Women with both vaginal prolapse and rectal prolapse likely represent a patient population with more severe pelvic floor dysfunction. Postoperatively, these patients may be at increased risk of complications as well as prolapse recurrence. In this study, the first primary objective was to compare the <30-day postoperative complications in women undergoing combined pelvic organ prolapse (POP) and rectal prolapse (RP) surgeries to those undergoing POP-only surgery and to determine preoperative predictors of <30-day complications. The second primary objective was to compare POP recurrence in women undergoing combined POP+RP surgery to those undergoing POP-only surgery and to determine predictors of POP recurrence.

This was a multicenter, retrospective cohort study at five academic hospitals and part of the AUGS-SGS Fellows Pelvic Research Network. Patients undergoing combined RP+POP surgery were matched by age, POP stage by leading compartment and POP procedure to those undergoing POP-only surgery from March 2003 and March 2020. Primary outcome measures were <30-day complications separated into Clavien-Dindo (CD) classes as well as 1) subsequent POP surgeries and 2) POP recurrence defined as patients who complained of vaginal bulge symptoms postoperatively. Data and percentages are presented for the combined surgery group followed by POP-only surgery group.

Two hundred and four women underwent combined surgery for RP+POP and 204 women underwent surgery for POP only. Average age (59.3+1.0 vs 59.0+1.0) and parity (2.3 vs 2.6) was similar in each group and most women were Caucasian (75.5% vs 76.0%). A higher proportion of combined patients had lower BMIs (25.3+0.4 vs 26.8+0.3, p<0.001), were more likely to be current smokers (13.2% vs 4.4%, p<0.001), were diagnosed with a connective tissue disorder (9.3% vs 2.0%, p<0.001) and had a psychiatric diagnosis (37.2% vs 16.2%, p<0.001). Average follow-up time was 307.2+31.5 days for the combined cohort and 487.7+49.9 days for the POP-only cohort.
A majority (68.1%) underwent abdominal POP repair while 31.9% underwent transvaginal POP repair only. The proportion of patients undergoing open versus minimally-invasive surgical (MIS) abdominal POP repair was similar between groups (30.9% vs 30.2% and 69.1% vs 69.8%). More anti-incontinence procedures (36.8% vs 57.8%, p<0.001) and hysterectomies (39.7% vs 48%, p=0.09) were performed at the time of surgery in the POP-only cohort.
One hundred and nine patients (26.7%) had at least one 30-day complication. The proportion of patients who had a complication in the combined group and POP-only group was similar (27.0% vs 26.0%, p=0.82). CD scores were similar between the groups (10.3% vs 9.3% Grade 1, 11.8% vs 12.3% Grade 2, 3.9% vs 4.4% Grade 3, 1.0% vs 0% Grade 4, 0.5% vs 0% Grade 5). Combined patients were less likely than POP-only patients to develop postop UTIs and urinary retention, but were more likely to be treated for wound infections and pelvic abscesses. Both groups had a similar number of patients who underwent reoperations for bleeding and mid-urethral sling release, although fewer combined patients underwent reoperation for small bowel obstruction. One patient in the combined group developed colonic perforation after combined sacrospinous hysteropexy and Delorme repair and subsequently died.
After adjusting for combined vs POP-only surgery, patients who had anti-incontinence procedures (aOR=1.85, 95% CI 1.16, 2.94, p=0.02) and perineorrhaphies (aOR=1.68, 95% CI 1.05, 2.70, p=0.02) were more likely to have <30-day postoperative complications.
Twelve patients in the combined group and 15 patients in the POP-only group (5.9% vs 7.4%, p=0.26) had subsequent POP repair. In the combined group, 10 patients (4.9%) underwent one repair and 2 patients (1.0%) underwent two repairs. All patients who had recurrent POP surgery in the POP-only group had one subsequent POP repair. Twenty-one patients in the combined surgery and 28 patients in the POP-only group (10.3% vs 13.7%, p=0.26) reported recurrent POP.
On multivariable analysis adjusted for number of prior POP repairs, combined vs POP-only group and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent POP surgery if they had had 2 or more prior POP repairs (aOR=6.06, 95% CI 2.10, 17.5, p=0.01). A multivariable model for predicting recurrent POP was created by adjusting for combined vs POP-only group (aOR=0.65, 95% CI 0.35, 1.22), minimally-invasive (MIS) POP repair (aOR=0.57, 95% CI 0.31, 1.06), perineorrhaphy (aOR=0.51, 95% CI 0.24, 1.08) and multiparity (aOR=0.83, 95% CI 0.26, 2.69). Risk factors were not statistically significant but the overall model did indicate that these variables may be significant in predicting which patients are more at risk of recurrent POP (p-value 0.04 and AUC 0.66).

In our cohort of patients, 26.7% of patients had at least one <30-day complication and the proportion of patients with a postoperative complication was similar between the combined group and POP-only group. Most of these complications were minor requiring antibiotics or foley catheter placement. Patients in the POP-only group were more likely to develop postoperative UTIs (5.4% vs 6.9%) and urinary retention (4.4% vs 7.4%), which may be attributable to the higher number of anti-incontinence procedures performed in this group. Patients in the combined group were more likely to be treated for wound infections (2.5% vs 2.0%) and pelvic abscesses (1.5% vs 1.0%). Some studies suggest that operating time > 180 minutes and increased intraoperative blood loss are risk factors for postoperative infections. Surgical time and blood loss are more likely to be elevated in combined procedures where surgeons dissect and repair both the pelvic organs and the rectum.
Anti-incontinence procedures and perineorrhaphies were both risks factors for developing <30-day complications. As previously discussed, patients may be at increased risk for urinary retention and UTIs after anti-incontinence procedures. Perineorrhaphies may increase the risk of wound infection or wound cellulitis as stitches are placed between the vagina and rectum.
In both groups, a similar number of patients reported symptomatic POP recurrence (10.3% vs 13.7%) and underwent subsequent POP surgery (5.9% vs 7.4%). Although fewer patients reported postoperative vaginal bulge symptoms and had subsequent POP surgery in the combined group, the average follow up time was 180 days less compared to the POP-only group. If these patients had been followed for a longer time period, it is possible that more patients would have complained of symptomatic recurrent POP and undergone POP surgery. In this cohort, the only significant risk factor for having a subsequent POP surgery was a history of 2 or more prior POP repairs. On multivariable analysis, protective factors for subsequent POP surgery which approached significance included undergoing a combined POP+PR repair, undergoing an MIS POP repair, having a perineorrhaphy at the time of surgery and multiparity. Patients who have combined surgery may have significant improvement in their pelvic floor support by suspending both the rectum and the pelvic organs. This double reinforcement may outweigh the higher risk of prolapse recurrence that can occur with more severe pelvic floor dysfunction.

In conclusion, in this retrospective cohort study, patients undergoing combined POP+RP surgery had a similar risk of <30-day postoperative complications compared to patients undergoing POP-only surgery. Combined patients also had a similar risk of recurrent POP and subsequent POP surgery compared to patients undergoing POP-only surgery.

Continence 2S2 (2022) 100234
DOI: 10.1016/j.cont.2022.100234