May 13, 2019

Concurrent Urogynecologic Surgery and Hemorrhoidectomy Is Safe, Study Confirms

No difference found in serious adverse post-operative events

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Pelvic floor disorders and hemorrhoids may share a common etiology, namely abnormalities in collagen metabolism. When the two disorders coexist in the same patient, that patient may choose to undergo concurrent surgery. Few studies, however, have reported on the safety of combined surgery, and there are no reports looking at the impact of hemorrhoidectomy on concurrent urogynecologic surgery. The risk of adverse events following concurrent hemorrhoidectomy and urogynecologic surgery is similar to that of undergoing the vaginal procedure only, a new study finds.

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Common etiology, adjacent surgical sites

“We find that these disorders can overlap,” says Viviana Casas-Puig, MD, a research fellow in the Cleveland Clinic Center for Urogynecology & Pelvic Reconstructive Surgery, and first author on the study. “Given the proximity of surgical sites, we believe concurrent procedures may be reasonable in an attempt to minimize morbidity related to multiple surgeries and anesthetic risks.”

“Our current clinical environment is one that puts increasing importance on safety and patient satisfaction,” she added. “Thus, with this study, we wanted to assess the safety of combined surgery by comparing patients who underwent concurrent vaginal urogynecologic and hemorrhoid surgery with those who underwent urogynecologic surgery alone.”

The matched cohort study reviewed patients who, over a 10-year period, underwent urogynecologic surgery with or without concurrent hemorrhoidectomy. The subjects were 57 ± 12 years of age and had a body mass index of 28.9 ± 5.6 kg/m2. Both cohorts were relatively similar, with the exceptions that those in the concurrent group were more likely to have had previous surgery for pelvic organ prolapse (27.3% vs 15.2%; P = 0.09) and more likely to report fecal incontinence (27.3% vs 13.6%; P = 0.05). The rate of adverse events in concurrent cases was 10.4%, after excluding minor adverse events, such as discharge home with a Foley catheter or a post-operative urinary tract infection (UTI).

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Analysis revealed no statistically significant difference in rates of major post-operative events, which included transfusion, hematoma, ileus and small bowel obstruction, in each group.

Minor adverse events increased with concurrent procedures

Among the concurrent group, there was a statistically significant increase in a few, more minor, post-operative events. Following discharge, patients in the concurrent group called their doctor’s office 1-7 times compared to 0-10 calls from patients undergoing the urogynecologic procedure only (P = 0.01). Unplanned office visits were 27.2% for patients undergoing concurrent procedures compared to 12.6% for those who had the urogynecologic procedure alone (P = 0.003). The majority of both unplanned office visits and phone calls were for complaints of pain.

The rate of reoperation was 3% in the concurrent group compared to 0% in the group that had urogynecologic surgery alone (P = 0.01). More patients in the concurrent group were discharged home with a Foley catheter (42.4% vs 18.2%; P = 0.002) and more developed UTIs (33.3% vs 10.6%; P = 0.005). One in three patients undergoing concurrent surgery reported severe postoperative pain.

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“While the incidence of reoperation was higher in the concurrent cases, the rate of serious perioperative adverse events was low and did not differ between the groups,” says Cecile Ferrando, MD, MPH, senior author on the study. “Concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery is a safe choice, though patients should be counseled about their increased risk of minor postoperative events, and that the pain may be greater than in urogynecologic surgery alone. It’s important to remember that, while discharge with a Foley catheter or the development of a UTI are considered minor relative to other serious medical events, they are not insignificant for patients.”

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