B. Vakili, Y.T. Zheng, N. Franco, R.R. Chesson

Louisiana State University Health Sciences Center, New Orleans, LA

OBJECTIVE:  To evaluate potential risk factors for recurrent pelvic organ prolapse (POP) after reconstructive pelvic surgery for prolapse.

MATERIALS AND METHODS:  This was a retrospective cohort study of 335 patients having undergone surgery for symptomatic POP from February 1998 to January 2004. Patients must have had at least 3 months of follow up. Variables, such as demographics, surgical route, surgical procedure, and pre-operative physical exam findings, were abstracted from the office charts. Recurrent POP was defined in one of three ways: 1) any descensus of any vaginal wall (recurrent prolapse), 2) descensus beyond the hymen (recurrent stage 3 prolapse), and 3) additional reconstructive pelvic surgery (further surgery). Statistical analysis was performed using the t-test for means comparison, Chi-Square for frequency comparison, Fisher’s Exact Test for non-parametric frequency comparison, and logistic regression to build a risk models for each measure of recurrence.

RESULTS:  In this group 134/335 (40.0%) had recurrent prolapse, 10/335 (3.0%) had recurrent stage 3 prolapse, and 44/335 (13.1%) had further pelvic reconstructive surgery. The median follow up was 10 months (3-67). The following were associated with recurrent prolapse: higher parity {3.2 vs. 2.8: [t318 = 2.454; p=0.017]}, longer post-operative follow up interval (16.6 months vs. 12.5 months: [t334 = 3.010; p=0.003]}, age greater than 60 {84/182 (46.2%) vs. 48/143 (33.6%): [÷21 =5.261; p=0.022]}, and not having a concurrent anti-incontinence procedure {56/111 (50.5%) vs. 80/224 (35.7%): [÷21 =6.683; p=0.010]}. Recurrent stage 3 prolapse was associated with age greater than 65 {8/150 (5.3%) vs. 2/175 (1.1%): [Fisher’s; p=0.049]} and a longer follow up interval {29.1 months vs. 13.7 months: [t335 = 2.635; p=0.027]}. Further pelvic surgery was associated with longer follow up {20.8 months vs. 13.1 months: [t335 = 3.916; p<0.001]}, a weaker levator contraction {1.6 vs. 2.2: [t212 = -2.560; p=0.011]} and, when measured (n=67), a larger pre-operative Pelvic Organ Prolapse-Quantification point Aa {2.2 vs. 0.48: [t65 = 3.615; p=0.001]}. Regression models were created for each outcome incorporating all possible factors (p<0.10) and using a stepwise, backwards technique. Results with odds ratios are found in the adjoining table. Variables studied but not associated with recurrence included BMI, tobacco use, menopausal status, hormone replacement therapy, prior hysterectomy, prior urogynecologic procedures, cesarean-only deliveries, suture material, and use of graft material.

CONCLUSIONS:  Surgical failures rates are variable depending upon how they are defined. Recurrence is strongly associated with time, a factor which underscores the importance of long term follow up.

Key Words:  pelvic organ prolapse, outcomes, risk factors, surgery

Recurrent prolapse (r = 0.297)	Odds Ratio [95% CI]
Follow up > 1year	2.174 [1.346, 3.509]
Age > 60	1.610 [1.012, 2.564]
Anti-incontinence procedure	0.474 [0.291, 0.774]
Recurrent stage 3 prolapse (r = 0.407)
Follow up > 1 year	7.519 [1.555, 35.714]
Age > 65	5.102 [1.053, 25.000]
Further surgery (r = 0.583)
Aa > 1 (n=67)	13.514 [2.597, 69.444]

Disclosure - Consultant: N. Franco, Lilly, AMS Inc.; RR Chesson, Lilly.