14: Perioperative outcomes in patients with autoimmune connective tissue disorders (AICTDs)

Abstract

To compare rates and severity of perioperative complications following pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery in patients with and without autoimmune connective tissue disorders (AICTD). The secondary objective was to evaluate pre- and postoperative pelvic floor symptoms including a POP and SUI symptom recurrence. In this retrospective cohort study, we identified patients with AICTDs by ICD-9 codes and those known to surgeons. Controls without AICTDs were matched to the primary POP or SUI procedure and surgeon. Primary outcome was complication rate up to 6 weeks postoperative. Secondary outcomes were preoperative and postoperative pelvic floor symptoms including symptoms of a bulge or stress incontinence, and need for reoperation or pessary placement for recurrent POP or SUI. A sample size of 88 patients with AICTDs and 88 controls was calculated to detect a 20% difference in complications with 80% power and a significance level of 0.05. We identified 84 patients with AICTDs and 84 matched controls. The distribution of AICTDs included rheumatoid arthritis (50%), Sjögren’s disease (17%), systemic lupus erythematosus (9%), psoriatic arthritis (5%), polymyositis (4%), mixed connective tissue disorders (4%), scleroderma (2%), and other autoimmune connective tissue disorders (9%). Race, ethnicity, age (mean 62.3 years old), tobacco use (6%), prior POP (7.1%), and SUI (19.1%) surgery, and prior hysterectomy (6%) were similar between groups. AICTD patients and controls were mostly post-menopausal (79.2%) and had similar vaginal parity (mean 2.2). AICTD patients had higher BMI (30.1 vs. 27.4, p < 0.0050) and baseline Charlson Comorbidity scores (2.5 vs. 1.1, p < 0.0001). Eighty-eight percent of patients had POP surgery comprised of 73% apical support procedures, 79% posterior repairs, and 58% anterior repairs. Forty-eight percent had concomitant hysterectomy and 62% had SUI surgery with the majority being mid-urethral slings (54%). Patients with AICTDs had more blood loss (128.2 vs. 93.9 ml, p = 0.0196) and more total perioperative complications (25% vs. 10%, p = 0.0079). However, there were no differences between groups in rates of specific categories of preoperative complications (see Table 1). For those with at least one postoperative complication, there was no difference in Clavien-Dindo grades between groups. Seventy-five percent of complications were classified as grade I, 13% as grade II, 8% as grade III, 4% as grade IV, and there were no grade V complications. Of the 84 patients with AICTDs, 17 (20%) are on daily systemic oral steroids, 25 (30%) are on immunomodulators or disease-modifying medications, and 9 (11%) are on both. Use of systemic oral steroids, immunomodulators, or disease-modifying medications did not impact the rates of complications. There were no differences in POP recurrence (4%), SUI recurrence (9%), de novo SUI (4%), additional SUI treatment (1%), and preoperative and postoperative symptoms or anatomic outcomes between groups. Patients with AICTDs have more severe medical co-morbidity as defined by the Charlson Comorbidity score, and higher overall complication rates following surgery for POP and SUI compared with matched controls.