Trends in inpatient prolapse procedures in the United States, 1979–2006

doi:10.1016/j.ajog.2010.01.017

American Journal of Obstetrics and Gynecology

Volume 202, Issue 5, May 2010, Pages 501.e1-501.e7

Presented at the 30th Annual Scientific Meeting of the American Urogynecologic Society, Hollywood, FL, Sept. 24-26, 2009.

https://doi.org/10.1016/j.ajog.2010.01.017 Get rights and content

Objective

We sought to describe national trends for inpatient procedures for pelvic organ prolapse from 1979–2006.

Study Design

The National Hospital Discharge Survey was analyzed for patient and hospital demographics, as were International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedures codes from 1979–2006. Age-adjusted rates (AARs) per 1000 women were calculated using the 1990 US Census data.

Results

There was a significantly decreasing trend in the AARs for inpatient prolapse procedures, from 2.93–1.52 per 1000 women from 1979–2006. AARs for hysterectomy decreased from 8.39–4.55 per 1000 women from 1979–2006. Over the study period, AARs remained at about the 1979 level among the women ≥52 years old (2.73–2.86; P = .075). In women <52 years old, AARs declined to less than one-third of the 1979 rate (3.03–0.84; P < .001).

Conclusion

AARs for inpatient procedures for prolapse in the United States remained stable for women aged ≥52 years from 1979–2006; rates declined by two-thirds for women aged <52 years.

Section snippets

Materials and Methods

Methods have been previously described.¹⁰ Deidentified data were abstracted from the NHDS, a federal dataset utilizing a multistate probability sampling of inpatient hospital discharges in the United States. Medical records from 466 nonfederal short-stay hospitals, approximately 8% of all US hospitals, were selected by systematic random sampling. Approximately 270,000 discharges were collected per year from January 1979–December 2006. The survey recorded up to 7 discharge diagnosis codes and 4

Results

According to NHDS data, approximately 5,632,900 inpatient procedures for prolapse were performed in the United States from 1979–2006. The number of women undergoing prolapse procedures decreased from 231,100 in 1979 to 186,900 in 2006. AARs of prolapse surgery per 1000 women also decreased, from 2.93 in 1979 to 1.52 in 2006 (Figure 1). When stratified by age, the AAR for women aged ≥52 years was 2.73 in 1979 and 2.86 in 2006, while in women aged <52 years the AAR declined from 3.03–0.84 (Figure

Comment

Overall, rates of inpatient surgical procedures for pelvic organ prolapse declined from 1979–2006. However, AARs for inpatient prolapse procedures for women ≥52 years old have remained stable from 1979–2006, while rates have declined by two-thirds for women <52 years old. The decrease in overall numbers of procedures and AARs reflects a decline in number of procedures performed in women <52 years old. We believe the dramatic decrease in inpatient prolapse procedures performed in women <52 years

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Cited by (99)

Risk factors of lower urinary tract injury with laparoscopic sacrocolpopexy
2022, AJOG Global Reports
Citation Excerpt :
Although bladder injuries are generally detected intraoperatively, 62%–87% of ureteral injuries are unrecognized.7,26–28 In patients with unrecognized injuries compared with recognized ureteral injuries, the odds of 90-day readmission and acute renal failure are increased 24-fold, with the odds of fistula and sepsis increased 6-fold and 2-fold, respectively.7 These injuries are also more difficult to manage when detected postoperatively.
Lower urinary tract injuries can occur during pelvic reconstructive surgery, including sacrocolpopexy. The reported injury rates range from 0.4% to 10.6% with laparoscopic sacrocolpopexy, 1.1% to 3.3% with abdominal sacrocolpopexy, and 2.3% to 10% with robotic sacrocolpopexy. Specific literature identifying the risk factors for lower urinary tract injury during pelvic reconstructive surgery is lacking; therefore; we aim to identify the patient characteristics predisposing a patient to lower urinary tract injury during laparoscopic sacrocolpopexy.
The primary objective of this study was to identify the patient-specific risk factors for lower urinary tract injury with laparoscopic sacrocolpopexy.
This was an age-matched, case-control study including patients who underwent laparoscopic sacrocolpopexy from July 2014 to December 2017 in a high-volume female pelvic medicine and reconstructive surgery practice. The patients were excluded if they underwent laparoscopic uterosacral ligament suspension, had abnormal urinary tract anatomy, or for incorrect, incomplete, or duplicated data. Risk factors such as race, body mass index, pelvic organ prolapse quantification stage, previous abdominal and/or vaginal surgeries, and concurrent procedures (lysis of adhesions, adnexal surgery, midurethral sling placement, and anterior or posterior colporrhaphy) were analyzed. Groups were compared using the Student t-test for independent samples and chi-square tests. Conditional logistic regression was used to estimate the crude and adjusted odds ratios.
A total of 930 patients were identified during electronic medical record chart review using the current procedural terminology code 57425 (laparoscopic colpopexy). A total of 167 patients met the exclusion criteria, resulting in a total of 763 patients for primary analysis. The prevalence of lower urinary tract injury was 2.4% (17 bladder injuries and 1 ureteral injury out of 763 laparoscopic sacrocolpopexy procedures). These 18 cases were age-matched to 72 controls. The mean age and body mass index of all patients was 64.8 years (±9.32) and 26.5 kg/m² (±3.99), respectively. Most of the patients were Caucasian, had previously undergone abdominal and/or vaginal surgery, had pelvic organ prolapse stage 3 or greater, and underwent concurrent surgeries, including adnexal surgery and midurethral sling placement at the time of laparoscopic sacrocolpopexy. A history of previous hysterectomy (odds ratio, 19.94; 95% confidence interval, 2.48–160.38; P=.005) and lysis of adhesions at the time of laparoscopic sacrocolpopexy (odds ratio, 4.94; 95% confidence interval, 1.05–23.19; P=.043) were associated with an increased odds of lower urinary tract injury in unadjusted models. In a multivariable logistic regression model controlling for the previously listed variables, a history of previous hysterectomy remained significantly associated with lower urinary tract injury (adjusted odds ratio, 162.41; 95% confidence interval, 3.21–8227; P=.011). Race, body mass index, pelvic organ prolapse quantification system stage, previous abdominal and/or vaginal surgery, and concurrent procedures were not associated with an increased risk of lower urinary tract injury.
Although lower urinary tract injury with laparoscopic sacrocolpopexy only occurred in 2.4% of patients, previous hysterectomy increased this risk substantially. As sacrocolpopexy is the common treatment for prolapse after hysterectomy or recurrent prolapse, this increased risk of lower urinary tract injuries can guide surgical counseling on the basis of patient-specific risk factors and aid in setting appropriate postoperative patient expectations.
Rectal prolapse and pelvic descent
2021, Current Problems in Surgery
Citation Excerpt :
POP affects millions of women. Approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States.85,86 One in 5 women will undergo surgery for prolapse or incontinence by 80 years of age, and up to 30% of these women will require a second pelvic floor operation.87,88
A Meshless Practical Laparoscopic Sacrohysteropexy Modification and Long-term Outcomes
2020, Journal of Minimally Invasive Gynecology
To describe a new modification of laparoscopic sacrohysteropexy without using a mesh and report the 3-year outcomes.
A prospective cohort study.
Minimally Invasive Gynecology Unit, Bursa Uludag University Hospital, Turkey.
Women who were diagnosed with ≥ stage 2 uterine prolapse.
A laparoscopic sacrohysteropexy modification using a polyester fiber suture instead of a standard polypropylene mesh.
The primary outcome was the anatomic success of the repair, with success defined as objective parameters using the pelvic organ prolapse quantification system. The secondary outcomes were subjective outcomes, which were assessed using the quality-of-life scales. Forty-seven women who underwent the procedure were followed up for a minimum of 3 years. Forty-four of the 47 patients had stage 0 or 1 prolapse at the end of the second year, according to the primary outcomes. The anatomic success rate was 93.6%. In the secondary outcomes, 2 patients were not satisfied with their pelvic floor after the second year. The subjective cure rate was 95.7%. There was a statistically significant improvement in both pelvic organ prolapse quantification and quality-of-life scores in the third postoperative year. The mean operating time was 84.6 minutes, and the mean estimated blood loss was 21.3 mL. There were no bladder or bowel complications in the perioperative or postoperative period.
Laparoscopic sacrohysteropexy can be performed safely with this meshless modification in uterine prolapse as an alternative.
Incidence and risk factors for venous thromboembolism events after different routes of pelvic organ prolapse repairs
2020, American Journal of Obstetrics and Gynecology
Venous thromboembolism events, including deep venous thrombosis and pulmonary embolism are the most common cause of preventable deaths in hospitalized patients in the United States. Although the risk of venous thromboembolism events in benign gynecologic surgery is generally low, the potential for venous thromboembolism events in urogynecologic population is significant because most patients undergoing the pelvic organ prolapse surgery have increased surgical risk factors.
This study aimed to investigate the incidence and risk factors for venous thromboembolism events within 30 days after different routes of the pelvic organ prolapse surgery in a large cohort population using the American College of Surgeons-National Surgical Quality Improvement Program.
This retrospective cohort study used Current Procedural Terminology codes to identify pelvic organ prolapse repairs with and without concurrent hysterectomy performed during 2011–2017 in the American College of Surgeons-National Surgical Quality Improvement Program database. Demographics, preoperative length of hospital stay, operative time, preoperative comorbidities, smoking status, American Society of Anesthesiologists classification system scores, along with other variables were collected. Postoperative 30-day complications, including readmission, reoperation, and mortality, were collected. The incidence rates of venous thromboembolism, as defined by American College of Surgeons-National Surgical Quality Improvement Program, were compared among different surgical routes. Descriptive statistics were used, and logistic regression was performed to identify associations.
Among 91,480 pelvic organ prolapse surgeries identified, 63,108 were analyzed: 43,279 (68.6%) were performed vaginally, 16,518 (26.2%) laparoscopically, and 3311 (5.2%) abdominally. A total of 34,698 (55.0%) underwent a concurrent hysterectomy. Of 63,108 subjects, 133 developed venous thromboembolism within 30 days after surgery (0.21%; 95% confidence interval, 0.18–0.25; P<.0001). More than half (60%) of venous thromboembolism events occurred within 10 days after surgery. For all surgical routes, older age (P<.041), higher body mass index (P=.002), race or ethnicity (P=.04), longer operating time (P<.0001), inpatient status (P<.0001), American Society of Anesthesiologists 3 or 4 (P<.0001), having preoperative renal failure (P=.001), and chronic steroid use (P=.02) were significantly associated with venous thromboembolism. In addition, in the vaginal pelvic organ prolapse repair group, concurrent hysterectomy (P=.03) and preoperative dyspnea (P=.01) were associated with development of venous thromboembolism. In the abdominal pelvic organ prolapse repair, concurrent hysterectomy (P=.005) and hypertension requiring medication (P=.04) were also independently associated with venous thromboembolism development (Table 1). The incidence of venous thromboembolism was highest in abdominal repairs (0.72%), followed by laparoscopic repairs (0.25%) and vaginal repairs (0.16%). After adjusting for confounders, abdominal compared with vaginal approach (adjusted odds ratio, 3.27; 95% confidence interval, 1.93–5.41; P<.0001), longer operative time (adjusted odds ratio, 1.005; 95% confidence interval, 1.003–1.006; P<.0001), older age (adjusted odds ratio, 1.020; 95% confidence interval, 1.00–1.037; P=.015), greater body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01–1.07; P=.0006), American Society of Anesthesiologists 3 or 4 (adjusted odds ratio, 1.55; 95% confidence interval, 1.03–2.31; P=.03), and preoperative renal failure (adjusted odds ratio, 8.87; 95% confidence interval, 1.16–44.15; P=.04) remained significantly associated with developing venous thromboembolism. Neither laparoscopic repair (compared with vaginal repair) nor concurrent procedures (hysterectomy, antiincontinence procedure, vaginal mesh insertion) were found to be significantly associated with the development of venous thromboembolism. The abdominal pelvic organ prolapse repairs were associated with an increased hazard of venous thromboembolism (hazard ratio, 3.27; 95% confidence interval, 1.96–5.45; P<.0001). Venous thromboembolism development was associated with 30-day mortality, readmission, and reoperation (all P<.0001).
The overall incidence of venous thromboembolism after pelvic organ prolapse repairs based on a recent, large cohort database was very low, confirming the finding in previous smaller cohort studies. The highest venous thromboembolism risk was associated with abdominal route, and more than 60% of venous thromboembolism events occurred within 10 days after surgery. Thus, focus should be placed on risk-reducing strategies in the immediate postoperative period, with greater emphasis on patients undergoing abdominal surgery.
Symptomatic pelvic organ prolapse in middle-aged women: a national matched cohort study on the influence of childbirth
2020, American Journal of Obstetrics and Gynecology
The relative impact of age, pregnancy, and vaginal delivery on symptomatic pelvic organ prolapse is still an unresolved issue that involves the controversial question about the protective effect of cesarean section.
The purpose of this study was to compare the age-related prevalence of symptomatic genital prolapse in nulliparous, vaginal- and cesarean-delivered women aged 40–64 years.
This Swedish, nationwide matched cohort study involved 14,335 women. Three restricted, randomly selected source cohorts of women (nulliparous women unexposed to childbirth [n = 9136], 1-para cesarean delivered women, exposed to 1 pregnancy [n = 1412], and 1-para women exposed to 1 pregnancy followed by vaginal delivery [n = 3787]) were retrieved from the Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014. The surveys used a postal and Internet-based questionnaire containing validated questions for pelvic floor disorders. Symptomatic prolapse was defined by the question, “Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina?” In this study the symptom frequencies, sometimes and often, were defined as a positive response. Parous women were all assessed 20 years postnatally. One-to-one matching with an age interval for pairing of 3 years and 3 units of body mass index (kilograms per square meter) was used in women aged 40–64 years. The procedure succeeded in 2635 of 2640 women (99.8%), resulting in an adequate distribution of age and body mass index (kilograms per square meter) between matched groups. For comparison between groups, a Fisher exact test was used for categorical variables and the Mann-Whitney U test for continuous variables. Trend between matched groups was analyzed with Mantel-Haenszel statistics. Estimated, age-related values of symptomatic prolapse were obtained by logistic regression analysis.
In nulliparous and cesarean-delivered women, the prevalence of symptomatic prolapse was relatively similar and below 5% across ages 40–64 years. In contrast, in women after vaginal delivery, there was an accelerating increase in the prevalence of symptomatic genital prolapse up to 65 years of age. Estimated probability from the regression model increased 4-fold, from 3.8% at 40 years to 13.4% at 64 years of age. The observed induction period associated with 1 vaginal delivery seemed to be at least 20 years among women giving birth in their early 20s. At age 64 years, the estimated probability of symptomatic prolapse was 12 times higher after vaginal delivery compared with cesarean deliery (13.4% [95% confidence interval, 9.4–18.9] vs 1.1% [95% confidence interval, 0.4–2.5], P < .0001). The calculated reduction of symptomatic prolapse by cesarean delivery at 64 years of age was thus 92%.
In this national matched cohort study, the interaction between vaginal delivery and aging was the most important factor for the occurrence of symptomatic prolapse. Because the effect of aging can be modified only to a small extent, preventive strategies for genital prolapse should focus on how to avoid the adverse events related to a vaginal delivery.
Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database
2020, Journal of Minimally Invasive Gynecology
The objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH).
This was a retrospective cohort study. A secondary analysis of the 2006–2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned.
Hospitals participating in the NSQIP program.
Women who underwent hysterectomy with MISCP.
Not applicable.
A total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3–3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome.
Regardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.

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: Cite this article as: Jones KA, Shepherd JP, Oliphant SS, et al. Trends in inpatient prolapse procedures in the United States, 1979–2006. Am J Obstet Gynecol 2010;200:501.e1-7.

: Reprints not available from the authors.

: This study was supported by Grant no. UL1 RR024153 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Information on NCRR is available at http://www.ncrr.nih.gov.

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Meeting paperAUGS paperTrends in inpatient prolapse procedures in the United States, 1979–2006

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Meeting paper
AUGS paper
Trends in inpatient prolapse procedures in the United States, 1979–2006