Stage IV pelvic organ prolapse may be treated by multiple surgical modalities, and support of the vaginal apex is an essential aspect of surgical intervention for a durable repair. Our aim is to describe patient characteristics and practice patterns in the United States associated with various surgical approaches. We hypothesize that there is a high rate of apical suspension with advanced prolapse and increased utilization of colpocleisis in older patients.

The 2006-2016 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients with a primary postoperative diagnosis of stage IV pelvic organ prolapse by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) code 618.3. The primary outcome was type of prolapse repair, including concurrent hysterectomy, which may impact choice of prolapse surgery. Secondary outcomes were the proportion of apical suspensions and colpocleisis and patient or surgical characteristics associated with performance of an apical repair.

Pelvic reconstructive surgeries were delineated using Current Procedural Terminology (CPT) codes for apical repair (sacrospinous, iliococcygeus, or uterosacral suspensions and sacral colpopexy), anterior, posterior, enterocele and/or paravaginal repair, hysteropexy, and colpocleisis. Concurrent hysterectomy and use of mesh were noted. Chi-square analysis was used to evaluate patient factors associated with type of prolapse repair. Factors significant on univariate analysis were included in multivariable logistic regression analysis to adjust for confounding variables.

In total, 2,802 women underwent surgery for stage IV pelvic organ prolapse from 2006-2016. Mean age was 65.4 +/- 11.2 years, and gynecologic surgeons performed 97.7% of these surgeries. Overall, 46.7% of patients underwent an apical suspension: sacral colpopexy in 487 patients (17.4%), sacrospinous ligament or iliococcygus suspension in 429 patients (15.3%), and uterosacral ligament suspensions in 398 patients (14.2%). 56.9% (n=1593) of patients had an anterior and/or posterior repair. 

Concurrent hysterectomy was performed in 47.2% (n=1,323) of women, and vaginal hysterectomy was the most common surgical route (n=937). At the time of hysterectomy for prolapse, 61.6% (n=815) of women received a concurrent prolapse repair of any type, and only 38.3% (n=507) had an apical suspension or colpocleisis. Post-hysterectomy, 65.1% of patients (n=834) underwent an apical suspension (56.4%, n=834) or colpocleisis (8.7%, n=129).

On multivariable logistic regression analysis, apical suspension was less likely at the time of surgery in patients ≥80 years old (OR 0.42, CI 0.31-0.57, p<0.001) and in those who had a concurrent hysterectomy (OR 0.41, CI 0.35-0.48, p<0.001), adjusting for patient functional status. 

Overall, 5.4% (n=152) of patients underwent colpocleisis. Mean age at the time of colpocleisis was ## +/- ## years. Colpocleisis was associated with older age (OR 57.6, CI 7.93-418.39, p<0.001 for age ≥70 years) and post-hysterectomy status (OR 0.2, CI 0.13-0.33, p<0.001 for concurrent hysterectomy) on multivariable logistic regression, adjusting for patient characteristics including functional status.

Finally, 7.9% (n=220) of patients had a mesh-augmented prolapse repair and 34 (1.2%) patients had a hysteropexy.

In the United States, stage IV POP is treated by gynecologic surgeons. An apical suspension procedure is performed in only 46.7% of patients overall and for 38.3% of patients at the time of hysterectomy. Rates of sacral colpopexy versus vaginal approaches to vault suspension are similar. An apical suspension is more common in younger patients. Colpocleisis represents a small proportion of repairs and is associated with older age and post-hysterectomy status.

Addressing the vaginal apex at the time of repair of advanced stage pelvic organ prolapse is important for prevention of recurrence. This retrospective analysis of a United States database shows that the minority of patients receive an apical vaginal vault suspension at the time of surgery for stage 4 pelvic organ prolapse. Enhanced training in apical support procedures are needed to improve this discrepancy in the surgical treatment of advanced prolapse.