Association between method of pelvic organ prolapse repair involving the vaginal apex and re-operation: a population-based, retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Vaginal apical suspension is essential for the surgical treatment of pelvic organ prolapse (POP). We aim to evaluate whether the method of apical repair is associated with different re-operation rates for POP recurrence or surgical complications. METHODS: Population-based, retrospective cohort study of all Ontario women receiving primary apical POP repairs from 2003 to 2015. Primary exposure was the method of apical POP repair. Primary outcome was re-operation for recurrent POP, and secondary outcomes were surgical procedures for genito-intestinal (GI) or genitourinary (GU) complications, fistula repair, and mesh revision or removal. RESULTS: Forty-three thousand four hundred fifty-eight women were included. Overall, the number of mesh-based apical repairs decreased over time, while the number of native-tissue repairs slightly increased (p < 0.001). Multivariable Cox proportional hazards (Cox PH) analysis demonstrated a significant increase in repeat POP operations for transvaginal mesh apical repairs (adjusted HR 1.28 [95% CI: 1.10-1.48]), but not in abdominal mesh repairs (adjusted HR 0.96 [95% CI: 0.81-1.13]) compared with vaginal native tissue apical repairs. Overall risk of repeat surgery for fistulas or GI and GU complications remained low (< 0.5%). Risk of mesh removal or revision was 11.5-11.9%, with no difference between abdominal versus vaginal mesh on multivariable analysis (adjusted HR 0.99 [95% CI: 0.78-1.26]). CONCLUSIONS: Re-operation for recurrent POP is highest in transvaginal mesh apical repairs; however, this risk did not differ between abdominal mesh and vaginal native tissue apical repairs. GI and GU re-operations are rare. There is no difference in mesh removal or revision rates between abdominal and vaginal mesh repairs.

Hysterectomy in Ontario: A Population-Based Study of Outcomes and Complications in Minimally Invasive Compared with Abdominal Approaches.

OBJECTIVE: As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. METHODS: This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). RESULTS: Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. CONCLUSION: The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

The effect of pelvic factures on future stress incontinence and pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Pelvic fractures in women significantly disrupt the pelvic floor, which may cause stress urinary incontinence (SUI) or pelvic organ prolapse (POP). Our objective was to assess the incidence of operative treatment for SUI and POP after pelvic fracture. METHODS: We used administrative data from Ontario, Canada, to conduct a retrospective cohort study. Female patients who underwent operative repair of a pelvic fracture between 2002 and 2010 were identified. The primary outcomes were the subsequent surgical treatment of SUI or POP. To compare the incidence with that of the general population, patients who had operative repair of a pelvic fracture were matched (1:2) to a person in the general population (with a propensity score to account for measurable potential confounders). Our primary analysis was a Cox proportional hazards model to compare hazard ratios (HR) in subjects with a pelvic facture and those without. RESULTS: We identified 390 female patients with a median age of 47 (IQR 30-67) years. Our median follow-up period was 5.9 (4.1-8.3) years. The absolute risk of SUI surgery after pelvic fracture was 3.3 % (13 out of 390) compared with 1.0 % (8 out of 769) in the matched general population sample. The HR for SUI surgery was 5.8 (95 % CI 2.2-15.1). The absolute risk of POP surgery after pelvic fracture was 1.8 % (7 out of 390) compared with 0.9 % (7 out of 769) in the matched general population. The HR for POP surgery was 2.3 (95 % CI 0.9-5.8). CONCLUSIONS: Among patients who had a pelvic fracture requiring operative repair, there appears to be a significantly increased chance of surgery for SUI, but not for POP.

The evaluation of stress incontinence prior to primary surgery.

OBJECTIVE: To provide clinical guidelines for the evaluation of women with stress urinary incontinence prior to primary anti-incontinence surgery. OPTIONS: The modalities of evaluation range from basic pelvic examination through to the use of adjuncts including ultrasound and urodynamic testing. OUTCOMES: These guidelines provide a comprehensive approach to the preoperative evaluation of urinary incontinence to ensure that excessive evaluation is avoided without sacrificing diagnostic accuracy. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Comprehensive evaluation of women considering surgery to treat urinary incontinence is essential to rule out causes of incontinence that may not be amenable to surgical treatment. Simplifying the evaluation minimizes the discomfort and embarrassment potentially experienced by women. RECOMMENDATIONS: 1. Thorough evaluation of each woman is essential to determine the underlying etiology of the urinary incontinence and to guide management. (II-3B) 2. Preoperative pelvic examination should be performed to identify pelvic masses that may provoke lower urinary tract symptoms (e.g., a large fibroid uterus impinging on the bladder), concomitant pelvic organ prolapse, and to rule out latent stress incontinence. All of these findings may necessitate a modification of the surgical approach. (III-C) 3. Hypermobility of the urethra should be confirmed preoperatively, as women with fixed, well-supported bladder necks are less likely to experience a cure following standard anti-incontinence procedures. (II-2B) 4. Stress incontinence should be objectively demonstrated prior to anti-incontinence surgery. (III-B) 5. The volume of postvoid residual urine should be measured prior to anti-incontinence surgery. Elevated postvoid residual volumes are uncommon and should signal the need for further evaluation of the voiding mechanism. (III-C) 6. Urinary tract infection should be identified and treated prior to initiating further investigation or therapeutic intervention for urinary incontinence. (II-2B) 7. In women presenting with pure stress incontinence that can be objectively demonstrated during examination, preoperative urodynamic testing is not necessary (II-3B). For women with other lower urinary tract symptoms and/or mixed urinary incontinence, the clinician s judgment must guide the use of preoperative urodynamic testing (II-3B). VALIDATION: These guidelines have been approved by the Urogynaecology Committee and the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.