TEMPORAL TRENDS IN PELVIC ORGANPROLAPSE SURGERY IN CANADA
S. LISONKOVA1, Q. WEN2, M. SANAEE 1, G. M. MURACA 1, R.GEOFFRION 3, M. LAROUCHE 4, G. W. CUNDIFF 1;
1Obstetrics and Gyneacology, Univ. of BritishColumbia, Vancouver, Canada, 2Langara Coll., Vancouver,Canada, 3Univ. of British Columbia, Vancouver, Canada,4Obstetrics and Gynaecology, McGill Univ., Montreal,Canada.
Introduction: Despite arelatively high lifetime risk of pelvic organ prolapse (POP), therate of inpatient POP surgery declined in the US between 1979 and2006. Obstetric trauma, which also declined over time, is one ofthe risk factors for POP. Temporal trends in POP surgery in Canadaare understudied.
Objective: To examine regional variationand temporal trends in surgery for pelvic organ prolapse, and itscorrelation with severe obstetric trauma rates in Canada.
Methods:We used information on all hospitalizations in Canada (excludingQuebec) from 2004 to 2014. POP surgery was identified using CanadianClassification for Health Interventions; POP and severe obstetrictrauma was identified using ICD-10-CM diagnostic codes, the latterincluded 3rd/4th degree perineal tear, highvaginal and cervical tear, and injury to pelvic organs, joints, andligaments. Age-specific and province-specific rates of POP surgeryand obstetric trauma were calculated using female population numbersfrom Statistics Canada. Type of POP surgery included: 1) surgeryinvolving artificial material - mesh (e.g., repair of cystoceleand/or rectocele with artificial graft or prosthesis); 2) vaginalobliteration (e.g., obliteration and total excision of vagina, withdiagnosis of POP); 3) other procedures involving native tissue repair(anterior and/or posterior colporrhaphy); and 4) hysterectomy only(with no other POP procedure and with diagnosis of POP). Temporaltrends were assessed by the Cochran-Armitage test, age-standardizedrates were calculated using average Canadian female population as astandard. The rates of obstetric trauma among women aged 14-44 yearsin the period between 1995 and 2000 were correlated with the rates ofPOP surgery 10 years later among women aged 25-54 years (in theperiod between 2005 and 2010).
Results: Age-standardizedrates of POP surgery declined from 18.7 per 10,000 women in 2004 to13.9 in 2014; the rates of native tissue repair procedures declinedfrom 14.5 to 11.2 per 10,000 women, and hysterectomy rates declinedfrom 2.4 per 1.3 per 10,000; while the rates of vaginal obliterationincreased from 0.1 to 0.3 per 10,000 women (all p-values less than0.01); the rates of surgery involving artificial mesh increased from1.6 in 2004 to 2.1 per 10,000 women in 2007 and then declined to 1.1per 10,000 women in 2014. POP surgery rates increased with age, withthe highest rates among 65-74 years old (36.5 per 10,000 women); thispattern differed by the type of surgery; e.g., vaginal obliterationwas low among younger women and increased only at age 65-69, with thehighest rates at age 80-84 years (1.5 per 10,000 women); whilehysterectomy increased in younger women, peaked at the age of 44-49(3.9 per 10,000 women) and declined sharply afterwards. Overall, POPsurgery declined in all age groups between 2004 and 2014 (Figure).Age-standardized rates varied by province, ranging from 1.7 per10,000 women in Yukon to 29.7 per 10,000 in Newfoundland. The rate ofobstetric trauma among women aged 15-44 years declined from 24.1 per10,000 women in 1995 to 20.5 per 10,000 women in 2000; this declinehighly correlated with the decline in POP surgery rates among women25-54 years from 14.4 in 2005 to 12.6 per 10,000 women in 2010(correlation coefficient 0.90, p-value less than 0.05).
Conclusions:Except for the rates of vaginal obliteration surgery that increased,inpatient surgery for pelvic organ prolapse declined in Canadabetween 2004 and 2014. This may be partly due to a population-leveldecline in the rates of obstetric trauma during previous years.However, given the long waitlists for POP surgery across Canada, thisdecline may also be due to insufficient number of availablespecialists or other barriers to specialized urogynecology care.Age-standardized rates varied considerably betweenprovinces/territories, also suggesting varying access to POP surgeryacross Canada.
References: 1 Obstet Gynecol2014;123:1201-6. 2 Am J Obstet Gynecol 2010;200:501.e1-7. 3 ObstetGynecol 2012;119:233-9.