TRENDS IN HYSTERECTOMY FOR PROLAPSE: AN ANALYSIS OF THE EFFECT OF THE COVID-19 PANDEMIC

ABSTRACT

Introduction: The COVID-19 pandemic has had a considerable and evolving impact on delivery of surgical care to patients. During the early stages of the pandemic, resource scarcity was experienced by many healthcare systems. This led to the implementation of a surgical moratorium on elective surgeries in New York State between the months of March through June 2020. Certain specialties, specifically those performing elective surgeries, experienced significant strain and transformation. Objective: This study aims to describe perioperative and intraoperative characteristics of patients undergoing hysterectomy for pelvic organ prolapse (POP) with and without concomitant urogynecology procedures between 2019-2021 at a multi-hospital healthcare system that experienced significantly strain and a subsequent moratorium on elective surgery during the first peak of the pandemic. Methods: This is a retrospective cohort analysis of all patients in a multi-hospital healthcare system in New York City who underwent hysterectomy for POP from August 19th, 2019 through August 11th, 2021. Cases were identified using procedural and diagnostic codes for hysterectomy and POP, respectively. Patients were separated into three cohorts based on dates corresponding to phases of the COVID-19 pandemic. The 'early peak' was defined from March through June 2020, coinciding with the New York State moratorium. The primary outcome was the stage of POP for patients undergoing surgery. Secondary outcomes included concomitant urogynecologic procedures, route of surgery, time from indication to procedure, length of inpatient stay, and utilization of pre-operative medical assessment/clearance (POMA). Results: A total of 253 cases were included 106 (41.90%), 15 (5.93%), and 132 (52.17%) patients in the 'pre-pandemic','early peak pandemic', and 'stable pandemic' groups, respectively. Although not statistically significant, vaginal hysterectomy approach was performed less frequently during the 'early peak pandemic' and 'stable pandemic' cohorts (P = 0.0544). The 'early peak pandemic' cohort had significantly more stage IV POP compared to other cohorts (P = 0.0021). Rates of concomitant urogynecology procedures including slings, anterior or posterior repair, or apical repair did not differ between the cohorts. Further, cystoscopy was utilized intraoperatively more frequently in the 'stable pandemic' cohort (P = 0.0272). Time from surgical indication to operation was also significantly different with patients most frequently waiting at least 3 months in the 'early peak pandemic' group (P = 0.0132). Length of inpatient stay did not demonstrate a significant difference (P = 0.3982). The most frequent postoperative complication was transient voiding dysfunction, and this was observed more commonly in the 'stable pandemic' cohort (P = 0.0236), though overall no cases were complicated by persistent voiding dysfunction or urinary retention requiring surgical intervention in any group. Conclusions: In late spring 2020, when the moratorium was lifted, surgical volume returned to pre-peak numbers. However, time from booking to day of surgery remained significantly longer during and after the 'peak'. There was a statistically significant increase in patients with stage IV POP during the 'early peak' and 'stable' pandemic periods. There was a statistically significant increase in use of precautionary measures peri and intra-operatively during the 'peak' and 'stable pandemic' periods with significant increases in use of POMA performed outpatient by anesthesia and an increased utilization of intraoperative cystoscopy.