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Vaginal Prolapse Surgery Vaginal prolapse surgery An epidemiological perspective Studies of native tissue repair versus implants, surgeons´ practical experiences and five year follow-up in the Swedish National Quality Register for Gynecological Surgery Emil Nüssler Department of Clinical Sciences Obstetrics and Gynecology Umeå 2019 This work is protected by the Swedish Copyright Legislation (Act 1960:729) Dissertation for PhD ISBN: 978-91-7855-113-2 ISSN: 0346-6612 New Series No: 2051 Front page illustration by Marcus Dall Overgaard, Aarhus, Denmark Layout: Birgitta Bäcklund Electronic version available at: http://umu.diva-portal.org/ Printed by: CityPrint i Norr AB Umeå, Sweden 2019 “The best thing for being sad is to learn something. That's the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honour trampled in the sewers of baser minds. There is only one thing for it then — to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting.” Merlin T.H. White, The Once and Future King i TABLE OF CONTENTS Abstract .......................................................................................................... iii Svensk sammanfattning ................................................................................. vi Dansk resumé ................................................................................................. ix Deutsche Zusammenfassung ......................................................................... xii Original papers .............................................................................................. xv Introduction and background .......................................................................... 1 Synthesis .......................................................................................................... 1 Historical overview ............................................................................................. 1 Definitions and prevalence ................................................................................... 3 Pathophysiology and risk factors .......................................................................... 3 Anatomy ......................................................................................................... 3 Age ................................................................................................................ 5 Childbirth/parity ............................................................................................... 5 Obesity ........................................................................................................... 5 Other risk factors ............................................................................................. 5 Symptoms of pelvic organ prolapse ...................................................................... 6 Local symptoms ............................................................................................... 6 Urinary symptoms ............................................................................................ 6 Sexual symptoms ............................................................................................. 6 Other symptoms .............................................................................................. 6 Pelvic organ prolapse, and taboo ........................................................................ 7 Diagnostic considerations .................................................................................... 7 The Pelvic Organ Prolapse Quantification system .................................................. 7 Size of the prolapse protrusion in relation to the hymen (centimeter hymen) ........... 8 Patient-reported symptoms ............................................................................... 8 Treatment of pelvic organ prolapse ....................................................................... 9 Non-surgical treatment ....................................................................................... 9 Adjunct therapy ............................................................................................... 9 Pelvic floor muscle training ................................................................................ 9 Menopausal hormone therapy ............................................................................ 9 Pessaries .......................................................................................................10 Surgical treatment .............................................................................................10 Native tissue repair (colporrhaphy) ......................................................................10 Mesh-augmented repair .....................................................................................11 ii Prognosis and results of surgical treatments .........................................................12 Long-term follow-up ........................................................................................12 Comparison of treatments, and introduction of surgical mesh ............................... 12 Impact of surgeon experience on operative results ..............................................16 Epidemiology of national register studies ...........................................................16 The Swedish health care system – and the link to national patient registers ........... 17 Population-based health care registers and quality registers in Sweden .................18 Terminology used in national quality registers ....................................................19 The Swedish National Quality Register for Gynaecological Surgery ........................20 Scientific rationale .............................................................................................22 Aims .............................................................................................................. 23 Methods ......................................................................................................... 24 Papers I & II .....................................................................................................24 Paper III ..........................................................................................................27 Outcome measures ............................................................................................29 Paper IV ...........................................................................................................29 Register data – risk of retreatment within 5 years ...............................................29 Validation and design of the 5-year questionnaire ...............................................30 Ethical considerations ................................................................................... 35 Statistical methods ............................................................................................35 Papers I & II ...................................................................................................35 Paper III ........................................................................................................35 Paper IV ........................................................................................................36 Results .......................................................................................................... 37 Paper I 37 Paper II 39 Paper III ..........................................................................................................43 Single-surgeon cohort .....................................................................................43 Surgeon & assistant cohort...............................................................................45 Paper IV ...........................................................................................................46 Five-year follow-up by questionnaire: validation .................................................52 General discussion ........................................................................................ 55 Papers I & II .....................................................................................................59 Paper III ..........................................................................................................60 Paper IV ...........................................................................................................61 Conclusion ..................................................................................................... 63 Further research ................................................................................................63 Acknowledgements ....................................................................................... 64 References .................................................................................................... 65 Appendix Paper I-IV iii ABSTRACT Background Pelvic organ prolapse (POP) is a common condition that impacts on quality of life for many women. The mean age of Swedish women operated for POP is 60 years, and with a life expectancy of approximately 84 years this means that the average patient will live 24 years subsequent to the operation. Therefore, sustainable long-term
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