By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: The main objective of this study was to determine whether the use of apical suspension at the time of vaginal hysterectomy varies by surgeon specialty.
SOURCE: Sheyn D, El-Nashar S, Mahajan ST, et al. Apical suspension utilization at the time of vaginal hysterectomy for pelvic organ prolapse varies with surgeon specialty. Female Pelvic Med Reconstr Surg 2020;26:370-375.
This was a retrospective, nested, cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database between the years 2014 and 2016. This database captures data regarding more than 150 perioperative variables of patients ≥ 18 years of age from more than 600 participating hospitals. NSQIP uses the Current Procedural Terminology (CPT) codes to identify procedures. The ACS-NSQIP has collected hysterectomy-specific data since 2014, including parity, presence, and location of endometriosis; history of abdominal and pelvic surgery; and the surgeon’s subspecialty.
For this study, the hysterectomy data set was combined with the general data set using unique patient identifiers. Subjects undergoing vaginal hysterectomy who had a diagnosis of pelvic organ prolapse were identified using ICD-9-CM codes. The procedures patients underwent, including vaginal hysterectomy, intraperitoneal or extraperitoneal suspension, anterior or posterior vaginal wall repairs, urethropexy, and sling, were identified using CPT codes. Subjects who underwent non-gynecologic surgery or other forms of hysterectomy (abdominal or laparoscopic) with colpopexy, colpocleisis, bowel resection, lymph node dissection, or other tumor-related surgery and with preoperative or postoperative diagnostic codes for malignancy were excluded. Subjects with incomplete records also were excluded. The primary outcome of the analysis was the likelihood of apical suspension at the time of surgery. A secondary analysis investigated complication rates by the presence or absence of apical suspension at the time of hysterectomy and the risk factors for complications.
Of the 3,932 vaginal hysterectomies performed for pelvic organ prolapse during the study period, nearly one-third were performed by a urogynecologist. In this group, patients were more likely to be Caucasian and older and to have a higher presurgical risk. Apical suspension was performed in one-third of all hysterectomies. Sixty percent of obstetrician-gynecologists (OB/GYNs) performed vaginal hysterectomy alone without apical suspension, while 7% of urogynecologists performed vaginal hysterectomy alone. In analysis with matching by propensity score, 901 hysterectomies were performed by urogynecologists and 1,802 were performed by OB/GYNs with well-matched preoperative characteristics. (A propensity score is the calculated score of the probability the group assignment is dependent on baseline characteristics or variables. For this study, the propensity score was calculated for the likelihood of undergoing surgery by either a urogynecologist or an OB/GYN and was used to match cases performed by urogynecology subspecialists to those performed by OB/GYNs by preoperative characteristics and using a ratio of 1:2).
The average age of patients in the matched group was 55.9 years. The majority were healthy, and 92% had some amount of uterine prolapse by diagnostic code. In the matched group, 82% of urogynecologists performed apical suspension at the time of vaginal hysterectomy and 20% of OB/GYNs performed apical suspension. OB/GYNs were more likely to perform vaginal hysterectomy alone without apical suspension. Overall, there was no difference in the rate of complications between those who did and did not undergo apical suspension, with urinary tract infection and nonoperative readmissions as the most common complications. After adjusting for confounders, apical suspension was not associated with an increased risk of complication.
The 2017 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on choosing a route for hysterectomy emphasizes that minimally invasive hysterectomies are preferred. Of these, ACOG recommends vaginal hysterectomy as the route of choice when feasible.1 As described by Hoffman et al for decades, “One of the most widely accepted criteria for vaginal hysterectomy has been pelvic relaxation with descensus or prolapse.”2 Surgeons who regularly perform this procedure are keenly aware that performing a vaginal hysterectomy in a woman with no uterine descensus can be very challenging, although mild or moderate prolapse facilitates the procedure. Therefore, it seems logical to inquire regarding the use of apical suspension procedures at the time of vaginal hysterectomy.
The authors of this study found a low rate of apical suspension at the time of vaginal hysterectomy despite investigating only vaginal hysterectomies performed with a listed diagnosis of prolapse. The lack of routine use of an apical procedure regardless of prolapse diagnosis also was reported by Ross et al.3 This study used the National Inpatient Sample to identify vaginal hysterectomies performed between 2004 and 2013. In this sample, the apical support procedure was performed in only 3% of vaginal hysterectomies without a diagnosis of prolapse and in 37% of hysterectomies performed with a diagnosis of prolapse (20% of the whole sample). The 2007 ACOG practice bulletin on pelvic organ prolapse established that hysterectomy alone is not an adequate treatment for pelvic organ prolapse.4 Also, there is evidence that demonstrates that reestablishing support to the vaginal apex at the time of hysterectomy decreases the risk of apical prolapse after hysterectomy.5 Despite this, the authors of the current study find continuing trends of low use of apical suspension procedures at the time of vaginal hysterectomy for a diagnosis of prolapse. This finding varies by surgeon specialty. Specifically, 44% of the time OB/GYNs performed vaginal hysterectomy alone without concomitant prolapse procedure.
Although the lack of clear definitions of apical loss, as well as the lack of clear guidelines, may contribute to this trend, careful surgical planning prior to vaginal hysterectomy may aid in changing these practice patterns. Surgical planning for any patient undergoing vaginal hysterectomy should include a thorough evaluation of prolapse by anterior, posterior, and apical vaginal compartments, as well as an examination of the genital hiatus. The support of the apex dramatically affects the support of the anterior and posterior vaginal walls, so much so that anterior or posterior prolapse should be considered apical support loss until proven otherwise by examining each compartment separately.6 In addition, Lowder et al demonstrated that an enlarged genital hiatus size is predictive of apical vaginal support loss, in particular a Pelvic Organ Prolapse Quantification measurement of genital hiatus of ≥ 3.75 cm.7 The current study demonstrates that care of women undergoing vaginal hysterectomy frequently does not align with the standard of care. Women undergoing vaginal hysterectomy with symptomatic pelvic organ prolapse should be offered apical suspension and reconstructive surgery. Similarly, women with asymptomatic prolapse undergoing vaginal hysterectomy should be counseled about the risks and benefits of a concomitant apical procedure. A review of individual risk factors for prolapse should be discussed with women undergoing vaginal hysterectomy for non-prolapse indications. However, since apical descent is a consideration in criteria to assess vaginal hysterectomy feasibility, women undergoing vaginal hysterectomy without a diagnosis of prolapse should be offered an apical suspension procedure.
- Committee on Gynecologic Practice. Committee Opinion No. 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol 2017;129:e155-e159.
- Hoffman M, Spellacy WN. The Difficult Vaginal Hysterectomy: A Surgical Atlas. Springer Science+Business Media;1995.
- Ross WT, Meister MR, Shepherd JP, et al. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: A national estimate. Am J Obstet Gynecol 2017;217:436.e1-436.e8.
- ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 85: Pelvic organ prolapse. Obstet Gynecol 2007;110:717-729.
- Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999;180:859-865.
- Lowder JL, Park AJ, Ellison R, et al. The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse. Obstet Gynecol 2008;111:152-157.
- Lowder JL, Oliphant SS, Shepherd JP, et al. Genital hiatus size is associated with and predictive of apical vaginal support loss. Am J Obstet Gynecol 2016;214:718.e1-8.