Int Urogynecol J (2012) 23:865–872

DOI 10.1007/s00192-011-1647-1

ORIGINAL ARTICLE

Changing trends of surgical approaches for uterine prolapse:

an 11-year population-based nationwide descriptive study
Ming-Ping Wu & Cheng-Yu Long & Kuan-Hui Huang &
Chin-Chen Chu & Ching-Chung Liang &
Chao-Hsiun Tang

Received: 30 June 2011 / Accepted: 24 December 2011 / Published online: 24 January 2012
# The International Urogynecological Association 2012

Abstract Health Insurance Research Database (NHIRD). The NHIRD

Introduction and hypothesis The interest of uterus-preserving
surgery has been growing. Based on a nationwide database,
we examined surgical procedures for uterine prolapse in
Taiwan during the study period of 1997–2007, a total of
11 years.
Methods The operations, either uterine suspension or hys-
terectomy, due to the diagnosis of uterine prolapse were
indentified into the study. Data on several parameters were
collected for analysis, i.e., the surgical type, patient factors
(age and concomitant anti-incontinence surgery), surgeon
factors (age and gender), and hospital factors (accreditation
level and ownership). Data of this study were obtained from
the inpatient expenditures by admission files of the National
was established by the National Health Research Institute
with the aim of promoting research into current and emerging
medical issues in Taiwan.
Results In total, 31,038 operations were identified for this
study. There was a trend for increased use of uterine suspension
with uterine preservation during the latter years, evidenced by
joinpoint regression analyses. More women who were younger
(<50 years) or had concomitant anti-incontinence surgery
received uterine suspension. Younger surgeons (<50 years)
and male surgeons tended to perform more uterine suspensions.
As for hospital accreditation, more uterine suspension surgeries
were performed in regional hospitals, followed by local hospi-
tals and medical centers. As for hospital ownership, more

Dr. Tang and Dr. Liang contributed equally to this work.

M.-P. Wu C.-C. Chu
Division of Urogynecology and Pelvic Floor Reconstruction, Department of Anesthesiology,
Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital,
Chi Mei Foundation Hospital, Tainan, Taiwan
Tainan, Taiwan

M.-P. Wu
C.-C. Liang (*)
Department of Obstetrics and Gynecology, College of Medicine,
Department of Obstetrics and Gynecology,
Taipei Medical University,
Chang Gung Memorial Hospital,
Taipei, Taiwan
Linkou Medical Center,
Chang Gung University College of Medicine,
C.-Y. Long
Taoyuan, Taiwan
Department of Obstetrics and Gynecology,
e-mail: ccjoliang@adm.cgmh.org.tw
Kaohsiung Municipal Hsiao-Kang Hospital,
Kaohsiung Medical University,
Kaohsiung, Taiwan
C.-H. Tang (*)
K.-H. Huang School of Health Care Administration,
Division of Gynecology, College of Medicine,
Department of Obstetrics and Gynecology, Taipei Medical University,
Kaohsiung Chang Gung Memorial Hospital 250 Wu-Xing Street,
and Chang Gung University College of Medicine, Taipei 110, Taiwan
Kaohsiung, Taiwan e-mail: chtang@tmu.edu.tw
866
uterine suspension surgeries were performed in private hospitals,
followed by not-for-profit and government-owned hospitals.
Conclusions There has been a considerable change in the
surgical approach for uterine prolapse in Taiwan over the
past 11 years. Patient age and concomitant anti-incontinence
surgery, surgeon age and gender, and hospital accreditation
and ownership may correlate with the choice of surgery for
women with uterine prolapse.
Keywords Hospital accreditation . Hospital ownership .
Hysterectomy . National Health Insurance Research Database
(NHIRD) . Pelvic organ prolapse (POP) . Uterine prolapse .
Uterine suspension . Vaginal suspension
Introduction
Pelvic organ prolapse (POP) is a commonly encountered
women’s health issue. As to prevalences in the Women’s
Health Initiative, 41% of women aged 50–79 years showed
some amount of POP, including cystocele in 34%, rectocele in
19%, and uterine prolapse in 14% [1]. In a multicenter study of
1006 women aged 18–83 years presenting for routine gyneco-
logical care, 24% had normal support and 38% had stage I,
35% had stage II, and 2% had stage III POP [2]. The preva-
lence of POP increases as the life expectancy increases. POP is
also known to have a negative impact on a patient’s quality of
life [3]. The lifetime risk of undergoing prolapse or continence
surgery is 11.1% [4]. Different feasible surgical approaches
include vaginal, abdominal, and laparoscopic procedures.
Attitudes toward sexuality and psychological value of
reproductive organs have changed in Western countries over
the last few decades [5]. However, repair of POP with a
concomitant hysterectomy is still considered a standard
treatment. During the past decade, interest has been growing
in uterus-preserving surgery worldwide [3]. Several surgical
approaches with the aim of preserving the uterus have been
developed, e.g., sacral hysteropexy [6], uterosacral ligament
uterine suspension [7], and sacrospinous ligament uterine
suspension [8]. Recently, the concept of uterine preservation
during surgery to repair a prolapse and the use of adjuvant
prostheses have been evolving [5, 9]. Use of a transvaginal
mesh with either surgeon-tailored or commercial procedural
kits is blossoming and becoming popular in the field [10,
11]. However, its influence on vaginal hysterectomies and
the choice of surgeries for POP remain unknown.
Our hypothesis that hysterectomy would be performed
less commonly with the uterine suspension more commonly
as the evolving concept of uterine-preserving pelvic recon-
structive surgery has evolved favoring retention of the uterus.
With our previous experience of analyzing changing trends for
anti-incontinence surgery [12], we conducted this 11-year
population-based nationwide study to describe changing
Int Urogynecol J (2012) 23:865–872
trends of surgeries for uterine prolapse based on the National
Health Insurance (NHI) claims data in Taiwan. Also, we
evaluated some related variables, including patient age,
concomitant anti-incontinence surgery, surgeon age and
gender, and hospital parameters of accreditation (medical
center, regional hospital, and local hospital), and ownership
(government-owned, not-for-profit, and private) where the
surgeries were performed.
Materials and methods
The NHI program in Taiwan
Detailed information on NHI was given in our previous
work [12]. Briefly, the NHI program in Taiwan was put into
effect in March 1995 and features comprehensive and universal
coverage. Financing sources of NHI primarily come from
payroll taxes with additional subsidies from general govern-
ment revenues. The NHI covered approximately 93.1% of the
total population in Taiwan in 1996 to 99.3% in 2007. During
1996 and 2007, approximately 96.2% of the hospitals in
Taiwan were contracted with the Bureau of NHI [12].
Data sources
The data used in this study were obtained from the NHI
Research Database (NHIRD). The NHIRD was established
by the National Health Research Institute, in cooperation
with the Bureau of NHI, with the aim of promoting research
into current and emerging medical issues in Taiwan. Three
types of files from the NHIRD were used in this study. First,
inpatient expenditures by admission contain information on
all NHI-reimbursed hospital discharges pertaining to inpa-
tient characteristics and dates of admission and discharge
and also include one major and four minor diagnosis codes
(based upon the International Classification of Diseases, 9th
Revision, Clinical Modification, ICD-9 CM), one major and
four minor surgery codes, and ownership of the medical
facility. Second, the registry of contracted medical facilities
provides data on each medical institution’s accreditation
level and geographic location. Third, the registry of medical
personnel provides data on each medical professional’s
date of birth, gender, type of profession, and specialty.
Confidentiality assurances were addressed by abiding
the data regulations of the Bureau of NHI, and institutional
review board approval was waived.
Study subjects
Study subjects were the operations, either uterine suspension
or hysterectomy due to the diagnosis of uterine prolapse in
Taiwan between 1 January 1997 and 31 December 2007. The
Int Urogynecol J (2012) 23:865–872
women who received multiple surgeries were also identified;
therefore, the cases were actually individual procedure rather
than women. A diagnosis of uterine prolapse included ICD-9
CM diagnosis codes 618.1 for uterine prolapse without men-
tion of vaginal wall prolapse; 618.2 for uterovaginal prolapse,
incomplete; 618.3 for uterovaginal prolapse, complete; and
618.4 for uterovaginal prolapse, unspecified, but not vaginal
vault prolapse (618.5 prolapse of the vaginal vault after a
hysterectomy). The women received various surgical
approaches for uterine prolapse, including uterine suspension
(ICD-9 CM operation code 69.22 for other uterine suspension,
including hysteropexy, Manchester operation, and placation
of uterine ligament) or vaginal suspension (70.77 for vaginal
suspension and fixation). A concomitant hysterectomy
was described as a subtotal abdominal hysterectomy
(or supracervical hysterectomy) (68.3), a total abdominal
hysterectomy (68.4), a laparoscopic hysterectomy (68.51
or 68.5 vaginal hysterectomy with 54.21 laparoscopy),
and a vaginal hysterectomy (68.59 or 68.5 vaginal hysterec-
tomy without 54.21 laparoscopy). The concomitant anti-
incontinence surgery was described as plication of the
urethra–vesical junction, e.g., a Kelly–Kennedy opera-
tion (59.3); suprapubic sling operation, e.g., Goebel–
Frangenheim–Stoeck suspension (59.4); retropubic urethral
suspension, e.g., a Marshall–Marchetti–Kranz operation,
Burch procedure (59.5); paraurethral suspension (needle
suspension), e.g., Pereyra suspension (59.6); injection of
an implant into the urethral and/or bladder neck, e.g.,
collagen implant (59.72); and others (59.79), e.g., abdominal
perineal urethral suspension, tension-free vaginal tapes
(TVTs), etc. The transvaginal mesh either tailored by
surgeon or commercial kits was not covered by the
NHI. Therefore, the coding and use were not available.
Additionally, we used joinpoint regression analysis [13]
to identify changes in trends (if any change in trend
occurred) in proportion to the two types of surgery during
1997–2007.
Variable definitions
The variables used in this study fall into the following three
categories: first, age and concomitant anti-incontinence
surgery were patient characteristics; second, age and
gender were surgeon characteristics; and third, accreditation
level and hospital ownership were hospital characteristics.
Patients were divided into four 10-year age groups of <50 to
≥70 years. The surgeon’s age was divided into six 5-year age
groups of <35 to ≥55 years. In Taiwan, hospitals are accredited
by the Taiwan Joint Commission on Hospital Accreditation
which is supervised by the Department of Health, and classified
into three levels based on healthcare quality, medical teaching
ability, clinical capabilities, and bed capacity: medical centers,
regional hospitals, and local hospitals. Hospital ownership was
867
classified into not-for-profit hospitals, government-owned
hospitals, or private for profit hospitals.
Statistical analysis
Chi-squared tests were performed to examine differences in
the distribution of the two types of surgeries, i.e., uterine
suspension and hysterectomy, according to patient, surgeon,
and hospital characteristic groups. A multiple logistic
regression was used to examine the independent effects
of each individual variable in choosing a hysterectomy
to treat uterine prolapse. We used joinpoint regression
analysis to identify points of significant inflection in
trends. The analysis starts with minimum number of
inflections (joinpoints), and tests whether one or more
additional joinpoints should be added to the model. In
the final model, each joinpoint indicates there was a
statistically significant change in trend (either increase or
decrease). The annual percentage change (APC) is calculated
for the time segments on either side of inflection points. The
analyses were performed using Joinpoint Regression Program
Version 3.4.3 (Statistical Research and Applications Branch,
National Cancer Institute, Bethesda MD, 2010). The signifi-
cance of the statistics was determined using a p value of <0.05.
All analyses in this study were carried out using SAS system
software for Windows (version 9.01).
Results
Overall change in the surgical trend
In total, 30,888 women who received 31,038 operations,
either hysterectomy or uterine suspension, were identified
for this study. One hundred forty-five women received more
than one operation with a reoperation rate 0.47%. Twenty-
eight women received two uterine suspensions; 112 women
received one uterine suspension, followed by hysterectomy.
Five women received two uterine suspensions, followed by
hysterectomy. The multiple operation proportion was 0.48
%. The percentage of uterine suspension and hysterectomy
were 9.4–13.6% vs. 86.5–90.7% after 2004 and were 7.7–
9.4% vs. 90.6–92.3% before 2003. According to the trend
test by joinpont regression analysis, there was a trend for
increased use of uterine suspension with uterine preserva-
tion (the uterine suspension group) during the latter years
(Fig. 1). The joinpoint regression analysis identified one
significant inflection points, generating two distinct trends
between 1997 and 2007. For uterine suspension, a signifi-
cant raise was observed after 2003 (APC012.26, p<0.05).
With the same change point (year 2003) identified, the result
showed that there was a significant decline in the trend from
2003 to 2007 (APC0−1.31, p<0.05).
868 Int Urogynecol J (2012) 23:865–872

Fig. 1 Trends in surgical procedures for uterine prolapse in Taiwan by year in 1997–2007 (joinpoint test showed a significant raise with
a slope 0 12.25, p<0.005)

Types of surgery among different patient factors Type of surgery by surgeon age and gender

During the study period, younger women (<50 years) received
more uterine suspensions (25.1% vs. 74.9%) compared to the
older group (≥50 years) (2.6–6.4% vs. 93.6–97.4%) (χ2 0
3288.3, p<0.0001) (Fig. 2). Women who had concomitant
anti-incontinence surgery (8.8% vs. 91.2%) received more
uterine suspensions compared to those without concomitant
surgery (15.9% vs. 84.1%) (χ2 0139.5, p<0.0001) (Fig. 2).
Younger surgeons (<50 years) performed more uterine
suspensions (9.3–10.7% vs. 89.3–90.7%) compared to
older surgeons (≥50 years) (6.3–7.5% vs. 92.5–93.7%)
(χ2 074.8, p<0.0001). Female surgeons performed fewer
uterine suspensions (4.0% vs. 96.0%) compared to male
surgeons (9.9% vs. 90.1%) (χ 2 089.2, p < 0.0001)
(Fig. 3).

Fig. 2 Types of surgery for % 8184 6167 8932 7755 28430 2608
uterine prolapse in Taiwan 2.9 2.6
100%
according to patient age 6.4 8.8
15.9
and concomitant anti- 25.1
incontinence surgery 80%

60%

40% 74.9 93.6 97.1 97.4 91.2 84.1

20%

0%
<50 50-59 60-69 70 no yes
Patient age Anti-incontinence
Hysterectomy Uterine suspension
Int Urogynecol J (2012) 23:865–872 869

Fig. 3 Types of surgery for % 2328 6309 7966 6795 4701 2939 28654 2384
uterine prolapse in Taiwan 100%
7.5 6.3 4.0
according to surgeon age and 9.3 10.1 10.7 10.0 9.9
gender
80%

60%

90.7 89.9 89.3 90.0 92.5 93.7 90.1 96.0

40%

20%

0%
<35 35-39 40-44 45-49 50-54 55 Male Female
Surgeon age Surgeon gender
Hysterectomy Uterine suspension

Type of surgery by hospital accreditation level
and ownership type
As for hospital accreditation, more uterine suspensions
were performed in regional hospitals (10.2% vs. 89.9%),
followed by local hospitals (9.4% vs. 90.6%) and medical
centers (8.9% vs. 91.1%) (χ2 012.1, p00.0007). As for
hospital ownership, more uterine suspensions were
performed in private hospitals (13.4% vs. 86.6%), followed
by not-for-profit (8.7% vs. 91.4%) and government-
owned hospitals (6.5% vs. 93.5%) (χ 2 0254.2,
p<0.0001) (Fig. 4).
Results from the multiple logistic regression are given in
Table 1. Older patients (≥50 years old) had a greater chance
of receiving hysterectomy compared to younger patients
(<50 years old) (odds ratio (OR) 4.9–12.3, 95% confidence
interval (CI) 4.4–14.3). Women who had concomitant anti-
incontinence surgery had a lower chance of receiving hys-
terectomy compared to those without concomitant surgery
(OR 0.7, 95% CI 0.6–0.8). Older surgeons (≥50 years old)
had a greater chance of performing hysterectomy compared
to younger surgeons (OR 1.4, 95% CI 1.1–1.7). Female
surgeons had a greater chance of performing a hysterectomy
compared to male surgeons (OR 2.3, 95% CI 1.8–2.8). We
further found an interaction between surgeon age and gender.
The tendency to choose hysterectomy was even higher
for a female surgeon of advanced age. The OR was
1.673 for a female age of <35 years, which increased
to 20.858 for those who were aged ≥55 years. As for
hospital accreditation, there was a lower rate of hysterectomy
being performed in regional hospitals (OR 0.9, 95% CI 0.8–
0.9), while there was a greater chance of hysterectomy being
performed in local hospitals (OR 1.4, 95% CI 1.3–1.6)
compared to medical centers. As for hospital ownership,
there were lower chances of hysterectomy being performed in
both not-for-profit (OR 0.7, 95% CI 0.6–0.8) and private
hospitals (OR 0.4, 95% CI 0.4–0.5) compared to
government-owned ones.

Fig. 4 Types of surgery for 14304 10669 6065 8366 14017 8655
%
uterine prolapse in Taiwan 100%
8.9 10.2 9.4 6.5 8.7
according to hospital 13.4
accreditation and
ownership 80%

60%

91.1 89.9 90.6 93.5 91.4 86.6

40%

20%

0%
Medical Regional Local Hospital Government Nonprofit Private
Center Hospital
Hospital Accreditation Hospital Ownership
Hysterectomy Uterinesuspension
870 Int Urogynecol J (2012) 23:865–872

Table 1 Multiple logistic regression for choosing hysterectomy based upon their personal goals for surgery, their general
OR 95% CI p Value medical condition, and their concern for prolapse recurrence.
This and our previous study also observed that patient age is
Patient age <50 Ref one of the correlative factors which should be taken into
50–59 4.9 4.4 5.5 <0.0001 account when selecting an appropriate surgical type [12].
60–69 11.2 9.8 12.8 <0.0001 The need for concomitant anti-incontinence surgery
≥70 12.3 10.6 14.3 <0.0001 makes uterine-preserving surgery more common. It is
With anti-incontinence No Ref postulated that combined procedures of uterine suspen-
Yes 0.7 0.6 0.8 <0.0001 sion and anti-incontinence surgery are more commonly
Surgeon age <35 Ref performed by subspecialists in urogynecology. Apical
35–39 1.0 0.8 1.1 0.6391 prolapse frequently coexists with some lower urinary
40–44 0.9 0.8 1.1 0.4369 tract symptoms, e.g., urinary incontinence and urinary
45–49 1.0 0.9 1.2 0.7973 retention; thus, a thorough pelvic evaluation should look
50–54 1.4 1.2 1.7 0.0002 for both conditions. Stress urinary incontinence (SUI)
≥55 1.4 1.1 1.7 0.0066 has a population-based prevalence of nearly 40% in
Surgeon gender Male Ref most industrialized countries, usually with severe implication
Female 2.3 1.8 2.8 <0.0001 for daily function, social interactions, sexuality, and psycho-
Hospital accreditation Medical center Ref logic well-being [18]. Although many women with advanced
Regional hospital 0.9 0.8 0.9 0.0025 apical prolapse remain continent despite the loss of anterior
Local hospital 1.4 1.3 1.6 <0.0001 vaginal and bladder/urethral support; however, 8%–40% of
Hospital ownership Government Ref continent women develop symptoms of SUI after surgical
Not-for-profit 0.7 0.6 0.8 <0.0001
correction of the prolapse [19, 20]. Moreover, Altman et al.
Private 0.4 0.4 0.5 <0.0001
reported that hysterectomy increases the risk for subsequent
SUI surgeries during a 30-year observational period in the
Ref reference Swedish Inpatient Registry with a hazard ratio of 2.4 (95% CI
2.3–2.5), (179 vs. 76 per 100,000 person-years) [21]. Liang et
Discussion al. reported that continent patients suffering from severe POP
with a positive pessary test are considered to be at high risk of
Our study offers observational data of a surgical trend of developing postoperative symptomatic SUI [22]. The addition
increased use of uterine suspension with uterine preservation of TVTs to endopelvic fascia plication (RR 5.5, 95% CI
during the latter years, which is evidenced by the trend 1.36–22.32) and Burch colposuspension to an abdominal
regression analysis. Traditionally, vaginal hysterectomy sacrocolpopexy (RR 2.13, 95% CI 1.39–3.24) were followed
was a standard surgical treatment for uterovaginal prolapse. by a lower risk of women developing new postoperative de
The adoption of a vaginal hysterectomy varied, especially in novo SUI [23]. Therefore, it is important to determine if a
the need for concomitant removal of the adnexa [14]. Our woman has associated lower urinary tract symptoms, prior to
previous study [15] and a report by Babalola et al. [16] found apical suspension. Therefore, the concomitant procedure can
that vaginal hysterectomies decreased by 34% during the past prevent postoperative SUI in patients requiring surgical
decade. Postulated possible reasons for the decrease in vaginal correction for SUI.
hysterectomies were a decrease in the incidence of uterine Younger surgeons (<50 years old) tended to perform
prolapse, a lack of exposure to vaginal surgery during more uterine-preserving surgeries, while older surgeons
gynecologic training, and the evolving concept of uterine- (≥50 years old) performed more hysterectomies in our study.
preserving pelvic reconstructive surgery [14]. Whether this reflects their training background and/or the
Younger women (<50 years old) were more likely to have concept of pelvic floor reconstruction is still elusive. Eckert
received uterine suspension in our study. This finding may et al. reported that nationwide trends toward the increased
be attributable to higher expectations of the quality of life use of nonoperative, minimally invasive, endoscopic tech-
among younger women [12]. Preservation of the uterus was niques are altering the operative experience of surgeons and
recently shown to positively contribute to a patient’s residents in training. This may radically change the abilities
self-esteem, body image, confidence, and sexuality [5, 8, and expectations for the field of general surgery [24]. Our
17]. Therefore, patients’ attitudes about the psychological data offered the correlative data between surgeon age and
value of reproductive organs may have influenced their surgi- surgical choice, which is possibly influenced by the training
cal choice. Women will weigh certain factors, e.g., durability, background of surgeons. Surgeons’ gender was also a
recovery time, complications, foreign body risks, and desire significant determinant in choosing surgery types: male sur-
for vaginal intercourse. Therefore, patients choose a procedure geons tended to perform more uterine-preserving surgeries,
Int Urogynecol J (2012) 23:865–872
while female surgeons performed more hysterectomies. Further
adjustment for surgeon age revealed that surgeon gender was
still an influencing factor and became more obvious at an
advanced age. The explanation for the difference due
to surgeon gender is unclear.
There were significant differences in choices of surgical
types between hospital accreditation levels and owner-
ship categories. More uterine-preserving surgeries were
performed in regional hospitals, and more hysterectomies
were performed in local hospitals compared to medical
centers. The different levels of hospital accreditation
may mean that their doctors have different specialized
surgical training including apprenticeship-style training,
curriculum- and case-based programs, or independent
and integrated specialty training programs [25]. Therefore,
in addition to patient conditions, the choice of surgical proce-
dures is dependent to some extent on the hospitals where the
surgery is performed [12, 26]. As for hospital ownership,
more uterine suspensions were performed in private hospitals,
followed by not-for-profit and government-owned hospitals;
this may have been due to the more conservative, traditional
character of government-owned hospitals. This variability
would, in turn, have implications for both patients and the
surgical modality selected.
Surgery is designed to repair and reconstruct the weakened
pelvic floor and restore normal function. It is indicated only
when the prolapse causes significant symptoms and when
conservative nonsurgical measures have failed [27]. There is
a paucity of high-quality data comparing different types of
apical prolapse, e.g. uterine prolapse repair procedures; the
literature mostly contains evidence from controlled studies
rather than randomized trials. Our study offers observational
data .Further high-quality randomized control trials are still
necessary to evaluate the advantages and disadvantages of
uterine-preserving procedures.
Limitations of this study included the following due to its
retrospective observational character: first, the possibility of
miscoding existed due to coding by medical affair personnel
instead of surgeons themselves; second, the exact proce-
dures performed were not specified, e.g., sacrohysteropexy,
uterosacral ligament uterine suspension, and sacrospinous
ligament uterine suspension; and third, information on out-
of-pocket payments for the commercial transvaginal mesh
kit, which is not covered by insurance, was unknown. As for
the reimbursement of the medical costs, the NHI program
covers 98% of the patients and 98% of the hospitals; there-
fore, the effect of insurance coverage on the choice may
have been minor. Nevertheless, despite these limitations,
this study provides a descriptive analysis of surgeries for
uterine prolapse, based upon an 11-year population-based
nationwide databank including the surgical type, patient
age, concomitant anti-incontinence surgery, surgeon age
and gender, and hospital accreditation and ownership.
871
Our study offers population-based nationwide observations.
How to determine the best way to deal with uterine prolapse
demands further ongoing researches. In conclusion, there has
been a considerable change in the surgical approach for uterine
prolapse in Taiwan over the past 11 years. Certain variables
may correlate the choice of surgery, including patient age,
associated anti-incontinence surgery, surgeon age and gender,
and accreditation and ownership of the hospital where the
surgery is performed.
Acknowledgments We are appreciative of the grant support from
Chang Gung Memorial Hospital, Kaohsiung Medical Center,
CMRPG870821, and Chi Mei Foundation Hospital, CMNCKU9806.
We thank Dr. Yu-Tung Huang of Chang Gung University of Science
and Technology, for the assistance of statistical analysis for the trend
test.
Conflicts of interest None.
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