Intraoperative Complications During Apical Prolapse Surgery: An ACS-NSQIP Study

INTRODUCTION: Ambulatory surgical centers (ASC) offer lower costs, faster services, and higher patient satisfaction. Due to limited resources, individual patient and surgical risks are considered when determining appropriate cases to perform at an ASC. Literature is limited assessing the risk profile of apical prolapse surgeries to further consider performing these at an ASC. OBJECTIVE: To identify the rate of intraoperative complications during apical prolapse surgery utilizing a large national database. METHODS: We performed a retrospective observational study utilizing the 2022 and 2023 American College of Surgeons National Surgical Quality Improvement Program database to identify the rate of intraoperative complications during apical prolapse surgery. Women undergoing minimally invasive sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament suspension, vaginal mesh, and hysteropexy were identified using the CPT codes 57425, 57282, 57283, 57267, and 58400, respectively. The primary objective was to determine the rate of intraoperative complications during apical prolapse surgery. Intraoperative complications included an unplanned conversion to laparotomy and/or a blood transfusion within 24 hours of surgery. The rate of intraoperative complications during each type of apical prolapse surgery was analyzed as a secondary objective. Categorical data were expressed as an absolute number and percentage. Continuous data were reported as a median with range due to the skewed distribution. RESULTS: Three thousand six hundred ninety-five women patients underwent apical prolapse surgery: 2,367 (64.1%) minimally invasive sacrocolpopexy, 320 (8.7%) uterosacral ligament suspensions, 939 (25.4%) sacrospinous ligament suspension, 57 (1.5%) vaginal mesh, and 12 (0.3%) hysteropexy (Table 1). The median (range) age of the entire cohort was 65 years (54–71) and the median body mass index (BMI) was 28.0 kg/m2 (24.8–31.7). Most patients were White (73.4%) with a class 2 (67.6%) American Society of Anesthesiologists (ASA) physical status. The median preoperative hematocrit, creatinine, and International Normalized Ratio (INR) were 40.3% (38.0–42.5), 0.76 mg/dL (0.67–0.86), and 1.0 (1.0–1.0), respectively. A concomitant sling was performed in 979 cases (26.5%) and a concomitant hysterectomy was performed in 1,191 (32.3%) cases. The most common route for concomitant hysterectomy was laparoscopic/robotic (26.7%). Additional prolapse surgeries performed at the time of apical suspension were anterior and/or posterior colporrhaphy (45.0%) and paravaginal repair (0.4%). The median operative time was 136 minutes (93–193). The overall intraoperative complication rate was 0.2% (n=8) with 6 (0.2%) cases of unplanned conversion to laparotomy and 2 (0.05%) patients receiving a blood transfusion within 24 hours of surgery. The intraoperative complication rate for minimally invasive sacrocolpopexy, uterosacral ligament suspension, and sacrospinous ligament suspension were 0.2%, 0.6%, 0.2%, respectively. There were no intraoperative complications during the vaginal mesh or hysteropexy cases. The rate of unplanned conversion to laparotomy was highest amongst uterosacral ligament suspension surgeries at 0.6% (n=2). The rate of blood transfusion within 24 hours of surgery was highest amongst sacrospinous ligament suspensions at 0.1% (n=1). CONCLUSIONS: The rate of intraoperative complication at the time of apical prolapse surgery is low at 0.2%. Given the low risk of complication during an apical prolapse surgery, further consideration should be given to performing these surgeries at an ASC.Table 1