Racial and Ethnic Disparities in Native Tissue Apical Suspension for Prolapse

Objectives: To determine whether racial and/or ethnic disparities exist for the provision of apical suspension at the time of native tissue prolapse repair.

Methods: We utilized the Healthcare Cost and Utilization Project National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) inclusive of the entire 2019 year, employing appropriate Current Procedural Terminology and ICD-10 codes. Bivariate analysis identified demographic and hospital-based differences between native tissue apical suspension (uterosacral ligament suspension/sacrospinous ligament suspension with or without anterior/posterior colporrhaphy) versus non-apical suspension (anterior/posterior colporrhaphy alone) at the time of vaginal hysterectomy for prolapse, which were then adjusted for with multivariable logistic regression. We performed a separate analysis of post-hysterectomy prolapse surgeries.

Results: There were 62,553 total vaginal hysterectomies, 26,094 (41%) in the setting of a prolapse diagnosis. Of the vaginal hysterectomies performed for prolapse, 14,027 (54%) included a native tissue apical suspension procedure (Figure 1). The mean age was 60. The cohort identified as non-Hispanic White 73%, Black 5%, Hispanic 15%, Asian 3%, Native American 0%, and Other 3%. In bivariate analysis, Black patients were more likely to undergo an apical suspension procedure compared to non-Hispanic White patients (OR 1.38, 95% CI: 1.13-1.67, p< 0.001). Hispanic patients were less likely to undergo an apical suspension procedure (OR 0.72, 95% CI: 0.61-0.85, p< 0.001). Other factors associated with apical suspension include: age, payor status, chronic lung disease or diabetes, metropolitan size, hospital location, hospital bed size, and zip code quartile. In a regression model controlling for these variables, Black patients remained more likely to undergo an apical suspension procedure compared to those who identify as White (aOR 1.26, 95% CI: 1.04-1.53, p=0.02), and Hispanic patients were less likely to undergo an apical suspension procedure (aOR 0.74, 95% CI: 0.63-0.87, p< 0.001) (Table 1).

In the analysis of patients with prior hysterectomy, there were 60,074 prolapse surgeries, and only 18% (10,605) of those surgeries included a native tissue apical suspension (Figure 1). Compared to non-Hispanic White patients, Black patients, Hispanic patients, and Asian patients were all less likely to undergo an apical suspension procedure at the time of prolapse repair post-hysterectomy (i.e. these patients were more likely to undergo anterior/posterior colporrhaphy alone).

Conclusions: Apical suspension at the time of native tissue prolapse repair with vaginal hysterectomy was more likely to occur in patients who identified as Black compared to non-Hispanic White. Hispanic patients were less likely to have an apical suspension performed at the time of hysterectomy. In the post-hysterectomy cohort, White patients were more likely than others to undergo an apical suspension. Overall, the data demonstrate a paucity of apical suspension with native tissue repairs, particularly with prior hysterectomy. Racial and/or ethnic disparities continue to exist in the surgical treatment of pelvic organ prolapse.