Obesity and retropubic surgery for stress incontinence: Is there really an increased risk of intraoperative complications?

doi:10.1016/j.ajog.2006.07.012

American Journal of Obstetrics and Gynecology

Volume 195, Issue 6, December 2006, Pages 1794-1798

https://doi.org/10.1016/j.ajog.2006.07.012 Get rights and content

Objective

The objective of the study was to evaluate the impact of obesity on length of surgery, blood loss, and intra- and postoperative complications in women who underwent retropubic surgery for stress urinary incontinence.

Study design

Of 449 women participating in a multicenter, randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti-incontinence procedures. This is a prospective nested cohort study of these women, 79 (32%) of whom were obese (body mass index 30 or greater) and 171 (68%) overweight or normal weight (body mass index less than 30). Data collected included demographic variables, past medical history, physical examination, and intraoperative and postoperative complications. Data were analyzed with Fisher's exact for dichotomous variables, Student t tests for continuous variables, and analysis of variance for multivariate analysis. Significance was set at P < .05.

Results

Obese women undergoing stress urinary incontinence surgery were younger than nonobese women (48.7 versus 51.9 years, respectively, P < .019). The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P = .006) or abdominal paravaginal repairs (P = .001); therefore, estimated blood loss, change in hematocrit, length of stay, surgery, and suprapubic catheterization comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 versus 284 P = .03); however, change in hematocrit was lower for obese than nonobese women (6.6 versus 7.3, P = .048). Mean length of surgery was 15 minutes longer in obese women (P = .02). Length of hospital stay did not vary between groups (P = NS). Major intraoperative complications were uncommon (14 [5.6%]), with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections, or postoperative major complications were likewise similar between groups (all P > .05).

Conclusion

Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications.

Section snippets

Material and methods

Women participating in a multicenter, randomized trial to evaluate the use of prophylactic antibiotics in women who had suprapubic catheters placed after surgery for SUI were eligible to participate. All 6 sites obtained institutional review board approval. Two hundred fifty of the 449 women (56%) recruited for the main study underwent retropubic urethropexy as well as other reparative procedures, gave BMI data, and were included in the present analysis. Results of the main study have been

Results

Two hundred fifty women underwent retropubic urethropexy and gave BMI data, of whom 79 (32%) were obese, 92 (36%) overweight, and 79 (32%) normal weight. No differences in demographic or outcome variables between overweight and normal-weight women were observed (all P = NS); therefore, all comparisons are between obese and nonobese women. Retropubic procedures performed included 168 open Burch (67%), 12 laparoscopic Burch (5%), 44 Marshall-Marchetti-Krantz (18%), and 25 Ball-Burch procedures

Comment

Results of the National Health and Nutrition Examination Survey 1999 to 2000 indicate that an estimated 64% of U.S. adults are either overweight or obese.⁵ Obese women are at increased risk for SUI with each 5-unit increase in BMI, resulting in a 60% to 100% increase in the risk of daily incontinence.6, 7 Weight loss as small as 5% to 10% of body weight results in significant reduction of incontinence symptoms and should be part of the first line therapy for SUI for obese women.6, 7 Weight

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Cited by (34)

Pelvic floor dysfunction and obesity
2023, Best Practice and Research: Clinical Obstetrics and Gynaecology
Obesity is a growing condition within the society and more patients, who have underlying obesity, are presenting with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction (PFD). The effect of obesity on general health has been well documented, and its impact on the cardiovascular, endocrine, and musculoskeletal systems has been extensively studied. There is now a growing body of evidence on the effects of obesity on the female urogenital system. It seems to influence the prevalence, presentation, assessment, management, and outcome of various types of LUTS and PFD.
A holistic approach is needed to assess and manage these patients. A clear understanding of the functions of the pelvic floor and the way it can be affected by obesity is essential in providing holistic care to this group. A frank discussion about patient weight is required in the clinics handling PFD. A multimodal approach to weight loss would help improve PFD symptoms and progression.
Patients with obesity should still be offered standard treatment options for all PFDs and should not be forced to lose weight as a prerequisite before starting treatment. However, they should also be made aware of the impediments that being overweight adds to their care and their expectations should be managed accordingly.
Impact of obesity on operative complications and outcome after sacrocolpopexy: A systematic review and meta-analysis
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Some studies have suggested that obesity may influence the complication rate and effectiveness of sacrocolpopexy, but this remains a matter of debate. A retrospective study of women with pelvic organ prolapse undergoing sacrocolpopexy reported that obesity may increase the risk of both perioperative and postoperative complications [7], but another study found no significant difference in complications between obese women and those of healthy weight [8]. Regarding surgical effectiveness, the general view is that gynaecologic surgery is associated with increased morbidity in obese patients [9].
Surgery is required by many obese women with pelvic organ prolapse, and sacrocolpopexy is considered to be an effective method to correct apical prolapse. However, to the authors’ knowledge, epidemiological studies have not been summarized formally.
A systematic literature search of Pubmed, Medline (Ovid) and Embase databases was undertaken for articles written in English. Statistical analysis was performed using Revman 5.3.
In total, 7315 patients in 12 studies were included in this meta-analysis. No significant differences were found between obese women and non-obese women in terms of re-operation rate [risk ratio (RR) 1.19, 95 % confidence interval (CI) 0.88–1.59; p = 0.25], postoperative Pelvic Organ Prolapse Quantification System stage ≥2 (RR 0.86, 95 % CI 0.64–1.16; p = 0.33), transfusion rate (RR 0.91, 95 % CI 0.57–1.44; p = 0.68), mesh erosion rate (RR 1.62, 95 % CI 0.74–3.51; p = 0.23), overall rate of surgical complications (RR 1.17, 95 % CI 0.91–1.50; p = 0.23) and length of hospital stay [mean difference (MD) 0.13 days, 95 % CI −0.05 to 0.31; p = 0.15). Additionally, no differences were found in the rates of bladder injury, ileus and urinary incontinence between obese women and non-obese women. However, obese women were associated with a higher laparoconversion rate (RR 3.00, 95 % CI 1.71–5.31; p = 0.0002), higher rate of infection (RR 1.65, 95 % CI 1.25–2.20; p = 0.0005), longer operative duration (MD 14.93 min, 95 % CI 10.14–19.73; p < 0.00001) and higher estimated blood loss (MD 18.01 ml, 95 % CI 8.22–27.80; p = 0.0003) compared with non-obese women.
The complications and curative effects of sacrocolpopexy for obese women are similar to those of non-obese women, except for the higher laparoconversion rate, higher rate of infection, longer operative duration and higher estimated blood loss in obese women. Obesity increases the operational difficulty of sacrocolpopexy to a certain extent, although it does not increase the mesh erosion rate or prolapse recurrence rate. Gynaecologists need to be aware of the possibility of the abovementioned risks when choosing sacrocolpopexy for obese patients with middle pelvic defects.
Maternal obesity and major intraoperative complications during cesarean delivery
2017, American Journal of Obstetrics and Gynecology
Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications.
To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD).
This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m², BMI 30 to 39.9 kg/m², BMI 40 to 49.9 kg/m², and BMI ≥ 50 kg/m². The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision.
A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m², 47% BMI 30 to 39.9 kg/m², 12% BMI 40 to 49.9 kg/m² and 3% BMI ≥ 50 kg/m². Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m², 3.2% BMI 30 to 39.9 kg/m², 2.6% BMI 40 to 49.9 kg/m² and 4.3% BMI ≥ 50 kg/m² (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m² had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m². Women with BMI 30 to 39.9 kg/m² (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication.
In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity.
Effectiveness of Transobturator Tape Procedure in Obese and Severely Obese Women: 3-Year Follow-up
2015, Urology
To assess the efficacy and safety of transobturator tape (TOT) for the treatment of stress urinary incontinence in severely obese and obese women.
We retrospectively reviewed the women who underwent a TOT procedure at 2 institutions between March 2005 and March 2013. The patients were divided into 3 groups according to the World Health Organization body mass index (BMI) values: normal weight group (BMI <25 kg/m²; group 1), obese group (BMI = 30-34 kg/m²; group 2), and severely obese group (BMI ≥35 kg/m²; group 3). Overweight women (BMI = 25-29 kg/m²) were omitted. Patients filled in the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) preoperatively and at the postoperative follow-up visits. The severity of urinary incontinence was classified by ICIQ-SF: slight (1-5), moderate (6-12), severe (13-18), and very severe (19-21). Patient satisfaction was assessed using a visual analog scale. Subjective improvement was defined as an ICIQ-SF score ≤12 and satisfaction with surgery (visual analog scale score ≥80).
A total 470 women met the requirements for inclusion. There were 153 women in group 1, 72 women in group 2, and 32 women in group 3. Mean follow-up period was at least 12 months in all the groups. The difference between the groups according to mean operative time was significant (P <.001). The objective cure, subjective success (cured and improved), patient satisfaction rates, and complications were similar between the groups.
Obesity and severe obesity do not seem to be risk factors for the failure of TOT procedure. However, postoperative urgency urinary incontinence rate was higher in severely obese women, and more women showed improvement instead of cure among severely obese women.
Obesity and pelvic floor dysfunction
2015, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
A subjective improvement was noted among all the BMI groups, but a lesser objective efficacy was noted with an increasing BMI [18,33]. It has also been observed in a case–control study that, compared with the non-obese population, the operating time was more prolonged with a slightly higher estimated blood loss in obese patients undergoing tape procedures for urinary incontinence [19,31]. It is useful to counsel the patients prior to the procedure with the available evidence and local data on outcomes after incontinence surgery before making an informed decision about surgical treatment among the other options available.
Obesity is associated with a high prevalence of pelvic floor disorders. Patients with obesity present with a range of urinary, bowel and sexual dysfunction problems as well as uterovaginal prolapse. Urinary incontinence, faecal incontinence and sexual dysfunction are more prevalent in patients with obesity. Uterovaginal prolapse is also more common than in the non-obese population. Weight loss by surgical and non-surgical methods plays a major role in the improvement of these symptoms in such patients. The treatment of symptoms leads to an improvement in their quality of life. However, surgical treatment of these symptoms may be accompanied by an increased risk of complications in obese patients. A better understanding of the mechanism of obesity-associated pelvic floor dysfunction is essential.
Obesity and female stress urinary incontinence
2013, Urology
Citation Excerpt :
Although retropubic midurethral sling surgery on the obese patient is perceived to be more difficult by surgeons, there is no evidence that complications, such as blood loss and visceral injuries, are higher in obese patients. Even when a significantly longer operating time was reported, this was not associated with a higher complication rate.33 Because the obese female population has a high prevalence of stress urinary incontinence, these patients often present for surgical evaluation.
The purpose of this article was to review the epidemiology, pathophysiology, and treatment options for stress urinary incontinence in the obese female patient and draw conclusions regarding the optimal treatment of this condition in this unique patient population. Obesity results in increased intra-abdominal pressure and this leads to weakening of the pelvic floor innervation and musculature. Weight loss through lifestyle modification and bariatric surgery improves stress urinary incontinence. Success of stress urinary incontinence surgery in obese women is similar to nonobese patients. Obese women should not be excluded from potentially curative surgery based on their body mass index (BMI) alone.

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Supported in part by Department of Health and Human Services/National Institutes of Health/National Center Research Resources/General Clinical Research Center Grant 5M01 RR00997.

Presented at the 32nd Annual Meeting of the Society of Gynecologic Surgeons, April 3-5, 2006, Tucson, AZ.

Reprints not available from the authors.

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Transactions from the Thirty-Second Annual Scientific Meeting of the Society of Gynecologic SurgeonsObesity and retropubic surgery for stress incontinence: Is there really an increased risk of intraoperative complications?

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Am J Obstet Gynecol

J Urol

Eur Urol

J Urol

Lancet

Obstet Gynecol

Chest

Transactions from the Thirty-Second Annual Scientific Meeting of the Society of Gynecologic Surgeons
Obesity and retropubic surgery for stress incontinence: Is there really an increased risk of intraoperative complications?