32: Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women undergoing a mid-urethral sling in academic centers within the United States

Abstract

The aim of this study was to look at reoperation rates for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a primary mid-urethral sling with or without concurrent POP repair. We hypothesized that women undergoing an SUI procedure with concurrent prolapse repairs would have decreased rates of reoperation for both prolapse and stress urinary incontinence. We also theorized that concurrent hysterectomy would be associated with lower rates of reoperation for POP and SUI, while prolapse repair with mesh would be associated with higher complication rates but lower rates of reoperation. The Faculty Practice Solutions Center (FPSC) is an academic hospital consortium database with information from over 60,000 physicians. This database was used to identify a cohort of patients who were treated surgically for SUI with a mid-urethral sling, with or without concurrent prolapse repair between 2009 and 2011. These patients were followed until 2014 for any subsequent SUI or POP surgeries and for any mesh complications that occurred during this time period. Patient variables (age, region, insurance) as well as surgeon volume were analyzed. Concurrent prolapse repair was analyzed based on anatomic involvement (anterior, apical, posterior, or “complete”). Sub-analyses were performed to evaluate the differences in secondary procedures. Of the 20,484 patients who underwent an SUI repair with or without concurrent POP repair, 7.2% required reoperation within the follow up period. There was a significantly higher rate of reoperation in those women who underwent concurrent prolapse repair (8.6 vs 6.3%). Women who had a concurrent prolapse repair had a 2-to-5-fold higher hazard of undergoing a repeat prolapse repair. Concurrent hysterectomy was performed in 15% of patients. While its addition did not lower the hazard of requiring any secondary surgery, it lowered the rate of repeat prolapse surgery in patients who received a concurrent ‘complete’ repair (HR = 0.48). Prolapse mesh was placed in 5% of patients. Its use resulted in a higher hazard of requiring any additional surgery (HR = 1.4), and specifically, increased the hazard of requiring repeat prolapse repair (HR = 1.5). Post-operative fistula, although rare (0.4%), had a significant association with older patients (HR = 2.1) and prolapse mesh (HR = 2.7) placement. Medicaid insurance was associated with higher risk of requiring secondary surgery (HR = 1.3). With over 20,000 patients and up to a 5 year follow-up, this is one of the largest cohort studies performed on the surgical outcomes of mid-urethral slings with or without prolapse repair surgery. While the overall reoperation rate was low, the addition of prolapse repair surgery with the initial sling procedure was associated with higher reoperation rates. In contrast, the addition of a hysterectomy lowered the risk of secondary surgery in some patients. This data allows for a clearer understanding of reoperative rates for patients undergoing mid-urethral sling placement with or without prolapse repair.