Int Urogynecol J DOI 10.1007/s00192-016-3244-9
ORIGINAL ARTICLE
Role of concurrent vaginal hysterectomy in the outcomes of mesh-based vaginal pelvic organ prolapse surgery James C. Forde 1 & Bilal Chughtai 2 & Jennifer T. Anger 3 & Jialin Mao 4 & Art Sedrakyan 4
Received: 29 September 2016 / Accepted: 11 December 2016 # The International Urogynecological Association 2017
Abstract Introduction and hypothesis Hysterectomy is often performed at the time of pelvic organ prolapse (POP) surgery; yet, there is insufficient evidence regarding the specific effect of hysterectomy on outcomes. We sought to determine the outcomes and associated short-term complications of mesh-based POP surgery with and without concurrent hysterectomy. Methods We utilized the New York Statewide Planning and Research Cooperation System (SPARCS) database to identify patients under 55 years of age undergoing surgeries for POP with mesh between 2009 and 2014. Patients who had a hysterectomy at the time of meshbased POP surgery were compared with those who underwent mesh-based POP surgery without hysterectomy. Outcome measures of the patient groups before and after propensity score matching were compared. We assessed the difference Chi-squared tests and log-rank tests in the entire cohort and Mantel–Haenszel stratified
Chi-squared tests and Prentice-Wilcoxon tests in the matched cohort. Results A total of 1,601 women underwent mesh-based POP surgery. 921 patients underwent concurrent hysterectomy, whereas 680 had mesh-based uterine-preserving POP surgery. After propensity score matching, there was no difference in reintervention rates between groups for up to 3 years. Concurrent hysterectomy with meshbased POP repair was consistently associated with longer hospitalization (20.0% vs 12.8% stayed longer than 2 days) and higher charges (median charges were $22,689 vs $19,273). Conclusions Concurrent hysterectomy during mesh-based POP surgery in patients under 55 years led to more expensive charges and a longer stay compared with uterine-preserving mesh surgery. There was no difference in reintervention rates between groups for up to 3 years. Keywords Hysterectomy . Mesh . Pelvic organ prolapse
James C. Forde and Bilal Chughtai are co-first authors
Introduction * Bilal Chughtai
[email protected]
1
Beaumont Hospital, Dublin, Ireland D09 V2N0
2
Department of Urology, Weill Cornell Medical College/New York Presbyterian Hospital, 425 East 61st Street, 12th Floor, New York, NY 10065, USA
3
Department of Urologic Reconstruction, Urodynamics, and Female Urology, Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
4
Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
It is estimated that 90% of hysterectomies are performed for benign indications [1, 2]. Although the most common indication for hysterectomy is symptomatic uterine fibroids, this is closely followed hysterectomy as pelvic organ prolapse (POP) surgery [3]. It is estimated that more than 300,000 procedures are performed annually to treat POP in the USA [4]. Progression of prolapse is more common in women over 65 years of age [5] and surgery to treat POP is most frequently performed in patients aged 60–69 in the USA [6, 7]. However, a large proportion of women undergo surgery for POP at
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a younger age. It is estimated that over 30% of women undergoing POP surgery are classified as being perimenopausal or of reproductive age [7]. Repair of POP without concurrent hysterectomy has been shown to be less invasive and associated with the short-term benefits of reduced blood loss, shorter operating time, faster postoperative recovery. and fewer complications overall [8–10]. However, data on the impact of concurrent hysterectomy on mesh-based surgical outcomes at the time of POP repair, particularly for medium- and long-term benefits, including reintervention rates, remain relatively sparse [11]. Many patients may request uterine preservation surgery at the time of POP repair. Reasons for this include personal preferences, cultural beliefs, sexual identity, or reproductive preservation in younger patients [12]. There is ongoing debate regarding the effect of concurrent hysterectomy on outcomes of mesh-based POP surgery [13]. Using a population cohort from the state of New York, we analyzed all-inclusive data of women undergoing mesh-based POP repair. We sought to determine the complications of concurrent hysterectomy at the time of mesh-based POP surgery.
remove possible confounders. In addition, we traced patients’ records back to 1995 and excluded those who had undergone previous prolapse repair surgeries, sling procedures or any kind of hysterectomy before their identified surgery date within our study period. The study population (<55 years) was chosen to ensure that patients were less likely to have a hysterectomy before 1995 (before the age of 40 for the cut-off age of 55 years). Using these criteria, the oldest patient would have been 36 years old in 1995. This would make them unlikely to have had a hysterectomy and well below the mean age at which a hysterectomy is performed in the USA [2]. Mesh was defined as any synthetic or biological augmenting material and identified by procedure codes. Additional inclusion criteria were a diagnosis of POP (ICD-9-CM 618.0–618.9). All procedures were identified using ICD-9-CM procedure codes (international classification of diseases, 9th revision, clinical modification) and CPT-4 codes (current procedural terminology coding system, 4th edition; Appendix 1). Patients undergoing mesh-based prolapse repair surgery via an abdominal approach were excluded. The use of these data was approved by the Institutional Review Board at Weill Cornell Medicine in New York City.
Materials and methods Variable definition and study endpoint Data source Our study utilized the New York Statewide Planning and Research Cooperation System (SPARCS), which is a database that collects patient-level details from every hospital discharge, ambulatory surgery, outpatient service, and emergency department in New York state. It contains patient demographics, diagnoses, procedures, length of stay, outcome, and charges. Patients are assigned a unique encrypted identifier to allow for longitudinal studies. Study population We identified women aged under 55 who received mesh-based surgeries for pelvic organ prolapse (POP) between 2009 and 2014. We further subdivided this group of patients into those who received hysterectomy at the time of POP and those who did not (uterinepreservation based on exclusion criteria). We excluded all patients with a diagnosis of fibroids, abnormal vaginal bleeding, gynecologic cancer, or cervical dysplasia, and patients receiving a concurrent sling procedure, to
Patient characteristics included age (<35, 35–44, 45–54), race (white and nonwhite), insurance status (Medicare, Medicaid, commercial, and other), and comorbidities. Comorbidities were identified using algorithms validated by Wilcoxon and colleagues [1]. Facility-related characteristics included service type (inpatient and outpatient service), facility ownership (state, nonstate/nonprofit, private), facility academic status (teaching and nonteachi n g ) , a n d f a ci l i t y vo l um e o f P O P p r o ce d u r e s . Information on facility ownership and academic status was obtained from the American Hospital Association database using the facility’s name. Facility volume was calculated based on the average annual volume of POP procedures, and summarized into low, medium, and high volume, according to tertiles. Primary outcomes included re-intervention rates and associated safety events within 90 days and at 1 and 3 years following the initial procedure. Secondary outcomes included length of stay and charges at baseline hospitalization. Safety events within 90 days included medical complications (acute myocardial infarction, stroke, pulmonary embolism, perioperative shock, deep
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venous thrombosis, and respiratory complications), other surgical complications (stricture or kinking of the ureter, persistent postoperative fistula, postoperative infection, vesical fistula, urinary–genital tract fistula, digestive– genital tract fistula), bleeding, postoperative urinary tract infections, and urinary retention. Readmission into hospital was also examined within 90 days. Patients who underwent repeat prolapse and mesh revision procedures (CPT-4 57295, 57296, 57415) were counted as having reintervention. We identified reintervention, urinary retention, and pain within 1 year and 3 years post-initial procedure. Patients were censored at the time death was recorded in SPARCS during the follow-up period. Statistical analysis We compared the baseline characteristics of two patient groups among those who underwent prolapse repair: those who underwent concurrent hysterectomy and those who did not. Differences in baseline characteristics between patient groups were examined using the percentage difference of event counts. We used propensity score matching to adjust for differences between the hysterectomy and uterine-sparing groups. The propensity score of each individual was obtained from a multivariate logistics regression based on patient characteristics (age, race, and insurance status), procedure year, comorbidities, service type, facility academic status, facility ownership, and procedure volume. Nearest neighbor matching was performed at a 1:1 fixed ratio, using a caliper width of 0.2 of the standard deviation of the logit of the propensity score. We then examined the differences in baseline characteristics of the two groups before and after propensity score matching to assess the reduction of heterogeneity by propensity score matching (see Table 6). Patients with missing information regarding facility characteristics were excluded from propensity score matching. Similarly, we compared the outcome measures of the patient groups before and after propensity score matching. We assessed the difference using Chisquared tests in the entire cohort and Mantel–Haenszel stratified Chi-squared tests in the matched cohort. Length of stay was compared using Wilcoxon rank sum test in the original cohort and using the signed rank test in the matched cohort. Nonparametric timeto-event analyses were conducted in both cohorts to compare the relative risk of undergoing reintervention, urinary retention, and pain at 1 year and 3 years following the initial procedures. The log rank test was
utilized in the entire cohort, whereas the Prentice– Wilcoxon test [14] was utilized in the matched cohort to assess the difference between the two patient groups. Kaplan–Meier curves were constructed to visualize freedom from reintervention within 1 year. All analyses were performed using SAS v9.4 (SAS Institute, Cary, NC, USA).
Results We identified 1,601 women aged less than 55 years of age undergoing mesh-based POP repair between 2009 and 2014 in New York state. 921 of them had undergone a hysterectomy at the time of POP repair, whereas 680 underwent uterine-preserving surgery at the time of POP repair. The overall numbers of mesh-based POP surgeries declined from 305 procedures in 2009 to 186 procedures in 2014. We observed an overall increase in the proportion of patients receiving concurrent hysterectomy at the time of POP repair compared with those undergoing uterine-preserving POP surgery from 2009 to 2014 (P < 0.001). Patient characteristics Most patients undergoing prolapse repair surgeries were aged between 44 and 54 (68.9% (n = 1,103); Table 1). Fewer patients were aged younger than 35 in the hysterectomy group than in the uterine-preserving group (hysterectomy vs uterine-preserving: 3.5% vs 7.9%; p value < 0.001). Patients receiving concurrent hysterectomy were more likely to have commercial insurance (81.7% vs 73.7%; p = 0.001) and less likely to have Medicaid insurance (12.4% vs 17.9%; p = 0.001). Comorbidity profiles between two patient groups differed. We observed a slightly higher prevalence of hypertension (16.7% vs 14.9%; p = 0.31), anemia (4.8% vs 2.6%; p = 0.03), and depression (9.2% vs 6.0%; p = 0.02) among patients undergoing hysterectomy than patients undergoing uterine-preserving surgery. Most prolapse repair surgeries were performed in inpatient settings, including 88.4% (n = 1,415) of nonstateowned and 92.3% (n = 1,479) of nonprofit facilities. Patients receiving a concurrent hysterectomy were more likely to be treated at a high-volume facility (46.7% vs 22.8%; p < 0.01) and at a teaching facility (60.7% vs 57.5%; p = 0.2) than patients receiving uterinepreserving POP surgery. Balance between the two groups was achieved after propensity score matching.
Int Urogynecol J Table 1 Demographics and comorbidities of patients undergoing mesh-based POP surgery with hysterectomy or uterine-preserving surgery, between 2009 and 2014 in New York state Before propensity score matching
After propensity score matching
Hysterectomy, n (%) Uterine-preserving, n (%) p value Hysterectomy, n (%) Uterine-preserving, n (%) p value Total Year 2009 2010 2011 2012 2013 2014 Age (years) <35 35–44 44–54 Race Nonwhite White Missing Insurance Medicare Medicaid Commercial Other Comorbidities Coronary artery disease Hypertension Diabetes Chronic pulmonary disease Obesity Anemia Peripheral vascular disease Depression Procedure type Outpatient Inpatient Facility ownership State Non-state, non-profit Freestanding Teaching facility Facility volume Low Medium High
921
680
455 <0.01
136 (14.8%) 173 (18.8) 181 (19.7) 179 (19.4) 126 (13.7) 126 (13.7)
169 (24.9) 177 (26.0) 124 (18.2) 92 (13.5) 58 (8.5) 60 (8.8)
32 (3.5) 241 (26.2) 648 (70.4)
54 (7.9) 171 (25.1) 455 (66.9)
192 (20.8) 724 (78.6) 5 (0.5)
183 (26.9) 491 (72.2) 6 (0.9)
28 (3.0) 114 (12.4) 752 (81.7) 27 (2.9)
34 (5.0) 122 (17.9) 501 (73.7) 23 (3.4)
NR 154 (16.7) 69 (7.5) 102 (11.1) 54 (5.9) 44 (4.8) NR 85 (9.2)
NR 101 (14.9) 40 (5.9) 73 (10.7) 32 (4.7) 18 (2.6) NR 41 (6.0)
19 (2.1) 902 (97.9)
167 (24.6) 513 (75.4)
59 (6.4) 862 (93.6) NR 559 (60.7)
55 (8.1) 617 (91.4) NR 388 (57.5)
208 (22.6) 283 (30.7) 430 (46.7)
329 (48.4) 196 (28.8) 155 (22.8)
455 0.77
100 (22.0) 114 (25.1) 94 (20.7) 78 (17.1) 32 (7.0) 37 (8.1)
99 (21.8) 114 (25.1) 91 (20.0) 69 (15.2) 44 (9.7) 38 (8.4)
23 (5.1) 119 (26.2) 313 (68.8)
28 (6.2) 112 (24.6) 315 (69.2)
115 (25.3) 337 (74.1) 3 (0.7)
115 (25.3) 337 (74.1) 3 (0.7)
20 (4.4) 67 (14.7) 354 (77.8) 14 (3.1)
22 (4.8) 69 (15.2) 348 (76.5) 16 (3.5)
NR 76 (16.7) 35 (7.7) 53 (11.6) 24 (5.3) 19 (4.2) NR 38 (8.4)
NR 70 (15.4) 26 (5.7) 51 (11.2) 23 (5.1) 15 (3.3) NR 35 (7.7)
19 (4.2) 436 (95.8)
20 (4.4) 435 (95.6)
39 (8.6) 416 (91.4)
37 (8.1) 418 (91.9)
262 (57.6)
273 (60.0)
179 (39.3) 148 (32.5) 128 (28.1)
160 (35.2) 167 (36.7) 128 (28.1)
<0.01
0.7
0.01
1
<0.01
0.31 0.21 0.83 0.31 0.03 0.02 <0.01
0.96
0.05
0.20 <0.01
0.59 0.23 0.83 0.88 0.48 0.71 0.87
0.81
0.46 0.33
NR not recorded
Primary outcomes Patients who received concurrent hysterectomy were more likely to have medical complications (2.5% vs 1.7%; p = 0.28) and to be readmitted (3.7% vs 3.3%; p = 0.70) within 90 days. No difference was found for medical complications, bleeding, urinary tract infection, urinary retention, other surgical complications, and readmission into the inpatient department within 90 days between the hysterectomy and uterine-0sparing group (Fig. 1) after propensity score matching. Among patients who underwent POP repair surgery with and
without a hysterectomy, 60 and 43 of them had a reintervention within 3 years following initial surgery respectively. After propensity score matching, there was no significant difference in 1-year (3.1% vs 4.6%, p = 0.24) and 3-year (6.6% vs 6.6%, p = 0.94) risk of reintervention between the two groups (Fig. 2; Tables 2 and 3). There were 73 and 58 patients in the hysterectomy group and uterine-preserving group experiencing urinary retention within the 3-year followup, without significant difference between groups after propensity score matching (7.7% vs 9.7%, p = 0.30). The risk of having a pelvic pain diagnosis within the
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Fig. 1 Risk ratio of 90-day safety events comparing patients undergoing pelvic organ prolapse (POP) surgery with hysterectomy with patients undergoing POP with uterine-preserving surgery. Top: before propensity score matching; bottom: after propensity score matching
1-year and 3-year follow-up was not significantly different in the two patient groups after propensity score matching either. Secondary outcomes Patients who received concurrent hysterectomy had a longer stay (2 days vs 1 day; p < 0.01). The total hospital charges were also higher ($24,113 vs $17,550; p < 0.01) compared with patients who received uterine-preserving surgery. After propensity score matching, concurrent hysterectomy with POP repair was consistently associated with longer hospitalization (20.0% vs 12.8% stayed longer than 2 days; p < 0.01) and higher charges (median charges were $22,689 vs $19,273; p < 0.01).
Discussion We found that concurrent hysterectomy at the time of meshbased POP surgery led to more expensive charges and a longer stay compared with uterine-preserving surgery, and overall we found that there was no difference in reintervention rates between the groups for up to 3 years postoperatively. The overall numbers of mesh-based POP surgeries declined between 2009 and 2014. This is likely accounted for by the ongoing controversy regarding the use of mesh for POP repair following the safety communications from the FDA [15]. Although we observed an overall increase in the proportion of patients receiving concurrent hysterectomy at the time of POP repair compared with those undergoing uterine-preserving POP surgery from 2009 to 2014, the number of hysterectomies
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Fig. 2 Time to reintervention following POP surgery between 2009 and 2014 in New York state. Top left: 1-year follow-up before propensity score matching; top right: 1-year follow-up after propensity score matching; bottom left: 3-year follow-up before propensity score
matching; bottom right: 3-year follow-up after propensity score matching. Kaplan–Meier plot shows the number of patients at risk and 95% Hall–Wellner bands
performed decreased. Wright et al. previously reported that 36.4% fewer hysterectomies were performed in 2010 compared with 2002 [16]. The authors of this study suggest that the decline in hysterectomy might be due to less invasive alternatives to hysterectomy, such as endometrial ablation and uterine artery embolization as treatments for benign gynecological disease. A recent multicenter study by Korbly et al. evaluated patient preferences among women being examined during initial urogynecological evaluation for either a uterine preservation approach or hysterectomy at the time of prolapse surgery [17]. They concluded that a higher proportion of women preferred uterine preservation to hysterectomy. Patient preference was associated with geographic region, patient education level, and also a belief that the uterus is important for a sense of self [17]. The higher proportion of concurrent hysterectomy during POP treatment observed in our study may reflect the different attitude
toward hysterectomy among women who opted for surgical treatment. It is also possible that pre-surgical counseling and assessment has been a more significant factor in deciding the surgical approach than women’s own preference. We found a longer length of stay (2 vs 1 days) and a costlier procedure ($3,416 after propensity score matching) in the concurrent hysterectomy group. Neuman and Lavy compared the outcomes of concurrent vaginal hysterectomy at the time of meshbased POP repair with mesh repair only [18]. Seventy-nine women presenting with moderate to severe uterine prolapse underwent POP repair, with vaginal hysterectomy performed in 44 patients and uterine-sparing in 35 patients. They reported a statistically significantly longer stay for patients undergoing concurrent hysterectomy at the time of mesh-based POP surgery (4.2 days vs 1.5 days; p < 0.05). Longer hospital stays may be due to the added recovery needed after the hysterectomy. However, practice
Int Urogynecol J Table 2 Outcomes at index hospitalization and 90-day safety events of patients undergoing mesh-based POP surgery with hysterectomy or uterinepreserving surgery between 2009 and 2014 in New York state Before propensity score matching Hysterectomy Uterine(%) preserving (%)
After propensity score matching**
p RR (hysterectomy vs value uterine preservation)
Hysterectomy Uterine(%) preserving (%)
(n = 680)
(n = 455)
p RR (hysterectomy vs value uterine-preserving)
Index hospitalization Length of stay Median (IQR)*
(n = 921)
2 (1–2)
1 (1–2)
<0.01
2 (1–2)
1 (1–2)
<0.01
>75th percentile (2 days) Total charges ($)
152 (16.5)
68 (10.0)
<0.01
1.65 (1.26–2.16)
91 (20.0)
58 (12.8)
<0.01
1.57 (1.16–2.12)
Median* >75th percentile ($30,345) 90-day safety Medical complicationsa Bleeding
24,113 301(32.7)
17,550 99(14.6)
<0.01 <0.01
2.24 (1.83-2.75)
22,689 137(30.1)
19,273 90(19.8)
<0.01 <0.01
1.52 (1.21-1.92)
(n = 897)
(n = 664)
(n = 449)
(n = 446)
22 (2.5)
11 (1.7)
0.28
1.48 (0.72–3.03)
13 (2.9)
10 (2.2)
0.54
1.30 (0.57–2.96)
14 (1.6)
13 (2.0)
0.55
0.80 (0.38–1.68)
NR
NR
Urinary tract infection Urinary retention Other surgical complications Inpatient readmission
26 (2.9)
20 (3.0)
0.90
0.96 (0.54–1.71)
14 (3.1)
15 (3.4)
0.84
0.93 (0.45–1.93)
52 (5.8)
43 (6.5)
0.58
0.90 (0.61–1.32)
26 (5.8)
34 (7.6)
0.27
0.71 (0.43–1.17)
12 (1.3)
NR
NR
NR
33 (3.7)
22 (3.3)
18 (4.0)
17 (3.8)
0.88
1.06 (0.55–2.05)
0.70
1.11 (0.65–1.89)
(n = 455)
*p value is obtained from the Wilcoxon rank-sum test in the original cohort and the signed rank test from the matched cohort **Risk ratios (RR) and p values calculated using the stratified Mantel–Haenszel test a
Medical complications include acute myocardial infarction, stroke, pulmonary embolism, postoperative shock, deep venous thrombosis and respiratory complication
Table 3 Long-term reintervention and safety events comparing patients undergoing mesh-based POP surgery with hysterectomy or uterinepreserving surgery between 2009 and 2014 in New York state
Before propensity score matching
1-year follow-up Reintervention Urinary retention Pain 3-year follow-up Reintervention Urinary retention Pain
After propensity score matching
Hysterectomy, n (%)
Uterinepreserving, n (%)
p value*
Hysterectomy, n (%)
Uterinepreserving, n (%)
p value**
35 (3.8) 67 (7.3)
27 (4.0) 49 (7.2)
0.92 0.95
14 (3.1) 30 (6.6)
21 (4.6) 36 (7.9)
0.24 0.45
16 (1.7)
26 (3.8)
0.01
10 (2.2)
19 (4.2)
0.10
60 (6.5) 73 (7.9)
43 (6.3) 58 (8.5)
0.64 0.74
30 (6.6) 35 (7.7)
30 (6.6) 44 (9.7)
0.94 0.30
23 (2.5)
31 (4.6)
0.03
14 (3.1)
22 (4.8)
0.18
*p value is obtained from log rank test comparing differences in survival function between the two patient groups **p value is obtained using the Prentice–Wilcoxon test comparing differences in survival function between the two patient groups
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patterns may have an effect on hospital stay, such that those who undergo a hysterectomy are more likely to have a longer admission planned than those who undergo POP repairs alone. In our study, patients who underwent POP repair with uterine preservation were more likely to receive the surgery in an ambulatory surgical setting, with a planned admission of <24 h. We also noted no difference in perioperative and postoperative complications between the two groups. Existing published series have reported similar findings [19, 20]. Chu et al. compared surgical outcomes in 39 patients undergoing POP repair with mesh and concurrent hysterectomy to 52 patients in whom the uterus was preserved. They reported no significant differences between groups with regard to mesh extrusion, urinary symptoms, abnormal sensation or other postoperative complications. They also reported no major perioperative complications, except for one blood transfusion in the hysterectomy group [20]. Although these findings reflected a single surgeon’s experience, our population-based data showed similar patterns. There was no statistically significant difference in reintervention for mesh implantation, neither for mesh complications nor for repeat POP surgery, within 1 or 3 years following the initial prolapse repair procedure after propensity score matching. Gutman and Maher performed a meta-analysis of published studies on patients undergoing mesh-based POP surgery [13]. They reported no difference in anatomical success rates between patients who underwent uterine-sparing surgery and those who underwent hysterectomy at the time of POP surgery. They also noted no significant reduction in mesh exposure rates when the uterus was preserved compared with concurrent hysterectomy [13]. Although minimally invasive sacrocolpopexy studies report much higher mesh exposure rates when a total (vs supracervical) hysterectomy is performed, (23% vs 5%), we may be seeing that hysterectomy with mesh-based repairs using a vaginal approach is associated with lower rates of mesh-related complications [21]. There were inherent limitations in using claims-based data, including the fact that the severity of POP and clinical detail cannot be captured. We did apply statistical methods to minimize the residual confounding and reduce the imbalance between groups. Potential unmeasured confounding, such as physicians’ and patients’ preferences, may have created limitations to the observational study design. In addition, miscoding and under-coding may have occurred and the follow-up of patients may also be incomplete because of the use of a state database. With the data available, we were not able to separate those patients who received a biological mesh from those who received a synthetic mesh. However, to our knowledge, biologics make up a small proportion of the materials used, with synthetic mesh accounting for the vast majority. In addition, to avoid loss to follow-up due to relocation of patients to another state or country, follow-up was limited to 3 years. This meant that long-term outcomes after this time point were not available. To strengthen our data, we only identified patients who had undergone POP surgery for the
first time under the age of 55 years between 2009 and 2014. Patients who had had any type of hysterectomy or POP or urinary incontinence surgery during the previous 15 years were excluded. Although our exclusion criteria likely minimized the number of women with a previous hysterectomy, it is possible that a small percentage of women had undergone a hysterectomy at a young age, and were included in the uterinesparing cohort. However, we expect this number to be very low, given that previous studies have reported the mean age of women undergoing hysterectomy in the USA to be between 43 and 48 years, depending on the surgical approach used [2]. However, it can be argued that women without a uterus are comparable with women undergoing uterine-sparing procedures, and hence the rare inclusion of these women in our analysis should not significantly affect our findings. To date, evidence for the role of concurrent hysterectomy at the time of mesh-based vaginal POP repair has been limited, with a lack of randomized controlled trials or multiple prospective cohort studies [13]. Neuman and Lavy reported on the short- and medium-term benefits of the posterior intravaginal slingplasty (PIVS), facilitating the preservation of a prolapsed uterus. However, they highlighted the need for long-term data [18]. Otherwise, the efficacy of concurrent hysterectomy at the time of mesh-based POP surgery has been demonstrated in retrospective cohort studies, but with a follow-up of less than 1 year [19, 20]. Using population-based studies we compared outcomes of concurrent vaginal hysterectomy at the time of mesh-based POP surgery with patients who underwent mesh-based POP surgery only, assessing the rates, outcomes, and associated short- and medium-term complications. The inclusion of data for the entire New York state area, recent years, and all age groups makes this study important in defining age-dependent mesh safety. The cohort was additionally matched to controls for confounding variables, which further strengthened the comparisons made between the groups.
Conclusion Concurrent hysterectomy during mesh-based POP surgery in women under 55 years of age led to more expensive charges and longer hospital stay compared with uterine-preserving mesh surgery. There was no difference in the reintervention rates between groups for up to 3 years. Compliance with ethical standards Funding None. Conflicts of interest J.A. declares that she is an investigator and expert witness for Boston Scientific Corporation.
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Appendix
Table 4
Definition for procedures
ICD-9 procedure code
CPT-4 code
Mesh-specific procedure codes Repair of cystocele and rectocele 70.53 Insertion of mesh or other prosthesis for with graft or prosthesis repair of pelvic floor defect Repair of cystocele with graft or prosthesis 70.54 Repair of rectocele with graft or prosthesis 70.55 Vaginal construction with graft or prosthesis 70.63 Vaginal reconstruction with graft or prosthesis 70.64 Vaginal suspension and fixation with graft or 70.78 prosthesis Other operations on cul-de-sac with graft or 70.93 prosthesis Insertion of biological graft 70.94* Insertion of synthetic graft or prosthesis 70.95* General prolapse repair codes Repair of cystocele and rectocele, no graft 70.50 Rectocele repair Repair of cystocele, no graft 70.51 Anterior colporrhaphy, repair of cystocele Repair of rectocele, no graft 70.52 Posterior colporrhaphy, repair of rectocele Other operations on cul-de-sac 70.92 Combined anteroposterior colporrhaphy (repair of vaginal enterocele), no graft with enterocele repair Vaginal construction, no graft 70.61 Combined anteroposterior colporrhaphy Vaginal reconstruction, no graft 70.62 Enterocele repair, vaginal approach Vaginal suspension and fixation, no graft 70.77 Colpocleisis Colpocleisis 70.80 Colpopexy, vaginal, extraperitoneal approach Other uterine suspension 69.22 Colpopexy, vaginal, intraperitoneal approach Vaginal repair of chronic inversion of uterus 69.23 Paravaginal defect repair, vaginal approach Other repair of uterus and supporting structures 69.29 Pereyra procedure, including anterior colporrhaphy Other operation on supporting structure of the uterus 69.98 Uterine suspension Obliteration of vaginal vault and 70.4 Uterine suspension total excision of vagina Vaginal hysterectomy, with repair of enterocele Vaginal hysterectomy, with colpo-urethrocystopexy, complicated Vaginal hysterectomy with repair of enterocele, complicated Concurrent hysterectomy Subtotal abdominal hysterectomy 68.3× Partial hysterectomy Total abdominal hysterectomy 68.4× Total hysterectomy Vaginal hysterectomy 68.5× Vaginal hysterectomy
57267
45560 57240 57250 57270 57268 57260 57120 57282 57283 57285 57289 58400 58410 58270 58293 58294
Laparoscopic radical hysterectomy Laparoscopy-assisted vaginal hysterectomy
58180 58150, 58152, 58275, 58280 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58293, 58294 58200, 58210, 58285 58541, 58542, 58543, 58544, 58570, 58571, 58572, 58573 58548 58550, 58552, 58553, 58554
Revise vaginal graft via vagina Revise vaginal graft, open abdominal Remove vaginal foreign body
57295 57296 57415
Radical abdominal hysterectomy Radical vaginal hysterectomy
68.6× Extensive hysterectomy 68.7× Laparoscopic hysterectomy
Other and unspecified hysterectomy
68.9
Removal/revision of mesh
*Must be used concurrently with other prolapse repair codes
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Appendix
Table 5
Definition for complications
ICD-9 diagnosis/procedure code
CPT-4 code
Medical complications Acute myocardial infarction Acute myocardial infarction Intermediate coronary syndrome Acute coronary occlusion without myocardial infarction Other acute and subacute forms of ischemic heart disease, other Cardiac complications, not elsewhere classified Stroke
410.x 411.1 411.81 411.89 997.1
Iatrogenic cerebrovascular infarction or hemorrhage Subarachnoid hemorrhage
997.02 430
Intracerebral hemorrhage Nontraumatic extradural hemorrhage Subdural hemorrhage
431 432.0 432.1
Unspecified intracranial hemorrhage Pulmonary embolism
432.9
Pulmonary embolism and infarction
415.1, 415.11, 415.12, 415.13 415.19
Postoperative shock Postoperative shock not elsewhere classified Deep vein thrombosis Phlebitis and thrombophlebitis of deep veins of lower extremities Phlebitis and thrombophlebitis of lower extremities, unspecified Phlebitis and thrombophlebitis of iliac vein Phlebitis and thrombophlebitis of unspecified site Other venous embolism and thrombosis of inferior vena cava Acute venous embolism and thrombosis of deep vessels of lower extremity Acute venous embolism and thrombosis of other specified veins Other venous embolism and thrombosis of unspecified site Respiratory complications Empyema with fistula Empyema without mention of fistula Iatrogenic pneumothorax Pulmonary collapse Acute edema of lung, unspecified Pulmonary insufficiency following trauma and surgery Acute respiratory failure Ventilator associated pneumonia Continuous invasive mechanical ventilation Non-invasive mechanical ventilation Bleeding
998.0, 998.00, 998.01, 998.02, 998.09 451.1 451.2 451.81 451.9 453.2 453.4, 453.40, 453.41, 453.42 453.8 453.9
510.0 510.9 512.1 518.0 518.4 518.5 518.81 997.31 96.70, 96.71, 96.72 93.90
Continuous positive airway pressure (CPAP) Insert emergency airway
94660 31500
Int Urogynecol J Table 5 (continued) ICD-9 diagnosis/procedure code
CPT-4 code
Hemoperitoneum (nontraumatic) Hemorrhage or hematoma complicating a procedure not elsewhere classified Hemorrhage complicating a procedure
568.81 998.1
Hematoma complicating a procedure
998.12
Hematoma of vulva Urinary tract infection
998.11 624.5
Cystitis Acute cystitis
595 595.0
Trigonitis
595.3
Other specified types of cystitis
595.89
Cystitis, unspecified Urinary tract infection, site not specified
595.9 599.0
Other surgical complications Stricture or kinking of ureter
593.3
Persistent postoperative fistula
998.6
Postoperative infection not elsewhere classified Vesical fistula, not elsewhere classified Urinary–genital tract fistula, female
998.5× 596.2 619.0
Digestive–genital tract fistula, female Urinary retention Bladder neck obstruction
619.1
Other specified causes of urethral stricture
598.8
Urethral/bladder catheterization 51701 (simple) Cystourethroscopy with dilation 52281 of stricture Dilation of urethra 53660, 53661, 53665
Urethral stricture, unspecified
598.9
Dilate urethra stricture
53600, 53601, 53605, 53620, 53621
Urinary obstruction
599.6×
Repair of bladder wound
51860, 51865
Postoperative urethral stricture
Retention of urine Splitting of urinary stream Slowing of urinary stream Straining on urination Cystostomy Urethral/bladder catheterization (simple) Bladder injury Rupture of bladder, nontraumatic Hemorrhage into bladder wall Injury to bladder and urethra, without mention of open wound into cavity Suture of laceration of bladder Pain Interstitial cystitis Dyspareunia/pelvic pain
596.0 598.2
788.2× 788.61 788.62 788.65 57.1 57.94 596.6 596.7 867.0 57.81 595.1 625.0
Int Urogynecol J
Appendix Table 6 Demographics and comorbidities of patients undergoing mesh-based POP surgery with hysterectomy or uterine-preserving surgery between 2009 and 2014 in New York state
Before propensity score matching
After propensity score matching
Hysterectomy
Uterinepreserving
Hysterectomy
Uterinepreserving
Total
921
680
455
455
Year 2009
136 (14.8)
169 (24.9)
10.1
100 (22.0)
99 (21.8)
2010
173 (18.8)
177 (26.0)
7.2
114 (25.1)
114 (25.1)
0.0
2011 2012
181 (19.7) 179 (19.4)
124 (18.2) 92 (13.5)
1.4 5.9
94 (20.7) 78 (17.1)
91 (20.0) 69 (15.2)
0.7 2.0
2013
126 (13.7)
58 (8.5)
5.2
32 (7.0)
44 (9.7)
2.6
2014
126 (13.7)
60 (8.8)
4.9
37 (8.1)
38 (8.4)
0.2
Age <35
Difference (%)
Difference (%)
0.2
32 (3.5)
54 (7.9)
4.5
23 (5.1)
28 (6.2)
1.1
241 (26.2) 648 (70.4)
171 (25.1) 455 (66.9)
1.0 3.4
119 (26.2) 313 (68.8)
112 (24.6) 315 (69.2)
1.5 0.4
Nonwhite White
192 (20.8) 724 (78.6)
183 (26.9) 491 (72.2)
6.1 6.4
115 (25.3) 337 (74.1)
115 (25.3) 337 (74.1)
0.0 0.0
Insurance Medicare Medicaid Commercial
28 (3.0) 114 (12.4) 752 (81.7)
34 (5.0) 122 (17.9) 501 (73.7)
2.0 5.6 8.0
20 (4.4) 67 (14.7) 354 (77.8)
22 (4.8) 69 (15.2) 348 (76.5)
0.4 0.4 1.3
27 (2.9)
23 (3.4)
0.5
14 (3.1)
16 (3.5)
0.4
NR
NR
NR
NR
154 (16.7) 69 (7.5)
101 (14.9) 40 (5.9)
1.9 1.6
76 (16.7) 35 (7.7)
70 (15.4) 26 (5.7)
1.3 2.0
102 (11.1)
73 (10.7)
0.3
53 (11.6)
51 (11.2)
0.4
54 (5.9)
32 (4.7)
1.2
24 (5.3)
23 (5.1)
0.2
44 (4.8) NR
18 (2.6) NR
2.1
19 (4.2) NR
15 (3.3) NR
0.9
85 (9.2)
41 (6.0)
3.2
38 (8.4)
35 (7.7)
0.7
19 (2.1) 902 (97.9)
167 (24.6) 513 (75.4)
22.5 22.5
19 (4.2) 436 (95.8)
20 (4.4) 435 (95.6)
0.2 0.2
59 (6.4) 862 (93.6)
55 (8.1) 617 (91.4)
1.7 2.2
39 (8.6) 416 (91.4)
37 (8.1) 418 (91.9)
0.4 0.4
559 (60.7)
388 (57.5)
3.2
262 (57.6)
273 (60.0)
2.4
208 (22.6) 283 (30.7) 430 (46.7)
329 (48.4) 196 (28.8) 155 (22.8)
25.8 1.9 23.9
179 (39.3) 148 (32.5) 128 (28.1)
160 (35.2) 167 (36.7) 128 (28.1)
4.2 4.2 0.0
35–44 44–54 Race
Other Comorbidities Coronary artery disease Hypertension Diabetes Chronic pulmonary disease Obesity Anemia Peripheral vascular disease Depression Procedure type Outpatient Inpatient Facility ownership State Nonstate, nonprofit Teaching facility Facility volume Low Medium High
Int Urogynecol J
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