Regional Variations in Hysterectomy at Time of Prolapse Surgery in Young Women

INTRODUCTION: Pelvic organ prolapse is a common pelvic floor disorder affecting up to 50% of women who have given birth, often leading to both emotional and physical distress. Surgical treatment options include sacrospinous ligament fixation, uterosacral ligament suspension, and sacrocolpopexy. Historically, hysterectomy has been performed with prolapse repairs. Pelvic reconstructive surgery can be done with or without a hysterectomy, and via a multitude of techniques with regard to hysterectomy. As there are different risks and benefits to different pelvic reconstructive and hysterectomy techniques, it is important to understand variations in care across the country in order to investigate cost effectiveness in health care delivery and promote value-based medicine. OBJECTIVE: The primary objective of this study is to assess regional variation in the United States in the type of hysterectomy and pelvic reconstructive surgery performed during prolapse repair in women aged 40 or younger. METHODS: This retrospective cohort study used data from the Healthcare Cost and Utilization Project (HCUP) database. Women were identified based on CPT codes for pelvic reconstructive surgery (57282, 57283, 57425). Regional variations were compared based on pelvic reconstructive surgery and the type of hysterectomy performed (including not performed) in women aged 40 or younger. Secondarily, regional variations were compared between women aged 40 or less and 65 and older undergoing pelvic reconstructive surgery. Univariate and multivariate analyses were used to analyze the data where appropriate. RESULTS: Among women aged 40 or younger, we observed a variation in the type of apical suspension by region (p<0.001). The highest rate of sacrocolpopexy was observed in the Northeast (22.7%) compared to the lowest in the West (14.6%) (p<0.001) (Figure 1). A vaginal apical suspension was more commonly performed in the South (18.2%) (p=0.001). Similarly, significant geographic variation was seen for hysterectomy at the time of pelvic reconstruction in women under 40 (p<0.001). The highest rate of transvaginal hysterectomy was observed in the Midwest (19.1%) compared to the lowest in the Northeast (11.8%) (p<0.001) (Figure 2). The highest rate of total laparoscopic hysterectomy was observed in the Midwest and the South at 21.6% for both, whereas the West had the lowest at 16.6% (p<0.001). Regarding laparoscopic-assisted vaginal hysterectomy, the highest rate was observed in the West at 13.7% (p<0.001). The highest rate of laparoscopic supracervical hysterectomy was seen in the Northeast at 5.33% with the lowest rate seen in the South at 2.71% (p<0.001). Regional variations in pelvic reconstructive surgery and hysterectomy compared with women over 65 can be seen in Figures 1 and 2. CONCLUSIONS: Significant regional variations were observed in apical suspension as well as type of hysterectomy performed during pelvic reconstructive surgery in women 40 years of age or younger in the United States. Regional differences were different between 40 years of age or less and women aged 65 and greater.