1-year Outcomes Following Bulking or Sling at the Time of Pelvic Organ Prolapse Repair

Objectives: To compare post-procedure reoperation rates for stress incontinence (SUI) in patients undergoing either mid-urethral sling (MUS) or urethral bulking (UB) at the time of concomitant repair of pelvic organ prolapse (POP).

Methods: This was a retrospective cohort study utilizing data from the Premier Healthcare Database of patients between 2001 and 2018. Using CPT codes we identified patients undergoing laparoscopic or abdominal sacrocolpopexy (SCP), anterior and/or posterior repair, vaginal graft augmentation, uterosacral, sacrospinous or illeococcygeus repair. Patients undergoing concomitant UB or MUS were identified using CPT codes: 51715 and 57287, respectively, between the years 2001 and 2018. Patients undergoing concomitant non-gynecologic surgery, Burch urethropexy, or oncologic surgery and those who did not undergo concomitant POP and incontinence correction, were excluded from the analysis. Additional data collected included demographic and comorbidity data. The primary outcome was a repeat anti-incontinence procedure at 1 year; the composite complication rate was the secondary outcome. Patients were stratified by incontinence procedure type, group comparison was performed using Wilcoxon Rank-Sum, and descriptive statistics were expressed as median and interquartile ranges. Multivariable regression was performed to determine predictors of reoperation and complications; we included variables with a p-value ≤0.2 on univariable analysis as potential confounders. A statistical significance was set at ≤0.05.

Results: Over the study period, 540 (0.6%) underwent UB and 91,005 (99.4%) underwent MUS. The UB group was older (58.1+/- 23.5 vs 55.3 +/- 13.1 years, p< 0.001), and had a higher median Charlson Comorbidity Index, 3.0 (IQR 2.0-3.0) vs 1.0 (0.0-3.0), p< 0.001. The most common concomitant POP repair in the UB group was posterior repair, 27%, and combined anterior/posterior repair in the MUS group, 28%. In the UB group the rate of a second procedure within 1 year was higher compared to MUS (7.2% vs 0.86%, p< 0.001); 4.1% underwent repeat UB and the remainder undergoing MUS. In the MUS group 0.58% underwent repeat MUS and remainder UB. After adjusting for confounders MUS was associated with a decreased probability of a repeat anti-incontinence procedure at 1 year, (aOR=0.11, 95%CI: 0.08-0.16). The incidence of any complication at 1 year was higher with UB (17.6% vs 13%, p< 0.001). This was primarily due to a higher rate of minor complications including UTI (6.7% vs 5.3%, p< 0.001) and postoperative urinary retention, (8.5% vs 4.6%, p< 0.001).

Conclusions: UB at the time of POP repair is associated with a higher rate of repeat procedure and minor postoperative morbidity up to 1 year after surgery.