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Association Between Concomitant Hysterectomy and Repeat Surgery for Pelvic Organ Prolapse Repair in a Cohort of Nearly 100,000 Women

Dallas, Kai, MD; Elliott, Christopher S., MD, PhD; Syan, Raveen, MD; Sohlberg, Ericka, MD; Enemchukwu, Ekene, MD, MPH; Rogo-Gupta, Lisa, MD

doi: 10.1097/AOG.0000000000002913
Contents: Urogynecology: Original Research

OBJECTIVE: To evaluate the association of hysterectomy at the time of pelvic organ prolapse (POP) repair with the risk of undergoing subsequent POP surgery in a large population-based cohort.

METHODS: Data from the California Office of Statewide Health Planning and Development were used in this retrospective cohort study to identify all women who underwent an anterior, apical, posterior or multiple compartment POP repair at nonfederal hospitals between January 1, 2005, and December 31, 2011, using Current Procedural Terminology and International Classification of Diseases, 9th Revision procedure codes. Women with a diagnosis code indicating prior hysterectomy were excluded, and the first prolapse surgery during the study period was considered the index repair. Demographic and surgical characteristics were explored for associations with the primary outcome of a repeat POP surgery. We compared reoperation rates for recurrent POP between patients who did compared with those who did not have a hysterectomy at the time of their index POP repair.

RESULTS: Of the 93,831 women meeting inclusion criteria, 42,340 (45.1%) underwent hysterectomy with index POP repair. Forty-eight percent of index repairs involved multiple compartments, 14.0% included mesh, and 48.9% included an incontinence procedure. Mean follow-up was 1,485 days (median 1,500 days). The repeat POP surgery rate was lower in those patients in whom hysterectomy was performed at the time of index POP repair, 3.0% vs 4.4% (relative risk [RR] 0.67, 95% CI 0.62–0.71). Multivariate modeling revealed that hysterectomy was associated with a decreased risk of future surgery for anterior (odds ratio [OR] 0.71, 95% CI 0.64–0.78), apical (OR 0.76, 95% CI 0.70–0.84), and posterior (OR 0.69, 95% CI 0.65–0.75) POP recurrence. The hysterectomy group had increased lengths of hospital stay (mean 2.2 days vs 1.8 days, mean difference 0.40, 95% CI 0.38–0.43), rates of blood transfusion (2.5% vs 1.5, RR 1.62, 95% CI 1.47–1.78), rates of perioperative hemorrhage (1.5% vs 1.1%, RR 1.32, 95% CI 1.18–1.49), rates of urologic injury or fistula (0.9% vs 0.6%, RR 1.66, 95% CI 1.42–1.93), rates of infection or sepsis (0.9% vs 0.4%, RR 2.12, 95% CI 1.79–2.52), and rate of readmission for an infectious etiology (0.7% vs 0.3%, RR 2.54, 95% CI 2.08–3.10) as compared with those who did not undergo hysterectomy.

CONCLUSION: We demonstrate in a large population-based cohort that hysterectomy at the time of prolapse repair is associated with a decreased risk of future POP surgery by 1–3% and is independently associated with higher perioperative morbidity. Individualized risks and benefits should be included in the discussion of POP surgery.

Hysterectomy at the time of prolapse repair is associated with a 1–3% decreased risk of future prolapse surgery.

Stanford University School of Medicine, Stanford, and Santa Clara Valley Medical Center, San Jose, California.

Corresponding author: Kai Dallas, MD, Department of Urology, Stanford School of Medicine, 300 Pasteur Drive, Grant Building, 2nd Floor, Room S-287, Stanford, CA 94305-5118; email:

Supported by the Valley Medical Foundation.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Society of Urodynamics, Female Pelvic Medicine, & Urogenital Reconstruction Annual Meeting, February 26, 2018–March 2, 2018, Austin, Texas; and presented as a poster at the American Urologic Association Annual Meeting, May 18–21, 2018, San Francisco, California.

Each author has indicated that he or she has met the journal's requirements for authorship.

Peer review history is available at

© 2018 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.