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Long-term Reoperation Risk after Mesh-Augmented versus Native Tissue Transvaginal Prolapse Repair

Wednesday, October 4, 2023

5:20 PM – 5:30 PM US PST

Location: Oregon Ballroom

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Image Label: Breakdown of reoperation for complications or sequelae of index surgery

Presenting Author(s)

Nemi M. Shah, MD

Urogynecologist
TriValley Urology, United States

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Co-Author(s)

JT

Jasmine Tan-Kim, MD

Attending Physician
Kaiser Permanente San Diego
San Diego, California, United States
Shawn Menefee, MD

Division Director
Kaiser Permanente
San Diego, California, United States

Disclosure(s):

Nemi M. Shah, MD: No financial relationships to disclose

Jasmine Tan-Kim, MD: No financial relationships to disclose

Shawn Menefee, MD: Neuspera: Research Funding (Ongoing)

Objective: To compare the incidences of all-cause reoperation among mesh-augmented, graft-augmented, and native tissue transvaginal apical prolapse repairs over a period of two through 15 years.

Methods: This multicenter, retrospective cohort study included adult women who underwent mesh-augmented, graft-augmented, or reconstructive native tissue transvaginal repair of apical prolapse (sacrospinous ligament fixation, uterosacral ligament suspension) from January 2006 through December 2018 with follow-up through July 2021. Women who underwent concomitant rectal prolapse repair were excluded. Data were abstracted using procedural and diagnosis codes. The primary outcome was all-cause reoperation, including reoperations for recurrent prolapse and adverse events or sequelae, over the study follow-up period. Rates of reoperation were compared using a chi-square test. Time-to-event distributions were contrasted with a log rank test with correction for multiplicity. Censoring events included exit from the health maintenance organization and death.

Results: The final cohort included 6,891 women with mean age of 58.9 (standard deviation ±11.2) years and body mass index of 28.3 kg/m2 (±5.1) at the time of index surgery. Most women were postmenopausal (80.5%) and either Hispanic (47.7%) or White (41%). The overall all-cause reoperation rate was 7.6%, or 10.9 reoperations per 1,000 patient-years. Graft-augmented prolapse repairs had the highest all-cause reoperation rate of 11.1%, followed by mesh-augmented (9.5%) and native tissue (7.3%) repairs (P=0.02). Pairwise comparisons of time-to-event distributions, however, were not significant (P=0.23-0.71).

Of the three groups, mesh-augmented prolapse repairs had the highest rate of reoperations for complications at 5.5% as compared to graft-augmented (2.3%) and native tissue (1.2%) repairs (P < 0.001). Only the pairwise comparison of time-to-reoperation between mesh-augmentation versus native tissue was significant with P < 0.001. 91.4% of the reoperations for complications in the mesh-augmented group were for mesh excision. Approximately 20% of the reoperations for complications were for graft excision in the graft-augmented group.

Graft-augmented repairs demonstrated the highest rate of reoperations for recurrent prolapse at 9.3%, while native tissue repairs had the second highest rate (6.3%). Mesh-augmented repairs had the lowest reoperation rate for recurrence at 4.6% (P =0.04). The number of reoperations per patient-years in the mesh-augmented group was significantly lower than that of the native tissue group (P=0.02) with a trend towards being lower than the graft-augmented group that did not meet statistical significant after Bonferroni correction (P =0.06). The most commonly performed reoperation for prolapse across all groups was posterior colporrhaphy (48.8%).

Conclusions: All-cause reoperation per patient-years across mesh-augmented, graft-augmented, and native tissue prolapse repairs were similar in this cohort of over 6,800 women. In the subset of patients selected to undergo mesh-augmented repairs, benefit over native tissue was demonstrated in terms of durability but at the cost of increased operative complications. Graft-augmented repairs in this cohort did not demonstrate a clear advantage in terms of durability or safety.