ABSTRACT
Introduction: With the strain placed on the medical system by the ongoing surges of the Covid-19 pandemic, inpatient surgery is often suspended, and same day discharge rates are increasing. Sacrospinous ligament fixation (SSLF) is an apical suspension procedure performed retroperitoneally;retroperitoneal hemorrhage and nerve injury are potential severe complications. Given these risks, providers vary in their preference for same day discharge vs. routine overnight admission after this procedure. Objective: To establish the safety of outpatient SSLF and evaluate the frequency of complications identified during the hospital stay. Methods: This is a retrospective cohort study of women who underwent SSLF by Urogynecologists at our large, academic institution between March 2018 and October 2021. Patients were identified from the Gynecologic Enhanced Recovery Surgical database, which includes all surgical patients in the department of OBGYN. The data was collected from the electronic medical record (EMR) to track compliance and outcomes in real time for quality improvement purposes during implementation of our enhanced recovery protocol. Institutional IRB approval was obtained. Descriptive statistics were performed. Student's t-test and two-sample tests-of-proportions were used, with a p-value <0.05 denoting statistical significance. Results: A total of 165 patients underwent SSLF;23 were outpatient, and 142 were admitted for at least one night. Over 90% of patients in both groups identified as white, non-Hispanic, and English-speaking. The mean BMI for both groups was 28.8 kg/m2. The outpatient group was younger (57.9 years compared to 64.7 years;P = 0.0051);outpatients were more likely to have commercial insurance (P = 0.0143) and inpatients to have Medicare (P = 0.0282). Almost double the proportion of those in the inpatient group had anxiety and depression, but this did not achieve statistical significance. Outpatients were more likely to be never smokers (P = 0.0175) and use narcotics preoperatively (P = 0.0385). They had a lower mean ASA score (P = 0.0067), Charleston Comorbidity Index score (P = 0.0452), total length of surgery (P < 0.001), total length of anesthesia (P < 0.001), and estimated blood loss (P = 0.0142). Those who went home the same day were more likely to have been the first case (P = 0.0123), and same-day discharge rates increased significantly after the onset of the Covid-19 pandemic (P = 0.0039). Both complications that required operative intervention were identified in the post-anesthesia care unit on the day of surgery. Notably, 30-day post-operative complications were proportionally lower in the outpatient group, but this did not achieve significance. Most of the complications were urinary tract infections, including the sole complication identified in the outpatient group. Conclusions: With the ongoing Covid-19 pandemic and rapidly evolving practice patterns, it is important to establish the safety of outpatient surgery. Our study demonstrates that outpatient SSLF is safe for appropriately selected patients after routine post-operative monitoring including serial vital signs and assessment of neuropathic pain. Severe complications requiring reoperation can often be identified immediately after surgery. Thirty-day post-operative complication rates did not significantly differ between patients undergoing outpatient versus inpatient SSLF.
ABSTRACT
Objective: Raising concerns regarding safety of synthetic meshes have led to changes in practice (Zacche et al, 2018). In July 2018, a “pause” for vaginal mesh surgery has been introduced by NHS England. Then, the unprecedented challenge of Covid hit the urogynaecology service. We aim to provide an up-to- date report on surgical trends for women with pelvic organ prolapse (POP). Design: We retrospectively analysed data from the public domain Hospital Episode Statistics (HES) database, which contains information from NHS hospitals in England. Method: Surgical interventions are coded using the Office of Population Censuses and Surveys Surgical Operations and Procedures, Fourth Edition (OPCS-4). A report covering a financial year (from April until March) is released every year. We considered numbers for “all procedures”, which have been published since 2013. Results: Overall, annual POP procedures declined from over 30000 (between 2013 and 2017) to a nadir of 8848 (in 2020-2021). Following the vaginal mesh “pause”, admissions for sacrocolpopexy and sacrohysteropexy more than halved, with respective numbers of 1275 and 585 procedures (in 2016-2017) versus 471 and 245 (in 2019-2020). Sacrospinous fixation of vagina reduced to a lesser extent, from approximately 3000 in the years preceding the “pause” to 2630 in 2019-2020. Concomitantly, suspension of the uterus without mesh increased 2-fold, with a peak of 105 in 2018-2019, while there were small numbers (less than 30 per year) for infracoccygeal hysteropexy throughout the study period. Up to 2019-2020, no significant shifts in practice were noted for Manchester repairs and obliterative procedures, with admissions in the order of 200s and 400s, respectively. Of note, we counted nearly 140 vaginal repairs with mesh-augmentation in 2018-2019 and 2019-2020, while there was a negative trend for native tissue repairs. In fact, numbers for anterior and posterior repairs dropped from 9621 and 6000 (in 2017-2018) to 7414 and 4596 (in 2019-2020), respectively. The report for 2020-2021 highlighted an obvious decrease in admissions for all procedures during the Covid pandemic. Compared to the previous year, reduction rates ranged from 49.2% (colpocleisis) to 69.8% (sacrocolpopexy). Conclusions: Despite a “pause” for vaginal mesh surgery, admissions for alternative options including native tissue repairs have dropped. Procedures involving abdominal mesh have markedly decreased in the last few years. Interestingly, surgeons are still offering vaginal repairs with mesh-augmentation. However, we are unable to further comment on whether this was synthetic or biological. These trends may have an impact on the training of future urogynaecologists.
ABSTRACT
Objective: Since the release of warnings regarding mesh safety, changes in practice have been described (Zacche et al, 2018). In July 2018, NHS England introduced a “pause” for mid-urethral slings (MUS). Finally, service provision has been largely affected by the Covid pandemic. However, consequences on day-to- day practice are mainly unknown. This study aims to provide an up-to- date report on surgical trends for female stress urinary incontinence (SUI) in England. Design: This is a retrospective analysis of the Hospital Episode Statistics (HES) database, which includes public domain information on procedures performed across NHS hospitals in England. Method: Procedures were identified through the Office of Population Censuses and Surveys Surgical Operations and Procedures, Fourth Edition (OPCS-4) coding system. Each report covers a financial year (from April until March). We extracted data from “all procedures” codes, which have been published since 2013. Data between April 2012 and March 2021 are presented. Results: SUI procedures declined from 13778 in 2012-2013 to 2080 in 2020-2021. MUS was by far the first procedure for SUI until the “pause”, with numbers dropping from 4520 (2017-2018) to 765 (2018-2019). Admissions for colposuspension and autologous fascial sling (AFS) started to rise in 2017-2018, with a total of 592 admissions (from 394 in the preceding report). Following the MUS “pause”, numbers for traditional surgery increased more than 2-fold and peaked in 2019-2020, with 898 and 447 admissions for colposuspension and AFS, respectively. In 2018-2019, bulking agents (BA) became the first procedure for SUI, with 3209 admissions. Numbers for BA grew even further in 2019-2020 (n = 3771). In 2020-2021, during the Covid pandemic, admissions markedly dropped for all procedures. BA remained the first procedure for SUI, with 1480 admissions versus 346 colposuspensions and 178 AFS. Interestingly, 23 MUS were inserted following the “pause”. Surprisingly, numbers of tape removals decreased between 2018-2019 (n = 591) and 2019-2020 (n = 431). Then, they reached their nadir in the last report, with 228 admissions. Conclusions: Following the MUS “pause”, BA represents the most commonly performed procedure for SUI. Traditional surgery is gaining popularity and colposuspension appears to be the preferred over AFS. Overall, there is a marked drop in SUI procedures performed. As such, this may have a strong impact on both urogynaecologists' training and maintenance of acquired skills. Finally, although numbers have reduced, there is still a need for centres able to offer removal of MUS.