Pelvic floor disorders, including stress urinary incontinence and pelvic organ prolapse (POP), commonly affect older women and often require surgical intervention. Literature on surgical outcomes for POP is often in younger, healthy individuals and does not factor in frailty, which commonly affects older individuals and has been shown to negatively impact surgical outcomes. To address this important clinical need, we created UroRisk, a prognostic surgical risk calculator that specifically factors in frailty, in addition to other comorbidities, for older women undergoing surgery for POP.

A retrospective analysis of Medicare beneficiaries undergoing surgery for urinary incontinence and POP was conducted using the Medicare Carrier, Outpatient, and MedPAR files between 2014-2016. Beneficiaries were categorized according to surgery type, including: Sling: Sling procedure for stress urinary incontinence; A/P repair: Anterior/Posterior POP repair; Apical repair: Apical repair for POP; A/P repair with sling: Anterior/Posterior POP repair with sling procedure for stress urinary incontinence; A/P repair with hysterectomy: Anterior/Posterior POP repair with hysterectomy; A/P repair with sling and hysterectomy: Anterior/Posterior POP repair, with sling procedure for stress urinary incontinence with hysterectomy; Apical repair with sling: Apical repair for POP, with sling procedure for stress urinary incontinence; Apical repair with A/P repair: Apical repair for POP with Anterior/Posterior POP repair; Apical repair with A/P repair and sling: Apical repair for POP, with Anterior/Posterior POP repair, with sling procedure for stress urinary incontinence; Apical repair with hysterectomy: Apical repair for POP with hysterectomy; Apical repair with sling and hysterectomy: Apical repair for POP with sling procedure for stress urinary incontinence, with hysterectomy; Apical repair with AP repair and hysterectomy: Apical repair for POP with anterior/Posterior POP repair with hysterectomy; Apical repair with A/P repair, sling, and hysterectomy: Apical repair for POP, with Anterior/Posterior POP repair, with sling procedure for stress urinary incontinence with hysterectomy; Colpocleisis; and Colpocleisis with hysterectomy. Baseline frailty was calculated for each subject using the Claims-Based Frailty Index (CFI), a validated measure of frailty comprised of 93 variables. All variables within the CFI and the 17 variables in the Charlson Comorbidity Index were then individually entered into stepwise logistic regression models to determine which variables were most highly predictive of postoperative complications of interest. Variables found to be most highly predictive were then combined into categories. Calibration curves and tests of model fit, including C-statistics, Brier scores, and Spiegelhalter p-values were calculated to ensure the prognostic accuracy of these variables for each outcome of interest.

A total of 108,479 subjects were included. Mean age was 73.62 years and the majority (91.68%) of subjects were White. The most common procedures were A/P repair (N=19,274, 17.77%), sling procedure for stress urinary incontinence (N=11,908, 10.98%), and apical repair for POP with A/P repair (N=11,695, 10.78%). Approximately 50,356 subjects (46.42%) had CFI scores consistent with prefrail, 4,752 (4.38%) had CFI scores consistent with mildly frail (0.25 ≤ CFI < 0.35), and 362 (0.33%) had CFI scores consistent with moderately-to-severely frail. Thirteen prognostic variable categories were determined to be highly predictive of postoperative complications of interest. All models demonstrated low Brier scores, indicating high model accuracy, and high C-statistic and Spiegelhalter p-values, indicating excellent model discrimination and calibration, respectively. Each outcome also demonstrated excellent model fit on calibration curves. The Figure shows model fit for any complication within 30 days of surgery.

UroRisk is a novel surgical tool for older adult women undergoing surgery for stress urinary incontinence and POP that specifically factors in frailty. Results demonstrated high accuracy, calibration, and discrimination among all models.

UroRisk serves as a valuable resource to patients and clinicians for those undergoing consideration for stress urinary incontinence and POP surgery, particularly as the population continues to age and as more older, frail women are considered for surgical intervention.

Continence 7S1 (2023) 100772
DOI: 10.1016/j.cont.2023.100772