Apical support at the time of hysterectomy for uterovaginal 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.

The association between surgeon subspecialty training and postoperative outcomes following surgery for pelvic organ prolapse

BACKGROUND

Symptomatic pelvic organ prolapse is common and affects 25% to 35% of women worldwide. As this growing patient need is being met by surgeons from diverse training backgrounds, it is important to both characterize the differences in surgeon practice patterns and examine postoperative outcomes to ensure optimal patient care.

OBJECTIVE

To determine the association between surgeon specialty and postoperative outcomes following surgery for pelvic organ prolapse.

STUDY DESIGN

This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program Gynecologic reconstructive surgery targeted database between 2014 and 2018. Pelvic organ prolapse surgeries were identified using Current Procedural Terminology codes, and surgical cases performed by urogynecologists or obstetrician-gynecologists were included for analysis. The primary outcome was any 30-day postoperative complication following prolapse surgery. The secondary outcomes were any major or minor postoperative complications, genitourinary complications, reoperation, or readmission within 30-days following surgery. Descriptive statistics were used to characterize the cohort, and pairwise analyses were used to describe the differences between the cases performed by the surgeon specialties. Multivariable logistic regression was used to control for potential confounders.

RESULTS

A total of 3358 women underwent prolapse surgery-68% performed by urogynecologists and 32% by obstetrician-gynecologists. The 30-day postoperative complication rate was higher for surgeries performed by obstetrician-gynecologists than for surgeries performed by urogynecologists (10.7% vs 7.0%, respectively; P<.001). There was no difference in the readmission rates between the 2 groups (2.1% vs 2.0%; P=1.000). However, the reoperation rates were higher for surgeries performed by obstetrician-gynecologists (1.8% vs 1.0%; P=.040). In a multivariable logistic regression model controlling for age, body mass index, American Society of Anesthesiology class, smoking, and type of concomitant surgery (hysterectomy, apical suspension, other prolapse surgery, obliterative procedure, or sling), prolapse surgery performed by a urogynecologist remained associated with nearly 40% lower odds of any 30-day postoperative complication (adjusted odds ratio, 0.62; 95% confidence interval, 0.48-0.80).

CONCLUSION

Prolapse surgery performed by a urogynecologist is associated with lower odds of any 30-day postoperative complication than that performed by an obstetrician-gynecologist.

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.

A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study

Background

The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH).

Methods

This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed.

Results

Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6–12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1–4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1–5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230).

Conclusion

The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01591-z.

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.

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.

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.

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.

Motion of the vaginal apex during strain and defecation

INTRODUCTION AND HYPOTHESIS

Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers.

METHODS

This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4-S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects.

RESULTS

Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p < 0.001). Differences in the vector magnitude, although not statistically significant, showed a trend indicating shorter lengths with maximum evacuation.

CONCLUSIONS

The vaginal apex is a highly mobile structure demonstrating significantly more mobility during defecation compared with strain. The data obtained contradict the general perception that the vaginal apex is relatively fixed within the pelvis of normally supported women.

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

BACKGROUND

In gynecological surgery, one particular area of concern after hysterectomy is the risk of developing an enterocele or vaginal apical prolapse. The aims of this study were to evaluate the safety and efficacy of prophylactic McCall culdoplasty (MC) performed during mini-total laparoscopic hysterectomy (mini-TLH), as well as to compare the differences in apical support, total vaginal length (TVL), and sexual function at one and two years postoperatively.

METHODS

Data were retrospectively reviewed for all women who underwent mini-TLH and mini-TLH + MC at a tertiary care center between August 2012 and January 2016 were from the hospital database. There were 18 women who underwent mini-TLH + MC and were considered as the study group, while 20 women who were treated with mini-TLH were considered as the control group. The primary outcome measures were the differences in apical support and TVL and impact on sexual function.

RESULTS

After mini-TLH + MC, the apical vaginal support difference was improved by 2.2 cm. The mean difference in C point was 1.03 cm in the mini-TLH group, which was not significant at two years after the operation. The vaginal vault descent at two years after operation was more prominent in the mini-TLH group than the mini-TLH + MC groups. Apical support changes at two years after the operation were more prominent in the mini-TLH group (0.5 ± 0.6 cm) than the mini-TLH + MC group (1.9 ± 1.2 cm).

CONCLUSION

Prophylactic MC by a vaginal approach during mini-TLH is safe, satisfactory, and efficient for apical support without severe morbidity.

Apical Suspension Utilization at the Time of Vaginal Hysterectomy for Pelvic Organ Prolapse Varies With Surgeon Specialty

OBJECTIVE

To evaluate whether utilization of apical suspension procedures at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty.

METHODS

This was a retrospective cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2016. International Classification of Diseases, Ninth Revision, Clinical Modification with a diagnosis of pelvic organ prolapse who underwent vaginal hysterectomy with any combination of pelvic reconstructive procedures. Propensity score matching using available preoperative clinical data was used to ameliorate selection bias by specialty at a ratio of 1 female pelvic reconstructive surgeon (FPMRS) surgeon to 2 obstetrician-gynecologists (OBG). Descriptive statistics were reported as means with standard deviations. Pairwise analysis using Student t test and Fisher exact test was performed where appropriate.

RESULTS

After propensity score matching, there were 901 cases performed by FPMRS and 1802 performed by OBG. The overall utilization rate of apical suspension in the matched cohort was 81.7% for FPMRS and 19.8% for OBG (P < 0.001). Obstetrician-gynecologists were more likely to perform vaginal hysterectomy without apical suspension compared with FPMRS (44.3% vs 5.8%; P < 0.001) and were also more likely to perform nonapical vaginal repair without also performing an apical suspension, (17.7% vs 9.3%, P < 0.001), compared to urogynecologists. On multivariable logistic regression, having surgery performed by FPMRS was the only significant variable associated with an increased likelihood of undergoing apical suspension (adjusted odds ratio, 5.34; 95% confidence interval, 4.48-6.36).

CONCLUSIONS

The FPMRS physicians are more likely to perform apical suspension with vaginal hysterectomy for prolapse repair compared with OBG.

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.

Apical Vaginal Support: The Often Forgotten Piece of the Puzzle

Pelvic organ prolapse is common among women who have delivered vaginally or had a hysterectomy. In a total hysterectomy, the apical vaginal support is transected. Although evidence supports re-establishment of apical support, our research showed that this rarely occurs in hysterectomies. To address our lack of definitions of "significant" apical support loss and recommendations to guide surgeons as to when they should perform an apical support procedure, we analyzed patient data and found that a simple assessment of the genital hiatus can effectively screen for significant apical support loss. Our work will hopefully highlight the importance of apical support loss and current deficits in research and clinical guidelines.

Definitions of apical vaginal support loss: a systematic review

OBJECTIVE

We sought to identify and summarize definitions of apical support loss utilized for inclusion, success, and failure in surgical trials for treatment of apical vaginal prolapse.

BACKGROUND

Pelvic organ prolapse is a common condition affecting more than 3 million women in the US, and the prevalence is increasing. Prolapse may occur in the anterior compartment, posterior compartment or at the apex. Apical support is considered paramount to overall female pelvic organ support, yet apical support loss is often underrecognized and there are no guidelines for when an apical support procedure should be performed or incorporated into a procedure designed to address prolapse.

STUDY DESIGN

A systematic literature search was performed in 8 search engines: PubMed 1946-, Embase 1947-, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings, using key words for apical pelvic organ prolapse and apical suspension procedures through April 2016. Searches were limited to human beings using human filters and articles published in English. Study authors (M.R.L.M., J.L.L.) independently reviewed publications for inclusion based on predefined variables. Articles were eligible for inclusion if they satisfied any of the following criteria: (1) apical support loss was an inclusion criterion in the original study, (2) apical support loss was a surgical indication, or (3) an apical support procedure was performed as part of the primary surgery.

RESULTS

A total of 4469 publications were identified. After review, 35 articles were included in the analysis. Prolapse-related inclusion criteria were: (1) apical prolapse (n = 20, 57.1%); (2) overall prolapse (n = 8, 22.8%); or (3) both (n = 6, 17.1%). Definitions of apical prolapse (relative to the hymen) included: (1) apical prolapse >-1 cm (n = 13, 50.0%); (2) apical prolapse >+1 cm (n = 7, 26.9%); (3) apical prolapse >50% of total vaginal length (-[total vaginal length/2]) (n = 4, 15.4%); and (4) cervix/apex >0 cm (n = 2, 7.7%). Sixteen of the 35 studies (45.7%) required the presence of symptoms for inclusion. A measurement of the apical compartment (relative to the hymen) was used as a measure of surgical success or failure in 17 (48.6%) studies. Definitions for surgical success included: (1) prolapse stage >2 in each compartment (n = 5, 29.4%); (2) prolapse >-[total vaginal length/2] (n = 2, 11.8%); (3) apical support >-[total vaginal length/3] (n = 1, 5.9%); (4) absence of prolapse beyond the hymen (n = 1, 5.9%); and (5) point C at ≥-5 cm (n = 2, 11.8%). Surgical failure was defined as: (1) apical prolapse ≥0 cm (n = 2, 11.8%); (2) apical prolapse ≥-1 cm (n = 2, 11.8%); (3) apical prolapse >-[total vaginal length/2] (n = 3, 17.6%); and (4) recurrent apical prolapse surgery (n = 1, 5.9%). Ten (28.6%) of the 35 studies also included symptomatic outcomes in the definition of success or failure.

CONCLUSION

Among randomized, controlled surgical trials designed to address apical vaginal support loss, definitions of clinically significant apical prolapse for study inclusion and surgical success or failure are either highly variable or absent. These findings provide limited evidence of consensus and little insight into current expert opinion.

Genital hiatus size is associated with and predictive of apical vaginal support loss

BACKGROUND

Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely.

OBJECTIVE

The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support.

STUDY DESIGN

This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated.

RESULTS

Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models).

CONCLUSIONS

Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery.

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

BACKGROUND

It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse.

OBJECTIVE

The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates.

STUDY DESIGN

This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications.

RESULTS

POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315).

CONCLUSION

Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.

Concomitant apical suspensory procedures in women with anterior vaginal wall prolapse in the United States in 2011

INTRODUCTION

Although the surgical restoration of apical support has been shown to decrease reoperation rates, it is unclear whether this has been incorporated into current practice. The aims of this study were to determine the rate of concomitant apical suspensory procedures in women with anterior vaginal wall prolapse undergoing surgical repair in 2011 and to identify associated factors.

METHODS

This cross-sectional study queried the Nationwide Inpatient Sample for women with a primary diagnosis of cystocele who underwent prolapse repair in 2011. The study cohort was analyzed for demographics, concomitant procedures, and hospital characteristics. The rate of apical suspensory procedures was determined. Factors potentially associated with receiving concomitant apical suspensory procedure were evaluated using univariate analysis and multivariate logistic regression.

RESULTS

A total of 2,900 women in the database had a primary diagnosis of cystocele and underwent surgical prolapse repair in 2011. 925 (31.9 %) subjects underwent a concomitant apical suspensory procedure. The mean age in the study cohort was 61.9 ± 12.8 years. Hysterectomies were performed in 11.1 % of subjects. 61.1 % were performed vaginally, 26.5 % laparoscopically, and 12.5 % abdominally. On multivariate analysis, age greater than 50 years, Caucasian race, concomitant hysterectomy, and an urban teaching hospital setting were independently associated with receiving concomitant apical suspensory procedure in 2011.

CONCLUSIONS

Despite evidence that the restoration of apical support is important for optimal anterior support, the overall rate of concomitant apical suspensory procedures is low. Several factors may play a role in whether or not women receive an apical suspensory procedure. This study highlights opportunities to improve the quality of surgical care provided to women with anterior vaginal prolapse.

Apical Suspension at the Time of Hysterectomy for Uterovaginal Prolapse: A Comparative Analysis of 2001 and 2011

OBJECTIVES

The primary aim of this study was to compare the proportion of concomitant apical procedures in women undergoing hysterectomy for uterovaginal prolapse in 2001 and 2011. The secondary aim was to identify factors associated with receiving concomitant apical procedures in 2001 and 2011.

METHODS

The Nationwide Inpatient Sample database was queried for women with a primary diagnosis of uterovaginal prolapse who underwent hysterectomy in 2001 and 2011. The study cohort was analyzed for demographics, clinical factors, and concomitant procedures. Factors potentially associated with receiving concomitant apical procedure were evaluated using univariable analysis and multivariate logistic regression.

RESULTS

A total of 14,647 women were identified (5867 in 2001 and 8780 in 2011). In 2001, 26.9% women received a concomitant apical procedure, and this proportion increased to 48.2% in 2011 (odds ratio, 2.53; 95% confidence interval, 2.36-2.72; P < 0.0001). In 2001, the mean (SD) age was 53.8 (14.1) years compared with 56.8 (13.3) years in 2011. Although vaginal hysterectomy was most common in both years, a concomitant apical procedure was more likely to be performed with abdominal hysterectomy (P < 0.001). On multivariate analysis, age older than 50 years (P = 0.0001), abdominal route of hysterectomy (P < 0.0001), and undergoing hysterectomy at an academic teaching hospital (P < 0.0001) were independently associated with concomitant apical procedures in both 2001 and 2011.

CONCLUSIONS

Although the proportion of concomitant apical repair was higher in 2011 compared with 2001, it is still low given the existing data demonstrating the importance of a concomitant apical procedure at the time of hysterectomy for uterovaginal prolapse.

Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial

OBJECTIVE

To investigate whether uterus preserving vaginal sacrospinous hysteropexy is non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments in the surgical treatment of uterine prolapse.

DESIGN

Multicentre randomised controlled non-blinded non-inferiority trial.

SETTING

4 non-university teaching hospitals, the Netherlands.

PARTICIPANTS

208 healthy women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery.

INTERVENTIONS

Treatment with sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments. The predefined non-inferiority margin was an increase in surgical failure rate of 7%.

MAIN OUTCOME MEASURES

Primary outcome was recurrent prolapse stage 2 or higher of the uterus or vaginal vault (apical compartment) evaluated by the pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months' follow-up. Secondary outcomes were overall anatomical recurrences, including recurrent anterior compartment (bladder) and/or posterior compartment (bowel) prolapse, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning.

RESULTS

Sacrospinous hysteropexy was non-inferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n=0, 0%) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n=4, 4.0%, difference -3.9%, 95% confidence interval for difference -8.6% to 0.7%). At 12 months, overall anatomical recurrences, functional outcome, quality of life, complications, hospital stay, measures on postoperative recovery, and sexual functioning did not differ between the two groups. Five serious adverse events were reported during hospital stay. None was considered to be related to the type of surgery.

CONCLUSIONS

Uterus preservation by sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for surgical failure of the apical compartment at 12 months' follow-up.

TRIAL REGISTRATION

trialregister.nl NTR1866.