Surgical correction of the genital hiatus at the time of sacrocolpopexy – a 7-year markov analysis

Abstract

Narrowing the genital hiatus with a posterior repair at the time of sacrocolpopexy may reduce the odds of prolapse recurrence but increases the risk of surgical complications or dyspareunia. Our objective was to perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We used TreeAge Pro® to construct a decision model comparing sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. A Markov model was embedded in the decision model to simulate prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring operative take-back, and postoperative dyspareunia. Costs included index surgery, surgical retreatment and complications. Costs, probabilities, and utilities were gathered from Medicare reimbursement data, published literature, and institutional billings department (Table 1). We modeled effectiveness as quality-adjusted-life years (QALY). Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as costs / effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. Sensitivity analyses were performed by varying input variables across a wide range to identify thresholds where our conclusions could change. Our model showed that SCP was the dominant strategy with lower costs (-$ 9699.02) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. Tornado plots showed that the analysis was most influenced by the cost of SCP and cost of SCP+PR. In one-way sensitivity analyses, the model outcome would change only if the cost of SCP was greater than SCP+PR which is not reasonable with the longer operative time and associated surgical complications. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was 49.5% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR were 9.9% less than the rate associated with SCP alone. None of the scenarios above were reasonable. In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.