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

Abstract

Background Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports re-establishment 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 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 Inpatient Sample was used to identify hysterectomies performed from 2004–2013 for benign indications. ICD-9 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 between 2004 and 2013. In both non-prolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (p <0.0001). 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 <0.0001). 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<0.0001). 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. Conclusions 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 re-establishing apical vaginal support at time of hysterectomy regardless of indication.

Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse

“…In the current study, 32% (961/3,000) of hysterectomies had no concomitant prolapse procedures. This is consistent with prior studies that showed between 27% and 63% of women undergoing surgery for prolapse had an isolated hysterectomy performed [23,28]. In our study, women with concurrent prolapse procedures at the time of hysterectomy had 50% increased odds of having had a pessary offer.…”

Comparison of laparoscopic techniques for apical organ prolapse repair – a systematic review of the literature

“…Apical support is the keystone of female pelvic organ support . Stage ≥ II anterior prolapse is highly suggestive of clinically significant apical descent.…”

“…8 The Integral Theory assumes sagittal support of the organs between the pubic symphysis and sacrum, including pubourethral ligaments and pubocervical fascia attached to the pericervical ring, which is then attached to uterosacral ligaments. 9,10 Pubocervical ligaments attach to the anterior, cardinal ligaments to the lateral, and uterosacral ligaments to the posterior parts of the pericervical ring. Damage to these structures results in clinical uterine prolapse or enterocoele.…”

“…2 Apical support is the keystone of female pelvic organ support. 10 Stage ≥ II anterior prolapse is highly suggestive of clinically significant apical descent. As cystocele stage increases, the predictive value of apical prolapse also increases.…”

Prophylactic McCall Culdoplasty by a Vaginal Approach during Mini-Laparoscopic Hysterectomy

“…Suspension of the vaginal apex to the uterosacral ligaments or to the sacrospinous ligaments at the time of vaginal hysterectomy is the mainstay for the prevention of posthysterectomy vaginal vault prolapse [1]. An increased likelihood of performing an apical support procedure has been shown to be associated with increased age, hospital type (urban vs. teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) in hysterectomies performed without diagnosis of prolapse [2].…”