Cost Effectiveness Analysis of Prophylactic High Uterosacral Ligament Suspensions During Benign Hysterectomies

INTRODUCTION: The current standard of care for a hysterectomy (Hyst) is incorporating uterosacral ligaments into vaginal cuff closure to mitigate future pelvic organ prolapse (POP). High uterosacral ligament suspension (USLS) is a procedure that results in higher cuff attachment and is typically used to treat POP, but is seldomly performed prophylactically during Hysts. Data is lacking whether optimally suspending the vagina with prophylactic USLS should be included as a standard technique with all Hysts to reduce resultant POP; therefore, computer modeling is the only current avenue for investigation. OBJECTIVE: To evaluate the overall costs and cost-effectiveness of adding prophylactic USLS in women undergoing Hysts. METHODS: A cost-effectiveness model was created using TreeAge Pro. Costs in 2024 $US included Medicare Physician Fee Schedules and Diagnosis-Related Group costs for facility fees. Costs included USLS costs and frequency-weighted complication costs. Outcomes reported ΔCosts, so Hyst costs which were similar ± USLS were not included. A utility of 0.815 for POP occurrences after Hyst ± USLS (mean = 7 years from Hyst) was incorporated from published literature. As timing of POP development was a key determinant of ΔEffectiveness, sensitivity analysis varied from 0–20 years with standard 3% discount rate. Model time horizon was fluid and determined by timing of POP development. The other determinant of ΔEffectiveness was prolapse prevention by USLS. With no data, we assumed POP was less likely with USLS+Hyst than Hyst. This preventive benefit was varied 0% (no prevention) to baseline post-Hyst POP risk (full prevention). In most cost-effectiveness analyses, inputs are known and cost-effectiveness is calculated comparing incremental cost-effectiveness ratio (ICER) to willingness-to-pay thresholds (WTP=$100K). Conversely, with an unknown preventive benefit of USLS, we worked backward determining which values of preventive benefit would make routine USLS cost-effective. RESULTS: USLS added $4,992.87 in total costs. Figure 1 demonstrates 1-way sensitivity analysis of ICER for prophylactic USLS varying the preventive benefit of USLS. Prophylactic USLS is cost-effective anytime its ICER is within $100K per QALY of Hyst (WTP, where adjusted curves intersect in). Anytime prophylactic USLS reduced POP risk by ≥7.1%, it was cost-effective. Two-way sensitivity analysis varied both USLS preventative benefit and time until POP, and USLS was cost-effective in 87.0% (Figure 2). Regardless of time until POP, USLS must reduce POP by 5.8–10.5% to cross the cost-effectiveness frontier. The base-case threshold of 7.1% at 7 years is on this frontier. Treatment costs of POP were not included due to high variability, but since any preventive benefit of USLS lowered that group’s rate of POP, their inclusion would only improve cost-effectiveness of USLS and lower the needed preventive benefit threshold. CONCLUSIONS: Adding prophylactic USLS to Hysts increases costs and complications as with any additional procedure. However, with modest POP prevention, USLS is cost-effective. Prospective comparative studies may be impractical due to required follow-up ≥7 years to confirm these potential benefits based on the actual resultant % reduction in prolapse. It may be reasonable to include high USLS when Hyst is performed.