Apical Support Procedure at the Time of Hysterectomy: Regional experience at one tertiary care institution

Apical Support Procedure at the Time of Hysterectomy: Regional experience at one tertiary care institution | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Apical Support Procedure at the Time of Hysterectomy: Regional experience at one tertiary care institution Kirsten Kent, Paula Walewicz, Melissa Huggins, Melanie Meister This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7780213/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 30 You are reading this latest preprint version Abstract Background To investigate the rate of performance of concomitant apical support procedure at time of benign hysterectomy for uterovaginal prolapse at one tertiary care institution. Methods This was a retrospective cohort study of patients who underwent benign hysterectomy at our institution over a 22-year period. Eligible patients were identified by ICD and CPT codes and data were abstracted retrospectively. Factors associated with performance of an ASP were investigated and compared using multivariable logistic regression. Results 388 patients underwent benign hysterectomy with a diagnosis of prolapse. The mean age was 58 (SD 13); most were white (325, 83.8%), non-Hispanic (375, 92.0%), with private insurance (193, 49.7%). 259 (66.7%) had uterovaginal prolapse and of those, 203 (70.2%) underwent an apical support procedure. On multivariable analysis, patients were nearly 3-fold more likely to undergo an ASP if they had a diagnosis of uterovaginal prolapse and nearly 70% less likely to undergo an ASP if their procedure was performed by a general gynecologist without a sub-specialist. Conclusions At our institution, approximately 75% of benign hysterectomies performed for prolapse incorporate an apical support procedure. Although this is better than the rates in other regions, ongoing efforts to educate surgeons, particularly non-subspecialists, on the importance of re-establishing apical vaginal support at time of hysterectomy for prolapse is needed. Uterovaginal prolapse apical support procedure prolapse hysterectomy Background Hysterectomy is one of the most common major surgical procedures in women in the United States with approximately 500,000 hysterectomies performed annually [1]. Of all hysterectomies, nearly 90% are performed for benign disease and 17% for prolapse [2,3]. As the population ages, the total number of women who have surgery for prolapse is estimated to increase 50% by 2050. A large proportion of the women who have prolapse have a hysterectomy as part of their repair. It has been demonstrated that hysterectomy alone is an ineffective treatment for prolapse, as it does not restore Level I support. After the removal of the uterus, the apical uterosacral ligament support is compromised, which increases the risk of recurrent prolapse [5]. Apical support procedures (ASP) restore Level 1 support at the time of hysterectomy by reattaching the vaginal cuff to the uterosacral ligaments, sacrospinous ligaments, or the anterior longitudinal ligament of the sacrum via a mesh graft. Performance of an ASP is crucial to the prevention of future prolapse and is indicated at the time of hysterectomy when a diagnosis of prolapse, particularly uterovaginal prolapse, is present. A large national database study examined rates of Apical Support Procedures (ASP) performed at the time of benign hysterectomy and found that ASPs are not routinely performed at time of hysterectomy, regardless of presence of prolapse diagnosis. The rate of ASP at time of hysterectomy for prolapse ranges from 31.3% to 82.7% among other regional and national database studies [4]. A regional study examined factors associated with performance of ASP and found that ASPs were more likely to be performed by fellowship trained surgeons [6]. Similar findings were noted in another study examining performance of ASP at the time of benign hysterectomy using a different regional dataset [6]. This study also found that urogynecologists and minimally invasive gynecologists are more likely to perform an ASP concurrent with hysterectomy compared with general gynecologists. We sought to investigate the rate of performance of ASP at the time of benign hysterectomy for prolapse at our institution. We hypothesize that surgeons at our institution perform ASPs at the time of hysterectomy and fellowship-trained surgeons are more likely to perform ASPs. Given the reduction in recurrent prolapse if an ASP is incorporated at the time of hysterectomy, understanding our institutional practice will help inform ongoing educational and quality-improvement efforts within our health system. Methods All hysterectomies performed for benign indications with a diagnosis of prolapse for women aged 18 and older from 2001 to 2023 were identified by Healthcare Enterprise Repository for Ontological Narration (HERON) data from our institution. HERON is a search tool that provides de-identified data from the hospital electronic medical record and the clinical billing system. International Classification of Diseases 9th edition (ICD-9) procedure codes, International Classification of Diseases 10th edition (ICD-10) procedure codes, and Current Procedural Terminology (CPT) codes were used as demonstrated in appendix A . Demographics including age, race, ethnicity, and type of insurance, as well as surgical factors including diagnosis, hysterectomy route, concomitant procedures, apical support procedure performance, and surgeon subtype were abstracted from the medical record. Demographics and surgical variables were compared between patients who did and did not have concomitant apical support procedures using students t-test and Chi-square as appropriate. Univariable and multivariable logistic regression was performed to explore factors associated with incorporation of a concomitant apical support procedure. SAS version 9.4 (Cary, NC) was used for statistical analysis. This study was approved by the institutional review board at our hospital. Results From 2001 to 2023, 388 patients with a diagnosis of prolapse underwent hysterectomy for benign conditions. Demographics of these patients are demonstrated in Table 1 . Most patients were white (325, 83.8%), non-Hispanic (375, 92.0%), with private insurance (193, 49.7%). 259 (66.7%) had uterovaginal prolapse and 289 (74.5%) underwent an apical support procedure. Relevant concomitant procedures include anterior repair (46, 11.9%), posterior repair (95, 24.5%), combined anterior/posterior repair (140, 36.1%), enterocele repair (47, 12.1%), abdominal colpopexy (2, 0.5%), laparoscopic colpopexy (134, 34.5%), extraperitoneal colpopexy (1, 0.3%), and intraperitoneal colpopexy (106, 27.3%). Co-surgeries with more than one surgeon were performed in 29.6% of cases and included Urogyn with Ob/Gyn (24, 19.7%), MIGS (29, 23.8%), Gyn Onc (9, 7.4%), and other (11, 9.0%) or Urology with Ob/Gyn (19, 15.6%), MIGS (6, 4.9%), Gyn Onc (17, 3.9%), and other (5, 4.1%). Other co-surgeons included a general surgeon, colorectal surgeon, surgical oncologist, or radiologist. Table 1 Comparison of patients undergoing an apical support procedure vs none. Continuous variable (age) presented as mean (SD), p-value calculated using independent samples t-test. Categorical variables presented as n(%) and p-value calculated using chi-square. Surgeon subtype is not a mutually exclusive category, some procedures were performed by more than one surgeon. SD, standard deviation; ASP, apical support procedure; UVP, uterovaginal prolapse; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; Abd SCH, abdominal supracervical hysterectomy; LAVH, laparoscopic-assisted vaginal hysterectomy. Total Sample N = 388 Apical support procedure (n = 289) No ASP (n = 99) p-value Age (mean, SD) 58 (13) 58.4 (12.0) 57.1 (14.9) 0.36 Race 0.04 White 325 (83.8) 250 (86.5) 75 (75.8) Black 26 (6.7) 17 (5.9) 9 (9.1) Other 37 (9.5) 22 (7.6) 15 (15.2) Ethnicity 0.64 Hispanic 31 (8.0) 22 (7.6) 9 (9.1) Non-Hispanic 357 (92.0) 267 (92.4) 90 (90.9) Insurance 0.47 Public 177 (45.6) 130 (46.8) 47 (51.1) Private 193 (49.7) 148 (53.2) 45 (48.9) Prolapse Diagnosis 0.01 Uterovaginal prolapse 259 (66.8) 203 (70.2) 56 (56.6) Vaginal prolapse without uterine prolapse 129 (33.2) 86 (29.8) 43 (43.4) Hysterectomy route < 0.0001 TAH 3 (0.8) 1 (0.4) 2 (2.2) TLH 81 (21.7) 57 (20.1) 24 (26.7) TVH 139 (37.2) 101 (35.6) 38 (42.2) Lsc SCH 93 (24.9) 93 (32.8) 0 (0) Abd SCH 21 (5.6) 11 (3.9) 10 (11.1) LAVH 36 (9.6) 21 (7.4) 15 (16.7) Other 1 (0.3) 0 (0) 1 (1.1) Surgeon subtype < 0.0001 Urogynecology 304 (78.4) 235 (81.3) 69 (69.7) Urology 50 (12.9) 43 (14.8) 5 (5.1) General gynecology 71 (18.3) 10 (3.5) 18 (18.2) Minimally invasive gynecology 41 (10.6) 0 (0.0) 6 (6.1) Gynecologic Oncology 28 (7.2) 1 (0.4) 1 (1.0) Patients undergoing hysterectomy with concomitant ASP were most likely to be white (250, 86.5% of ASP vs 75, 75.8% of no ASP, p-0.36) and have a diagnosis of uterovaginal prolapse (203, 70.2% of ASP vs 56, 56.6% of no ASP, p-.01, Table 1 ). Hysterectomies with concomitant ASP were more likely to be performed via the total vaginal (101, 35.6%) and laparoscopic supracervical routes (93, 32.8%) compared to vaginal (38, 42.2%) and total laparoscopic (24, 26.7%) routes when an ASP was not performed (p < .0001). Hysterectomies with concomitant ASP were more likely performed by Urogynecologists and Urologists (p < .0001). On multivariable logistic regression, patients were 3-fold more likely to have a concomitant ASP if they had a diagnosis of uterovaginal prolapse (aOR 2.97, 95% CI 1.57–5.62). Patients had a 68% lower odds of undergoing concomitant ASP if their surgery was performed by only a general gynecologist (aOR 0.32, 95% CI 0.12–0.82, Table 2 ). Table 2 Logistic regression analysis. Univariable and multivariable logistic regression analysis predicting likelihood of undergoing an apical support procedure. Multivariable model adjusts for age, race, ethnicity, insurance, prolapse diagnosis, hysterectomy route, and surgeon subtype. All laparoscopic supracervical hysterectomies included an ASP. This was maintained in the analysis but is removed from the table. OR, odds ratio; aOR, adjusted odds ratio; SD, standard deviation; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; Abd SCH, abdominal supracervical hysterectomy; LAVH, laparoscopic-assisted vaginal hysterectomy. OR (95% CI) aOR (95% CI) Age (mean, SD) 1.01 (0.99–1.03) 1.02 (0.99–1.04) Race White Ref Ref Black 0.57 (0.24–1.32) 0.41 (0.14–1.14) Other 0.44 (0.21–0.89)* 0.04 (0.004–0.44)* Ethnicity Hispanic 0.82 (0.37–1.86) 10.1 (0.85–120.2) Insurance Public 0.84 (0.53–1.35) 0.94 (0.47–1.88) Prolapse Diagnosis Uterovaginal prolapse 1.81 (1.13–2.90)* 2.97 (1.57–5.62)* Hysterectomy route TAH 0.21 (0.02–2.4) 0.17 (0.01–2.93) TVH 1.12 (0.61–2.05) 1.03 (0.49–2.14) Abd SCH 0.46 (0.17–1.23) 0.34 (0.11–1.08) LAVH 0.59 (0.26–1.33) 0.55 (0.21–1.41) Surgeon subtype General gynecology 0.16 (0.07–0.37)* 0.32 (0.12–0.82)* Minimally invasive gynecology < 0.001 (999.99) < 0.001 (999.99) Gynecologic Oncology 0.29 (0.02–4.75) 24.70 (999.99) Urology 2.53 (0.96–6.62) 1.63 (0.39–6.80) Discussion Over the last 20 years, apical support procedures (ASP) were performed at the time of benign hysterectomy for prolapse about 75% of the time at our institution, which is similar to other regions and exceeds national trends. In our sample ASPs were more likely to be performed by subspecialist gynecologists, particularly urogynecologists. It is notable that when a urogynecologist was included in the surgical team, it was more common that uterovaginal prolapse was a listed diagnosis compared to non-apical prolapse diagnoses. The literature describes the rate of ASP at time of hysterectomy for prolapse to range from 31.3% to 82.7% among other regional and national database studies. Our institutional data of 75% is similar to other regions and exceeds national trends. Similar to national studies, women who were non-Hispanic and privately insured were more likely to undergo ASP at time of hysterectomy. Like other regional studies, we found that ASPs were more likely performed at the time of hysterectomy for prolapse if the procedure involved a subspecialty surgeon (urogynecologist or urologist). Our findings are limited by the use of billing/coding data, which are subject to errors in coding and limitations of coding to capture nuances in exam findings. Without real time discussion and questioning, it is impossible to assess surgeon decision making when deciding for or against ASP. Additionally, our findings are limited by data from a single academic institution, which may not be representative of community-based practices or practices outside of our region. To target educational and quality-improvement initiatives appropriately, we must understand whether the surgeons are aware of the data supporting the incorporation of an ASP at the time of hysterectomy for prolapse or if the lack of incorporation represents a surgical skill deficit. Conclusions Hysterectomies without an ASP are at greater risk of prolapse recurrence. This demonstrates the need for ongoing educational and quality-improvement initiatives to address the importance of diagnosing uterovaginal prolapse in women with vaginal prolapse undergoing hysterectomy prior to surgery. This would allow the surgeon to plan for an ASP if present. Eligible patients in this study were selected by having a prolapse diagnosis code associated with hysterectomy. It is notable that some patients in our sample had a diagnosis of vaginal prolapse without uterovaginal prolapse, and an ASP would not necessarily have been indicated. When we controlled for this specific diagnosis code in our multivariable regression, there were still differences in the rate of ASP performance between sub-specialists and general gynecologists. We still found differences in the rate of ASP performance, however, when we controlled for this variable in our multivariable regression. As education initiatives at the residency and postgraduate levels continue, rates of ASP at time of hysterectomy will hopefully continue to increase. Ongoing education initiatives are needed to continue to improve rates of ASP at time of hysterectomy, particularly for non-subspeciality gynecologists, to reduce the risk of future prolapse for these patients. For some patients, access to care by a Urogynecology or Urology subspecialist is limited due to geographic limitations or excessive wait times to access care [9,10]. Our data supports referral to a subspecialist to optimize care for these patients. Subspecialist involvement could include operating as co-surgeons, which may improve access to subspecialty care. Abbreviations Apical support procedures (ASP) Healthcare Enterprise Repository for Ontological Narration (HERON) International Classification of Diseases 9 th edition (ICD-9 International Classification of Diseases 10 th edition (ICD-10) Current Procedural Terminology (CPT) Declarations Ethics approval and consent to participate: submitted to and approved by University of Kansas Medical Center Institutional Review Board. IRB 00150059. The need for consent to participate was waived by IRB. This study adhered to the Declaration of Helsinki. Consent for publication: not applicable Availability of data and materials: All data generated or analyzed during this study are included in this published article pages 8-10. Competing interests: The authors declare that they have no competing interests Funding: Not applicable Authors' contributions KK: data management, data analysis, manuscript writing PW: project development, data management, manuscript writing MH: project development, manuscript writing MM: project development, data analysis, manuscript writing Acknowledgements Authors' information (optional) Author Contributions The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Melanie Meister is a paid consultant for Abbvie Inc. This consulting role does not represent a conflict of interest for this study. The remaining authors have no relevant financial or non-financial interests to disclose. This is a retrospective study. The University of Kansas Institutional Review Board has confirmed that no ethical approval is required. IRB 00150059. References Health, United States. 2010: With Special Feature on Death and Dying. Hyattsville, MD: National Center for Health Statistics; 2011. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States, 2003. Obstet Gynecol . 2007;110(5):1091–1095. Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013;122:233–241. [PubMed: 23969789] Ross WT, Meister MR, Shepherd JP, et al. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol 2017;217:436.e1–8. [PubMed: 28716634] DeLancey J. Anatomy and Biomechanics of Genital Prolapse. Clinical Obstetrics and Gynecology. 1993; 36:897–909. Putman JG, Meister MR, Lenger SM, Lowder JL. Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training?. Female Pelvic Med Reconstr Surg . 2021;27(7):421–426. Lowder JL. Apical Vaginal Support: The Often Forgotten Piece of the Puzzle. Mo Med . Waitman LR, Warren JJ, Manos EL, Connolly DW. Expressing observations from electronic medical record flowsheets in an i2b2 based clinical data repository to support research and quality improvement. AMIA Annu Symp Proc. 2011;2011:1454-63. Epub 2011 Oct 22. PMID: 22195209; PMCID: PMC3243191. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243191/ Villegas-Echeverri JD, Ganyaglo GYK, Aklilu FA, Wasson M. FIGO statement: Disparities in patients' access to benign gynecological surgery. Int J Gynaecol Obstet . 2022;158(3):499–501. doi: 10.1002/ijgo.14323 Wieslander CK, Grimes CL, Balk EM, et al. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. Obstet Gynecol . 2023;142(5):1044–1054. doi: 10.1097/AOG.0000000000005389 Additional Declarations No competing interests reported. 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common major surgical procedures in women in the United States with approximately 500,000 hysterectomies performed annually [1]. Of all hysterectomies, nearly 90% are performed for benign disease and 17% for prolapse [2,3]. As the population ages, the total number of women who have surgery for prolapse is estimated to increase 50% by 2050. A large proportion of the women who have prolapse have a hysterectomy as part of their repair. It has been demonstrated that hysterectomy alone is an ineffective treatment for prolapse, as it does not restore Level I support. After the removal of the uterus, the apical uterosacral ligament support is compromised, which increases the risk of recurrent prolapse [5]. Apical support procedures (ASP) restore Level 1 support at the time of hysterectomy by reattaching the vaginal cuff to the uterosacral ligaments, sacrospinous ligaments, or the anterior longitudinal ligament of the sacrum via a mesh graft. Performance of an ASP is crucial to the prevention of future prolapse and is indicated at the time of hysterectomy when a diagnosis of prolapse, particularly uterovaginal prolapse, is present.\u003c/p\u003e\u003cp\u003eA large national database study examined rates of Apical Support Procedures (ASP) performed at the time of benign hysterectomy and found that ASPs are not routinely performed at time of hysterectomy, regardless of presence of prolapse diagnosis. The rate of ASP at time of hysterectomy for prolapse ranges from 31.3% to 82.7% among other regional and national database studies [4]. A regional study examined factors associated with performance of ASP and found that ASPs were more likely to be performed by fellowship trained surgeons [6]. Similar findings were noted in another study examining performance of ASP at the time of benign hysterectomy using a different regional dataset [6]. This study also found that urogynecologists and minimally invasive gynecologists are more likely to perform an ASP concurrent with hysterectomy compared with general gynecologists.\u003c/p\u003e\u003cp\u003eWe sought to investigate the rate of performance of ASP at the time of benign hysterectomy for prolapse at our institution. We hypothesize that surgeons at our institution perform ASPs at the time of hysterectomy and fellowship-trained surgeons are more likely to perform ASPs. Given the reduction in recurrent prolapse if an ASP is incorporated at the time of hysterectomy, understanding our institutional practice will help inform ongoing educational and quality-improvement efforts within our health system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAll hysterectomies performed for benign indications with a diagnosis of prolapse for women aged 18 and older from 2001 to 2023 were identified by Healthcare Enterprise Repository for Ontological Narration (HERON) data from our institution. HERON is a search tool that provides de-identified data from the hospital electronic medical record and the clinical billing system. International Classification of Diseases 9th edition (ICD-9) procedure codes, International Classification of Diseases 10th edition (ICD-10) procedure codes, and Current Procedural Terminology (CPT) codes were used as demonstrated in appendix \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eA\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eDemographics including age, race, ethnicity, and type of insurance, as well as surgical factors including diagnosis, hysterectomy route, concomitant procedures, apical support procedure performance, and surgeon subtype were abstracted from the medical record. Demographics and surgical variables were compared between patients who did and did not have concomitant apical support procedures using students t-test and Chi-square as appropriate. Univariable and multivariable logistic regression was performed to explore factors associated with incorporation of a concomitant apical support procedure. SAS version 9.4 (Cary, NC) was used for statistical analysis. This study was approved by the institutional review board at our hospital.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2001 to 2023, 388 patients with a diagnosis of prolapse underwent hysterectomy for benign conditions. Demographics of these patients are demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most patients were white (325, 83.8%), non-Hispanic (375, 92.0%), with private insurance (193, 49.7%). 259 (66.7%) had uterovaginal prolapse and 289 (74.5%) underwent an apical support procedure. Relevant concomitant procedures include anterior repair (46, 11.9%), posterior repair (95, 24.5%), combined anterior/posterior repair (140, 36.1%), enterocele repair (47, 12.1%), abdominal colpopexy (2, 0.5%), laparoscopic colpopexy (134, 34.5%), extraperitoneal colpopexy (1, 0.3%), and intraperitoneal colpopexy (106, 27.3%). Co-surgeries with more than one surgeon were performed in 29.6% of cases and included Urogyn with Ob/Gyn (24, 19.7%), MIGS (29, 23.8%), Gyn Onc (9, 7.4%), and other (11, 9.0%) or Urology with Ob/Gyn (19, 15.6%), MIGS (6, 4.9%), Gyn Onc (17, 3.9%), and other (5, 4.1%). Other co-surgeons included a general surgeon, colorectal surgeon, surgical oncologist, or radiologist.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of patients undergoing an apical support procedure vs none.\u003c/b\u003e Continuous variable (age) presented as mean (SD), p-value calculated using independent samples t-test. Categorical variables presented as n(%) and p-value calculated using chi-square. Surgeon subtype is not a mutually exclusive category, some procedures were performed by more than one surgeon. SD, standard deviation; ASP, apical support procedure; UVP, uterovaginal prolapse; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; Abd SCH, abdominal supracervical hysterectomy; LAVH, laparoscopic-assisted vaginal hysterectomy.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal Sample\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;388\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eApical support procedure (n\u0026thinsp;=\u0026thinsp;289)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo ASP (n\u0026thinsp;=\u0026thinsp;99)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (mean, SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.4 (12.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.1 (14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhite\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e325 (83.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e250 (86.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (75.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlack\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHispanic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNon-Hispanic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e357 (92.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e267 (92.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (90.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInsurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePublic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e177 (45.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130 (46.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e47 (51.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrivate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193 (49.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e148 (53.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (48.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProlapse Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUterovaginal prolapse\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e259 (66.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e203 (70.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56 (56.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVaginal prolapse without uterine prolapse\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129 (33.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86 (29.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (43.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHysterectomy route\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTAH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTLH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81 (21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57 (20.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTVH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e139 (37.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e101 (35.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (42.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLsc SCH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93 (24.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 (32.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbd SCH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (3.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLAVH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (9.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgeon subtype\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrogynecology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304 (78.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e235 (81.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69 (69.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral gynecology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMinimally invasive gynecology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGynecologic Oncology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePatients undergoing hysterectomy with concomitant ASP were most likely to be white (250, 86.5% of ASP vs 75, 75.8% of no ASP, p-0.36) and have a diagnosis of uterovaginal prolapse (203, 70.2% of ASP vs 56, 56.6% of no ASP, p-.01, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Hysterectomies with concomitant ASP were more likely to be performed via the total vaginal (101, 35.6%) and laparoscopic supracervical routes (93, 32.8%) compared to vaginal (38, 42.2%) and total laparoscopic (24, 26.7%) routes when an ASP was not performed (p\u0026thinsp;\u0026lt;\u0026thinsp;.0001). Hysterectomies with concomitant ASP were more likely performed by Urogynecologists and Urologists (p\u0026thinsp;\u0026lt;\u0026thinsp;.0001).\u003c/p\u003e\u003cp\u003eOn multivariable logistic regression, patients were 3-fold more likely to have a concomitant ASP if they had a diagnosis of uterovaginal prolapse (aOR 2.97, 95% CI 1.57\u0026ndash;5.62). Patients had a 68% lower odds of undergoing concomitant ASP if their surgery was performed by only a general gynecologist (aOR 0.32, 95% CI 0.12\u0026ndash;0.82, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eLogistic regression analysis.\u003c/b\u003e Univariable and multivariable logistic regression analysis predicting likelihood of undergoing an apical support procedure. Multivariable model adjusts for age, race, ethnicity, insurance, prolapse diagnosis, hysterectomy route, and surgeon subtype. All laparoscopic supracervical hysterectomies included an ASP. This was maintained in the analysis but is removed from the table. OR, odds ratio; aOR, adjusted odds ratio; SD, standard deviation; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; Abd SCH, abdominal supracervical hysterectomy; LAVH, laparoscopic-assisted vaginal hysterectomy.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (mean, SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.01 (0.99\u0026ndash;1.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.02 (0.99\u0026ndash;1.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhite\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlack\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.57 (0.24\u0026ndash;1.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.41 (0.14\u0026ndash;1.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.44 (0.21\u0026ndash;0.89)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.04 (0.004\u0026ndash;0.44)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHispanic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.82 (0.37\u0026ndash;1.86)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.1 (0.85\u0026ndash;120.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInsurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePublic\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.84 (0.53\u0026ndash;1.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.94 (0.47\u0026ndash;1.88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProlapse Diagnosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUterovaginal prolapse\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.81 (1.13\u0026ndash;2.90)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2.97 (1.57\u0026ndash;5.62)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHysterectomy route\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTAH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.21 (0.02\u0026ndash;2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.17 (0.01\u0026ndash;2.93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTVH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.12 (0.61\u0026ndash;2.05)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.03 (0.49\u0026ndash;2.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbd SCH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.46 (0.17\u0026ndash;1.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.34 (0.11\u0026ndash;1.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLAVH\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.59 (0.26\u0026ndash;1.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.55 (0.21\u0026ndash;1.41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgeon subtype\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral gynecology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e0.16 (0.07\u0026ndash;0.37)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.32 (0.12\u0026ndash;0.82)*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMinimally invasive gynecology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001 (\u0026lt;\u0026thinsp;0.001-\u0026gt;999.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001 (\u0026lt;\u0026thinsp;0.001-\u0026gt;999.99)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGynecologic Oncology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.29 (0.02\u0026ndash;4.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.70 (\u0026lt;\u0026thinsp;0.001-\u0026gt;999.99)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.53 (0.96\u0026ndash;6.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.63 (0.39\u0026ndash;6.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOver the last 20 years, apical support procedures (ASP) were performed at the time of benign hysterectomy for prolapse about 75% of the time at our institution, which is similar to other regions and exceeds national trends. In our sample ASPs were more likely to be performed by subspecialist gynecologists, particularly urogynecologists. It is notable that when a urogynecologist was included in the surgical team, it was more common that uterovaginal prolapse was a listed diagnosis compared to non-apical prolapse diagnoses.\u003c/p\u003e\u003cp\u003eThe literature describes the rate of ASP at time of hysterectomy for prolapse to range from 31.3% to 82.7% among other regional and national database studies. Our institutional data of 75% is similar to other regions and exceeds national trends. Similar to national studies, women who were non-Hispanic and privately insured were more likely to undergo ASP at time of hysterectomy. Like other regional studies, we found that ASPs were more likely performed at the time of hysterectomy for prolapse if the procedure involved a subspecialty surgeon (urogynecologist or urologist).\u003c/p\u003e\u003cp\u003eOur findings are limited by the use of billing/coding data, which are subject to errors in coding and limitations of coding to capture nuances in exam findings. Without real time discussion and questioning, it is impossible to assess surgeon decision making when deciding for or against ASP. Additionally, our findings are limited by data from a single academic institution, which may not be representative of community-based practices or practices outside of our region. To target educational and quality-improvement initiatives appropriately, we must understand whether the surgeons are aware of the data supporting the incorporation of an ASP at the time of hysterectomy for prolapse or if the lack of incorporation represents a surgical skill deficit.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eHysterectomies without an ASP are at greater risk of prolapse recurrence. This demonstrates the need for ongoing educational and quality-improvement initiatives to address the importance of diagnosing uterovaginal prolapse in women with vaginal prolapse undergoing hysterectomy prior to surgery. This would allow the surgeon to plan for an ASP if present. Eligible patients in this study were selected by having a prolapse diagnosis code associated with hysterectomy. It is notable that some patients in our sample had a diagnosis of vaginal prolapse without uterovaginal prolapse, and an ASP would not necessarily have been indicated. When we controlled for this specific diagnosis code in our multivariable regression, there were still differences in the rate of ASP performance between sub-specialists and general gynecologists. We still found differences in the rate of ASP performance, however, when we controlled for this variable in our multivariable regression.\u003c/p\u003e\u003cp\u003eAs education initiatives at the residency and postgraduate levels continue, rates of ASP at time of hysterectomy will hopefully continue to increase. Ongoing education initiatives are needed to continue to improve rates of ASP at time of hysterectomy, particularly for non-subspeciality gynecologists, to reduce the risk of future prolapse for these patients. For some patients, access to care by a Urogynecology or Urology subspecialist is limited due to geographic limitations or excessive wait times to access care [9,10]. Our data supports referral to a subspecialist to optimize care for these patients. Subspecialist involvement could include operating as co-surgeons, which may improve access to subspecialty care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eApical support procedures (ASP)\u003c/p\u003e\n\u003cp\u003eHealthcare Enterprise Repository for Ontological Narration (HERON)\u003c/p\u003e\n\u003cp\u003eInternational Classification of Diseases 9\u003csup\u003eth\u003c/sup\u003e edition (ICD-9\u003c/p\u003e\n\u003cp\u003eInternational Classification of Diseases 10\u003csup\u003eth\u003c/sup\u003e edition (ICD-10)\u003c/p\u003e\n\u003cp\u003eCurrent Procedural Terminology (CPT)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eEthics approval and consent to participate: submitted to and approved by University of Kansas Medical Center Institutional Review Board. IRB 00150059. The need for consent to participate was waived by IRB. This study adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsent for publication: not applicable\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials:\u0026nbsp;All data generated or analyzed during this study are included in this published article\u0026nbsp;pages 8-10.\u003c/li\u003e\n \u003cli\u003eCompeting interests:\u0026nbsp;The authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003eFunding: Not applicable\u003c/li\u003e\n \u003cli\u003eAuthors' contributions\u003c/li\u003e\n\u003c/ul\u003e\n\u003col\u003e\n \u003cli\u003eKK: data management, data analysis, manuscript writing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePW: project development, data management, manuscript writing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMH: project development, manuscript writing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMM: project development, data analysis, manuscript writing\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAcknowledgements\u003c/li\u003e\n \u003cli\u003eAuthors' information (optional)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eMelanie Meister is a paid consultant for Abbvie Inc. This consulting role does not represent a conflict of interest for this study. The remaining authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eThis is a retrospective study. The University of Kansas Institutional Review Board has confirmed that no ethical approval is required. IRB 00150059.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHealth, United States. 2010: With Special Feature on Death and Dying. Hyattsville, MD: National Center for Health Statistics; 2011.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG. Hysterectomy rates in the United States, 2003. \u003cem\u003eObstet Gynecol\u003c/em\u003e. 2007;110(5):1091\u0026ndash;1095.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013;122:233\u0026ndash;241. [PubMed: 23969789]\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRoss WT, Meister MR, Shepherd JP, et al. Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate. Am J Obstet Gynecol 2017;217:436.e1\u0026ndash;8. [PubMed: 28716634]\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDeLancey J. Anatomy and Biomechanics of Genital Prolapse. Clinical Obstetrics and Gynecology. 1993; 36:897\u0026ndash;909.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePutman JG, Meister MR, Lenger SM, Lowder JL. Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training?. \u003cem\u003eFemale Pelvic Med Reconstr Surg\u003c/em\u003e. 2021;27(7):421\u0026ndash;426.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLowder JL. Apical Vaginal Support: The Often Forgotten Piece of the Puzzle. \u003cem\u003eMo Med\u003c/em\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWaitman LR, Warren JJ, Manos EL, Connolly DW. Expressing observations from electronic medical record flowsheets in an i2b2 based clinical data repository to support research and quality improvement. AMIA Annu Symp Proc. 2011;2011:1454-63. Epub 2011 Oct 22. PMID: 22195209; PMCID: PMC3243191.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243191/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243191/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eVillegas-Echeverri JD, Ganyaglo GYK, Aklilu FA, Wasson M. FIGO statement: Disparities in patients' access to benign gynecological surgery. \u003cem\u003eInt J Gynaecol Obstet\u003c/em\u003e. 2022;158(3):499\u0026ndash;501. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijgo.14323\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.14323\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWieslander CK, Grimes CL, Balk EM, et al. Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review. \u003cem\u003eObstet Gynecol\u003c/em\u003e. 2023;142(5):1044\u0026ndash;1054. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000005389\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000005389\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Uterovaginal prolapse, apical support procedure, prolapse, hysterectomy","lastPublishedDoi":"10.21203/rs.3.rs-7780213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7780213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo investigate the rate of performance of concomitant apical support procedure at time of benign hysterectomy for uterovaginal prolapse at one tertiary care institution.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis was a retrospective cohort study of patients who underwent benign hysterectomy at our institution over a 22-year period. Eligible patients were identified by ICD and CPT codes and data were abstracted retrospectively. Factors associated with performance of an ASP were investigated and compared using multivariable logistic regression.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003e388 patients underwent benign hysterectomy with a diagnosis of prolapse. The mean age was 58 (SD 13); most were white (325, 83.8%), non-Hispanic (375, 92.0%), with private insurance (193, 49.7%). 259 (66.7%) had uterovaginal prolapse and of those, 203 (70.2%) underwent an apical support procedure. On multivariable analysis, patients were nearly 3-fold \u003cem\u003emore\u003c/em\u003e likely to undergo an ASP if they had a diagnosis of uterovaginal prolapse and nearly 70% \u003cem\u003eless\u003c/em\u003e likely to undergo an ASP if their procedure was performed by a general gynecologist without a sub-specialist.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt our institution, approximately 75% of benign hysterectomies performed for prolapse incorporate an apical support procedure. Although this is better than the rates in other regions, ongoing efforts to educate surgeons, particularly non-subspecialists, on the importance of re-establishing apical vaginal support at time of hysterectomy for prolapse is needed.\u003c/p\u003e","manuscriptTitle":"Apical Support Procedure at the Time of Hysterectomy: Regional experience at one tertiary care institution","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-14 16:19:17","doi":"10.21203/rs.3.rs-7780213/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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