate logistic regression, older age (adjusted odds ratio [aoR] 1.02, P < 0.001), higher BMI (aOR 1.01, P = 0.009), and use of vaginal mesh (aOR 2.75 P < 0.001) were associated with higher odds of uterine preservation. Uterine preservation decreased operative time about 30 minutes after controlling for confounders.

CONCLUSIONS

Patients with more comorbidities were more likely to undergo uterine-preserving surgeries, which offered reduced operative time and no differences in postoperative complications.

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.

Impact of frailty in benign gynecologic surgery: a systematic review

INTRODUCTION AND HYPOTHESIS

Frailty has been associated with increased risks of perioperative complications. This systematic review explores the associations between preoperative frailty and perioperative complications in benign gynecologic surgery.

METHODS

A comprehensive, systematic literature search was conducted using the PubMed interface for Medline, Embase, and Scopus databases through August 12, 2020. Articles were included if they described the utilization of frailty assessment tools in benign gynecologic patients in the pre- or perioperative setting. Study quality and evidence were evaluated by the Cochrane Risk of Bias Tool in Non-Randomized Studies and Grading of Recommendations, Assessments, Development, and Evaluations criteria.

RESULTS

One thousand one hundred twenty unique citations were identified, and five studies assessing frailty and perioperative outcomes were included. Three retrospective cohort studies utilized the American College of Surgeons National Surgical Quality Improvement Program database to assess the impact of frailty on perioperative outcomes in hysterectomies and pelvic organ prolapse repair procedures. One retrospective cohort study utilized a California database to assess frailty in prolapse repair surgeries. One cross-sectional study assessed frailty in new urogynecology patient visits. Four of these studies found that preoperative frailty is associated with an increased risk of perioperative complications. Overall, the evidence from the included studies is of low quality and at moderate to critical risk of bias.

CONCLUSIONS

There are few studies assessing the impact of frailty on perioperative complications in benign gynecologic surgery. This review demonstrates that preoperative frailty is significantly associated with adverse perioperative outcomes, but additional studies are needed to further explore this association.

Risk assessment for postoperative outcomes in a mixed hospitalized gynecological population by the Dutch safety management system (Veiligheidsmanagementsysteem, VMS) screening tool 'frail elderly'

Purpose

Frailty is associated with a higher risk for negative postoperative outcomes. This study aimed to determine the association between the screening tool of the Dutch safety management system, Veiligheidsmanagementsysteem (VMS) ‘frail elderly’ and postoperative complications in a gynecological population.

Methods

This cohort study included women aged 70 years or older, who were scheduled for any kind of gynecological surgery. VMS screening data (including risk for delirium, falling, malnutrition, and functional impairment) were extracted from the electronic patient records. VMS score could range between 0 and 4 patients with a VMS score of one or more were considered frail. Data on possible confounding factors and complications within 30 days after surgery, classified with the Clavien–Dindo classification, were collected. Regression analysis was performed.

Results

157 women were included with a median age of 74 years (inter quartile range 71–79). Most patients underwent prolapse surgery (52%) or hysterectomy (31%). Forty-one patients (26%) experienced any postoperative complication. Sixty-two patients (39%) were considered frail preoperatively by the VMS screening tool. Frailty measured with the VMS screening tool was not independently associated with postoperative complications in multivariable analysis (Odds ratio 1.18; 95% CI 0.49–2.82). However, a recent fall in the last 6 months (n = 208) was associated with postoperative complications (Odds ratio 3.90; 95% CI 1.57–9.66).

Conclusion

An independent association between frailty, determined by the VMS screening tool ‘Frail elderly’, and postoperative complications in gynecological surgery patients could not be confirmed. A recent fall in the last 6 months seems associated with postoperative complications.

Readmissions and perioperative outcomes for same-day versus next-day discharge after prolapse surgery

INTRODUCTION AND HYPOTHESIS

We aimed to evaluate the safety of same-day discharge (SDD) compared with next-day discharge (NDD) after prolapse surgery on a national level hypothesizing that readmission and complication rates after SDD would not be higher than NDD.

METHODS

We performed a retrospective cohort study using the National Surgical Quality Improvement Program database including 2014-2018. Current Procedural Terminology (CPT) codes were used to identify minimally invasive apical suspensions or obliterative procedures. Exclusion criteria were length of stay > 1 day, unrelated concomitant procedures, serious medical comorbidities, American Society of Anesthesiologists (ASA) Class >2, and complication during index admission. The primary outcome was 30-day readmission, and secondary outcomes included 30-day complications.

RESULTS

12,583 were included in analysis. SDD rate was 16.7%. The majority of women were white (91%) with a mean age of 59 years and mean body mass index of 28 kg/m². Medical comorbidities were similar between the SDD and NDD groups. Overall incidence of 30-day readmission was 1.7%. SDD had lower odds of 30-day readmission than NDD (aOR 0.63, 95% CI 0.41-0.98). SDD had lower odds of 30-day complications but this failed to reach statistical significance (aOR 0.67, 95% CI 0.44-1.03).

CONCLUSIONS

In this cohort, 30-day readmission and complication rates were not higher after SDD compared to NDD in women undergoing minimally-invasive apical suspension or obliterative procedures. We interpret these findings carefully given study limitations but believe our findings support the safety of SDD after minimally invasive apical suspension or obliterative procedures in a low-risk population.

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis

INTRODUCTION AND HYPOTHESIS

It is predicted that the number of women aged 80 years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly.

METHODS

The National Surgical Quality Improvement Program database was used to identify women age ≥ 80 years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications.

RESULTS

A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85 years (aOR 1.98), operative time > 3 h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications.

CONCLUSION

ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

Comparative Outcomes for Pelvic Organ Prolapse Surgery among Nursing Home Residents and Matched Community Dwelling Older Adults

PURPOSE

We compared short and long-term outcomes between nursing home residents and matched community dwelling older adults undergoing surgery for pelvic organ prolapse.

MATERIALS AND METHODS

This retrospective cohort study evaluates women 65 years old or older undergoing different types of pelvic organ prolapse repairs (anterior/posterior, apical and colpocleisis) between 2007 and 2012 using Medicare claims and the Minimum Data Set for Nursing Home Residents. Long-stay nursing home residents were identified and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race and Charlson score. Generalized estimating equation models were created to determine the relative risk of hospital length of stay 3 or more days, 30-day complications and 1-year mortality between the 2 groups. Kaplan-Meier curves were created comparing 1-year mortality between groups.

RESULTS

There were 799 nursing home residents and 1,598 matched community dwelling older adults who underwent pelvic organ prolapse surgery and were included in our analyses. Nursing home residents demonstrated statistically significant increased risk for hospital length of stay 3 or more days (38.9% vs 18.6%, adjusted RR 2.1, 95% CI 1.8-2.4), 30-day complications (15.1% vs 3.8%, aRR 3.9, 95% CI 2.9-5.3) and 1-year mortality (11.1% vs 3.2%, aRR 3.5, 95% CI 2.5-4.8) compared to community dwelling older adults. Kaplan-Meier curves illustrated similar survival findings at 1 year (11.1%, 95% CI 9.0-13.3 vs 3.2%, 95% CI 2.3-4.1, p <0.0001).

CONCLUSIONS

Despite matching on several characteristics, nursing home residents demonstrated worse short and long-term outcomes compared to community dwelling older adults, suggesting other key vulnerabilities exist that contribute additional surgical risk in this population.