This was a prospective cohort study aimed at evaluating the surgical outcomes and identifying factors linked to postoperative complications (patient-related and procedure-related factors) in the North-Eastern Democratic Republic of the Congo (DRC). The study was conducted between 1st January and 30th September, 2024 at three major hospitals in North-Eastern DRC with a high volume of gynecological surgeries, a good organization of gynecology services, the presence of at least one gynecologist in each structure and with the existence of a technical platform adapted to the management of genital prolapse in the context of resource-limited countries, including Cliniques Universitaires du Graben (CUG), Matanda Teaching Hospital, Fistula program Clinic (FISPRO).

The study included adult female patients who underwent surgical repair for genital prolapse at Cliniques Universitaires du Graben (CUG), Matanda Hospital, and Fistula program Clinic (FISPRO). Inclusion criteria consisted of women diagnosed with stage II or higher pelvic organ prolapse (according to the Pelvic Organ Prolapse Quantification [POP-Q] system) who underwent either vaginal or abdominal prolapse surgery and who signed the consent form. Pregnant women, women under 18 years of age, and those who declined to participate in the study were excluded.

Based on previous studies and a pilot review of medical records, a total of 112 adult female patients were included in the analysis. The sampling was exhaustive, and the sample size was calculated to provide sufficient statistical power (80%) to detect significant differences in postoperative complication rates, with a confidence level of 95%.

Two main types of surgical approaches were performed:

1) Vaginal surgery: including anterior and/or posterior colporrhaphy, with or without vaginal hysterectomy.

2) Abdominal surgery: including sacrocolpopexy or sacrohysteropexy.

The choice of surgical technique was based on the patient’s prolapse severity, surgeon preference, and availability of surgical materials. Surgeries were performed by experienced gynecological surgeons following standard operating protocols.

Data collection was prospective. A pre-prepared data collection form allowed us to gather relevant information from patients who underwent surgery for genital prolapse. During this study, patients with prolapse, after their eligibility was assessed and their written and informed consent obtained, were examined to determine the type of prolapse and then operated on according to the type of genital prolapse by a team consisting of a general surgeon, a urogynecologist, two obstetrician-gynecologists (all with five years of experience), and a member of the research team. All complications related to the procedure were investigated and recorded by the entire surgical team and a member of the research team during the perioperative period and/or in the immediate postoperative period (the first 48 hours), at hospital discharge (8-12 days), and three months later, looking for physical, sexual, digestive, and urinary signs related to the genital prolapse.

The variables for the study were collected on a data collection form. Age, origin, level of education, profession, socioeconomic level, gravidity, parity, history of cesarean section, perineal tear, hysterectomy, pelvic surgery, body mass index, menopausal status, notion of hypertension, type, degree of prolapse, pathologies associated with prolapse, approach, type of intervention or procedure performed, evolution and types of complications in the immediate peri- and postoperative period and 3 months after and were categorized as minor or major based on severity. The patients underwent surgery under spinal anesthesia with intraoperative antibiotic prophylaxis consisting of two grams of ceftriaxone administered by slow intravenous injection. Resumption of sexual activity was recommended two and a half months post-surgery. The primary outcome measure was the absence of recurrence of genital prolapse symptoms three months after surgery.

The primary outcome was the rate of postoperative complications, including infection, hemorrhage, urinary retention, prolapse recurrence, and wound dehiscence. Secondary outcomes included failures, reoperation rates, and patient-reported satisfaction (using a standardized questionnaire administered postoperatively).

Data were entered into Microsoft Office LTSC 2021 using R version 4.4.0 for statistical analysis. Descriptive statistics were calculated for baseline characteristics and postoperative outcomes. Continuous variables were expressed as means ± standard deviations, and categorical variables were presented as frequencies and percentages. Chi-square tests and independent t-tests were used to compare baseline characteristics between groups with and without complications. For all variables significant in bivariate analysis, a multivariate model of logistic regression was performed to identify independent predictors of postoperative complications, adjusting for potential confounders. A p-value < 0.05 was considered statistically significant. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to quantify the strength of associations.

The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Catholic University of Graben, in compliance with the ethical standards for research involving human subjects (IRB number: PMS. 02/24/UCG/CERM). Informed consent was obtained, and patient confidentiality was strictly maintained throughout data collection and analysis.

4.1.1. Sociodemographic Characteristics of Women Who Underwent Surgery for Genital Prolapse

The sociodemographic characteristics of the respondents are presented in Table 1. Indeed, the majority of the respondents had an average age of 55.5 years, came from rural areas (85.7%), were illiterate (56.3%), farmers (85.7%), and poor and very poor (58.9%).

Table 1. Distribution of cases according to sociodemographic characteristics.

¹Mean (SD); n (%).

4.1.2. Gynecological and Obstetric Characteristics of Patients Operated on for Genital Prolapse

The characteristics of the gynecological and obstetrical history of the respondents are presented in Table 2. Indeed, the majority of respondents were multiparous and grand multiparous in 80.4% of cases, and had a history of perineal tear (35.7%). of pelvic surgery (20.5%) and cesarean section (10.7%).

4.1.3. Environmental Characteristics

Table 3 distributes the cases according to the patient’s background. Indeed, the patients who underwent prolapse surgery had a normal BMI (80.4%), were menopausal (74.1%), and had hypertension in 9.8% of cases.

Table 2. Distribution of cases according to gynecological and obstetric characteristics.

¹Mean (SD); n (%).

Table 3. Distribution of cases according to environmental characteristics.

4.1.4. Clinical Profile of Operated Patients (Type, Degree, and Pathologies Associated with Genital Prolapse)

The type, degree, and associated pathologies of genital prolapse are presented in Table 4. Indeed, the patients who underwent surgery more frequently had cystocele (44.4%) and prolapse involving all three levels of the pelvis (33%). Third- and fourth-degree prolapse were predominant, occurring in 77.7% and 14.3% of cases, respectively. Vesicovaginal fistula was the associated pathology in 18.8% of cases.

Table 4. Distribution of cases according to type, degree of prolapse, and associated pathologies.

4.1.5. Types of Surgical Intervention

Table 5 categorizes the cases according to the type of surgical intervention. Indeed, patients with genital prolapse underwent vaginal surgery (95.5%). Anterior colporrhaphy was the most frequently performed procedure (44.6%), followed by triple perineal surgery with hysterectomy in 22% of cases.

Table 5. Distribution of cases according to the type of surgical intervention.

*CA: anterior colporrhaphy, TOP: triple perineal operation, CPP: posterior and perineal colporrhaphy.

4.1.6. Evolution and Types of Complications

Table 6 distributes the cases according to the evolution and types of complications. Indeed, the evolution of the operated patients was marked by complications in 11.6% of cases, and the major intraoperative complication was bladder injury in 15.4% of cases, and in the middle or late postoperative period, urinary incontinence in 30.7% of cases.

Table 6. Distribution of cases according to progression and types of complications.

1)SociodemographicFactors

The sociodemographic factors associated with the occurrence of postoperative complications are presented in Table 7. Indeed, age over 50 years (p-value = 0.002) and low socioeconomic level (poor or very poor) [p-value = 0.024] were factors associated with the occurrence of operative complications.

Table 7. Distribution of cases according to sociodemographic factors.

¹Mean (SD); n (%); ²Student’s t-test; Fisher’s exact test.

2)Gynecological andObstetric Factors

The gynecological and obstetric factors associated with the occurrence of postoperative complications are presented in Table 8. Indeed, no factor was significantly associated with the occurrence of complications, although they were found in multi- and grand multiparous women, women with a history of perineal tearing, and menopausal women.

Table 8. Distribution of cases according to gynecological and obstetric factors.

¹Mean (SD); n (%); ²Student’s t-test; Fisher’s exact test.

3)Environmental Factors

Environmental factors associated with the occurrence of postoperative complications are presented in Table 9. Indeed, overweight/obesity (p-value =0.041) was significantly associated with the occurrence of peri- or postoperative complications.

Table 9. Distribution of cases according to environmental factors.

¹n (%); ²Fisher’s exact test.

4)ClinicalFactors

Clinical factors associated with the occurrence of postoperative complications are presented in Table 10. Indeed, the mixed type, i.e., prolapse involving all three levels of the pelvis (p-value = 0.014), and the existence of pathologies associated with genital prolapse (p-value = 0.003), especially vesicovaginal fistula and cervical cancer (p-value <0.001). were clinical factors significantly associated with the occurrence of peri- or postoperative complications.

Table 10. Distribution of cases according to clinical factors.

¹n (%); ²Fisher’s exact test.

5)FactorsRelatedto theIntervention

The intervention-related factors associated with the occurrence of postoperative complications are presented in Table 11. Indeed, the type of intervention, especially triple perineal surgery with hysterectomy, anterior colporrhaphy, and hysterectomy with posterior and perineal colporrhaphy (p-value = 0.032). was significantly associated with the occurrence of peri- or postoperative complications.

Table 11. Distribution of cases according to intervention-related factors.

¹n (%); ²Fisher’s exact test; Other*: Hysterectomy alone, Manchester procedure, Richardson procedure, and hysterectomy combined with colpocleisis.

4.3.1. Sociodemographic and Environmental Factors

Age and BMI were significantly associated with the occurrence of postoperative complications (Table 12). Being 50 years of age or older increased the risk of postoperative complications 8.95-fold (p-value = 0.047). As for BMI, being overweight or obese increased this risk 4.97-fold (p-value = 0.022).

Table 12. Distribution of cases according to the multivariate analysis of sociodemographic and environmental factors.

¹% (n/N); ²aOR = adjusted odds ratio, cOR = crude odds ratio, CI = confidence interval.

4.3.2. Clinical and Therapeutic Factors

The presence of associated pathologies and the specific types of procedures performed were significantly associated with the occurrence of postoperative complications (Table 13). The presence of associated pathologies increased the risk of postoperative complications 8.84-fold (p-value = 0.012). Regarding the types of procedures performed, sacrocolpopexy increased this risk 38.8-fold (p-value = 0.028), and percutaneous nephrolithotomy (PCN) increased it 17.4-fold (p-value = 0.025).

Table 13. Distribution of cases according to multivariate analysis of clinical and therapeutic factors.

¹% (n/N); ²aOR = adjusted odds ratio, cOR = crude odds ratio, CI = confidence interval; Other*: Hysterectomy alone, Manchester procedure, Richardson procedure, and hysterectomy associated with colpocleisis.

The study’s findings have important implications for clinical practice, particularly in rural and resource-limited settings:

Increased Focus on Preventive Care: Given the high prevalence of prolapse among older women with high parity, there is a need for more robust preventive care strategies. Education on pelvic floor exercises, early medical intervention, and reducing the physical strain associated with agricultural labor can be beneficial.Improved Access to Surgical Care: Early diagnosis and intervention are critical to preventing the advanced stages of prolapse observed in this study. Expanding access to gynecological services in rural areas and implementing mobile health units could help address this issue.Addressing Postoperative Complications: The high rate of complications among older, poorer women indicates a need for tailored postoperative care, including better follow-up, enhanced nutritional support, and management of comorbidities to improve recovery outcomes.

This study raises important questions regarding the role of social determinants in the development and management of genital prolapse, suggesting that further research is needed to explore these factors in more depth. Future studies should focus on interventions to reduce the burden of prolapse in rural and low-income populations, including strategies for early detection and nonsurgical management. Additionally, research is needed to investigate the long-term effectiveness of different surgical techniques, particularly in high-risk populations, and to assess the impact of tailored postoperative care on reducing complications like urinary incontinence.

There is also a need for prospective studies to evaluate the efficacy of pelvic floor rehabilitation programs and their potential to prevent prolapse progression in multiparous and postmenopausal women.

5.3.1. Strengths

This study provides a comprehensive analysis of sociodemographic, clinical, and surgical factors related to genital prolapse, offering valuable insights for clinical practice and public health interventions.The focus on rural, low-income women is a particular strength, as this population is often underrepresented in prolapse research.The study’s large sample size provides robust data, enhancing the reliability of its findings.

5.3.2. Limitations

One limitation is the prospective nature of the study, which may introduce bias in the reporting and analysis of clinical outcomes.The study does not account for other potential confounding variables, such as genetic predisposition or access to healthcare services, which may have influenced both the development of prolapse and the outcomes of surgery.Follow-up data on long-term outcomes after surgery, including the recurrence of prolapse or incontinence, were not included, limiting the ability to assess the durability of surgical interventions.