Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse

The effect of concomitant hysterectomy on complications following pelvic organ prolapse surgery

PURPOSE

Pelvic organ prolapse (POP) surgery is performed with and without concomitant hysterectomy depending on a variety of factors. The objective was to compare 30-day major complications following POP surgery with and without concomitant hysterectomy.

METHODS

This was a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) multicenter database to compare 30-day complications using Current Procedural Terminology (CPT) codes for POP with or without concomitant hysterectomy. Patients were grouped by procedure: Vaginal prolapse repair (VAGINAL), minimally invasive sacrocolpopexy (MISC), and open abdominal sacrocolpopexy (OASC). 30-day postoperative complications and other relevant data were evaluated in patients who underwent concomitant hysterectomy compared to those who did not. Multivariable logistic regression models assessed the association of concomitant hysterectomy on 30-day major complications stratified by surgical approach.

RESULTS

60,201 women undergoing POP surgery comprised our cohort. Within 30 days of surgery, there were 1722 major complications in 1432 patients (2.4%). Prolapse surgery alone had a significantly lower overall complication rate than with concomitant hysterectomy (1.95% vs 2.81%; p < .001). Multivariable analysis revealed odds of complications following POP surgery was higher among women who underwent concomitant hysterectomy compared to those who did not have hysterectomy in VAGINAL (OR 1.53, 95% CI 1.36-1.72), OASC (OR 2.70, 95% CI 1.69-4.33), and overall (OR 1.46, 95% CI 1.31-1.62), but not in MISC (OR 0.99, 95% CI 0.67-1.46.) CONCLUSION: Concomitant hysterectomy at the time of pelvic organ prolapse (POP) surgery increases the risk of 30-day postoperative complications in comparison to prolapse surgery alone in our overall cohort.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

BACKGROUND

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization.

OBJECTIVE

This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy.

STUDY DESIGN

We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated.

RESULTS

There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001).

CONCLUSION

This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

High Uterosacral Ligament Fixation Versus McCall's Culdoplasty for Vaginal Vault Suspension in Utero-Vaginal Prolapse Surgery

INTRODUCTION

 There are high chances of post-hysterectomy vault prolapse (PHVP) if the vault is not well supported after vaginal hysterectomy in cases of pelvic organ prolapse (POP). High uterosacral ligament suspension (HUSLS) and McCall's culdoplasty are the well-recommended modalities to suspend the vault after vaginal hysterectomy. As both the procedures are accessible to non-urologic gynaecologists, the study was planned in cases of POP.  Objective: The study was conducted to compare the anatomic and functional outcomes of patients undergoing vaginal HUSLS vs. McCall's culdoplasty at the time of vaginal hysterectomy.

MATERIALS AND METHODS

This prospective interventional study was done in a tertiary care hospital. A total of 80 patients were included and divided into two groups of 40 patients each. In one group, patients underwent high uterosacral ligament suspension and in the second group, McCall's culdoplasty was done for vault suspension. All procedures were done by two trained surgeons. The effectiveness of both the procedures was assessed by preoperative and postoperative pelvic organ prolapse quantification (POP-Q) (up to two years). Patients were followed for two years to see for any postoperative problem/recurrence.

RESULTS

Vault suspension by HUSLS showed better results than McCall's culdoplasty, in terms of POP-Q point C, perineal body (PB), genital hiatus (GH) and total vaginal length (TVL) as compared to McCall's culdoplasty.

CONCLUSION

 The anatomical correction is much better with HUSLS, which suspends the vault in the normal vaginal axis. However, it takes longer compared to McCall's culdoplasty, so the procedure should be individualised and performed with several precautions.

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations

OBJECTIVE

The aim of the study was to compare national surgical practice patterns of performing apical suspension procedures (ASPs) at the time of hysterectomy for pelvic organ prolapse (POP) before and after the publication of the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on POP.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for hysterectomy cases performed for POP indications for the years 2015-2016 and 2018-2019. The primary outcome was the use of ASP at the time of hysterectomy for POP. Secondary outcomes included the use of anterior, posterior, and paravaginal prolapse repair procedures. Multivariable regression analysis was performed to identify factors associated with performing a hysterectomy without an ASP.

RESULTS

A total of 11,336 cases were included, and apical prolapse was the primary POP diagnosis in 86.3% of these cases. There was no statistically significant change in the utilization of ASPs in 2018-2019 compared with 2015-2016 (51.4% vs 49.8%, P = 0.081). Urogynecologists were significantly more likely than general gynecologists to perform ASPs (65.6% vs 37.5%, P < 0.001), which was confirmed on multivariable logistic regression analysis (adjusted odds ratio, 3.257; P < 0.001). The use of concomitant anterior repairs (44.1% vs 39.5%, P < 0.001) and posterior repairs (47.5% vs 41.3%, P < 0.001) increased in the 2018-2019 cohort.

CONCLUSIONS

There was no overall increase in the utilization of concomitant ASPs at the time of hysterectomy done for POP indications despite the 2017 American College of Obstetricians and Gynecologists practice bulletin. Urogynecologists were more likely to perform ASPs than general gynecologists.

Changes in Performance of Apical Suspension at the Time of Surgery for Prolapse: Assessment of the Influence of the American Urogynecologic Society and American College of Obstetricians and Gynecologists Practice Bulletin

OBJECTIVES

To assess the association of publication of the American Urogynecologic Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on pelvic organ prolapse and performance of an apical suspension at the time of surgery for pelvic organ prolapse.

METHODS

Surgical procedures performed with a primary diagnosis of uterovaginal or female genital prolapse, cystocele, or enterocele were isolated from the 2011 to 2019 American College of Surgeons National Surgical Quality Improvement Program Database. An autoregressive interrupted time series regression estimated the overall temporal trend in performance of an apical suspension and assessed for a change in trend associated with publication of the AUGS/ACOG Practice Bulletin in April 2017. A stratified analysis was also performed depending on performance of a concomitant hysterectomy, and sensitivity analysis was performed using only diagnoses of uterovaginal or vaginal vault prolapse.

RESULTS

There were 72,194 individuals identified; 83.4% had a diagnosis of uterovaginal or female genital prolapse, 15.2% cystocele and 1.4% enterocele. Only 36.6% of cases had an apical suspension. Prior to the practice bulletin publication, performance of an apical suspension grew at 0.19% per quarter (95% confidence interval [CI], 0.07-0.31), with a trend toward increased utilization (+0.12%; 95% CI, -0.06 to 0.30) after publication. The increase was greater among cases with a concomitant hysterectomy (+0.35%; 95% CI, 0.08-0.62). Sensitivity analyses found similar changes in trend.

CONCLUSIONS

Performance of apical suspensions during surgery for prolapse remains low and is increasing at less than 1% per year. The AUGS/ACOG practice guidelines were associated with minimal changes in this pattern. Incentives or other strategies may be needed to further encourage standard of care management of prolapse.

Outcomes of vaginal and laparoscopic hysterectomy with concomitant pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures.

METHODS

A total of 27,941 eligible LH and VH from the 2010-2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30 days of surgery were grouped into major (Clavien-Dindo grade ≥3) or minor (grade 1-2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran-Armitage tests and multivariate regression assessed changes over time.

RESULTS

The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639-0.791) and minor (aOR 0.659, 95% CI: 0.612-0.710) complications.

CONCLUSIONS

Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.

Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training?

OBJECTIVE

The objective of this study was to determine factors associated with performance of concomitant apical support procedures (ASPs) with benign hysterectomy at a regional medical system.

METHODS

Benign hysterectomies performed within 1 regional medical system from January 2011 to November 2017 were identified using International Classification of Diseases, Ninth and 10th Revision, and Current Procedural Terminology codes. Primary outcome was performance of concomitant ASP. χ2 Tests compared categorical variables. Multivariable logistic regression analysis was performed to determine factors associated with performance of concomitant ASP.

RESULTS

A total of 12,345 benign hysterectomies were performed during the study period. Uterovaginal prolapse was the primary diagnosis in 924 (7.48%) hysterectomies and an associated diagnosis in 1180 (9.56%) hysterectomies. A total of 686 patients (5.56%) had concurrent ASPs: 119 (17.3%) in patients without a diagnosis of prolapse and 567 (82.7%) with prolapse. Using multivariable logistic regression, controlling for age, race, insurance type, hospital type, procedure year, hysterectomy route, and surgeon training in patients with a diagnosis of prolapse, older age, supracervical hysterectomy, and surgeon training were associated with performance of ASPs.

CONCLUSIONS

Even in patients with a preoperative diagnosis of uterovaginal prolapse, ASPs are not routinely performed at time of hysterectomy. Fellowship-trained surgeons were more likely to perform ASPs. Ongoing educational efforts during training and postgraduate at the national and regional level on the importance of reestablishing apical vaginal support at time of hysterectomy is needed to prevent incident and recurrent post-hysterectomy vaginal vault prolapse.

Abdominal and vaginal pelvic support with concomitant hysterectomy for uterovaginal pelvic prolapse: a comparative systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse.

METHODS

A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2.

RESULTS

Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P = 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P = 0.01].

CONCLUSIONS

ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

Timing of diagnosis of complex lower urinary tract injury in the 30-day postoperative period following benign hysterectomy

BACKGROUND

Complex lower urinary tract injury resulting from hysterectomy is a rare but highly morbid complication. Although intraoperative recognition reduces the risk of serious sequelae, observational studies have shown that most complex lower urinary tract injuries are recognized in the postoperative period. To date, limited research exists describing the timing of diagnosis of complex lower urinary tract injury or risk factors associated with complex lower urinary tract injury diagnosed in the postoperative period.

OBJECTIVE

This analysis aimed to describe the time to diagnosis of complex lower urinary tract injury among women undergoing benign hysterectomy. We also aimed to identify the intraoperative risk factors for differences in type and timing of complex lower urinary tract injury in the 30-day postoperative period using a large prospective national surgical database.

STUDY DESIGN

This was a retrospective analysis using the National Surgical Quality Improvement Program hysterectomy data set from 2014 to 2018. All benign hysterectomies were included. Sociodemographic factors, health status, surgeon type, and other operative characteristics were extracted. A complex lower urinary tract injury was defined as at least 1 ureteral obstruction, ureteral fistula, or bladder fistula diagnosed within the first 30 days following surgery. Bivariate and multivariate logistic regression and cox proportional hazards assessed differences in odds of and time until diagnosis of complex lower urinary tract injury. Proportional hazard assumptions were evaluated with martingale residuals and supremum tests. Significance thresholds were 0.05 for all analyses.

RESULTS

In this study, 100,823 women met the inclusion criteria. Median time to diagnosis of complex lower urinary tract injury was 10 days (interquartile range, 3-19) and varied significantly based on type of injury (P<.01) with ureteral obstruction (6; interquartile range, 2-16) recognized earlier than ureteral fistula (12; interquartile range, 7-21) and bladder fistula (14; interquartile range, 4-23). In addition, 8.65% of complex lower urinary tract injury were diagnosed on the day of surgery. Total laparoscopic hysterectomy had the lowest rate of complex lower urinary tract injury in unadjusted and adjusted analysis, with abdominal hysterectomy (adjusted odds ratio, 2.02; 95% confidence interval, 1.21-3.36) and vaginal hysterectomy (adjusted odds ratio, 2.05; 95% confidence interval, 1.16-3.62) having greater odds of ureteral obstruction, whereas laparoscopic assisted vaginal hysterectomy had the greatest odds of fistula (adjusted odds ratio, 2.10; 95% confidence interval, 1.26-3.48). Concomitant apical suspension was associated with a 6-day reduction in median time to diagnosis (P=.01), and surgery with a gynecologic oncologist was associated with a 9.5-day increase in median time to diagnosis (P=.01). Cox proportional hazards analysis confirmed these findings when controlling for confounders.

CONCLUSION

Greater than 91% of complex lower urinary tract injury diagnoses in the National Surgical Quality Improvement Program hysterectomy database were diagnosed after the day of surgery. Route of hysterectomy, concomitant apical suspension, and primary surgeon specialty are associated with differences in both type of injury and time until diagnosis. These intraoperative risk factors should be considered when assessing for complex lower urinary tract injury in the 30-day postoperative period.

The effect of reconstructive vaginal surgery on quality of life and sexual functions in postmenopausal women with advanced pelvic organ prolapse in intermediate-term follow-up

OBJECTIVE

To compare sexual function and quality of life in women who underwent McCall culdoplasty versus sacrospinous ligament fixation for pelvic organ prolapse.

MATERIALS AND METHODS

This study was conducted in our urogyanecology clinic between July 2015 and June 2019. We included sexually active postmenopausal women who had undergone either McCall culdoplasty (n:80 patients) or sacrospinous ligament fixation (n:38 patients) procedure for threatened POP. Patients in both groups were matched according to age and body mass index. Sexual function between both groups was evaluated with the pelvic organ prolapse/urinary incontinence sexual function 12 patient-reported outcome measures (PROMs) and quality of life with the prolapse quality of life (PQOL) PROMs.

RESULTS

Emotional domain was low in the McCall culdoplasty group (21.4 ± 10.1 vs. 30.8 ± 15.2; p = 0.03). There were no significant differences in other P-QOL domains. Pain during intercourse was more in the sacrospinous ligament fixation group (2.9 ± 1.6 vs. 1.3 ± 1.1; p = 0.04). The mean operation time in the McCall culdoplasty group was shorter than the sacrospinous ligament fixation group (p = 0.03). There was no difference between the two surgical procedures performed in terms of intraoperative blood loss and hospital stay. The prevalence of recurrence in the McCall culdoplasty group was 6.2%, and that of sacrospinous ligament fixation was 5% (p = 0.75) in one year follow-up.

CONCLUSION

Our study demonstrated that McCall culdoplasty has a more positive effect on QOL and sexuality than sacrospinous ligament fixation in appropriately selected patients. McCall culdoplasty could be considered as a good option in the treatment of advanced pelvic organ prolapse in elderly patients.

Practice Patterns Regarding Apical Support Procedures at Time of Hysterectomy for Pelvic Organ Prolapse

OBJECTIVES

We sought to understand practice patterns of non-female pelvic medicine and reconstructive surgery (FPMRS) clinicians regarding concurrent apical support procedures during hysterectomies when primarily performed for the treatment of pelvic organ prolapse. We also sought to describe differences between those receiving and not receiving apical support.

METHODS

This retrospective study analyzed medical records of individuals undergoing hysterectomy for the primary indication of pelvic organ prolapse between 2012 and 2017 at all locations within the TriHealth system. Surgeries performed by board-certified FPMRS physicians were excluded. Comparisons were drawn between those who did and did not receive apical support.

RESULTS

A total of 236 charts met the inclusion criteria. Of these, 66 (28%) received concurrent apical suspension, and 94 (39.8%) underwent no reconstructive procedures. The annual proportion of those receiving apical suspension did not differ over the course of the study period. On average, the addition of apical support added 39.9 minutes (P < 0.001) to the length of surgery. There was, however, no difference noted in estimated blood loss. Risk factors for recurrent prolapse including chronic constipation, pulmonary disease, and connective tissue disorders were similar between groups.

CONCLUSION

When excluding FPMRS surgeons, data from our institution showed that most patients undergoing hysterectomy for prolapse did not receive concurrent apical support. This suggests areas of potential improvement for adopting into clinical practice the new American College of Obstetricians and Gynecologists recommendations regarding the treatment of prolapse. Furthermore, this may represent an important opportunity for peer outreach and education by FPMRS surgeons.

Apical suspension is underutilized for repair of stage IV pelvic organ prolapse: an analysis of national practice patterns in the United States

INTRODUCTION AND HYPOTHESIS

Support of the vaginal apex is paramount for a durable repair of pelvic organ prolapse (POP). Our aim is to assess national utilization of apical suspension procedures for the surgical treatment of complete POP. We hypothesize that there might be a high rate of apical suspension with advanced prolapse.

METHODS

The 2006-2016 National Surgical Quality Improvement Program database was queried for a primary postoperative diagnosis of complete POP. The primary outcome was type of repair. Secondary outcomes included patient characteristics associated with apical suspension or colpocleisis. Procedures were delineated using CPT codes. Chi-squared and multivariate logistic regression analyses were used to evaluate factors associated with repair type.

RESULTS

A total of 2,784 women underwent surgery for complete POP with a mean age of 64.6 ± 11.0 years. Overall, 1,300 (46.7%) patients underwent apical suspension: 487 sacrocolpopexies (17.5%), 428 extraperitoneal suspensions (15.4%), and 391 uterosacral suspensions (14.0%). 5.2% (144) underwent colpocleisis, and 47.5% (1,332) of women had a concurrent hysterectomy (CH). With CH, 38.6% (502) had apical suspension or colpocleisis versus 69.5% (940) of post-hysterectomy cases. On logistic regression, CH was inversely associated with apical suspension (adjusted odds ratio [aOR] 0.37, CI 0.32-0.44, p < 0.001). Colpocleisis was associated with older age (aOR 4.9 per 10 years, CI 3.8-6.3, p < 0.001), post-hysterectomy surgery (aOR 0.23, CI 0.1-0.4, p < 0.001 for CH), and higher comorbidity index (OR 1.7, CI 1.1-2.6, p = 0.009). Complication rates are similar with and without apical suspension (8.2% versus 7.0%, p = 0.269).

CONCLUSIONS

During surgery for complete POP, an apical suspension procedure is performed in 46.7% of patients and is more common post-hysterectomy.

Addressing apical support during hysterectomy for prolapse: a NSQIP review

OBJECTIVE

To describe national practice patterns regarding apical support procedures at time of hysterectomy for prolapse prior to the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on pelvic organ prolapse.

METHODS

This retrospective descriptive study analyzed 24 months of data from the National Surgical Quality Improvement Program (NSQIP) database, from 2015 and 2016. Patients undergoing hysterectomy for the indication of pelvic organ prolapse were included. Surgical details, diagnostic codes, subspecialty, patient demographics, and postoperative complications were collected. Comparisons were conducted between those who did and did not undergo apical support procedures. Further comparisons, including logistic regressions, were performed using subspecialty designation.

RESULTS

During the study period, 3458 hysterectomies were performed for the indication of pelvic organ prolapse. Of this population, 76% were White, with an average age of 61 years, BMI of 27.6, and parity of 2, and 90.5% carried the diagnosis of apical prolapse. Slightly over half (51.8%) had a concurrent procedure to support the vaginal apex. When performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) physicians, 65.7% underwent an apical suspension at time of hysterectomy for prolapse compared with 40.2% of non-FPMRS (p < 0.001). Annual rates of apical support procedures showed significant improvement from 49.5% in 2015 to 55.2% in 2016 (P < 0.001). Regarding surgical data, addition of apical support procedures increased operative time by 33 min, and reoperation was 1.3% higher (0.3% vs 1.6%).

CONCLUSION

Our results demonstrate that in the 2 years prior to ACOG's recommendation only 51.8% of women undergoing hysterectomy for pelvic organ prolapse received concurrent procedures to address apical support.

Is performing sacrospinous fixation with vaginal hysterectomy and McCall's culdoplasty for advanced uterovaginal prolapse preferable over McCall's culdoplasty alone?

Purpose of study

Advanced uterovaginal prolapse can significantly affect the quality of life in women and usually requires surgical management. McCall's culdoplasty (M) or sacrospinous fixation (SSF) are done at the time of vaginal hysterectomy with pelvic floor repair (VHPFR) to reduce recurrence, but recurrence rates of 15% and 33% have been reported with these procedures respectively. We hypothesize that combining VH-PFR with both McCall's culdoplasty and sacrospinous fixation (VH-PFR-M-SSF) may decrease recurrence rates compared to VH-PFR-M without significantly affecting other perioperative outcomes.

Methods

All patients with advanced uterovaginal prolapse and willing for VH-PFR at our institute from January 2015 to March 2018 were included after informed consent, except for medically unfit women and those preferring alternative management. We conducted a case control study comparing VH-PFR-M and VH-PFR-M-SSF with a follow-up period of 24 months. Qualitative and quantitative data were statistically analysed and Odds ratio and 95% Confidence interval was calculated. Kaplan Meier Curve was drawn and Log Rank test was used to compare recurrence.

Results

Out of 174 patients who underwent surgery in the study period, 131 patients (75.28%) underwent VH-PFR-M and 43 patients (24.71%) underwent VH-PFR-M-SSF. Both groups were comparable for age, body mass index, parity, postmenopausal status, comorbidities and aggravating factors. Patients with higher stage of prolapse were more in group 2 (p < 0.001). There were no intraoperative complications or postoperative surgical interventions in either group. The duration of surgery was not significantly different. Change in haematocrit was more in group 2 but no patient required blood transfusion. There was no statistically significant difference in recurrence rates between the 2 groups.

Conclusion

The procedure (VH PFR M-SSF) is safe and affordable with good results in Stage 3 with advanced bulge and stage 4 prolapse.

The effect of diagnosis-related group payment system on the quality of medical care for pelvic organ prolapse in Korean tertiary hospitals

PURPOSE

To assess changes in clinical practice patterns after implementing diagnosis-related group (DRG) payment system in July 2013 and its effect on the quality of care for pelvic organ prolapse (POP).

MATERIALS AND METHODS

Using the 2011-2016 administrative database from National Health Insurance claim data, we reviewed medical information of 7362 patients who underwent hysterectomies for POP in Korean tertiary hospitals. We compared changes in several variables including length of stay, concomitant procedures, outpatient visits and readmission within 30 days after discharge, and retreatment for POP or stress urinary incontinence within postoperative 1 year before and after DRG system.

RESULTS

After the introduction of DRG system, the average length of stay decreased (7.74 ± 2.88 to 6.63 ± 2.18 days, p<0.001) without increasing readmission rates. However, the number of outpatient visits increased (2.78±2.33 to 2.98±2.47, p<0.001). Regarding concomitant procedures, the rates of colpopexy and midurethral slings significantly decreased (7.87% and 9.84% to 4.93% and 2.93%, respectively, all p<0.001). Even though there was no difference in the reoperation rates, pessary insertion for recurrent POP significantly increased after the introduction of DRG system (0.10% to 0.38%, p = 0.015).

CONCLUSION

The implementation of DRG in Korean tertiary hospitals has led to increase of outpatient visits and reduced surgical management for POP, which indicates that the uniform application of DRG influences the quality of care for POP patients.

Teaching learners to raise the roof: a vaginal surgery simulator for apical suspension

INTRODUCTION AND HYPOTHESIS

The objective was to discuss the importance of apical suspension following vaginal hysterectomy and demonstrate a surgical model to aide in educating learners on a variety of apical suspension procedures.

METHODS

Rates of pelvic organ prolapse are not insignificant following hysterectomy. Re-support of the vaginal apex should be performed at the time of hysterectomy in those with or without a diagnosis of prolapse. Exposure to vaginal apical support procedures may be limited owing to declining rates of vaginal hysterectomy and limited trainee work hours. Surgical models are increasingly being used to supplement operating room experience. The model we present was originally developed for hysterectomy, although its design allows for teaching a variety of apical support procedures that incorporate the uterosacral ligament (USL) for support. We demonstrate performing a USL suspension, internal McCall suture, and modified McCall suture using the model.

RESULTS

The model is constructed from readily available supplies, is multi-use, and inexpensive. It allows learners to identify relevant anatomy, understand/visualize surgical steps, and practice suturing technique.

CONCLUSION

Pelvic organ prolapse is common in women, although opportunities to teach apical suspension procedures may be limited. The proposed vaginal surgery simulator can be used to supplement the experience of gynecological surgery trainees with apical suspension procedures.

Various Approaches and Treatments for Pelvic Organ Prolapse in Women

Pelvic organ prolapse (POP) is bulging of one or more of the pelvic organs into the vagina and triggered by multiple causes. It is a very common disorder, especially among older women. POP is characterized by protrusion of the presentation part visible by the naked eye, and problems with urination or bowel movements. POP can be diagnosed based on the onset of symptoms and a pelvic exam, and management options include medical and surgical treatment. Although medical treatment cannot correct the abnormal herniation of the pelvic structures, this can help alleviate symptoms. One of the disadvantages of surgical interventions is recurrence, and advances in surgical techniques have decreased recurrence rates of POP. Therefore, author will explain the gynecology and urology approach and treatment.

Outcomes of laparoscopic management of multicompartmental pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is an increasing medical problem with complex diagnostics and controversial surgical management. It causes a series of dysfunctions in the gynecological, urinary, and anorectal organs. Numerous procedures have been proposed to treat these conditions, but in recent years, ventral mesh rectocolposacropexy (VMRCS) has emerged as the procedure of choice for the surgical treatment of POP, especially by a laparoscopic approach. This surgical technique limits the risk of autonomic nerve damage, and the colpopexy allows the correction of concomitant prolapse of the middle compartment. However, symptoms derived from anterior compartment prolapse remain a major morbidity and sometimes require an additional procedure. The aim of this study is to evaluate the results of laparoscopic prosthetic rectocolposacropexy (LRCS) and colposacropexy (LCS) procedures performed to manage combined multicompartmental POP.

METHODS

Between November 2008 and December 2017, 38 patients with symptomatic POP underwent rectocolposacropexy (RCS) or colposacropexy (CS) by a laparoscopic approach. Demographics, mortality, morbidity, hospital stay, and functional outcomes were retrospectively analyzed.

RESULTS

The median operating time was 200 min (IQR 160-220). Additional simultaneous surgery for POP was performed in nine cases: five suburethral slings and four hysterectomies were performed. No mortality was recorded. The conversion rate was 7.89%. There were two intraoperative complications (5.26%): one enterotomy and one urinary bladder tear. Late complications occurred in 5.26% of cases. After a mean follow-up of 20 months, constipation was completely resolved or improved in 83.33% of patients, urinary stress incontinence was resolved or improved in 52.94%, and gynecological symptomatology was resolved or improved in 93.75%. The recurrence rate was 5.26%.

CONCLUSIONS

Laparoscopic mesh rectocolposacropexy and colposacropexy are safe and effective techniques associated with very low morbidity. In the medium term, they provide good results for POP and associated symptoms, but urinary symptomology has a worse outcome.

Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate

BACKGROUND

Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports reestablishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described.

OBJECTIVE

We sought to estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database.

STUDY DESIGN

The National (Nationwide) Inpatient Sample was used to identify hysterectomies performed from 2004 through 2013 for benign indications. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed.

RESULTS

There were 3,509,230 inpatient hysterectomies performed for benign disease from 2004 through 2013. In both nonprolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (P < .0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure.

CONCLUSION

This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of reestablishing apical vaginal support at time of hysterectomy regardless of indication.

Impact of surgical training on the performance of proposed quality measures for hysterectomy for pelvic organ prolapse

BACKGROUND

Recent healthcare reform has led to increased emphasis on standardized provision of quality care. Use of government- and organization-approved quality measures is 1 way to document quality care. Quality measures, to improve care and aid in reimbursement, are being proposed and vetted in many areas of medicine.

OBJECTIVES

We aimed to assess performance of proposed quality measures that pertain to hysterectomy for pelvic organ prolapse stratified by surgical training. The 4 quality measures that we assessed were (1) the documentation of offering conservative treatment of pelvic organ prolapse, (2) the quantitative assessment of pelvic organ prolapse (Pelvic Organ Prolapse-Quantification or Baden-Walker), (3) the performance of an apical support procedure, and (4) the performance of cystoscopy at time of hysterectomy.

STUDY DESIGN

Patients who underwent hysterectomy for pelvic organ prolapse from January 1 to December 31, 2008, within a large healthcare maintenance organization were identified by diagnostic and procedural codes within the electronic medical record. Medical records were reviewed extensively for demographic and clinical data that included the performance of the 4 proposed quality measures and the training background of the primary surgeon (gynecologic generalist, fellowship-trained surgeon in Female Pelvic Medicine and Reconstructive Surgery, and "grandfathered" Female Pelvic Medicine and Reconstructive Surgery). Data were analyzed with the use of descriptive statistics. Inferential statistics with chi-squared tests were used to compare performance rates of quality measures that were stratified by surgical training. Probability values <.05 were considered statistically significant.

RESULTS

Six hundred thirty patients who underwent hysterectomy for pelvic organ prolapse in 2008 had complete records available for analysis. Fellowship-trained surgeons performed 302 hysterectomies for pelvic organ prolapse; grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed 98 hysterectomies, and gynecologic generalist surgeons performed 230 hysterectomies. Fellowship-trained surgeons had the highest performance rates for individual quality measures (91.4-98.7%) and cumulative performance of all measures (80.8% of cases). Grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed significantly fewer measures (80.6-95.9% performance rate for individual measures; 65.3% cumulatively for all measures) than fellowship-trained surgeons and more than gynecologic generalists (64.3-70% for individual measures; 29.1% cumulatively for all measures). There was an association between surgeon training background and number of hysterectomies performed for pelvic organ prolapse, with specialist surgeons performing more hysterectomies. When quality measure performance was stratified by surgeon volume, similar significant associations were found, with high-volume surgeons performing more quality measures than low-volume surgeons.

CONCLUSION

Within a large healthcare maintenance organization, fellowship-trained Female Pelvic Medicine and Reconstructive Surgery surgeons were more likely to perform proposed quality measures in women who underwent hysterectomy for pelvic organ prolapse compared with those surgeons without such training. Grandfathered Female Pelvic Medicine and Reconstructive Surgery surgeons performed measures more frequently than gynecologic generalists but less than fellowship-trained surgeons. Further study is indicated to correlate the proposed quality measures with clinical outcomes.

The K-Technique: A Novel Technique for Laparoscopic Apical Suspension Using Barbed Sutures

OBJECTIVES

Hysterectomy is among the most common gynecologic procedures performed for women, second only to cesarean sections, and the proportion of it performed laparoscopically continues to increase. Addressing apical support at the time of the hysterectomy is crucial to minimizing the risk of posthysterectomy prolapse. Barriers to addressing apical support include the lack of experience in laparoscopic suturing and knot tying that require advanced skills and dexterity. The K-technique is a novel modification of the uterosacral ligament suspension procedure using the knot-less barbed suture technology, rendering suturing easier and quicker to perform.

METHOD

The vaginal cuff epithelium is closed with 2 unidirectional barbed sutures that are started at the lateral fornices and ran until the midsection. The same sutures will then serially purchase the anterior and posterior vaginal endopelvic fascia and the midsegment of the uterosacral ligament. Two more passes are thrown through the same structures, yet farther laterally, back and forth. A video illustration of the procedure is attached.

RESULTS

Eighteen patients underwent the procedure with no urinary tract injuries documented by cystoscopy and no postoperative morbidity documented during the 6-week postoperative follow-up period. Limited short- and long-term follow-up data are reassuring, but more will be needed to confirm the efficacy of barbed sutures in prolapse repair.

CONCLUSIONS

The K-technique combines the conventional uterosacral ligament suspension concept with the ease, effectiveness, and safety of barbed sutures. The technique might aid the surgeon to add the apical vaginal support when indicated.