Longitudinal Reoperation Risk after Apical Prolapse Procedures in Women Aged 65 Years and Older

Objectives: Evidence comparing the long-term reoperation risk among different surgical approaches for apical pelvic organ prolapse (POP) is limited. Our primary objective was to describe longitudinal reoperation risk among older women undergoing surgery to address apical POP. Our secondary objective was to compare risk of reoperation for prolapse and complication among different surgical approaches.

Methods: This nationwide, retrospective cohort study evaluated adult women (≥65 years old) within the national Centers for Medicare and Medicaid Services 5% Limited Data Set who underwent sacrocolpopexy (SCP), uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF), or colpocleisis (CC), or their uterine preserving equivalents, from January 1, 2011 through December 31, 2018 with follow up through December 31st 2019. The primary outcome was overall reoperation, and secondary outcomes included reoperation for POP and for complications. Rates were compared using a chi-squared test categorical variables, Wilcoxon-rank sum for continuous variables and Kaplan Meier estimates of cumulative incidence. Death and exit from CMS insurance were considered censoring events. We used cumulative incidence to calculate reoperation risk as a function of time at ≥1yr, ≥3yr, and ≥7yr.

Results: This cohort included 4,098 women who underwent surgery to treat apical POP: 1,034 underwent SCP, 717 USLS, 1,529 SSLF and 809 CC. Demographics varied among patients for each POP surgery. Patients who had a CC were older (p < 0.01), had a higher Charlson comorbidity index (p < 0.01), more likely to have diabetes (p < 0.01), COPD (p < 0.01), hypertension (p < 0.01), chronic pain (p=0.01), congestive heart failure (p < 0.01), and less likely to have a concomitant hysterectomy (p < 0.0) compared to patients undergoing SCP , SSLF or USLS. Cumulative incidence rates for reoperation are shown in Figure 1. Reoperation rates were low and increased over time. The overall reoperation risk through 7 years differed among procedure types (p < 0.01); 7.3% for CC, 10.4% for USLS, 12.5% for SCP and 15.0% for SSLF. Reoperation for recurrent POP through 7 years was 2.9% for CC, 7.3% for SCP, 7.7% for USLS and 9.9% for SSLF (p < 0.01). Reoperation for complications through 7 years was 5.3% for CC, 8.2% for SCP, 6.4% for USLS and 8.2% for SSLF (p < 0.01).

Conclusions: Surgical approach is a significant predictor of long-term risk of reoperation. CC offers the least likelihood of reoperation for prolapse, followed by SCP, while CC followed by USLS has the least risk of long-term reoperation for complication.