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.
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.
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%).
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.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160–6.
Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol. 2001;184(7):1496–501 discussion 501–3.
Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90.
Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116(5):1096–100.
DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717–24 discussion 24–8.
Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol. 2006;108(2):324–32.
Eilber KS, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, et al. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol. 2013;122(5):981–7.
Shull BL. Pelvic organ prolapse: anterior, superior, and posterior vaginal segment defects. Am J Obstet Gynecol. 1999;181(1):6–11.
Whiteside JL, Weber AM, Meyn LA, Walters MD. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol. 2004;191(5):1533–8.
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(4):859–65.
Dallenbach P. To mesh or not to mesh: a review of pelvic organ reconstructive surgery. Int J Women's Health. 2015;7:331–43.
Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016–24.
Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner AC, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34.
Larson KA, Smith T, Berger MB, Abernethy M, Mead S, Fenner DE, et al. Long-term patient satisfaction with Michigan four-wall sacrospinous ligament suspension for prolapse. Obstet Gynecol. 2013;122(5):967–75.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6.
Practice Bulletin No. 185 Summary: Pelvic Organ Prolapse. Obstet Gynecol. 2017;130(5):1170–2.
Shiloach M, Frencher SK Jr, Steeger JE, Rowell KS, Bartzokis K, Tomeh MG, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210(1):6–16.
Daley J, Forbes MG, Young GJ, Charns MP, Gibbs JO, Hur K, et al. Validating risk-adjusted surgical outcomes: site visit assessment of process and structure. National VA surgical risk study. J Am Coll Surg. 1997;185(4):341–51.
Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA Jr, et al. The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg. 2007;204(6):1089–102.
Khuri SF, Henderson WG, Daley J, Jonasson O, Jones RS, Campbell DA Jr, et al. Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the patient safety in surgery study. Ann Surg. 2008;248(2):329–36.
Steinberg SM, Popa MR, Michalek JA, Bethel MJ, Ellison EC. Comparison of risk adjustment methodologies in surgical quality improvement. Surgery. 2008;144(4):662–7 discussion -7.
Rooney K, Kenton K, Mueller ER, FitzGerald MP, Brubaker L. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol. 2006;195(6):1837–40.
Lowder JL, Park AJ, Ellison R, Ghetti C, Moalli P, Zyczynski H, et al. The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse. Obstet Gynecol. 2008;111(1):152–7.
Northington GM, Hudson CO, Karp DR, Huber SA. Concomitant apical suspensory procedures in women with anterior vaginal wall prolapse in the United States in 2011. Int Urogynecol J. 2016;27(4):613–9.
Adams-Piper ER, Guaderrama NM, Chen Q, Whitcomb EL. Impact of surgical training on the performance of proposed quality measures for hysterectomy for pelvic organ prolapse. Am J Obstet Gynecol. 2017;216(6):588 e1–5.
Fairchild PS, Kamdar NS, Berger MB, Morgan DM. Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse. Am J Obstet Gynecol. 2016;214(2):262 e1–7.
Morgan DM, Pulliam S, Adam RA, Swenson C, Guire K, Kamdar N, et al. Analysis of high-, intermediate-, and low-volume surgeons when performing hysterectomy for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2016;22(1):43–50.
Ross WT, Meister MR, Shepherd JP, Olsen MA, Lowder JL. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol. 2017;217(4):436 e1–8.
Yurteri-Kaplan LA, Mete MM, St Clair C, Iglesia CB. Practice patterns of general gynecologic surgeons versus gynecologic subspecialists for concomitant apical suspension during vaginal hysterectomy for uterovaginal prolapse. South Med J. 2015;108(1):17–22.
Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. Int Urogynecol J. 2015;26(2):207–12.
Conflict of interest
Sources of support
No sources of support reported.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Hill, A.M., Pauls, R.N. & Crisp, C.C. Addressing apical support during hysterectomy for prolapse: a NSQIP review. Int Urogynecol J 31, 1349–1355 (2020). https://doi.org/10.1007/s00192-020-04281-w
- Pelvic organ prolapse
- Apical support
- Practice patterns