Success and failure are dynamic, recurrent event states after surgical treatment for pelvic organ prolapse

Abstract

Background: The ideal measure of success after surgery for pelvic organ prolapse has long been debated. Historically, strict definitions based on anatomic perfection have dominated the literature. However, the importance of patient-centered perception of outcomes is equally or more important when comparing the success of various prolapse surgeries. Understanding the limitations of existing outcome definitions will guide surgical outcome reporting and comparisons of pelvic organ prolapse surgeries.

Objective: This study aimed to describe the relationships and overlap among the participants who met the anatomic, subjective, and retreatment definitions of success or failure after pelvic organ prolapse surgery; demonstrate rates of transition between success and failure over time; and compare scores from the Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, and quality-adjusted life years among these definitions.

Study design: Definitions of surgical success were evaluated at 3 or 6, 12, 24, 36, 48, and 60 months after surgery for ≥stage II pelvic organ prolapse in a cohort of women (N=1250) from 4 randomized clinical trials conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Surgical failure was defined by a composite measure requiring 1 or more of (1) anatomic failure (Pelvic Organ Prolapse Quantification point Ba, Bp, or C of >0), (2) subjective failure (presence of bothersome vaginal bulge symptoms), or (3) pessary or surgical retreatment for pelvic organ prolapse. Pelvic Organ Prolapse Distress Inventory, Short-Form Six-Dimension health index, and quality-adjusted life years were compared among participants who met a variety of definitions of success and failure including novel "intermittent" success and failure over time.

Results: Among the 433 of 1250 women (34.6%) who had surgical failure outcomes at ≥1 time point, 85.5% (370 of 433) met only 1 component of the composite outcome at the assessment of initial failure (anatomic failure, 46.7% [202 of 433]; subjective failure, 36.7% [159 of 433]; retreatment, 2.1% [9 of 433]). Only 12.9% (56 of 433) met the criteria for both for anatomic and subjective failure. Despite meeting the criteria for failure in primary study reporting, 24.2% of these (105 of 433) transitioned between success and failure during follow-up, of whom 83.8% (88 of 105) met the criteria for success at their last follow-up. There were associations between success or failure classification and the 1- and 2-year quality-adjusted life years and a time-varying group effect on Pelvic Organ Prolapse Distress Inventory and Short-Form Six-Dimension health index scores.

Conclusion: True failure rates after prolapse surgery may be overestimated in the current literature. Only 13% of clinical trial subjects initially met both subjective and objective criteria for failure. Approximately one-quarter of failures were intermittent and transitioned between success and failure over time, with most intermittent failures being in a state of "surgical success" at their last follow-up. Current composite definitions of success or failure may result in the overestimation of surgical failure rates, potentially explaining, in part, the discordance with low retreatment rates after pelvic organ prolapse surgery.

Keywords: anatomic definition; pelvic organ prolapse; quality of life; quality-adjusted life years; recurrent event; reoperation; subjective definition; surgical outcomes; time to event.

Conflict of interest statement

Disclosure statement: E. Lukacz reports potential conflicts of interest: consultant for Axonics, research funding from Boston Scientific and Cogentix/Uroplasty, royalties for UpToDate. G. Dunivan reports potential conficts of interest: research funding from Pelvalon and Viveve. M. Gantz reports potential conflicts of interest: grant support from Boston Scientific. The authors Jelovsek, Barber, Harvie, Mazloomdoost, Schaffer, Sridhar, Sung, Varner and Zyczynski report no conflicts of interest.

Copyright © 2020 Elsevier Inc. All rights reserved.

Figures

Figure 1.

STROBE participant flow

Figure 2.

Overlap of Surgical Outcome Definitions at Time of Initial Failure (N=433)

Figure 3.

Dynamic success and failure states after pelvic organ prolapse surgery over time for all participants. A state of success is indicated by a black circle, state of failure indicated by a red X and retreatment for pelvic organ prolapse indicated by a blue circle. The top group are the ‘persistent success’ participants who meet the definition of success at all time points. The bottom group are ‘persistent failures’ designated by red X at all follow-up visits. The middle group are participants that move back and forth between success and failure states over the follow-up period.

Figure 4.

Dynamic success and failure states after pelvic organ prolapse surgery over time in participants in the intermittent failure/success group. A state of success is indicated by a black circle, state of failure indicated by a red X and retreatment for pelvic organ prolapse indicated by a blue circle. The top group are the ‘terminal success’ participants who meet the definition of success at the last follow-up visit. The bottom group are ‘terminal failures’ who meet the definition of failure at their last follow-up visit.