Impact of hospital and surgeon case volume on morbidity in colorectal endometriosis management: a plea to define criteria for expert centers.

National and international guidelines recommend referring patients with severe forms of endometriosis to expert centers. However, there is a lack of clear criteria to define an expert center. We examined the roles of surgeon and hospital procedure volumes as determinants of morbidity in deep infiltrating endometriosis of the rectum and sigmoid colon (DIERS). METHODS: We conducted a French retrospective multicenter study of hospital facilities performing colorectal surgery for DIERS in 2015. The primary end point was to analyze the relation between case volume and the incidence of complications. We estimated the optimal cut-off (OCO) determined by a minimal p-value approach. RESULTS: The study included 56 hospital facilities and collected data of 1135 cases of surgical management of colorectal endometriosis. The mean and median number of procedures per year and per surgeon were 9.17 and 5.58, respectively. The overall rate of grade III-V complication was 7.6% (82/1135). One grade V complication occurred. The rates of rectovaginal fistula, anastomotic leakage, pelvic abscess, and ureteral fistula were: 2.7% (31/1135), 0.79% (9/1135), 3.4% (39/1135), and 0.70% (8/1135), respectively. An OCO of 20 procedures per center and per year (p < 0.001) was defined. The OCO per surgeon and per year varied between seven (p = 0.007) and 13 procedures (p = 0.03). In a multivariate analysis, we found that only the volume of activity was independently correlated to complication outcomes (p = 0.0013). CONCLUSION: Our results contribute to providing objective morbidity data to determine criteria for defining expert centers for colorectal surgery for endometriosis.

Genital prolapse repair using porcine skin implant and bilateral sacrospinous fixation: midterm functional outcome and quality-of-life assessment.

OBJECTIVES: To evaluate the midterm anatomic and functional outcome of genital prolapse repair by the vaginal route using a porcine skin implant (Pelvicol) and bilateral sacrospinous fixation. METHODS: From May 2001 to June 2006, 101 patients with Stage III-IV genital prolapse were treated using a porcine skin collagen implant and bilateral sacrospinous fixation. The functional results were evaluated using the Pelvic Floor Distress Inventory short form, Pelvic Organ Prolapse Distress Inventory-6, Colorectal Anal Distress Inventory-8, Urogenital Distress Inventory-6, Pelvic Floor Impact Questionnaire-7 (including Urinary Impact Questionnaire-7, Pelvic Organ Prolapse Impact Questionnaire-7, and Colo-Rectal-Anal Impact Questionnaire-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. RESULTS: Of the 101 patients, 89 (88%) completed all the questionnaires. The mean follow-up was 38 +/- 18 months. An improvement was noted in the Pelvic Organ Prolapse Distress Inventory-6 (P < .0001), Urogenital Distress Inventory-6 (P = .001), and Pelvic Floor Distress Inventory scores (P < .0001) but not in the Colorectal Anal Distress Inventory-8 scores. An improvement was noted in the Urinary Impact Questionnaire-7 (P < .0001), Pelvic Organ Prolapse Impact Questionnaire-7 (P < .0001), and Pelvic Floor Impact Questionnaire Short Form 7 (p < 0.0001) scores but not in the Colo-Rectal-Anal Impact Questionnaire-7 scores. The quartile distribution showed that women with a preoperative Pelvic Floor Distress Inventory-short form score >133 had a 45% chance of postoperative improvement and those with a preoperative Pelvic Floor Impact Questionnaire Short Form 7 score >195 had an 81% chance of postoperative improvement. Using multivariate regression analysis, the preoperative Pelvic Floor Distress Inventory score was negatively predictive of satisfaction (t = -2.03, P = .05) and the preoperative Pelvic Floor Impact Questionnaire Short Form 7 score was positively predictive of satisfaction (t = 2.40, P = .02). No differences in the pre- and postoperative Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores were noted. CONCLUSIONS: The results of our study have shown that biologic implantation and bilateral sacrospinous fixation are effective in high-grade genital prolapse repair. Validated questionnaires are potentially useful tools to predict the postoperative outcome.