Vaginal prolapse surgery - surgical activity, postoperative treatment, hospital stay and convalescense

This PhD dissertation was accepted by the Faculty of Health Sciences of the University of Copenhagen, and was defended on April 30, 2004.

Official opponents: Ian Milsom, Gothenburg, Sweden, Gunnar Lose, and Lars Michael Alling Møller.

Correspondence: Marianne Ottesen, MD, Department of Obstetrics and Gynecology, Hvidovre University Hospital, Kettegaard Alle 30, DK-2650 Hvidovre. E-mail: marianne.8sen@dadlnet.dk

Dan Med Bull 2004;51:237.

ABSTRACT

This PhD dissertation consists of a summary and four original papers based on studies conducted at the Department of Obstetrics and Gynecology and the Clinical Research Unit, Hvidovre University Hospital, Denmark, and at the Danish Centre for Evaluation and Health Assessment (CEMTV), The Danish National Board of Health, from 1999-2003.

The aims of the thesis were: To elucidate the opinion among Danish gynecologists about treatment principles, advice and restrictions after vaginal prolapse surgery. To investigate hospital stay and convalescence before and during and intervention study about fast track vaginal surgery. To analyze data about vaginal prolapse surgery in Denmark. This was achieved through a validated questionnaire sent to all Danish gynecologists (n=433) in 1999, a retrospective study including 188 women operated in a conventional setting in 1996-1998, a prospective study including 41 consecutive women undergoing vaginal prolapse surgery in a fast track setting in 1999-2000, and an analysis of all cases (n=10,555) of vaginal prolapse surgery in Denmark in 1999-2001.

The doctors' choice of treatment principles and recommendations varied considerably. Examples of lifting restrictions are: 2 kg from 1-12 weeks, 5 kg from 1-12 weeks and 10 kg from 2-12 weeks. Recommended sick leave was median 6 weeks in the case of strenuous work. Non-strenuous and strenuous activities could be resumed after median 1-2 weeks and after median 4-5 weeks, respectively.

Hospital stay was reduced from median 4 days to median 1 day irrespective of the procedure, the age, and medical history of the patient. The overall risk of complications after primary vaginal prolapse surgery was comparable in the two settings. Recommended convalescence was reduced from median 6 weeks for most activities to an actual, median convalescence of <1 week for most non-strenuous activities, <2 weeks for non-strenuous work, and <4 weeks for strenuous activities and strenuous work. There was a 26% increase in the number of vaginal prolapse procedures from 1999-2001. The surgical activity and the median hospital stay at different hospitals varied considerably, i.e. from 3 to 328 cases, and from median 1 to median 4 days in 2001, respectively. 4% were reoperated due to complications. The risk of reoperation was significantly higher after vaginal procedures combined with non-vaginal prolapse procedures, and after vaginal hysterectomy compared with the Manchester procedure.

The implementation of optimized, perioperative care programs with non-restrictive advice for the convalescence period will most certainly be of substantial socio-economic benefit. However, large-scale studies and follow-up is necessary to elucidate the risk of recurrence. Further studies to provide evidence basis for choice of surgical procedure are suggested. Consensus and guidelines about treatment principles and recommendations are desirable. An optimization of the DNPR and an urogynaecologic database including options to code for complexity and recurrent procedures for quality control is recommended.