Estimating Risk of Complications after Combined Pelvic Organ Prolapse and Rectal Prolapse

Objectives: Very little data exist regarding the postoperative risks of combined pelvic organ prolapse (POP) and rectal prolapse (RP) surgery versus RP-only surgery or POP-only surgery. Thus, our objective was to estimate the risk of Clavien Dindo (CD) grades I-IV postoperative complications in women undergoing combined POP+RP surgery compared to RP-only surgery and POP-only surgery through 30 days and 1 year.

Methods: The Medicare 5% limited data set was queried from 2011 to 2018 for women aged > 65 years who underwent combined POP+RP, POP-only, and RP-only surgery. Postoperative complications were identified using Current Procedural Terminology (CPT), International Classification of Diseases (ICD)-9 and ICD-10 codes and separated into CD grades I-IV. Baseline characteristics of each group were obtained. Ordinal logistic regression models were created to estimate the increased risk of combined POP+RP surgery on CD postoperative complications through 30 days and 1 year.

Results: A total of 12,319 patients were included: 97 combined POP+RP, 925 RP-only and 11,297 POP-only. The combined POP+RP and RP-only group were older than the POP-only group (74 vs. 79 vs. 72 years old, p< 0.001) and had higher mean Charlson comorbidity indices (2.0+ 1.9 vs. 2.4+2.3 vs. 1.6+1.9). After 30 days and 1 year postoperatively, the combined POP+RP group had the highest overall complication rate (23.7% and 56.7%) followed by the RP-only group (20.4% and 55.5%) and the POP-only group (19.6% and 50.4%). At 1 year postoperatively, the RP-only group had the highest number of CD grade III and IV complications compared to the POP+RP group and the POP-only group (24.6% vs. 22.7% vs. 13.9%), p< 0.001). Although there was evidence that combined POP+RP surgery had increased risk of more severe CD postoperative complications compared to POP-only surgery, this did not meet conventional levels of statistical significance until complications were grouped into “less severe” CD I and II and “more severe” CD III and IV (Tables 1 and 2). At 30 days postoperatively, predictors that increased the risk of progressively higher CD complications included undergoing an anti-incontinence procedure, having dual Medicare/Medicaid, increasing age and higher Charleston Comorbidity Indices. Undergoing an open surgical approach increased this risk at 1 year postoperatively (Table 1).

Conclusions: This study suggests that there is an increased risk of increasing severity of complications when POP surgery is combined with RP surgery compared to POP surgery alone at both 30 days and 1 year postoperatively.