Nationwide assessment of practice variability in the utilization of hysteropexy at laparoscopic apical suspension for uterine prolapse

Background While hysteropexy to preserve the uterus at uterine prolapse surgery has long been utilized, there is a scarcity in data describing nationwide patterns of use of the surgical procedure. Objectives To examine the national-level utilization and characteristics of hysteropexy at the time of laparoscopic apical suspension for uterine prolapse in the United States. Study Design This cross-sectional 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. Patients who had hysterectomy were assigned as the hysterectomy group, and those that did not have hysterectomy were assigned as the hysteropexy group. 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. The secondary outcome was surgical morbidity including urinary tract injury, intestinal injury, vascular injury, and hemorrhage. Results Hysteropexy was performed in 6,500 (11.7%) patients. In a multivariable analysis, characteristics associated with increased utilization of hysteropexy included (i) patient factors, such as older age, Medicare coverage, private insurance, self-pay, and medical comorbidity, (ii) pelvic floor dysfunction factor of complete uterine prolapse, and (iii) hospital factors, including medium bed capacity center and location in the Southern U.S. (all, P<.05). Conversely, (i) the patient factor of higher household income, (ii) gynecological factors such as uterine myoma, adenomyosis, and benign ovarian pathology, (iii) pelvic floor dysfunction factor with stress urinary incontinence, and (iv) hospital factors including Midwest / West U.S. regions and rural setting center were associated with decreased utilization of hysteropexy (all, P<.05). A classification-tree identified a total of 14 utilization patterns for hysteropexy at laparoscopic apical suspension. The strongest factor predicting if patients underwent hysteropexy was the presence or absence of uterine myomas; the rate of hysteropexy was decreased to 5.6% if myomas were present compared to 15% if no myomas (P<.001). Second layer factors were adenomyosis and hospital region. Patients with neither uterine myomas nor adenomyosis and surgery in the Southern US had the highest rate of hysteropexy (22.6%). Across the 14 patterns, the percentage rate difference between the highest and lowest patterns was 22.0%. Patients undergoing hysteropexy were less likely to undergo antero-posterior colporrhaphy, posterior colporrhaphy, and sling procedures (all, P<.05). Hysteropexy was associated with decreased risk of measured surgical morbidity (3.0 vs 5.4 per 1,000, adjusted-odds ratio 0.57, 95% confidence interval 0.36-0.90). Conclusion The results of current real-world practice data suggest that hysteropexy is being performed at the time of ambulatory laparoscopic apical suspension for uterine prolapse. There is a substantial variability in the utilization of hysteropexy based on patient, gynecological, pelvic floor dysfunction and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice may be of use.