Variability in the usage of hysteropexy at laparoscopic apical suspension

Objectives: To examine the national-level utilization and characteristics of hysteropexy at the time of laparoscopic apical suspension for uterine prolapse.

Methods: This retrospective cohort study queried the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population was 55,608 patients with a diagnosis of uterine prolapse who had laparoscopic apical suspension from 2016-2019. Exclusion criteria included prior hysterectomy, diagnosis of malignancy including pre-malignancy, and abdominal hysterectomy / colpopexy. Exposure was hysterectomy status. The American Medical Association's Current Procedural Terminology codes were used to identify hysterectomy modalities: total laparoscopic, laparoscopic supracervical, laparoscopy-assisted vaginal, and total vaginal. Patients who had any of these hysterectomy codes were assigned as the hysterectomy group, and those without any hysterectomy codes were assigned as the hysteropexy group in this study. The main outcome was clinical characteristics associated with hysteropexy, assessed with a multivariable binary logistic regression model. A classification-tree was further constructed to assess the utilization pattern of hysteropexy at laparoscopic apical suspension. A recursive partitioning analysis with chi-square automatic interaction detector method was used with a stopping rule of maximum three layers.

Results: Hysteropexy was performed in 6,500 (11.7%) patients. In a multivariable analysis, factors associated with increased utilization of hysteropexy included (i) patient factors, such as older age, Medicare, private insurance, self-pay, and medical comorbidity, (ii) gynecological factor of complete uterine prolapse, and (iii) hospital factors, including medium bed capacity center and South U.S. region (all, P< 0.05). Contrary, (i) the patient factor of higher household income, (ii) gynecological factors such as uterine myoma, adenomyosis, ovarian pathology, rectocele, and stress urinary incontinence, and (iii) hospital factors including Midwest / West U.S. regions and rural setting center were associated with decreased utilization of hysteropexy (all, P< 0.05). A classification-tree identified a total of 14 utilization patterns for hysteropexy at laparoscopic apical suspension (Figure panel). The first, strongest factor predicting if patients underwent hysteropexy was the presence of uterine myomas, which decreased to 5.6% if myomas compared to 15% if no myomas (P < 0.001). Second layer factors were adenomyosis and hospital region. Patients with neither uterine myomas nor adenomyosis and surgery in the South region had the highest rate of hysteropexy (22.7%). Across the 14 patterns, the percentage rate difference between the highest and lowest patterns was 22.0%. Patients undergoing hysteropexy were less likely to have antero-posterior colporrhaphy, posterior colporrhaphy, and sling procedure (all, P< 0.05).

Conclusions: The results of current real-world practice data suggest that hysteropexy is being performed at the time of ambulatory surgery-setting laparoscopic apical suspension for uterine prolapse. There is substantial variability in the utilization of hysteropexy based on patient, gynecological, and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice, as well as introducing an administrative code, may be useful.