Objective
We sought to determine the frequency of laboratory studies after female pelvic reconstructive surgery and the rate of intervention based on the results of these laboratory values at a single institution.
Study Design
We conducted a retrospective review of all patients undergoing female pelvic reconstructive surgery for pelvic organ prolapse by 5 fellowship-trained pelvic reconstructive surgeons at a single institution from Jan. 1, 2010, through Dec. 31, 2010. Exclusion criteria were outpatient procedures, isolated hysterectomy, and a combined surgery with another surgical team performing a separate procedure. Interventions based on the number of laboratory studies were classified as minor (electrolyte repletion, repeat laboratory tests, initiation of antibiotics) or major (transfusion, delayed discharge).
Results
A total of 356 patients were included in the final dataset and 100% of patients had routine postoperative laboratory studies. A total of 8771 laboratory values were obtained with a mean of 25 ± 18 laboratory values (0-133) per patient. One-third of postoperative patients (n = 120) underwent a total of 207 interventions based on abnormal laboratory results. The majority of interventions were minor (96%). Of the 120 patients who had a minor intervention, electrolyte repletion was the most common (78%), followed by repeat blood collection (40%) and initiation of antibiotics (4%). The major intervention rate was 4% (n = 8) and all underwent transfusion. Of the 8 transfused patients, 7 demonstrated clinical instability before transfusion and 1 was transfused based on laboratory values and a significant cardiac history.
Conclusion
Routine postoperative laboratory studies are not necessary for all patients after female pelvic reconstructive surgery and more judicious use based on clinical findings may limit unnecessary minor interventions.
The prevalence of pelvic organ prolapse (POP) increases with age and the United States continues to undergo a demographic shift with an increase in the number of women >65 years. The aging US population will increase the burden on the health care system through greater demands for care. Specifically, a study conducted by Luber et al indicated that the demand for services related to pelvic floor disorders will likely increase at twice the rate of the population. In keeping with this trend, the number of pelvic reconstructive surgeries performed in the United States will likely increase in the near future.
The shifts in US demographics and recent economic constraints have led to a greater emphasis on cost containment in the delivery of health care. The appropriate utilization of laboratory tests is crucial to achieving cost-efficient health care. Although laboratory tests incur a relatively small fee on a per-test basis, they are commonly used and amount to a significant strain on the health care system. A number of guidelines are available for the appropriate utilization of preoperative laboratory evaluation. In contrast, postoperative laboratory testing is guided primarily by nonevidence-based practice patterns.
Routine postoperative laboratory studies, including metabolic panels and hematologic profiles, continue to be a common component of postoperative care pathways after pelvic reconstructive surgery. There is a paucity of literature regarding the utility of postoperative laboratory tests across all surgical disciplines and the literature that is available questions the need for routine testing. A retrospective review conducted by Skenderis et al assessed the utility of routine postoperative laboratory tests after colorectal surgery and determined whether or not abnormal laboratory values altered patient care. Review of laboratory results from the time of surgery until a maximum of the fifth postoperative day demonstrated that the overall intervention rate based on the results of postoperative laboratory values was 1.4%. Such a low intervention rate suggests that more judicious use of postoperative laboratory tests may lead to improved cost containment. Similarly, a study by Kohli et al evaluated the need for routine hemoglobin after elective gynecologic surgery and concluded that routine postoperative hemoglobin assessment in asymptomatic women does not improve patient outcomes. Our objective was to determine the frequency of routine postoperative laboratory studies after female pelvic reconstructive surgery and the rate of intervention based on the laboratory results at a single institution.
Materials and Methods
We conducted an institutional review board–approved retrospective review of all patients undergoing pelvic reconstructive surgery for POP at a single institution. All surgeries were performed by 1 of 5 fellowship-trained pelvic reconstructive surgeons from Jan. 1, 2010, through Dec. 31, 2010. Electronic medical charts were queried by the following Current Procedural Terminology codes: 57240, 57250, 57260, 57265, 57268, 57270, 57120, 57280, 57283, 57425, 57267. Patients were excluded if they underwent an outpatient procedure, had a hysterectomy without concomitant pelvic floor reconstruction, or had a combined surgery with another surgical team performing a separate procedure, such as a laparoscopic sacrocolpopexy with simultaneous rectopexy performed by colorectal surgery.
The electronic medical charts were reviewed and the following data abstracted: demographic data, preoperative POP-quantification (POP-Q) stage, history of pelvic reconstruction, medical comorbidities, coagulation status, preoperative laboratory abnormality, type of operation performed, and perioperative parameters, such as blood loss, operating time, length of hospital stay, and postoperative laboratory values. Written informed consent was not required due to the anonymous nature of the data collection and the minimal risk to patients. Charts were carefully reviewed to evaluate if the interventions took place based on the postoperative laboratory studies vs clinical signs or symptoms. Timing of laboratory orders and daily progress notes were also reviewed for indications of interventions based on routine laboratory values. The assignment of laboratory values for each laboratory test is outlined in Table 1 . All postoperative laboratory values were classified as normal, low (below our institution’s reference range), or high (above our institution’s reference range). Postoperative interventions were classified as minor (electrolyte repletion, repeat laboratory evaluation, initiation of antibiotics) or major (transfusion, delayed discharge). Results were also evaluated after stratifying those who underwent a hysterectomy and those who did not at the time of pelvic reconstructive surgery. A 2-tailed t test was used to compare continuous variables and χ 2 analysis was used to compare ordinal data. Statistical significance was determined using an alpha of 0.05.
| Laboratory test | No. of laboratory values | Components |
|---|---|---|
| CBC | 4 | White blood cells, hemoglobin, hematocrit, platelets |
| CHEM-7 | 7 | Sodium, potassium, chloride, bicarbonate, serum urea nitrogen, creatinine, glucose |
| Coagulation panel | 3 | PTT, PT, INR |
| Magnesium | 1 | |
| Phosphorous | 1 |
Results
A total of 356 patients were included in the final dataset and 100% of patients had routine postoperative laboratory tests after pelvic floor reconstructive surgery. Mean age was 60.7 ± 13.2 years (22-92) and median American Society of Anesthesiologists physical status classification score was 2 (1-3). Median parity was 3 (0-8) and 22% (79/356) of patients had undergone a previous prolapse repair. The operative characteristics are outlined in Table 2 . The majority of patients (90%) underwent an apical suspension, 56% underwent an anterior repair, and 59% underwent a posterior repair with a mean operative time of 159.2 ± 79.7 minutes (28-433) and a mean estimated blood loss (EBL) of 135.3 ± 86.0 mL (20-800). Apical suspensions were performed using a transvaginal approach in 74% of patients, a minimally invasive abdominal approach (laparoscopic or robot-assisted laparoscopic) in 21% of patients, and an open abdominal approach in 5% of patients.
| Characteristic | Value |
|---|---|
| Apical suspension | 322/356 (90.2%) |
| Apical suspension approach | |
| Transvaginal | 238/322 (73.9%) |
| Laparoscopic/robotic | 69/322 (21.4%) |
| Open abdominal | 15/322 (4.7%) |
| Anterior repair | 200/356 (56.2%) |
| Posterior repair | 211/356 (59.3%) |
| Operating time, min a | 159.2 ± 79.7 (28-433) |
| EBL, mL a | 135.3 ± 86.0 (20-800) |
| Nights in hospital a | 1.7 ± 0.9 (1-10) |
A total of 8771 laboratory values were obtained with a mean of 25 ± 18 laboratory values (0-133) per patient; 2897 laboratory values (33%) were abnormal based on the range used by our institution and 345 patients (97%) had at least 1 abnormal laboratory value. One third of postoperative patients (n = 120) underwent a total of 207 interventions based on abnormal laboratory results ( Table 3 ). The majority of interventions were minor (96%). Of the 120 patients who had a minor intervention, electrolyte repletion was the most common (78%), followed by repeat blood collection (40%) and initiation of antibiotics (4%). None of the patients undergoing electrolyte repletion had a potassium level <3.2 mEq/L or a magnesium level <1.5 mg/dL.
