5: Long-term outcomes and predictors of failure after surgery for stage iv apical pelvic organ prolapse

Abstract

To compare outcomes after uterosacral ligament suspension or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP), and evaluate predictors of prolapse recurrence. The medical records of patients managed surgically for stage IV apical POP at our institution from January 2002 to June 2012 were reviewed. Additionally, a follow-up survey was sent to these patients. The primary outcome of prolapse recurrence, was defined based on recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival-free of prolapse recurrence was estimated using the Kaplan-Meier method and Cox proportional hazards models were fit to identify a set of factors independently associated with prolapse recurrence. Of 2,633 women who had surgery for POP, 399 women (15.2%) had stage IV apical prolapse and were managed with either uterosacral ligament suspension (n = 355) or sacrocolpopexy (n = 44). Those managed with uterosacral ligament suspension were significantly older (mean 70.7 vs 62.8 years; p < 0.001) and less likely to have a prior hysterectomy (39.7% vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2% vs 38.6%; p < 0.001). Among the patients without prolapse recurrence, the median follow-up was 4.3 years (interquartile range, 1.1–7.7). Survival-free of prolapse recurrence was not different between uterosacral ligament suspension and sacrocolpopexy (p = 0.41), with 5-year rates of 88.2% and 97.6%, respectively. After adjusting for type of surgery in a multivariable model, prior hysterectomy (adjusted hazard ratio [aHR] = 2.96; 95% confidence interval [CI] = 1.47–5.93) and younger age (aHR per 10-year decrease in age = 1.57, 95% CI = 1.14–2.15) were associated with an increased risk of prolapse recurrence; uterosacral ligament suspension approached statistical significance (aHR = 3.37, 95% CI = 1.00–11.43). After adjusting for type of surgical repair, younger age and history of prior hysterectomy were independently associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival-free of prolapse recurrence were obtained with both surgical techniques.