title: Hysterectomy at the time of colpocleisis: a decision analysis.
abstract: OBJECTIVE
  Colpocleisis is an obliterative procedure for the treatment of pelvic organ prolapse (POP) with success rates nearing 100 %. Concomitant hysterectomy is commonly performed to avoid potential difficulty or delay in diagnosis and management of endometrial cancer (EMC). The objective was to assess the utility of vaginal hysterectomy at the time of a colpocleisis using decision analysis.
  
  
  METHODS
  A decision analysis model was constructed to compare the outcomes of Le Fort colpocleisis (C) with those of colpocleisis and concomitant vaginal hysterectomy (CH). Probability and utility values from published data and expert opinions were utilized. As EMC risk changes with age, the total expected utility for each alternative was calculated for each decade using the rollback method. Sensitivity analysis was performed using Monte Carlo simulation. When evaluating specifically the risk of developing EMC in those patients with uterine conservation (C) and the risk of laparotomy in patients undergoing CH, one-way sensitivity analysis was used to determine a threshold for decision reversal. Two-way sensitivity analysis determined a threshold for complications common to both C and CH.
  
  
  RESULTS
  The expected overall utility for C was higher than for CH for all ages 30-90 years. This difference was statistically significant for ages 40-90, favoring C. The Monte Carlo simulation results confirmed that the difference between the two alternatives was statistically significant. Multiple one-way sensitivity analyses confirmed model robustness.
  
  
  CONCLUSIONS
  Colpocleisis should be preferred to CH. Concomitant hysterectomy commonly performed for cancer may be justified in patients younger than 40 years of age.
authors.affiliation: Department of Obstetrics and Gynecology, Tufts University School of Medicine Baystate Medical Center, 759 Chestnut Street, S-1681, Springfield, MA, 01199, USA. Keisha.jonesmd@bhs.org.
authors.forename: Keisha A
authors.initials: KA
authors.lastname: Jones
authors.affiliation: Department of Operations and Information Management, Isenberg School of Management, University of Massachusetts Amherst, Amherst, MA, USA.
authors.forename: Yueran
authors.initials: Y
authors.lastname: Zhuo
authors.affiliation: Department of Operations and Information Management, Isenberg School of Management, University of Massachusetts Amherst, Amherst, MA, USA.
authors.forename: Senay
authors.initials: S
authors.lastname: Solak
authors.affiliation: Department of Obstetrics and Gynecology, Tufts University School of Medicine Baystate Medical Center, 759 Chestnut Street, S-1681, Springfield, MA, 01199, USA.
authors.forename: Oz
authors.initials: O
authors.lastname: Harmanli
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D003198:Computer Simulation; D003661:Decision Support Techniques; D003663:Decision Trees; D016889:Endometrial Neoplasms / Q000453:epidemiology* / Q000517:prevention & control; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000706:statistics & numerical data*; D008875:Middle Aged; D009010:Monte Carlo Method; D056887:Pelvic Organ Prolapse / Q000601:surgery*; D011336:Probability; D018570:Risk Assessment; D014621:Vagina / Q000601:surgery*
keywords: Colpocleisis; Hysterectomy; Le Fort; Pelvic organ prolapse; Vaginal obliteration