Does parity affect type of prolapse surgery?

Troko J1, Cooper J1

Research Type

Clinical

Abstract Category

Pelvic Organ Prolapse

Abstract 453
Urogynaecology 4 - Pelvic Organ Prolapse
Scientific Podium Short Oral Session 22
Thursday 5th September 2019
16:07 - 16:15
Hall H2
Female Pelvic Organ Prolapse Surgery
1.Royal Stoke University Hospital of North Midlands
Presenter
J

Jason Cooper

Links

Abstract

Hypothesis / aims of study
It has been said that the first term pregnancy in a woman causes damage to the pelvic floor. (1) Hormonal and mechanical effects of a gravid uterus on the bladder increase the risk of urinary incontinence irrespective of mode of delivery (i.e. either vaginal or caesarean section). Vaginal delivery, particularly if prolonged in the second stage, operative, or of a large for gestational age baby increases a woman's risk of developing pelvic floor dysfunction, urinary incontinence, and prolapse. However is there variation in the risk of requiring surgery for vaginal prolapse secondary to incontinence or pelvic floor dysfunction depending on parity? This study looks at trends across different parities in a cohort of patients receiving corrective prolapse surgery.
Study design, materials and methods
614 procedures were performed between 2008 and 2019 at a university teaching hospital for repair of prolapse secondary to either incontinence or pelvic floor dysfunction. Anonymised patient details for patients who underwent surgery were collected contemporaneously into the national BSUG database and extracted retrospectively for analysis in an Excel spread sheet. All patients with missing data concerning parity were excluded (23).
Results
Over the 10 year period 591 patients had surgery for prolapse either involving the uterus, vault, anterior, or posterior vaginal wall. The average age  of the patients was 70 years, ranging from 34 to 95.  The majority of patients had two term pregnancies (45%) and parity ranged from 0 to 8. Procedures undertaken for uterine prolapse included vaginal hysterectomy (259) or hysteropexy (9) of which majority of patients had 2 term deliveries. Procedures for anterior wall prolapse repair totalled 291 including anterior colporrhaphy and transobturator insertion of mesh (TOAR Avaulta). Procedures for posterior wall prolapse included posterior colporrhaphy and mesh posterior repair (MPR) totalling 101 and treatment for vault prolapse involved sacrospinous fixation, sacrocolpocervicopexy, or colpoclesis (232). Bar hysteropexy, majority of the patients for all prolapse compartments had 2 term deliveries between averaging 42-48% of the number of patients. There was a higher rate of patients with 4 or more term deliveries requiring vault prolapse surgery (34 patients, 15%) compared with other compartment prolapses at 13, 22% (uterine); 16, 5.5% (anterior compartment); and 4,4% (posterior compartment).
Interpretation of results
The majority of patients had 2 term pregnancies prior to receiving all forms of surgery for prolapse apart from hysteropexy. This is not surprising given the national average of children per woman is currently 1.9 (2), although for this cohort of women in their 7th decade of life, the average number of children is most likely closer to 2.4. Women requesting hysteropexy had on average 1 child (25%) but no women underwent the procedure that were nulliparous. What’s more as there were a higher proportion of patients with 4 or more term deliveries requiring surgery for vault prolapse, this may be an indication that grand multiparous women are more likely to develop uterine or vault prolapse compared with other compartment prolapse. Notwithstanding, as 8.6% of women who underwent corrective surgery for vault prolapse were nulliparous, there are clearly other risk factors predisposing to vaginal prolapse apart from term delivery. The study was limited as data collected in the BSUG database did not specify whether women had vaginal deliveries or caesarean section nor did we analyze whether the women were having primary or repeat procedures.
Concluding message
On average, women from this cohort had 2 term deliveries prior to receiving prolapse surgery. Women with 4 or more deliveries were more likely to require surgery for vault prolapse and majority of women requesting hysteropexies had previously one child. With the decline in number of children per woman in the UK, will we see a reduction in the numbers of ladies requiring surgery for prolapse in the future?
References
  1. It is the first birth that does the damage: a cross sectional study 20 years after delivery - Kaman Atan I et al, International Urogynaecology Journal Volume 29 No 11 Nov 2018
  2. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/conceptionandfertilityrates/datasets/childbearingforwomenbornindifferentyearsreferencetable
Disclosures
Funding Nil Clinical Trial No Subjects Human Ethics not Req'd Retrospective data collated from national database, patients consent to data collection upon having surgery Helsinki Yes Informed Consent Yes