Previous literature has shown that methods for predicting perioperative risk in octogenarians, often underestimate risk of complications and that available risk calculators have poor predictive value for pelvic organ prolapse surgery (1). Patients of advanced age who opt for surgical correction of pelvic organ prolapse often choose between an obliterative or a reconstructive approach. The lower blood loss, shorter operative times and minimal anesthesia requirements associated with obliterative surgery make this approach desirable to many patients who do not wish to preserve vaginal length for sexual activity (2).

A previous study evaluated postoperative complications between reconstructive versus obliterative procedures among women aged over 75 and found no difference in complication rates (3). This study, however, was not adequately powered to detect differences in complications, including only 323 obliterative surgery patients.

Given the higher reported rate of perioperative complications in octogenarians we aimed to estimate perioperative complication rates for those choosing between obliterative or reconstructive vaginal approaches. This analysis of the National Surgical Quality Improvement Program (NSQIP) Database is the largest reported cohort of octogenarians undergoing surgery for pelvic organ prolapse and will facilitate improved patient counseling for this high-risk population. We hypothesized that there would be higher postoperative complications with the reconstructive approach, after adjustment for preoperative medical comorbidities and confounding surgical factors.

This retrospective, cohort study evaluated complication rates for octogenarian women undergoing pelvic organ prolapse surgery from 2012 to 2021 using the NSQIP database.  Patients were eligible for inclusion if they were aged 80 or older and had a diagnosis of pelvic organ prolapse for which they underwent surgery by a gynecologist or urologist. Patients were included in the obliterative surgery group if they underwent Lefort Colpocleisis, vaginal hysterectomy with total or partial vaginectomy, or vaginectomy alone, based on Current Procedural Terminology Codes. Patients were included in the reconstructive surgery group if they had an apical suspension procedure or multicompartment pelvic organ prolapse procedure by vaginal approach. Patients were excluded if they underwent single compartment prolapse surgery, since those patients would not typically be offered an obliterative approach due to the low morbidity of single compartment prolapse repair, if they underwent mesh-based prolapse surgery, or if they underwent additional surgery suggestive of an oncologic diagnosis (radical surgery or pelvic node dissection).

The primary outcome was a composite of any surgical complication occurring within 30 days of surgery. This included surgical site infection, perioperative blood transfusion, prolonged length of hospital stay (>7 days), discharge destination other than home, pneumonia, new onset renal failure, venous thromboembolism, myocardial infarction or cardiac arrest, stroke, wound dehiscence, sepsis, septic shock, reintubation, readmission, reoperation, and death within 30 days of surgery. Urinary tract infection (UTI) was excluded from the primary outcome, as it was felt that this complication was not sufficiently morbid, in most cases, to influence surgeon decision-making. Instead, UTI was evaluated as a secondary outcome. Other secondary outcomes considered were readmission or reoperation within 30 days of surgery, urinary tract injury, and any severe complication defined as Clavien-Dindo class IV complications. 

Descriptive statistics were used to summarize patient characteristics by approach (obliterative vs reconstructive). Multivariable logistic regression models were used to determine odds of complications adjusting for race, smoking status, body mass index, American Society of Anesthesiologists (ASA) classification, functional status, concurrent stress urinary incontinence procedure, concurrent hysterectomy, wound classification, and the following medical comorbidities: diabetes, known bleeding disorder, chronic obstructive pulmonary disease, and chronic steroid use. All analyses were performed using Stata 15.1 (StataCorp, LLC, College Station, TX, USA).

Four thousand, one hundred and forty-nine (4149) octogenarians met inclusion criteria, of which 2514 (60.6%) had reconstructive procedures and 1635 (39.4%) had obliterative procedures. Patients having reconstructive surgery tended to be younger (82.7 ±2.5 vs 83.4 ±2.7, p<0.001), more often ASA class 1-2 (46.1% vs 31.3%, p<0.002), and had lower rates of hypertension requiring medication (72.0% vs 75.8%, p<0.006). Reconstructive surgery was more often performed with hysterectomy (39.4% vs 14.2%, p<0.001) and less often performed with incontinence surgery (5.8% vs 15.5%, p<0.001). For those having reconstructive surgery, hospital length of stay was longer (1.47 ±1.84 days vs 1.03 ±1.31 days, p<0.001) and surgery was more often inpatient (45.7% vs 37.9%, p<0.001).

Multivariable logistic regression, adjusting for confounders, found no difference in the primary composite outcome of any complication excluding UTI between surgical approaches (Adjusted Odds Ratio, aOR 0.97 95% CI 0.76-1.24, p=0.82) or readmission (aOR 0.91 95% CI 0.64-1.30, p=0.64). Obliterative procedures was associated with a decreased odds of UTI (aOR 0.48 95% CI 0.34-0.67, p<0.001). The incidence of serious Clavien-Dindo Class IV complications occurred in 1.2% of patients.

In this cohort of octogenarians who underwent pelvic organ prolapse surgery, there was no difference in risk of complications within 30 days of surgery when comparing reconstructive and obliterative approaches, aside from UTI. 

Approximately nine precent of octogenarians experienced the primary composite outcome (any complication excluding UTI) but the incidence of serious Clavien-Dindo Class IV complications was uncommon. UTI was more common with reconstructive approaches. The sequelae of UTI can be more debilitating in individuals of advanced age. This risk could be a consideration in post-operative care protocols and monitoring.

Our study is consistent with prior literature suggesting that obliterative surgery is more common in older patients with medical co-morbidities (3). Despite tending to be older with more medical co-morbidities, patients undergoing obliterative surgery had a shorter length of stay in hospital and were more likely to have surgery completed as an outpatient procedure. Although there is known morbidity with hospital stays in the elderly, the clinical significance of a shortened length of stay is not clear. Further study into the patient/provider perspective of this difference and a cost-analysis may be beneficial to determine if this result should factor into surgical decision-making.

Reconstructive surgery was associated with an increased risk of UTI compared to obliterative surgery; nevertheless, rates of serious complications, readmission, and reoperation were low and similar between groups. These complication rates provide valuable information that can be used in preoperative counseling for women of advanced age considering surgery for pelvic organ prolapse. Patients and surgeons choosing between these two approaches may focus on anatomic outcomes, durability, and patient satisfaction-related factors.

Wherley SD, Chapman GC, Mahajan ST, Hijaz AK, Slopnick EA, Roberts K, et al. Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing pelvic organ prolapse surgery. Int Urogynecol J [Internet]. 2020 Oct 1 [cited 2023 Apr 2];31(10):2089–94.
Zebede S, Smith AL, Plowright LN, Hegde A, Aguilar VC, Willy Davila G. Obliterative LeFort colpocleisis in a large group of elderly women. Obstetrics and Gynecology [Internet]. 2013 Feb [cited 2023 Apr 2];121(2 PART 1):279–84.
Drain A, Escobar C, Pape D. Prolapse repair in the elderly patient: contemporary trends and 30-day perioperative complications. Int Urogynecol J [Internet]. 2020 Oct 1 [cited 2023 Mar 26];31(10):2095–100.

Continence 7S1 (2023) 100843
DOI: 10.1016/j.cont.2023.100843