Available online 3 May 2024

Author links open overlay panel, , , AbstractStudy Objective

To determine the long-term costs of hysterectomy with minimally-invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair.

Study Design

A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with uterosacral ligament suspension (USLS) or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome.

Setting

Tertiary center for urogynecology

Patients

Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse

Interventions

Comparison analysis of estimated long-term costs was performed

Measurements and Main Results

Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19,935 and that undergoing USLS as the primary index procedure cost $15,457, a difference of $4,478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30,054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse.

Conclusion

The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Section snippetsINTRODUCTION

Pelvic organ prolapse (POP) is a common condition, and the lifetime risk of undergoing POP surgery varies between 6% and 19% (1,2,3). The number of American women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050 (1,4). The optimal surgical choice for primary reconstructive repair depends on patient preferences and ranges from transvaginal native tissue repair (i.e. uterosacral ligament suspension (USLS) or sacrospinous ligament suspension)

MATERIALS AND METHODS

We built a decision analysis model using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Women presenting for primary surgical correction of uterovaginal prolapse were modeled to undergo either vaginal hysterectomy with uterosacral vault suspension or minimally invasive total hysterectomy with sacrocolpopexy (Figure 1).

We modeled the chance of complications of the index procedure, prolapse recurrence and choice of surgical retreatment based on published evidence (Table 1). We also modeled

RESULTS

Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19,935 and that undergoing USLS as the primary index procedure cost $15,457, a difference of $4,478. Our model showed that based on known recurrence risks and willingness to undergo a second prolapse surgery, 21.1% of women in the USLS group will ultimately be living with prolapse recurrence compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize the number of patients with

COMMENT

In our decision tree analysis, we demonstrate that for treatment of primary uterovaginal prolapse, MISCP remained more costly from a hospital-system perspective over time than USLS, regardless of the higher need for retreatment in the native tissue vaginal group. In our previous study, MISCP was approximately $4,200 more costly to perform per case than USLS, largely due to consumable supplies such as disposable instruments and the mesh graft. In this model, we now show that the higher index

Author Contributions

AS El Haraki: IRB application, data collection, and manuscript writing

JP Shepherd: statistical analysis, manuscript editing

CA Matthews: Principal investigator, project development, manuscript editing

LA Cadish: Data collection, statistical analysis, manuscript writing and editing

Uncited References

(7,8,9,12,13,15,16,17,18,19,20,21,22,23,24,29)

Declaration of competing interest

Catherine Matthews has grant support to institution from Boston Scientific Corporation and Coloplast; Catherine Matthews is a consultant to Boston Scientific Corporation and has received honoraria from Neomedic. All other authors have no conflicts to disclose.

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© 2024 Published by Elsevier Inc. on behalf of AAGL.