Background
Symptomatic pelvic organ prolapse is common and affects 25% to 35% of women worldwide. As this growing patient need is being met by surgeons from diverse training backgrounds, it is important to both characterize the differences in surgeon practice patterns and examine postoperative outcomes to ensure optimal patient care.
Objective
To determine the association between surgeon specialty and postoperative outcomes following surgery for pelvic organ prolapse.
Study Design
This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Gynecologic reconstructive surgery targeted database between 2014 and 2018. Pelvic organ prolapse surgeries were identified using Current Procedural Terminology codes, and surgical cases performed by urogynecologists or obstetrician-gynecologists were included for analysis. The primary outcome was any 30-day postoperative complication following prolapse surgery. The secondary outcomes were any major or minor postoperative complications, genitourinary complications, reoperation, or readmission within 30-days following surgery. Descriptive statistics were used to characterize the cohort, and pairwise analyses were used to describe the differences between the cases performed by the surgeon specialties. Multivariable logistic regression was used to control for potential confounders.
Results
A total of 3358 women underwent prolapse surgery—68% performed by urogynecologists and 32% by obstetrician-gynecologists. The 30-day postoperative complication rate was higher for surgeries performed by obstetrician-gynecologists than for surgeries performed by urogynecologists (10.7% vs 7.0%, respectively; P <.001). There was no difference in the readmission rates between the 2 groups (2.1% vs 2.0%; P =1.000). However, the reoperation rates were higher for surgeries performed by obstetrician-gynecologists (1.8% vs 1.0%; P =.040).
In a multivariable logistic regression model controlling for age, body mass index, American Society of Anesthesiology class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedure, or sling), prolapse surgery performed by a urogynecologist remained associated with nearly 40% lower odds of any 30-day postoperative complication (adjusted odds ratio, 0.62; 95% confidence interval, 0.48–0.80).
Conclusion
Prolapse surgery performed by a urogynecologist is associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.
Introduction
Symptomatic pelvic organ prolapse affects 25% to 35% of women worldwide and is expected to increase by 50% by the year 2050 because of population aging. In a query of the Centers for Medicare Services database between 2012 and 2014, Stone et al demonstrated that this growing need is being met by providers from diverse training backgrounds, with approximately 40% of Medicare prolapse surgery claims being submitted by non-urogynecologists. As the need for providers equipped to diagnose and manage prolapse increases, the importance of exploring surgeon practice patterns and operative outcomes becomes critical for optimizing patient care.
Why was this study conducted?
We aimed to determine whether the surgeon specialty (urogynecologist or obstetrician-gynecologist) is associated with differences in postoperative outcomes following surgery for pelvic organ prolapse.
Key findings
Prolapse surgery performed by a urogynecologist was associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.
What does this add to what is known?
In our cohort, the rate of concomitant apical suspension during surgery for pelvic organ prolapse was similarly low between cases performed by urogynecologists and those performed by obstetrician-gynecologists.
The association between surgeon operative volume, lower complication rate, and superior perioperative outcomes has been well-established within a variety of procedural specialties. Similar trends exist within the field of urogynecologic surgery, but few studies have investigated the impact of surgeon specialty and advanced training. In this study, we sought to determine the association between surgeon specialty and postoperative outcomes following pelvic organ prolapse surgery. We hypothesize that prolapse surgery performed by a urogynecologist (UROGYN) is associated with fewer postoperative complications than that performed by an obstetrician-gynecologist (OBG).
Materials and Methods
This was a retrospective database query of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) target file for gynecologic reconstructive surgery between 2014 and 2018. The NSQIP database captures over 150 perioperative variables, including preoperative comorbidities, intraoperative variables, and 30-day mortality and morbidity outcomes including reoperation and readmission from over 600 participating hospitals. The database uses Current Procedural Terminology (CPT) codes to report on all procedures. Data quality and interrater reliability are maintained by standardized reviewer training and systematic site audits in a process that has been previously described. , Since 2014, NSQIP has collected targeted data women undergoing reconstructive gynecologic surgery. This target file also includes additional variables not included in the general NSQIP dataset, such as parity, previous abdominal and pelvic surgery, and perioperative complications including prolonged urinary retention, ureteral obstruction and fistula, and bladder fistula. In addition, surgeon subspecialty is collected by a trained NSQIP abstractor, and a surgeon can be categorized within 1 of the following categories: gynecologic oncologist, obstetrician-gynecologist, urogynecologist, or other. This gynecology reconstruction dataset can be combined with the general NSQIP dataset using a unique numeric identifier assigned to each patient. This study was deemed exempt by the Northwestern University Institutional Review Board (STU00213609).
Within this subset of women included in the NSQIP gynecology reconstruction target file, we used CPT codes ( Appendix ) to identify all patients who underwent surgery for pelvic organ prolapse. We further categorized the prolapse procedures as apical procedures (uterosacral ligament suspension, sacrospinous ligament fixation, and sacrocolpopexy), other procedures (anterior colporrhaphy, posterior colporrhaphy, combined anterior-posterior colporrhaphy, and transvaginal mesh), and obliterative procedures. We also identified women who underwent concomitant midurethral slings and concomitant hysterectomy. Patients with partially or fully dependent functional status, American Society of Anesthesiology (ASA) classes 4 or 5, gynecologic malignancy, missing or incomplete data were excluded from analysis. The NSQIP-determined surgeon subspecialty was extracted, and cases were stratified into the following 2 groups on the basis of surgeon specialty: UROGYN and OBG. Surgeons who were identified as urogynecologists were categorized as UROGYN, whereas surgeons who were identified as obstetrician-gynecologists were categorized as OBG. The cases performed by surgeons for whom a subspecialty was not identified and those whose subspecialty was missing were excluded from this analysis.
We extracted demographic data including age, body mass index, race (which we categorized as White, Black, and other), smoking status, ASA class, and type of concomitant hysterectomy. The perioperative characteristics extracted from the database included operative time, type of procedures performed, length of stay, and 30-day postoperative complications, which are defined by NSQIP a priori. We defined major complications as any of the following: myocardial infarction, pneumonia, renal failure, sepsis, cerebrovascular accident, deep or organ space surgical site infection, wound dehiscence, unplanned reintubation, intubation for greater than 48 hours, blood transfusion, deep vein thrombosis, pulmonary embolism, cardiopulmonary arrest, and death. Minor postoperative complications were defined as urinary tract infections and superficial incisional surgical site infections. The primary outcome was the presence of any tracked NSQIP postoperative complication in the 30 days following surgery. The Secondary outcomes included major and minor postoperative complications, genitourinary complications, reoperation, and readmission in the 30 days following surgery.
We performed descriptive statistics to describe the overall study cohort and compared clinical and demographic variables between the 2 groups to identify differences between cases performed by UROGYN and OBG surgeons. The Student’s t test and Mann–Whitney U tests were used to compare continuous variables, and the chi-square (χ 2 ) and Fisher exact tests were used to compare categorical variables. The association between surgeon specialty and any 30-day postoperative complication was examined using multivariable logistic regression controlling for age, body mass index (BMI), ASA class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedures, or sling). A P value of <.05 was considered statistically significant. All data were analyzed with R version 4.0.3 (R Core Team 2020, Vienna, Austria).
Results
A total of 3558 women underwent prolapse surgery performed by a UROGYN or an OBG during the study period. The patient demographics and surgical characteristics stratified by surgeon specialty are presented in Table 1 . The mean age±standard deviation was 62±12 years, and the median BMI (interquartile range) was 28.3 (25–32) kg/m 2 . Most of the patients were White (90%) and had an ASA class of 2 (64%). OBGs performed 1126 (32%) cases, and UROGYNs performed 2432 (68%) cases. Most of the cases did not include a concomitant hysterectomy (75%) or apical suspension (60%). A combined anterior-posterior repair was the most common procedure performed in both the groups (71%).
| Characteristic | Overall N=3558 | FPMRS n=2432 | OBG n=1126 | P value |
|---|---|---|---|---|
| Age (y) a | 62.4 (11.8) | 62.5 (12.0) | 62.4 (11.5) | .85 |
| Race b | .07 | |||
| White | 1693 (90.0) | 1232 (91.0) | 461 (87.5) | |
| Black | 112 (6.0) | 74 (5.5) | 38 (7.2) | |
| Other | 76 (4.0) | 48 (3.5) | 28 (5.3) | |
| BMI (kg/m 2 ) c | 28.3 (15.2–32.2) | 29.0 (5.6) | 29.2 (5.6) | .26 |
| ASA class b | <.001 | |||
| 1 | 378 (10.6) | 232 (9.5) | 146 (13.0) | |
| 2 | 2261 (63.5) | 1530 (62.9) | 731 (64.9) | |
| 3 | 919 (25.8) | 670 (27.5) | 249 (22.1) | |
| Smoker b | 277 (7.8) | 181 (7.4) | 96 (8.5) | .29 |
| Hysterectomy b | <.001 | |||
| None | 2677 (75.2) | 1889 (77.7) | 788 (70.0) | |
| LAVH | 78 (2.2) | 23 (0.9) | 55 (4.9) | |
| TLH | 55 (1.5) | 25 (1.0) | 30 (2.7) | |
| TVH | 748 (21.0) | 495 (20.4) | 253 (22.5) | |
| Apical procedures b | <.001 | |||
| None | 2120 (59.6) | 1451 (59.7) | 669 (59.4) | |
| Uterosacral | 550 (15.5) | 441 (18.1) | 109 (9.7) | |
| Sacrospinous | 829 (23.3) | 514 (21.1) | 315 (28.0) | |
| Sacrocolpopexy | 59 (1.7) | 26 (1.1) | 33 (2.9) | |
| Other procedures b | <.001 | |||
| None | 500 (14.1) | 333 (13.7) | 167 (14.9) | |
| Anterior | 153 (4.3) | 127 (5.2) | 26 (2.3) | |
| Posterior | 227(6.4) | 183 (7.5) | 44 (3.9) | |
| Combined APR | 2515 (70.8) | 1638 (67.4) | 877 (78.1) | |
| Mesh | 157 (4.4) | 148 (6.1) | 9 (0.8) | |
| Obliterative b procedure | 62 (1.7) | 55 (2.3) | 7 (0.6) | <.001 |
| Sling b | 806 (22.7) | 624 (25.7) | 182 (16.2) | <.001 |
| Operative time (min) c | 105.0 (65.3–154.0) | 110.0 (68.0–157.0) | 93.5 (64.0–149.0) | <.001 |
| Length of stay (d) c | 1 (1–1) | 1 (0–1) | 1 (1–2) | <.001 |
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