Original Article

Practice Patterns of General Gynecologic Surgeons Versus Gynecologic Subspecialists for Concomitant Apical Suspension during Vaginal Hysterectomy for Uterovaginal Prolapse

Authors: Ladin A. Yurteri-Kaplan, MD, MS, Mihriye M. Mete, PhD, Chris St Clair, MS, RN, Cheryl B. Iglesia, MD

Abstract

Objectives: We hypothesized that subspecialists perform more concomitant apical suspensions during transvaginal hysterectomy for uterovaginal prolapse as compared with general gynecologists.

Methods: Retrospective analysis of the MedStar Health EXPLORYS database for women undergoing transvaginal hysterectomy for prolapse. Appropriate International Classification of Diseases-9 codes for uterine prolapse and incomplete and complete uterovaginal prolapse along with Current Procedural Terminology codes were used to determine frequency of transvaginal hysterectomy alone, transvaginal hysterectomy plus nonapical repair, and transvaginal hysterectomy plus concomitant apical suspension.

Results: A total of 946 patients underwent vaginal hysterectomy for prolapse, with 5.5 years follow-up. Thirty-five percent (n = 334) underwent transvaginal hysterectomy alone, 20% (n = 184) underwent transvaginal hysterectomy plus nonapical repair, and 45% (n = 428) underwent transvaginal hysterectomy plus apical suspension. Seventy-two percent of patients operated on by general gynecologists compared with 4% of patients operated on by urogynecologists had a transvaginal hysterectomy alone. Only 10% of patients operated on by general gynecologic surgeons compared with 78% operated on by urogynecologists received a concomitant apical suspension for prolapse ( P < 0.0001). Forty-four patients (4.7%) required repeat surgery for recurrent prolapse. Because of the small number of repeat surgeries, preoperative degree of prolapse and type of index procedure did not significantly affect the need for repeat surgery.

Conclusions: The majority of prolapse procedures involving hysterectomies performed by general gynecologists do not include apical suspension, whereas urogynecologic subspecialists consistently perform apical suspension.

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References

1. Nygaard I, Bradley C, Brandt D. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol 2004;104:489-497.
 
2. Wu JM, Hundley AF, Fulton RG, et al. Forecasting the prevalence of pelvic floor disorders in US women: 2010 to 2050. Obstet Gynecol 2009;114:1278-1283.
 
3. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-1316.
 
4. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol 2014;123:141-148.
 
5. Wu JM, Kawasaki A, Hundley AF, et al. Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050. Am J Ostet Gynecol 2011;205:230.e1-e5.
 
6. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-506.
 
7. Clark AL, Gregory T, Smith VJ, et al. Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2003;189:1261-1267.
 
8. Denman MA, Gregory WT, Boyles SH, et al. Reoperation 10 years after surgical managed pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2008;198:555.e1-e5.
 
9. Chen L, Ashton-Miller JA, Hsu Y, et al. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol 2006;108:324-332.
 
10. Walters MD, Ridgeway BM. Surgical treatment of vaginal apex prolapse. Obstet Gynecol 2013;121(2 Pt 1):354-374.
 
11. Eilber KS, Alperin M, Khan A, et al. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol 2013;122:981-987.
 
12. Fialkow MF, Newton KM, Weiss NS. Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1483-1487.
 
13. Shull BL, Bachofen C, Coates KW, et al. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365-1373.
 
14. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014;311:1023-1034.
 
15. Rogo-Gupta LJ, Lewin SN, Kim JH, et al. The effect of surgeon volume on outcomes and resource use for vaginal hysterectomy. Obstet Gynecol 2010;116:1341-1347.
 
16. Sung VW, Rogers ML, Myers DL, et al. Impact of hospital and surgeon volumes on outcomes following pelvic reconstructive surgery in the United States. Am J Obstet Gynecol 2006;195:1778-1783.
 
17. Gotthart PT, Aigmueller T, Lang PF, et al. Reoperation for pelvic organ prolapse within 10 years of primary surgery for prolapse. Int Urogynecol J 2012;23:1221-1224.
 
18. Green-top guideline no.46: the management of post hysterectomy vaginal vault prolapse. RCOG Br Soc Urogynaecol 2007:1-13.