Changing trends of surgical approaches for uterine prolapse: an 11-year population-based nationwide descriptive study

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1 Int Urogynecol J (2012) 23: DOI /s ORIGINAL ARTICLE Changing trends of surgical approaches for uterine prolapse: an 11-year population-based nationwide descriptive study Ming-Ping Wu & Cheng-Yu Long & Kuan-Hui Huang & Chin-Chen Chu & Ching-Chung Liang & Chao-Hsiun Tang Received: 30 June 2011 / Accepted: 24 December 2011 / Published online: 24 January 2012 # The International Urogynecological Association 2012 Abstract Introduction and hypothesis The interest of uterus-preserving surgery has been growing. Based on a nationwide database, we examined surgical procedures for uterine prolapse in Taiwanduringthestudyperiodof , a total of 11 years. Methods The operations, either uterine suspension or hysterectomy, due to the diagnosis of uterine prolapse were indentified into the study. Data on several parameters were collected for analysis, i.e., the surgical type, patient factors (age and concomitant anti-incontinence surgery), surgeon factors (age and gender), and hospital factors (accreditation level and ownership). Data of this study were obtained from the inpatient expenditures by admission files of the National Health Insurance Research Database (NHIRD). The NHIRD was established by the National Health Research Institute with the aim of promoting research into current and emerging medical issues in Taiwan. Results In total, 31,038 operations were identified for this study. There was a trend for increased use of uterine suspension with uterine preservation during the latter years, evidenced by joinpoint regression analyses. More women who were younger (<50 years) or had concomitant anti-incontinence surgery received uterine suspension. Younger surgeons (<50 years) and male surgeons tended to perform more uterine suspensions. As for hospital accreditation, more uterine suspension surgeries were performed in regional hospitals, followed by local hospitals and medical centers. As for hospital ownership, more Dr. Tang and Dr. Liang contributed equally to this work. M.-P. Wu Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital, Tainan, Taiwan M.-P. Wu Department of Obstetrics and Gynecology, College of Medicine, Taipei Medical University, Taipei, Taiwan C.-Y. Long Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan K.-H. Huang Division of Gynecology, Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan C.-C. Chu Department of Anesthesiology, Chi Mei Foundation Hospital, Tainan, Taiwan C.-C. Liang (*) Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine, Taoyuan, Taiwan ccjoliang@adm.cgmh.org.tw C.-H. Tang (*) School of Health Care Administration, College of Medicine, Taipei Medical University, 250 Wu-Xing Street, Taipei 110, Taiwan chtang@tmu.edu.tw

2 866 Int Urogynecol J (2012) 23: uterine suspension surgeries were performed in private hospitals, followed by not-for-profit and government-owned hospitals. Conclusions There has been a considerable change in the surgical approach for uterine prolapse in Taiwan over the past 11 years. Patient age and concomitant anti-incontinence surgery, surgeon age and gender, and hospital accreditation and ownership may correlate with the choice of surgery for women with uterine prolapse. Keywords Hospital accreditation. Hospital ownership. Hysterectomy. National Health Insurance Research Database (NHIRD). Pelvic organ prolapse (POP). Uterine prolapse. Uterine suspension. Vaginal suspension Introduction Pelvic organ prolapse (POP) is a commonly encountered women s health issue. As to prevalences in the Women s Health Initiative, 41% of women aged years showed some amount of POP, including cystocele in 34%, rectocele in 19%, and uterine prolapse in 14% [1]. In a multicenter study of 1006 women aged years presenting for routine gynecological care, 24% had normal support and 38% had stage I, 35% had stage II, and 2% had stage III POP [2]. The prevalence of POP increases as the life expectancy increases. POP is also known to have a negative impact on a patient s quality of life [3]. The lifetime risk of undergoing prolapse or continence surgery is 11.1% [4]. Different feasible surgical approaches include vaginal, abdominal, and laparoscopic procedures. Attitudes toward sexuality and psychological value of reproductive organs have changed in Western countries over the last few decades [5]. However, repair of POP with a concomitant hysterectomy is still considered a standard treatment. During the past decade, interest has been growing in uterus-preserving surgery worldwide [3]. Several surgical approaches with the aim of preserving the uterus have been developed, e.g., sacral hysteropexy [6], uterosacral ligament uterine suspension [7], and sacrospinous ligament uterine suspension [8]. Recently, the concept of uterine preservation during surgery to repair a prolapse and the use of adjuvant prostheses have been evolving [5, 9]. Use of a transvaginal mesh with either surgeon-tailored or commercial procedural kits is blossoming and becoming popular in the field [10, 11]. However, its influence on vaginal hysterectomies and the choice of surgeries for POP remain unknown. Our hypothesis that hysterectomy would be performed less commonly with the uterine suspension more commonly as the evolving concept of uterine-preserving pelvic reconstructive surgery has evolved favoring retention of the uterus. With our previous experience of analyzing changing trends for anti-incontinence surgery [12], we conducted this 11-year population-based nationwide study to describe changing trends of surgeries for uterine prolapse based on the National Health Insurance (NHI) claims data in Taiwan. Also, we evaluated some related variables, including patient age, concomitant anti-incontinence surgery, surgeon age and gender, and hospital parameters of accreditation (medical center, regional hospital, and local hospital), and ownership (government-owned, not-for-profit, and private) where the surgeries were performed. Materials and methods The NHI program in Taiwan Detailed information on NHI was given in our previous work [12]. Briefly, the NHI program in Taiwan was put into effect in March 1995 and features comprehensive and universal coverage. Financing sources of NHI primarily come from payroll taxes with additional subsidies from general government revenues. The NHI covered approximately 93.1% of the total population in Taiwan in 1996 to 99.3% in During 1996 and 2007, approximately 96.2% of the hospitals in Taiwan were contracted with the Bureau of NHI [12]. Data sources The data used in this study were obtained from the NHI Research Database (NHIRD). The NHIRD was established by the National Health Research Institute, in cooperation with the Bureau of NHI, with the aim of promoting research into current and emerging medical issues in Taiwan. Three types of files from the NHIRD were used in this study. First, inpatient expenditures by admission contain information on all NHI-reimbursed hospital discharges pertaining to inpatient characteristics and dates of admission and discharge and also include one major and four minor diagnosis codes (based upon the International Classification of Diseases, 9th Revision, Clinical Modification, ICD-9 CM), one major and four minor surgery codes, and ownership of the medical facility. Second, the registry of contracted medical facilities provides data on each medical institution s accreditation level and geographic location. Third, the registry of medical personnel provides data on each medical professional s date of birth, gender, type of profession, and specialty. Confidentiality assurances were addressed by abiding the data regulations of the Bureau of NHI, and institutional review board approval was waived. Study subjects Study subjects were the operations, either uterine suspension or hysterectomy due to the diagnosis of uterine prolapse in Taiwan between 1 January 1997 and 31 December The

3 Int Urogynecol J (2012) 23: women who received multiple surgeries were also identified; therefore, the cases were actually individual procedure rather than women. A diagnosis of uterine prolapse included ICD-9 CM diagnosis codes for uterine prolapse without mention of vaginal wall prolapse; for uterovaginal prolapse, incomplete; for uterovaginal prolapse, complete; and for uterovaginal prolapse, unspecified, but not vaginal vault prolapse (618.5 prolapse of the vaginal vault after a hysterectomy). The women received various surgical approaches for uterine prolapse, including uterine suspension (ICD-9 CM operation code for other uterine suspension, including hysteropexy, Manchester operation, and placation of uterine ligament) or vaginal suspension (70.77 for vaginal suspension and fixation). A concomitant hysterectomy was described as a subtotal abdominal hysterectomy (or supracervical hysterectomy) (68.3), a total abdominal hysterectomy (68.4), a laparoscopic hysterectomy (68.51 or 68.5 vaginal hysterectomy with laparoscopy), and a vaginal hysterectomy (68.59 or 68.5 vaginal hysterectomy without laparoscopy). The concomitant antiincontinence surgery was described as plication of the urethra vesical junction, e.g., a Kelly Kennedy operation (59.3); suprapubic sling operation, e.g., Goebel Frangenheim Stoeck suspension (59.4); retropubic urethral suspension, e.g., a Marshall Marchetti Kranz operation, Burch procedure (59.5); paraurethral suspension (needle suspension), e.g., Pereyra suspension (59.6); injection of an implant into the urethral and/or bladder neck, e.g., collagen implant (59.72); and others (59.79), e.g., abdominal perineal urethral suspension, tension-free vaginal tapes (TVTs), etc. The transvaginal mesh either tailored by surgeon or commercial kits was not covered by the NHI. Therefore, the coding and use were not available. Additionally, we used joinpoint regression analysis [13] to identify changes in trends (if any change in trend occurred) in proportion to the two types of surgery during Variable definitions The variables used in this study fall into the following three categories: first, age and concomitant anti-incontinence surgery were patient characteristics; second, age and gender were surgeon characteristics; and third, accreditation level and hospital ownership were hospital characteristics. Patients were divided into four 10-year age groups of <50 to 70 years. The surgeon s age was divided into six 5-year age groups of <35 to 55 years. In Taiwan, hospitals are accredited by the Taiwan Joint Commission on Hospital Accreditation which is supervised by the Department of Health, and classified into three levels based on healthcare quality, medical teaching ability, clinical capabilities, and bed capacity: medical centers, regional hospitals, and local hospitals. Hospital ownership was classified into not-for-profit hospitals, government-owned hospitals, or private for profit hospitals. Statistical analysis Chi-squared tests were performed to examine differences in the distribution of the two types of surgeries, i.e., uterine suspension and hysterectomy, according to patient, surgeon, and hospital characteristic groups. A multiple logistic regression was used to examine the independent effects of each individual variable in choosing a hysterectomy to treat uterine prolapse. We used joinpoint regression analysis to identify points of significant inflection in trends. The analysis starts with minimum number of inflections (joinpoints), and tests whether one or more additional joinpoints should be added to the model. In the final model, each joinpoint indicates there was a statistically significant change in trend (either increase or decrease). The annual percentage change (APC) is calculated for the time segments on either side of inflection points. The analyses were performed using Joinpoint Regression Program Version (Statistical Research and Applications Branch, National Cancer Institute, Bethesda MD, 2010). The significance of the statistics was determined using a p value of <0.05. All analyses in this study were carried out using SAS system software for Windows (version 9.01). Results Overall change in the surgical trend In total, 30,888 women who received 31,038 operations, either hysterectomy or uterine suspension, were identified for this study. One hundred forty-five women received more than one operation with a reoperation rate 0.47%. Twentyeight women received two uterine suspensions; 112 women received one uterine suspension, followed by hysterectomy. Five women received two uterine suspensions, followed by hysterectomy. The multiple operation proportion was 0.48 %. The percentage of uterine suspension and hysterectomy were % vs % after 2004 and were % vs % before According to the trend test by joinpont regression analysis, there was a trend for increased use of uterine suspension with uterine preservation (the uterine suspension group) during the latter years (Fig. 1). The joinpoint regression analysis identified one significant inflection points, generating two distinct trends between 1997 and For uterine suspension, a significant raise was observed after 2003 (APC012.26, p<0.05). With the same change point (year 2003) identified, the result showed that there was a significant decline in the trend from 2003 to 2007 (APC0 1.31, p<0.05).

4 868 Int Urogynecol J (2012) 23: Fig. 1 Trends in surgical procedures for uterine prolapse in Taiwan by year in (joinpoint test showed a significant raise with aslope , p<0.005) Types of surgery among different patient factors During the study period, younger women (<50 years) received more uterine suspensions (25.1% vs. 74.9%) compared to the older group ( 50 years) ( % vs %) (χ , p<0.0001) (Fig. 2). Women who had concomitant anti-incontinence surgery (8.8% vs. 91.2%) received more uterine suspensions compared to those without concomitant surgery (15.9% vs. 84.1%) (χ , p<0.0001) (Fig. 2). Type of surgery by surgeon age and gender Younger surgeons (<50 years) performed more uterine suspensions ( % vs %) compared to older surgeons ( 50 years) ( % vs %) (χ , p<0.0001). Female surgeons performed fewer uterine suspensions (4.0% vs. 96.0%) compared to male surgeons (9.9% vs. 90.1%) (χ , p <0.0001) (Fig. 3). Fig. 2 Types of surgery for uterine prolapse in Taiwan according to patient age and concomitant antiincontinence surgery % 100% 80% % 40% % 0% < no yes Patient age Anti-incontinence Hysterectomy Uterine suspension

5 Int Urogynecol J (2012) 23: Fig. 3 Types of surgery for uterine prolapse in Taiwan according to surgeon age and gender % 100% 80% % 40% % 0% < Male Female Surgeon age Surgeon gender Hysterectomy Uterine suspension Type of surgery by hospital accreditation level and ownership type As for hospital accreditation, more uterine suspensions were performed in regional hospitals (10.2% vs. 89.9%), followed by local hospitals (9.4% vs. 90.6%) and medical centers (8.9% vs. 91.1%) (χ , p ). As for hospital ownership, more uterine suspensions were performed in private hospitals (13.4% vs. 86.6%), followed by not-for-profit (8.7% vs. 91.4%) and governmentowned hospitals (6.5% vs. 93.5%) (χ , p<0.0001) (Fig. 4). Results from the multiple logistic regression are given in Table 1. Older patients ( 50 years old) had a greater chance of receiving hysterectomy compared to younger patients (<50 years old) (odds ratio (OR) , 95% confidence interval (CI) ). Women who had concomitant antiincontinence surgery had a lower chance of receiving hysterectomy compared to those without concomitant surgery (OR 0.7, 95% CI ). Older surgeons ( 50 years old) had a greater chance of performing hysterectomy compared to younger surgeons (OR 1.4, 95% CI ). Female surgeons had a greater chance of performing a hysterectomy compared to male surgeons (OR 2.3, 95% CI ). We further found an interaction between surgeon age and gender. The tendency to choose hysterectomy was even higher for a female surgeon of advanced age. The OR was for a female age of <35 years, which increased to for those who were aged 55 years. As for hospital accreditation, there was a lower rate of hysterectomy being performed in regional hospitals (OR 0.9, 95% CI ), while there was a greater chance of hysterectomy being performed in local hospitals (OR 1.4, 95% CI ) compared to medical centers. As for hospital ownership, there were lower chances of hysterectomy being performed in both not-for-profit (OR 0.7, 95% CI ) and private hospitals (OR 0.4, 95% CI ) compared to government-owned ones. Fig. 4 Types of surgery for uterine prolapse in Taiwan according to hospital accreditation and ownership % 100% 80% % 40% % 0% Medical Center Regional Hospital Hospital Accreditation Hysterectomy Local Hospital Government Nonprofit Private Hospital Ownership Uterinesuspension

6 870 Int Urogynecol J (2012) 23: Table 1 Multiple logistic regression for choosing hysterectomy Discussion OR 95% CI p Value Patient age <50 Ref < < < With anti-incontinence No Ref Yes < Surgeon age <35 Ref Surgeon gender Male Ref Female < Hospital accreditation Medical center Ref Regional hospital Local hospital < Hospital ownership Government Ref Not-for-profit < Private < Ref reference Our study offers observational data of a surgical trend of increased use of uterine suspension with uterine preservation during the latter years, which is evidenced by the trend regression analysis. Traditionally, vaginal hysterectomy was a standard surgical treatment for uterovaginal prolapse. The adoption of a vaginal hysterectomy varied, especially in the need for concomitant removal of the adnexa [14]. Our previous study [15] and a report by Babalola et al. [16]found that vaginal hysterectomies decreased by 34% during the past decade. Postulated possible reasons for the decrease in vaginal hysterectomies were a decrease in the incidence of uterine prolapse, a lack of exposure to vaginal surgery during gynecologic training, and the evolving concept of uterinepreserving pelvic reconstructive surgery [14]. Younger women (<50 years old) were more likely to have received uterine suspension in our study. This finding may be attributable to higher expectations of the quality of life among younger women [12]. Preservation of the uterus was recently shown to positively contribute to a patient s self-esteem, body image, confidence, and sexuality [5, 8, 17]. Therefore, patients attitudes about the psychological value of reproductive organs may have influenced their surgical choice. Women will weigh certain factors, e.g., durability, recovery time, complications, foreign body risks, and desire for vaginal intercourse. Therefore, patients choose a procedure based upon their personal goals for surgery, their general medical condition, and their concern for prolapse recurrence. This and our previous study also observed that patient age is one of the correlative factors which should be taken into account when selecting an appropriate surgical type [12]. The need for concomitant anti-incontinence surgery makes uterine-preserving surgery more common. It is postulated that combined procedures of uterine suspension and anti-incontinence surgery are more commonly performed by subspecialists in urogynecology. Apical prolapse frequently coexists with some lower urinary tract symptoms, e.g., urinary incontinence and urinary retention; thus, a thorough pelvic evaluation should look for both conditions. Stress urinary incontinence (SUI) has a population-based prevalence of nearly 40% in most industrialized countries, usually with severe implication for daily function, social interactions, sexuality, and psychologic well-being [18]. Although many women with advanced apical prolapse remain continent despite the loss of anterior vaginal and bladder/urethral support; however, 8% 40% of continent women develop symptoms of SUI after surgical correction of the prolapse [19, 20]. Moreover, Altman et al. reported that hysterectomy increases the risk for subsequent SUI surgeries during a 30-year observational period in the Swedish Inpatient Registry with a hazard ratio of 2.4 (95% CI ), (179 vs. 76 per 100,000 person-years) [21]. Liang et al. reported that continent patients suffering from severe POP with a positive pessary test are considered to be at high risk of developing postoperative symptomatic SUI [22]. The addition of TVTs to endopelvic fascia plication (RR 5.5, 95% CI ) and Burch colposuspension to an abdominal sacrocolpopexy (RR 2.13, 95% CI ) were followed by a lower risk of women developing new postoperative de novo SUI [23]. Therefore, it is important to determine if a woman has associated lower urinary tract symptoms, prior to apical suspension. Therefore, the concomitant procedure can prevent postoperative SUI in patients requiring surgical correction for SUI. Younger surgeons (<50 years old) tended to perform more uterine-preserving surgeries, while older surgeons ( 50 years old) performed more hysterectomies in our study. Whether this reflects their training background and/or the concept of pelvic floor reconstruction is still elusive. Eckert et al. reported that nationwide trends toward the increased use of nonoperative, minimally invasive, endoscopic techniques are altering the operative experience of surgeons and residents in training. This may radically change the abilities and expectations for the field of general surgery [24]. Our data offered the correlative data between surgeon age and surgical choice, which is possibly influenced by the training background of surgeons. Surgeons gender was also a significant determinant in choosing surgery types: male surgeons tended to perform more uterine-preserving surgeries,

7 Int Urogynecol J (2012) 23: while female surgeons performed more hysterectomies. Further adjustment for surgeon age revealed that surgeon gender was still an influencing factor and became more obvious at an advanced age. The explanation for the difference due to surgeon gender is unclear. There were significant differences in choices of surgical types between hospital accreditation levels and ownership categories. More uterine-preserving surgeries were performed in regional hospitals, and more hysterectomies were performed in local hospitals compared to medical centers. The different levels of hospital accreditation may mean that their doctors have different specialized surgical training including apprenticeship-style training, curriculum- and case-based programs, or independent and integrated specialty training programs [25]. Therefore, in addition to patient conditions, the choice of surgical procedures is dependent to some extent on the hospitals where the surgery is performed [12, 26]. As for hospital ownership, more uterine suspensions were performed in private hospitals, followed by not-for-profit and government-owned hospitals; this may have been due to the more conservative, traditional character of government-owned hospitals. This variability would, in turn, have implications for both patients and the surgical modality selected. Surgery is designed to repair and reconstruct the weakened pelvic floor and restore normal function. It is indicated only when the prolapse causes significant symptoms and when conservative nonsurgical measures have failed [27]. There is a paucity of high-quality data comparing different types of apical prolapse, e.g. uterine prolapse repair procedures; the literature mostly contains evidence from controlled studies rather than randomized trials. Our study offers observational data.further high-quality randomized control trials are still necessary to evaluate the advantages and disadvantages of uterine-preserving procedures. Limitations of this study included the following due to its retrospective observational character: first, the possibility of miscoding existed due to coding by medical affair personnel instead of surgeons themselves; second, the exact procedures performed were not specified, e.g., sacrohysteropexy, uterosacral ligament uterine suspension, and sacrospinous ligament uterine suspension; and third, information on outof-pocket payments for the commercial transvaginal mesh kit, which is not covered by insurance, was unknown. As for the reimbursement of the medical costs, the NHI program covers 98% of the patients and 98% of the hospitals; therefore, the effect of insurance coverage on the choice may have been minor. Nevertheless, despite these limitations, this study provides a descriptive analysis of surgeries for uterine prolapse, based upon an 11-year population-based nationwide databank including the surgical type, patient age, concomitant anti-incontinence surgery, surgeon age and gender, and hospital accreditation and ownership. Our study offers population-based nationwide observations. How to determine the best way to deal with uterine prolapse demands further ongoing researches. In conclusion, there has been a considerable change in the surgical approach for uterine prolapse in Taiwan over the past 11 years. Certain variables may correlate the choice of surgery, including patient age, associated anti-incontinence surgery, surgeon age and gender, and accreditation and ownership of the hospital where the surgery is performed. Acknowledgments We are appreciative of the grant support from Chang Gung Memorial Hospital, Kaohsiung Medical Center, CMRPG870821, and Chi Mei Foundation Hospital, CMNCKU9806. We thank Dr. Yu-Tung Huang of Chang Gung University of Science and Technology, for the assistance of statistical analysis for the trend test. Conflicts of interest References None. 1. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A (2002) Pelvic organ prolapse in the Women s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 186: Swift SE, Tate SB, Nicholas J (2003) Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 189: , discussion Samuelsson EC, Victor FT, Tibblin G, Svardsudd KF (1999) Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. 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