Factors Associated With Stress Incontinence Surgery Following Hysterectomy for Prolapse

INTRODUCTION: Stress urinary incontinence (SUI) may become apparent, remain persistent, or worsen following surgical correction of prolapse. Surgeons often employ incontinence procedures to prevent or treat SUI. OBJECTIVE: This study seeks to identify factors associated with surgical treatment of SUI after hysterectomy for prolapse with and without a concomitant incontinence procedure. METHODS: We conducted a retrospective analysis of deidentified private payor insurance claims data for services from October 2015 to 2024. The cohort consisted of individuals undergoing hysterectomy for prolapse, identified by ICD-10-CM and CPT codes. Prolapse and SUI surgeries were categorized using CPT codes. The cohort was divided into those who underwent an incontinence procedure at time of hysterectomy and those who did not. The primary outcome was performance of an SUI surgery after the hysterectomy for prolapse. We excluded those who underwent an incontinence procedure prior to the index hysterectomy (n=10). Cox proportional hazards models adjusting patient and surgical attributes were used to assess for factors associated with subsequent SUI surgical treatment. RESULTS: We identified 7,007 patients who underwent hysterectomy for prolapse with a median of 1140 days of coverage (IQR 476–2120.5). The average age was 51.3 (SD 9.8) years. There were 35.5% (N=2,487) who underwent an incontinence procedure at the time of hysterectomy, and there were 3.5% (n=246) who underwent an incontinence surgery after hysterectomy. For those who underwent hysterectomy without an incontinence procedure (n=4,520), there were 3.0% (n=135) who underwent a subsequent incontinence procedure, with 82% (n=111) having a pubovaginal sling. Comparatively, for those who underwent hysterectomy with an incontinence procedure, there were 4.5% (n=111) who had a subsequent incontinence procedure, with pubovaginal slings performed in 23.4% (n=26). For those who underwent hysterectomy without an incontinence procedure, there was an increased hazard for subsequent incontinence treatment with a laparoscopic approach (HR 2.01, 95% CI 1.34–3.01) compared to a vaginal approach. Performance of an abdominal colpopexy was also associated with subsequent incontinence treatment (HR 4.9, 95% CI 1.76–13.79). For those who underwent hysterectomy with an incontinence procedure, obesity (BMI >40) was associated with increased likelihood of retreatment (HR 3.39, 95% CI 1.57–7.3). Concurrent gynecologic diagnoses such as menstrual disorders (fibroids, abnormal bleeding, menstrual pain) and adnexal pathology for those who did not have an incontinence procedure were associated with a lower likelihood of subsequent SUI surgery after hysterectomy. Performance of other prolapse procedures (e.g., anterior/posterior colporrhaphy) was not associated with subsequent treatment nor were patient socioeconomic factors in either group. CONCLUSIONS: Among women with commercial insurance undergoing hysterectomy for prolapse, subsequent treatment for SUI after hysterectomy is relatively rare. With only about one third of this hysterectomy for prolapse cohort undergoing SUI surgery and low rates of subsequent treatment, it seems likely that preoperative risk assessment is identifying individuals at higher risk for SUI after surgery. Patients undergoing laparoscopic or abdominal hysterectomy for prolapse are at higher risk for subsequent SUI surgery, and future studies could aim to identify modifiable factors leading to this increased risk for some individuals.