Defining success after surgery for pelvic organ prolapse

Abstract

Objectives: To describe pelvic organ prolapse surgical success rates using a variety of definitions with differing requirements for anatomic, symptomatic, or re-treatment outcomes.

Methods: Eighteen different surgical success definitions were evaluated in participants who underwent abdominal sacrocolpopexy within the Colpopexy and Urinary Reduction Efforts trial. The participants' assessments of overall improvement and rating of treatment success were compared between surgical success and failure for each of the definitions studied. The Wilcoxon rank sum test was used to identify significant differences in outcomes between success and failure.

Results: Treatment success varied widely depending on definition used (19.2-97.2%). Approximately 71% of the participants considered their surgery "very successful," and 85.2% considered themselves "much better" than before surgery. Definitions of success requiring all anatomic support to be proximal to the hymen had the lowest treatment success (19.2-57.6%). Approximately 94% achieved surgical success when it was defined as the absence of prolapse beyond the hymen. Subjective cure (absence of bulge symptoms) occurred in 92.1% while absence of re-treatment occurred in 97.2% of participants. Subjective cure was associated with significant improvements in the patient's assessment of both treatment success and overall improvement, more so than any other definition considered (P<.001 and <.001, respectively). Similarly, the greatest difference in symptom burden and health-related quality of life as measured by the Pelvic Organ Prolapse Distress Inventory and Pelvic Organ Prolapse Impact Questionnaire scores between treatment successes and failures was noted when success was defined as subjective cure (P<.001).

Conclusion: The definition of success substantially affects treatment success rates after pelvic organ prolapse surgery. The absence of vaginal bulge symptoms postoperatively has a significant relationship with a patient's assessment of overall improvement, while anatomic success alone does not.

Level of evidence: II.

Trial registration: ClinicalTrials.gov NCT00065845.

Fig. 1

Distribution of the maximum descent of the anterior (A), apical (B), and posterior (C) vaginal segments 2 years after surgery. Pelvic organ prolapse quantification (POP-Q) measurements are made in 1-cm increments with descent to the hymen equal to 0, with negative numbers indicating support proximal to the hymen, and positive numbers indicating prolapse beyond the hymen. Point Ba, maximum descent of anterior vaginal wall; point C, maximum descent of the cervix or vaginal cuff; point Bp, maximum posterior vaginal wall. Perfect anterior and posterior vaginal wall support corresponds to a value of -3 for Ba and Bp, respectively. Corresponding POP-Q stages are listed across the top. Barber. Defining Success After Prolapse Surgery. Obstet Gynecol 2009.

Fig. 2

Venn diagram of failures rates (in parentheses) using four definitions of success: two anatomic definitions (National Institutes of Health [NIH] “satisfactory” anatomic outcome [pelvic organ prolapse quantification (POP-Q) stage 0 or 1] and “no descent beyond the hymen”), subjective cure, and no re-treatment. Universe union of N=240 represents the participants who have data on all four definitions of success in the diagram. In the Venn diagram, we assume any re-treatment over the 2-year follow-up also fails by every other definition as well. Barber. Defining Success After Prolapse Surgery. Obstet Gynecol 2009.