Cost-effectiveness of Total Versus Supracervical Hysterectomy at Sacrocolpopexy

IMPORTANCE: Cervical preservation versus removal is commonly debated among urogynecologists performing sacrocolpopexy (SCP), the gold standard reconstructive procedure for prolapse. A randomized controlled trial is unlikely to ever be performed. OBJECTIVE: The objective was to compare the cost-effectiveness of total (TLH) versus supracervical (SCH) hysterectomy at the time of SCP. STUDY DESIGN: Markov microsimulation evaluated 5-year outcomes after SCP with TLH or SCH. Route-specific complications included bladder/ureteral injury, cuff dehiscence, port-site hernia, mesh exposure, prolapse recurrence with or without retreatment, and occult uterine cancer. Quality-adjusted life years (QALYs) incorporated recovery, prolapse recurrence, and cancer treatment states with an annual 3% discount rate. Probabilistic sensitivity analysis (PSA, n=10,000) assessed model uncertainty. RESULTS: Median costs were SCP/TLH=$16,117.50, SCP/SCH=$16,078.00 (Δ=$39.50, 0.2%). Median effectiveness was 4.65 QALYs for both. PSA showed TLH was more effective in 15.8%, SCH in 17.3%, with equal effectiveness in 67.0%. Net monetary benefit (NMB) favored SCH by $39.50 (<0.01% of total NMB). CONCLUSIONS: While risks vary between TLH and SCH, rare and mostly balanced complications, similar costs, and high efficacy regardless of route explain why both approaches perform equally overall.