Study identifies risk factors for recurrent pelvic organ prolapse after surgery
Women with higher BMI, greater anatomical failure and smoking had a greater recurrence of pelvic organ prolapse — or POP — within 5 years of surgery, according to a secondary analysis of the SAVE-U trial.
“Due to the scarcity in solid evidence on comparison between [sacrospinous hysteropexy and vaginal hysterectomy with uterosacral ligament suspension], strict guidelines are lacking and the choice for an operation is mainly based on surgeon’s experience and patient’s preference,” Sascha F. Schulten, MD, a PhD candidate in urogynecology at Radboud University Medical Center in The Netherlands, and colleagues wrote. “To improve shared decision-making, patient risk factors should also be considered in a personalized decision process. Knowledge of risk factors not only benefits tailored management of POP, but is also essential in prevention of POP and POP recurrence.”
Establishing a cohort
Schulten and colleagues analyzed annual 5-year follow-up data from 207 women randomly assigned to either sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension for stage 2 uterine prolapse as part of the SAVE-U trial — a nonblinded, multicenter, noninferiority randomized controlled trial conducted between 2009 and 2012.
The primary outcome was composite failure, which included prolapse beyond the hymen, bothersome bulge symptoms, repeat surgery or pessary use for recurrent prolapse. Secondary outcomes were bothersome vaginal bulge symptoms and categorization of POP Quantification (POP-Q) stage 2 or higher for overall anatomical failure in the apical, anterior, posterior or any compartment.
Risk factors
According to the researchers, composite failure occurred 164 times in 66 women during the follow-up period. Analyses showed a significantly higher risk for recurrence with higher BMI (OR = 1.1 [per 1 kg/m2]; 95% CI, 1.02-1.19), smoking (OR = 2.88; 95% CI, 1.12-7.42) and POP-Q point Ba (OR = 1.23 [per 1 cm]; 95% CI, 1.01-1.5).
Both BMI and POP-Q point Ba were associated with a greater risk for overall anatomical failure (OR = 1.15; 95% CI, 1.07-1.25; and OR = 1.14; 95% CI, 1-1.3, respectively) and anterior compartment recurrence (OR = 1.11; 95% CI, 1.02-1.22; and OR = 1.17; 95% CI, 1.02-1.34, respectively).
The study also showed that smoking was a risk factor for bothersome vaginal bulge symptoms (OR = 3.8; 95% CI, 1.48-9.75). However, having a stage 3 or 4 POP-Q before surgery significantly reduced bothersome bulge symptoms (OR = 0.32; 95% CI, 0.11-0.89). The researchers noted that bulge symptoms fluctuated over time.
“The finding that recurrences and bothersome bulge symptoms fluctuate over time is a novel and important finding that could contribute to adequate preoperative counseling and managing expectations,” they wrote.
They also found that the risk for posterior compartment recurrence was significantly greater with vaginal hysterectomy compared with sacrospinous hysteropexy (OR = 5.21; 95% CI, 2.05-13.27).
“This study adds to the evidence on risk factors for POP recurrence by providing data of long-term follow-up and multivariable analysis for multiple outcome measures,” Schulten and colleagues wrote. “These results can help in the identification of high-risk patients preoperatively, which could facilitate individualized counseling.”
Moving forward, the researchers suggested studies examine the impact of smoking and smoking cessation on prolapse surgery success and use family history and pelvic floor imaging in their analyses.