Is There a Diminishing Benefit with Increasing Time of Laparoscopic Sacrocolpopexy?

Objectives: To determine whether there is an operative time threshold beyond which laparoscopic sacrocolpopexy (LSCP) is less beneficial than abdominal sacrocolpopexy (ASCP)

Methods: The NSQIP database was used to compare patients undergoing LSCP or ASCP, with or without hysterectomy and concomitant procedures, between the years 2011 and 2018. Patients who were undergoing concomitant oncologic procedures and/or non-gynecologic procedures, emergent surgery, or had diagnostic codes for malignancy, any surgery missing an operative time, operative time lasting < 45 minutes or >8 hours, and any surgery using both abdominal and laparoscopic methods were excluded. The primary outcomes of interest were the occurrence of any major complications: transfusion, VTE, sepsis, deep or organ space surgical site infection, wound dehiscence, cerebro- and cardiovascular events, GI and GU injury, reoperation, readmission, reintubation and death; and the length of stay. Demographics, comorbidities, and preoperative laboratory values were also collected. Comparison between groups was performed using the Chi-Square, Wilcoxon Ranksum, Student’s t-test, and Fisher’s exact test where appropriate. Descriptive statistics are expressed as means and standard deviations and medians and interquartile ranges where appropriate. Multivariable regression to identify risks of complications and prolonged hospital stay was performed using logistic and negative binomial models, respectively. Missing data were addressed using multiple imputation analysis. Generalized additive models were applied to the analysis to account for non-linear relationships between dependent and independent variables.

Results: There were a total of 13,678 SCPs performed, with majority (78.6%) being LSCP. The groups were relatively similar with no significant differences in preoperative characteristics. The mean operating time was slightly less for ASCP compared to LSCP (183 +/- 83 minutes vs 191 +/- 80 minutes; p< 0.001) and the mean LOS was longer (2.2 +/-2.8 days vs 1.1 +/- 3.9 days, p< 0.001). The rate of major complications was higher for ASCP (11.3% vs 6.4%, p< 0.001). After adjusting for confounders, ASCP was not associated with an increase in the probability of major complications compared to LSCP (aOR=1.59, 95%CI:0.99-2.54) and there was no significant interaction between procedure and operative time, (aOR=1.06, 95%CI: 0.94-1.20). ASCP was still associated with a prolonged LOS (aOR=2.19, 95%CI: 2.00-2.38). The interaction between procedure and operative time was significant (aOR=0.958, 95%CI: 0.93-0.98) indicating that a longer surgery is less likely to increase LOS after ASCP but more likely to increase LOS after LSCP, however, for procedures shorter than 6 hours, LSCP was associated with a shorter LOS.

Conclusions: For surgeries lasting less than 6 hours, LSCP is associated with similar morbidity and a shorter LOS when compared with ASCP.