Prophylactic apical suspension during elective benign hysterectomy for non-prolapse indications

Objectives: Our primary objective was to assess national trends and factors associated with performing prophylactic apical suspension procedures at the time of elective hysterectomy for benign, non-prolapse indications. Our secondary objective was to determine the rates of post-operative complications associated with performing prophylactic apical suspension procedures.

Methods: Secondary analysis of the National Surgical Quality Improvement Program database from 2014-2020. CPT codes were used to identify patients who underwent hysterectomy (abdominal, vaginal, laparoscopic/robotic), apical suspension (uterosacral, sacrospinous ligament suspension, McCall culdoplasty), and other concomitant procedures (anterior repair, posterior repair, combined anterior and posterior repair, sling). Patients undergoing hysterectomy for prolapse, malignancy, emergency, or obstetric indications were excluded. Two cohorts of patients were compared: hysterectomy without apical suspension and hysterectomy with apical suspension. Univariable analysis was performed to compare the two cohorts in terms of demographics and preoperative variables and postoperative complications. Multivariable logistic regression was then performed to identify factors associated with performing apical suspension procedures.

Results: Of 255,794 hysterectomies captured, only 572 (0.22%) prophylactic apical suspension was performed. During the study period, the proportion of hysterectomies performed by the laparoscopic/robotic route increased significantly from 59.4% to 73.2% (P < .0001) while the rate of apical suspension decreased from 0.4% to 0.15% (P < .01).

Univariable comparison showed that the no apical suspension and apical suspension cohorts differed in regards to the following variables, respectively: mean age (28.8 vs 27.3, p< .001), mean parity (1.8 vs 2.4, p< .001) , mean BMI (31.6 vs 30.7, p=0.007), proportion with American Society of Anesthesia Class of 3 or 4 (23.2% vs 17.8%, p=0.003), proportion with history of prior pelvic surgery (28.4% vs 22.0%, p=.001), proportion with history of endometriosis (7.51% vs 2.6%, p< .001), mean uterine weight in grams (157 vs 117, p< .001), surgeon subspecialty, route of hysterectomy, and performance of other concomitant procedures. Of note, there were no difference in rates of post-operative complications.

Multivariable logistic regression controlled for aforementioned variables showed that apical suspension was significantly more likely to be performed (adjusted odds ratio, 95% confidence interval) if hysterectomy was performed vaginally or abdominally as compared to laparoscopically/robotically (aOR 46.25, 30.16-70.92 for vaginal and 1.96, 1.03-3.75 for abdominal), performed by a urogynecologist (aOR 3.34, 2.00-5.57), and uterine weight was less than 250 grams (aOR 3.85, 1.79-8.33). Performance of apical suspension did not increase the risk of any post-operative complications.

Conclusions: In addition to adding no significant increase in the risk of post-operative complications, performance of prophylactic apical suspension could help prevent post hysterectomy prolapse. However, it is rarely performed nationally. With a rise in laparoscopic/robotic route for hysterectomy, greater emphasis on prophylactic apical suspension may be warranted.