Cost Effectiveness of Prophylactic Uterosacral Ligament Suspension During Hysterectomy

IMPORTANCE: Standard hysterectomy care includes incorporating uterosacral ligaments into the vaginal cuff to reduce prolapse risk. A high uterosacral ligament suspension (USLS) results in a higher cuff attachment and is commonly used to treat prolapse but is rarely performed prophylactically. With limited data on its preventive value, computer modeling can assess whether prophylactic USLS should be routinely included to prevent prolapse. OBJECTIVES: This study evaluates the costs and cost-effectiveness of adding prophylactic USLS to benign hysterectomies. STUDY DESIGN: A cost-effectiveness model (TreeAge Pro, 2024 $U.S.) incorporated Medicare Physician Fee Schedules and Diagnosis-Related Group costs. A utility of 0.864 was assigned for prolapse occurrence following hysterectomy ± uterosacral ligament suspension, with a mean onset of 7 years. Sensitivity analysis varied prolapse onset (0-20 years) with a 3% discount rate. The model estimated the minimum additional percentage of prolapse prevented for prophylactic USLS to be cost-effective at a $100K per quality-adjusted life year threshold. RESULTS: USLS added $4,992.87 in costs. It was cost-effective when prolapse risk was relatively reduced by ≥7.1%. In 87.0% of modeled scenarios, USLS met cost-effectiveness criteria. The minimum preventive benefit required for cost-effectiveness ranged from 5.8% (immediate prolapse after hysterectomy) to 10.5% (20-year delay). Including prolapse treatment costs would further improve cost-effectiveness. CONCLUSIONS: Prophylactic USLS increases costs and procedural risks but is cost-effective with modest prolapse risk reduction. While prospective comparative studies may be impractical, and inclusion of prophylactic USLS with all hysterectomies may overly stress the current system, it would still be reasonable to consider prophylactic USLS during hysterectomies.