Does variation of surgical technique affect native tissue anterior pelvic organ prolapse repair outcomes?

INTRODUCTION AND HYPOTHESIS: The Variation in Surgical Technique study (VaST), demonstrated the large variation in surgical techniques used in native tissue (NT) anterior pelvic organ prolapse (POP) repairs. However, there are few comparative studies of different surgical techniques. This study was aimed at exploring whether surgical technique influenced the outcomes of NT anterior POP repairs. METHODS: The surgical techniques of 22 consultant surgeons performing NT anterior POP repairs were filmed and categorised. These surgeons performed 809 anterior repairs within the PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trial (PROSPECT). Logistical regression models were used to determine the influence of the different surgical techniques on subjective and objective outcomes, using data collected during PROSPECT. RESULTS: In adjusted multivariate linear regression models, fascial-flap repair was associated with an improved subjective outcome (POP-SS) compared with midline plication (ß = -2.50 [-4.42 to -0.57]; p = 0.01). At 12 months, separate fascial defect repair was associated with a poorer objective outcome than midline plication (OR 6.06 [1.82-3.52], p = 0.006). At 24 months, deep dissection was associated with a poorer POP-SS than superficial dissection (0.32-2.60, p = 0.0). Continuous-locking closure of the skin was also associated with improved POP-SS compared with continuous non-locking closure (12 months: ß = -1.94 [-3.42 to -0.45], p = 0.01). CONCLUSION: Surgical technique may influence the outcome of native tissue anterior POP repairs. Our results should not change practice but inform future research; to develop methods of explicitly recording surgical techniques and allow confirmation of the effect of these aspects of technique on outcome.

Surgical technique used in the UK for native tissue anterior pelvic organ prolapse repair (VaST).

INTRODUCTION: The PROSPECT study found that outcomes for native tissue and mesh prolapse repairs are similar but mesh repairs have a 10% risk of exposure. The current UK surgical mesh pause has led to renewed interest in native tissue surgery. Previous studies of native tissue anterior repair surgical techniques have been limited by the questionnaire study design. The objective of this study was to describe and categorise native tissue anterior repair surgical techniques. METHODS: This prospective qualitative study used a purposive sampling strategy to recruit surgeons. Data were collected through video-recorded observations of surgery, audio-recorded interviews with surgeons and field notes. The study took place in urogynaecology theatres in 21 UK centres. Thematic analysis was performed using computer-based software and themes of surgical technique were developed. RESULTS: Thirty consultant surgeons were recruited. In all steps of the anterior repair procedure, infiltration, dissection, method of fascial repair, type and method of suturing and suture placement, surgical technique varied between surgeons. The filming of surgery followed by immediate validation with the surgeons gave greater insight. Surgeons' terminology to describe techniques varied and the investigators' opinions of the techniques performed were not always consistent with the surgeons' descriptions. The concept of fascia in histological terms was not uniform amongst surgeons. CONCLUSION: VaST has demonstrated significant variation in native tissue anterior repair surgical techniques and inconsistency in the terminology used to describe them. These inconsistencies may prevent future meaningful research of prolapse surgery. The variation in technique could affect surgical outcomes and this should be explored further.

A UK questionnaire survey of current techniques used to perform pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: Evidence-based medicine should result in better standardisation of practice. This study aims to evaluate whether there remains variation in surgical techniques in native tissue and graft/mesh repairs of pelvic organ prolapse (POP) in UK practice. METHODS: A questionnaire survey was conducted to describe current surgical techniques for native tissue and graft/mesh POP repairs performed by a cohort of UK surgeons recruiting to a large multicentre prolapse trial (PROSPECT). RESULTS: The questionnaire return rate was 90% (n = 56 out of 62). Substantial variations in surgical techniques were seen at every step of the procedure. Native tissue repair: most surgeons used infiltration, 95% (n = 53 out of 56), but the volume used varied (10-80 ml). All but one surgeon performed a midline incision; this surgeon performed an elliptical incision. The depth of tissue dissection varied, being both above and below the vaginal muscularis (fascia). Fascial repair methods included midline, closure of separate fascial defects, paravaginal repair and rectal/levator plication. Graft/mesh repairs: many different products and manufacturers were used. There was variation in the method of attachment of graft/mesh inserts and their placement in relation to the fascia. For both native tissue and graft/mesh repairs, the method of fascial dissection, suturing methods and suture material varied. Most surgeons inserted a pack, 91% (n = 50 out of 55), soaked in varying substances before use. CONCLUSIONS: There is considerable variation between UK-based surgeons in the surgical techniques used to perform both native tissue and graft/mesh-augmented POP repairs. Further research is required to determine whether these differences influence outcome.

Evaluation of a modified early warning system for acute medical admissions and comparison with C-reactive protein/albumin ratio as a predictor of patient outcome.

The modified early warning score (MEWS) was developed as a track and trigger tool for the prompt identification of seriously ill patients on an acute medical ward. This paper examines its value in the setting of an acute medical admissions unit (MAU) and compares it to biochemical markers of acute and chronic disease. Three hundred unselected acute admissions to the MAU of the Queen Elizabeth Hospital, Gateshead, were assessed. Correlations between MEWS score and C-reactive protein (CRP) and albumin separately were assessed, and then the relationship between MEWS and the CRP/albumin ratio across the age spectrum was examined. The findings demonstrated a strong correlation between the MEWS score and CRP/albumin ratio (r=0.88, p<0.001) across the whole age spectrum. Length of stay correlated poorly with MEWS (r=0.08) and CRP/albumin ratio (r=0.15). Overall mortality was 5% and was predicted by both tools, with a MEWS score of >4 (relative risk (RR)=7.8) outperforming a CRP/albumin of >2 (RR=2.6). MEWS remains the gold standard for assessing outcome in acute medical admissions, but does have limitations in the elderly (those aged over 70 years). A raised CRP/albumin ratio was less sensitive for overall mortality than MEWS. It did, however, appear to be of greater value in the elderly, especially in those with acute exacerbations of chronic disease. Neither test accurately predicted length of stay.