Abstract
Background
Pelvic organ prolapse (POP) is a common disease that substantially impairs women’s quality of life. Nationwide data on the proportions of physician consultations and surgical management of POP in Japan are not available. Furthermore, surgical approaches, including minimally invasive surgeries, have diversified in recent years; however, the extent of their application and potential regional disparities in each procedure have not been evaluated at the national level.
Objective
To visualize the 10-year trends in the diagnosis and surgical procedure selection for POP in Japan from 2014 to 2024 and examine the regional variations in the selection of surgical procedures.
Study Design
This nationwide descriptive study used data extracted from the DeSC database, which is a repository of Japanese health insurance claims data.
Results
The proportion of patients with POP among all women aged 40 years or above in the database was 1.47% (112,775/7660,925; 95% confidence interval [CI]: 1.46%–1.48%). A total of 16,752 patients underwent surgery at least once, and the prevalence of surgery was 14.85% (16,752/112,775; 95% CI: 14.65%–15.06%). The rate of surgery was 53.3 per 1000 person-years. Among women diagnosed with POP, the proportion of hysterectomy with vaginal wall repair and transvaginal mesh surgery decreased after the introduction of insurance coverage for laparoscopic sacrocolpopexy (LSC) in 2016. Robot-assisted sacrocolpopexy (RSC) partially replaced LSC since gaining insurance coverage in 2020. Urethral sling surgery was the most frequently performed second surgery. Regional differences were observed in the proportions of consultations and surgical rates. The proportion of procedures chosen as initial surgery differed across regions; the implementation rates of vaginal vault suspension and RSC exhibited particularly large regional disparities.
Conclusion
This study offers valuable evidence to enhance patient education on POP in Japan and help mitigate regional inequalities in insured healthcare services.
Key words: claims database, minimally invasive surgery, nationwide, pelvic organ prolapse
Introduction
Pelvic organ prolapse (POP) is a condition wherein pelvic organs such as the bladder, uterus, rectum, small intestine, and vagina descend or protrude into the vaginal canal.1 POP is often accompanied by symptoms of discomfort, including urinary symptoms, that significantly diminish the quality of life.2,3 However, many patients with POP do not seek medical consultation due to psychological factors such as embarrassment.3,4 Since awareness of the disease is insufficient due to social barriers,5 clarifying the actual rate of medical consultations and visualizing the treatment trends are necessary.
The estimated prevalence of POP is 8.3% for symptomatic cases, according to a Swedish questionnaire survey,6 and 30.9% per a global meta-analysis of overall prevalence.7 The transition in surgical procedures from the 2000s to the 2010s has been reported, based on data from countries outside of Japan. In the past, native tissue repair accounted for the majority of procedures in the United Kingdom. The frequency of transvaginal mesh (TVM) surgery increased from 2007, but declined after peaking in 2009.8 In the United States, sacrocolpopexy, colpocleisis, and TVM procedures accounted for the majority of POP surgeries up to 2008. However, after the warning instituted by the Food and Drug Administration (FDA) about TVM in 2008,9 the number of TVM procedures declined markedly. In addition, a trend toward less invasive surgery has emerged: the frequency of traditional open sacrocolpopexy has decreased, whereas that of laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) have increased.10,11 However, to date, no study has examined the changes in surgical procedure selection for POP in Japan. Additionally, no study has described the latest surgical trends following the approval of insurance coverage for surgery, or examined the patterns of surgical procedure selection among patients who underwent second surgery.
In Japan, various treatments for POP are available, ranging from conservative management, such as pelvic floor muscle exercises, lifestyle guidance, and pessaries, to surgical treatments. Additionally, surgical approaches have become increasingly diverse, encompassing vaginal, abdominal, laparoscopic, as well as robot-assisted techniques.12 With the growing emphasis on minimally invasive surgery in recent years, LSC and RSC received universal health insurance coverage in April 2016 and April 2020, respectively, in Japan. The following surgical procedures for POP are also covered by health insurance in Japan: total hysterectomy plus vaginal wall repair, central vaginal closure (LeFort colpocleisis), vaginal vault suspension, TVM, vaginal wall repair, Halban colporrhaphy, and Manchester repair. Since urinary incontinence often coexists with POP, urethral sling surgery is frequently performed for urinary incontinence in patients with POP. Health insurance in Japan covers urethral sling surgery for the treatment of urinary incontinence. Tracking such developments and transitions in surgical procedures is essential to understand the dissemination of surgical techniques.
In Japan, these surgeries are divided between the departments of gynecology and urology, making it difficult to track changes and the actual situation in surgical procedures for POP through studies conducted at individual facilities or by professional societies. Consequently, regional or institutional differences in surgical techniques may exist. It is imperative for policymakers to elucidate the current status of POP treatment on a nationwide scale, as it will contribute to the standardization of care.
Therefore, this study aimed to describe the nationwide proportion of physician consultations, surgical rates, and annual trends in surgical procedures using a large-scale health insurance claims database in Japan.
Materials and methods
Data source
This retrospective observational study was conducted using data retrieved from the DeSC database (DeSC Healthcare, Inc) between April 2014 and August 2024. This database comprises administrative claims data of 17,500,000 insured individuals across all age groups, including those aged 75 years and above. The specific composition of insurers in the database has been described previously.13 The DeSC database records the individual’s year and month of birth; annual health check-up data; diagnoses based on the International Classification of Diseases, Tenth Revision (ICD-10), and examinations and procedures based on the original Japanese codes; medical institutions that billed the procedure code; and the regional code for the individual’s insurer. The DeSC database has been shown to be representative of the overall population of Japan.14
Variables of interest
The variables of interest included a diagnosis of POP defined by ICD-10 codes for conditions such as hysterocele (N81.2–N81.4), cystocele (N81.1), rectocele (N81.6), enterocele (N81.5), vaginal prolapse (N99.3), and other or unspecified POP (N81.8–N81.9), as well as receipt of a pessary and the type of surgery performed. Surgical procedures were identified using the original Japanese surgical procedure classification codes. Surgical procedures included LSC, RSC with the endoscopic surgical support equipment code, total hysterectomy plus vaginal wall repair, central vaginal closure (LeFort colpocleisis), vaginal vault suspension (vaginal or abdominal approach and laparoscopic approach), TVM, other vaginal surgeries (vaginal wall repair only, Halban colporrhaphy, and Manchester repair), and urethral sling surgery. The initial surgery was defined as the first surgery performed after the diagnosis of POP, and surgeries performed from the following month onward were defined as second surgeries.
Comorbidities were selected based on the components of the Charlson Comorbidity Index.15 The component comorbidities present 1 year before and after the diagnosis of POP were extracted. The ICD-10 codes for each condition are enumerated in Supplementary Table S1. For urinary symptoms associated with POP, we determined whether any of the following diagnoses were assigned within 1 year before or after the diagnosis of POP: urinary incontinence (N393, N394), dysuria (R391), urinary retention (R33), and urinary frequency (R35).
Data on body mass index were extracted from health check-up results obtained within 1 year prior to the diagnosis of POP. For the surgical center, we extracted data on the number of hospital beds, facility type (clinic with beds or hospital), and whether the facility was a university hospital. Additionally, the department responsible for the surgery was identified. Facilities were categorized into small (≤399 beds) and large (≥400 beds) using the median category (400–499 beds) as the cutoff.
Statistical analysis
The proportion of patients diagnosed with POP among all women aged 40 years or above in the database (as the proportion of physician consultations) was calculated. Using the insured person registry, we identified the number of insured women aged 40 years or above in each region. Among women with POP aged 40 years or older, we calculated the proportion of patients who received pessary treatment and those who underwent at least one surgical intervention, using all patients with POP in this age group as the total population. The surgical rate was defined as the number of surgeries per 1000 person-years from diagnosis to the first surgery or end of follow-up, whichever occurred first. The pessary rate was defined as the number of pessary initiations per 1000 person-years from diagnosis to the first surgery, month of obtaining the first pessary insertion code, or end of follow-up, whichever occurred first. Additionally, for the first surgical intervention, we determined the proportion of each surgical procedure among all procedures performed in each year from 2014 to 2024 to examine the annual trends. Follow-up duration was defined as the number of months from the first surgery to the second surgery or censoring, including withdrawal from the database. The median follow-up time was estimated using the Kaplan–Meier method. Finally, a Sankey plot was generated to visualize the transitions from the types of initial surgery to the type of second surgery in patients who underwent reoperation.
To examine regional differences, the proportion of consultations in each region was calculated with respect to the number of individuals diagnosed with POP in that region. Similarly, the surgery and pessary rates per 1000 person-years were calculated for each region. Poisson regression was used to analyze the regional differences in the surgery and pessary rates. Regional differences in procedure selection were tested using chi-squared tests, followed by post hoc pairwise comparisons with Bonferroni correction. Additionally, the coefficient of variation (CV) and systematic component of variation (SCV) were calculated to quantify regional variability. In the calculation of the SCV, the standardized procedure selection rate was defined as the proportion of each specific procedure relative to the total number of POP surgeries performed in each region over the study period.
Ethics
This study was approved by the Institutional Review Board of the University of Tokyo (2021010NI, approved on April 23, 2021). The study was conducted in accordance with the principles of the Declaration of Helsinki. The need for informed consent was waived, since the study used anonymized secondary data.
Results
Patient demographics
Overall, 112,775 patients were diagnosed with POP during the study period. The patients’ characteristics are shown in Table 1. The mean age at diagnosis was 75.1 years, with 7.1% of patients being 40 to 64 years of age. The mean age at first surgery was 74.3 years, and 21.7% of patients who underwent surgery were aged 80 years or above.
Table 1.
Patients’ characteristics
| Overall | |
|---|---|
| N | 112,775 |
| Age at diagnosisa (y) | 75.1 (7.7) |
| 40–64 | 8054 (7.1%) |
| 65–74 | 36,574 (32.4%) |
| 75–79 | 38,592 (73.8%) |
| ≥80 | 29,555 (26.2%) |
| Age at first pessarya (y) | 75.6 (7.2) |
| 40–64 | 3635 (5.6%) |
| 65–74 | 21,153 (32.3%) |
| 75–79 | 22,649 (34.6%) |
| ≥80 | 18,010 (27.5%) |
| Age at first surgerya (y) | 74.3 (6.9) |
| 40–64 | 1171 (7.0%) |
| 65–74 | 6823 (40.7%) |
| 75–79 | 5126 (30.6%) |
| ≥80 | 3632 (21.7%) |
| BMIa | 23.6 (3.3) |
| Type of POP | |
| Hysterocele | 93,990 (83.3%) |
| Cystocele | 33,734 (29.9%) |
| Rectocele | 4797 (4.3%) |
| Vaginal prolapse | 903 (0.8%) |
| Other POP/unclassified | 14,095 (12.5%) |
| Symptoms | |
| Dysuria | 3182 (2.8%) |
| Urinary retention | 2616 (2.3%) |
| Frequent urination | 6835 (6.1%) |
| Urinary incontinence | 4682 (4.2%) |
| Residential area | |
| Hokkaido, Tohoku | 11,291 (10.0%) |
| South Kanto | 4861 (4.3%) |
| North Kanto, Koshin | 18,245 (16.2%) |
| Hokuriku | 4210 (3.7%) |
| Tokai | 31,957 (28.3%) |
| Kinki | 25,593 (22.7%) |
| Chugoku | 5205 (4.6%) |
| Shikoku | 7802 (6.9%) |
| Kyushu | 3611 (3.2%) |
| Urban/rural | |
| Rural | 62,633 (56.4%) |
| Urban | 48,322 (43.6%) |
| Comorbidities | |
| Myocardial infarction | 1714 (1.5%) |
| Congestive heart failure | 18,632 (16.5%) |
| Peripheral vascular disease | 14,498 (12.9%) |
| Cardiovascular disease | 20,226 (17.9%) |
| Dementia | 5730 (5.1%) |
| Chronic pulmonary disease | 41 (0.0%) |
| Connective tissue disease | 5054 (4.5%) |
| Peptic ulcer | 17,602 (15.6%) |
| Mild liver disease | 20,266 (18.0%) |
| DM with no complications | 3590 (3.2%) |
| DM with complications | 8060 (7.1%) |
| Hemiplegia or paraplegia | 695 (0.6%) |
| Renal disease | 4117 (3.7%) |
| Severe liver disease | 322 (0.3%) |
| Malignant solid tumor | 10,321 (9.2%) |
| Hematologic malignancy/lymphoma | 1125 (1.0%) |
| HIV/AIDS | 16 (0.0%) |
AIDS, acquired immunodeficiency syndrome; BMI, body mass index; DM, diabetes mellitus; HIV, human immunodeficiency virus; POP, pelvic organ prolapse.
Mean (standard deviation).
Nariai. Nationwide trends in physician consultation and surgical management for pelvic organ prolapse in Japan, 2014 to 2024. AJOG Glob Rep 2026.
Consultation and surgical procedure
Overall, 1.47% of women aged 40 years or above consulted for a POP diagnosis (112,775/7660,925; 95% confidence interval [CI]: 1.46%–1.48%). A total of 16,752 patients underwent surgery at least once, and 14.85% (16,752/112,775; 95% CI: 14.65%–15.06%) of patients with POP underwent surgery. The rate of surgery was 53.3 per 1000 person-years. Among women diagnosed with POP, 65,447 (58.0%) received at least one pessary treatment. The pessary rate was 821.8 per 1000 person-years. Among the patients who underwent surgery, 45.1% tried at least one pessary treatment before surgery. The median interval between the first pessary treatment and the first surgery was 8 months (interquartile range: 3–22).
Surgical procedure selection
The trends in initial surgery selection are shown in Figure 1. In 2014, hysterectomy with vaginal wall repair was the most common surgical procedure, followed by TVM. After the introduction of insurance coverage for LSC in 2016, the proportion of hysterectomy with vaginal wall repair and TVM declined. Furthermore, after RSC received health insurance coverage in 2020, the proportion of LSC declined gradually.
Figure 1.
Annual trends in the proportion of each surgical procedure relative to the total number of surgeries performed in that year
Halban, colporrhaphy and Manchester repair; LeFort, LeFort colpocleisis (central vaginal closure); LSC, laparoscopic sacrocolpopexy; RSC, robot-assisted sacrocolpopexy; suspension, vaginal vault suspension; TVM, transvaginal mechanical surgery; vaginal, other vaginal surgeries including vaginal wall repair.
Nariai. Nationwide trends in physician consultation and surgical management for pelvic organ prolapse in Japan, 2014 to 2024. AJOG Glob Rep 2026.
The patient and facility characteristics according to the first surgery are shown in Supplementary Table S2. In older patients, LeFort colpocleisis was performed more frequently compared with other surgical procedures. In addition, patients who underwent LeFort colpocleisis had a higher proportion of comorbidities, including cardiovascular disease and diabetes. Among the patients who underwent urethral sling surgery, a large proportion had urinary incontinence (67.0%). RSC was performed more frequently in large hospitals (78.5%). Vaginal procedures were more commonly performed in the obstetrics and gynecology department, whereas TVM and LSC were performed more often in the urology department (Supplementary Table S3). RSC was performed at similar rates in both the urology and obstetrics and gynecology departments. When stratified by the patients’ age group (40–64, 65–74, 75–79, and 80 years old), the frequency of LSC and RSC increased in all age groups, and their proportion was relatively higher in the younger age groups (Supplementary Figure S1).
Choice of second surgery
The median follow-up duration between the first and second surgeries was 27 months (interquartile range 12–48). Figure 2 depicts a Sankey plot of the transition in the choice of surgical procedure from the first to the second surgery. The most frequently performed second surgery was urethral sling surgery. Among patients who underwent LSC or TVM as the initial surgery, urethral sling placement was a common subsequent procedure. Among patients who underwent hysterectomy with vaginal repair as first surgery, LeFort colpocleisis was the most common second procedure.
Figure 2.
Sankey plot showing the transitions in surgical procedures from the first to second surgery among patients who underwent second surgery
Nariai. Nationwide trends in physician consultation and surgical management for pelvic organ prolapse in Japan, 2014 to 2024. AJOG Glob Rep 2026.
Regional characteristics of diagnosis and surgery
Table 2 shows the number of insured women aged 40 years and older by insurer region, number of patients with POP, proportion of consultations, and surgical and pessary rates per 1000 person-years. The chi-squared test revealed statistically significant regional differences in the proportion of consultations, surgeries, and pessary treatments (P<.001). Compared with South Kanto (incidence rate ratio [IRR]=1.00), the surgical rate was significantly lower in Hokkaido, Tohoku (IRR=0.54, 95% CI: 0.49–0.60, P<.001); North Kanto, Koshin (IRR=0.68, 95% CI: 0.62–0.74, P<.001); and Kinki (IRR=0.70, 95% CI: 0.65–0.76, P<.001) (Supplementary Table S4). The frequency of pessary use was significantly higher in Hokkaido, Tohoku, North Kanto, Hokuriku, and Chugoku, compared with South Kanto (Supplementary Table S5).
Table 2.
Consultation and surgical rates by residential area
| Number of insured women aged ≥40 y | Number of patients with POP (per number of total women aged ≥40 y) | Number of surgeries (per number of POP patients) | Number of pessary initiations (per number of POP patients) | Surgical rate (per 1000 person-y) | Pessary rate (per 1000 person-y) | ||||
|---|---|---|---|---|---|---|---|---|---|
| P value | <.001a | <.001a | <.001a | <.001b | <.001b | ||||
| Hokkaido, Tohoku | 669,907 | 11,291 | (1.7%) | 1004 | (8.9%) | 6969 | (61.7%) | 32.73 | 564.63 |
| South Kanto | 606,950 | 4861 | (0.8%) | 706 | (14.5%) | 2692 | (55.4%) | 60.39 | 470.32 |
| North Kanto, Koshin | 1164,658 | 18,245 | (1.6%) | 1938 | (10.6%) | 12,348 | (67.7%) | 41.02 | 796.23 |
| Hokuriku | 366,535 | 4210 | (1.1%) | 518 | (12.3%) | 2317 | (55.0%) | 64.14 | 598.53 |
| Tokai | 2198,579 | 31,957 | (1.5%) | 5986 | (18.7%) | 17,082 | (53.5%) | 62.48 | 369.90 |
| Kinki | 1339,263 | 25,593 | (1.9%) | 3386 | (13.2%) | 15,072 | (58.9%) | 42.56 | 446.95 |
| Chugoku | 498,705 | 5205 | (1.0%) | 916 | (17.6%) | 2900 | (55.7%) | 92.51 | 622.63 |
| Shikoku | 571,901 | 7802 | (1.4%) | 1544 | (19.8%) | 3999 | (51.3%) | 79.18 | 408.72 |
| Kyushu | 244,427 | 3611 | (1.4%) | 754 | (20.9%) | 2068 | (57.3%) | 62.85 | 430.41 |
Chi-squared test
Poisson’s regression analysis.
Nariai. Nationwide trends in physician consultation and surgical management for pelvic organ prolapse in Japan, 2014 to 2024. AJOG Glob Rep 2026.
The overall chi-squared test revealed a significant difference in the selection of surgical procedures based on the patients’ residential region. Subsequent post hoc pairwise comparisons with Bonferroni correction among all regional combinations showed that each pairwise comparison was statistically significant (adjusted P<.05; Table 3). The analysis of regional variation revealed that the CV for each surgical procedure was the highest for vaginal vault suspension (CV=0.45) and RSC (CV=0.44). Similarly, the SCV indicated regional differences between vaginal vault suspension (SCV=31.41) and RSC (SCV=98.87). Additionally, between urban and rural areas, LeFort colpocleisis and urethral sling surgery exhibited a relatively high SCV, implying that the selection rates differed between urban and rural regions (Supplementary Table S6).
Table 3.
Proportions of procedure selection by residential area and variation statistics
| Residential area |
|||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Hokkaido, Tohoku | South Kanto | North Kanto, Koshin | Hokuriku | Tokai | Kinki | Chugoku | Shikoku | Kyushu | Total | CV | SCV | ||||
| LSC | 81 (8.1%) | 149 (21.1%) | 439 (22.7%) | 106 (20.5%) | 1633 (27.3%) | 285 (8.4%) | 133 (14.5%) | 236 (15.3%) | 166 (22.0%) | 3228 (19.3%) | 0.29 | 11.06 | |||
| RSC | 47 (4.7%) | 33 (4.7%) | 179 (9.2%) | 62 (12.0%) | 238 (4.0%) | 145 (4.3%) | 29 (3.2%) | 151 (9.8%) | 36 (4.8%) | 920 (5.5%) | 0.44 | 31.41 | |||
| Hysterectomy plus vaginal wall repair | 334 (33.3%) | 254 (36.0%) | 593 (30.6%) | 187 (36.1%) | 1753 (29.3%) | 1067 (31.5%) | 582 (63.5%) | 626 (40.5%) | 333 (44.2%) | 5729 (34.2%) | 0.28 | 10.00 | |||
| LeFort colpocleisis | 161 (16.0%) | 24 (3.4%) | 178 (9.2%) | 67 (12.9%) | 475 (7.9%) | 469 (13.9%) | 27 (3.0%) | 184 (11.9%) | 100 (13.3%) | 1685 (10.1%) | 0.28 | 18.91 | |||
| Vaginal vault suspension | 39 (3.9%) | 16 (2.3%) | 33 (1.7%) | 7 (1.4%) | 9 (0.2%) | 79 (2.3%) | 2 (0.2%) | 7 (0.5%) | 7 (0.9%) | 199 (1.2%) | 0.45 | 98.87 | |||
| Other vaginal surgeriesa | 155 (15.4%) | 112 (15.9%) | 265 (13.7%) | 37 (7.1%) | 321 (5.4%) | 361 (10.7%) | 44 (4.8%) | 103 (6.7%) | 53 (7.0%) | 1451 (8.7%) | 0.38 | 23.92 | |||
| TVM | 161 (16.0%) | 93 (13.2%) | 198 (10.2%) | 41 (7.9%) | 1423 (23.8%) | 912 (26.9%) | 92 (10.0%) | 211 (13.7%) | 48 (6.4%) | 3179 (19.0%) | 0.28 | 18.35 | |||
| Urethral sling surgery | 26 (2.6%) | 25 (3.5%) | 53 (2.7%) | 11 (2.1%) | 134 (2.2%) | 68 (2.0%) | 7 (0.8%) | 26 (1.7%) | 11 (1.5%) | 361 (2.2%) | 0.22 | 11.99 | |||
| Total | 1004 (100%) | 706 (100%) | 1938 (100%) | 518 (100%) | 5986 (100%) | 3386 (100%) | 916 (100%) | 1544 (100%) | 754 (100%) | 16,752 (100%) | |||||
CV=SD (proportion of surgery i)/mean (proportion of surgery i). SCV=1/k (∑(Oi–Ei)2/Ei2–∑1/Ei) × 100, where k is number of regions, Oi is observed number of surgery “i,” and Ei is the expected number of surgery “i” determined by the standardized procedure selection rate defined as the proportion of each specific procedure relative to the total number of surgeries over the study period.
CV, coefficient of variation; LSC, laparoscopic sacrocolpopexy; RSC, robot-assisted sacrocolpopexy; SCV, systematic component of variation; TVM, transvaginal mesh surgery.
Vaginal wall repair only, Halban colporrhaphy, and Manchester repair.
Nariai. Nationwide trends in physician consultation and surgical management for pelvic organ prolapse in Japan, 2014 to 2024. AJOG Glob Rep 2026.
Comments
Principal findings
The proportion of consultations for POP was estimated at 1.47%. A total of 16,752 (14.9%) patients with POP underwent surgery at least once. The surgical rate was 53.3 per 1000 person-years. The proportions of traditional hysterectomy and TVM declined, whereas those of LSC and RSC increased after the introduction of health insurance coverage. The most frequently performed second surgery was urethral sling surgery. Regional differences were observed in the proportion of consultations and surgical rates. The proportion of procedures chosen as the initial surgery differed across regions.
Results in the context of what is known
In our study, the proportion of consultations (1.47%) was lower than the estimated prevalence.6,7,16,17 Similarly, a study based on the Korean National Health Insurance database reported that the estimated diagnosis rate per the total female population was 0.07%.18 Several factors may explain the substantially lower proportion of patients receiving medical care compared with the estimated prevalence. First, some diagnostic codes may have been missing from the health insurance claims database. When no treatment is provided, the diagnostic code is often missing even if the condition is identified.19 Second, asymptomatic patients or patients who do not recognize their symptoms as being caused by POP may be less likely to seek medical consultation, resulting in underestimation. Third, the diagnosis may be missed if the physician lacks knowledge of POP. Finally, individuals may not seek medical care because of embarrassment or lack of knowledge about the condition.
In our study, the mean age of patients diagnosed with POP was 75.1 years. Compared with the mean age of patients with POP in recent claims database-based reports (63.9 years),18 our cohort comprised a substantially older population. Nevertheless, similar to previous studies,6,17 a subset of younger patients (aged <65 years) with POP was represented in our cohort. In addition, the mean age at the first POP surgery was 74.3 years, suggesting that older patients received surgery compared with the mean ages at surgery documented in prior studies.18,20,21
Previous research has shown regional variations in healthcare expenditure, which were ascribed to population structure, medical resources, and economic disparities.22,23 Differences in lifestyle habits across regions, such as parity, exercise habits, and occupations involving increased intra-abdominal pressure, may be associated with POP24; therefore, the possibility that the prevalence of POP varies by region cannot be eliminated. In this study, we also found regional differences in the choice of surgical technique for POP. Highly difficult procedures, such as RSC and LSC, accounted for roughly similar proportions of all surgeries in both urban and rural areas, indicating that these techniques are generally accessible. Nonetheless, RSC exhibited a higher CV and SCV, suggesting heterogeneous adoption of this technique across regions. These differences may arise from patient factors, such as later consultation for advanced POP, comorbidities, or older age at diagnosis, and the local availability of specialized referral hospitals. It is also possible that differences in the roles of the urology and gynecology departments in performing each technique contributed to these regional disparities, particularly given that the CV and SCV between the urology and gynecology departments were relatively high for LSC.
This study reported the annual trends in the initial surgical procedures. In recent years, a trend toward less invasive surgery for POP has emerged in Japan. The decline in TVM procedures commenced with the introduction of insurance coverage for LSC in 2016, suggesting that the change in case numbers may have been influenced more by the development of alternative surgical techniques rather than the FDA warning. Urethral sling surgery remained the most common choice for second surgery. Although this claims database-based analysis could not determine the indication for second surgery, namely whether it was performed for recurrent POP, persistent symptoms, or de novo POP of a different anatomical compartment, the results suggested that urethral sling surgery continues to fulfill certain needs as second surgery in Japan. The indication of second surgery may include repair of DeLancey level 3 defects25 that cannot be improved by other procedures or persistent voiding symptoms that failed to improve after the initial surgery.
Clinical implications
The treatment rates observed in this study were lower than the estimated prevalence of POP reported in previous studies, suggesting that POP may be undiagnosed in patients in Japan. The proportion of advanced techniques such as sacrocolpopexy has increased concurrently with health insurance coverage, suggesting that insurance approval has facilitated widespread application of these procedures. Regional differences in procedure selection and surgical rates suggest that the same patient may receive different treatments depending on the geographic location of the surgical center. Hence, healthcare providers and policymakers should be aware of the current status of POP diagnosis and treatment observed in this study. They may need to consider revising surgical reimbursements or the distribution of medical specialties to improve POP care.
Research implications
Databases containing more granular data are required to facilitate a more detailed examination of the regional differences in POP consultation proportions and surgical rates. These data include disease severity, diagnostic context, and region-specific lifestyle factors. Furthermore, the observed variations in surgical rates and procedure selection across regions can be attributed to the presence and distribution of referral hospitals as well as the availability of urology, obstetrics, and gynecology surgeons within each region. Consequently, further research incorporating a database on hospital structural characteristics is necessary.
Strength and limitations
To the best of our knowledge, this is the first study to provide a detailed nationwide description of the proportion of consultations and surgical rates for POP and trends in surgical choices in Japan. The use of the DeSC database enabled the hitherto cumbersome acquisition of nationwide statistics due to fragmentation among academic societies and the division of surgical procedures between urology and gynecology.
This study has some limitations. The DeSC database includes information from several insurers and has been shown to represent Japan’s overall population.14 However, because some insurers, including employment-based health insurance, are not a part of the DeSC, it may not accurately capture the entire nationwide situation. Additionally, differences in the reimbursement structure by insurance type may have biased the results. Second, the accuracy of the POP diagnosis in this database has not been validated; therefore, misclassification and underestimation of the proportion of patients receiving treatment are possible. Third, since the accuracy of the surgical codes has also not been validated in previous studies, misclassification of surgical procedures is possible. Additionally, the claims database does not document conservative treatment modalities such as pelvic floor physical therapy, as these treatments do not have relevant claims coding. Consequently, it is possible that other forms of physical therapy and noninsurance–covered treatment strategies may introduce bias in patient decision-making regarding surgery and choice of surgical procedure. Fourth, the POP stage or symptom severity is not adequately captured by claims databases, indicating the need for alternative methods of assessment. Consequently, further research is necessary to compare disease severity and surgical management options. However, it is assumed that patients who underwent surgery were highly likely to be symptomatic. Finally, because the DeSC database is based on insurance records, if a patient leaves their insurer, their observation period may be shorter, and the first surgery recorded in the database may not always be the patient’s first surgery. These should be considered as inherent limitations of the database.
Conclusions
We used a nationwide database to provide a detailed description of the proportions of consultations and trends in POP surgery in Japan. The proportion of consultations was 1.47%, which is lower than the prevalence rates reported in other countries, suggesting that a substantial number of patients with latent POP did not seek medical attention or remained undiagnosed. The proportion of consultations varied by the region of residency, suggesting potential regional disparities in diagnosis, medical access, and awareness of POP within Japan. In recent years, trends toward less invasive procedures have emerged, with a rise in the proportions of LSC and RSC, while those of hysterectomy and TVM have relatively decreased. These findings provide crucial data to support patient education initiatives for POP in Japan and address regional disparities in insurance-covered medical care.
AJOG Global Reports at a Glance.
Why was this study conducted?
Previous nationwide descriptive studies on pelvic organ prolapse demonstrated the treatment trends but failed to detail regional differences in procedure selection or second surgery choice.
Key findings
Overall, 1.47% women aged ≥40 years received consultation for pelvic organ prolapse between 2014 and 2024 (surgery rate, 53.3 per 1000 person-years). Following insurance coverage, traditional hysterectomy and transvaginal mesh surgery rates decreased, whereas laparoscopic- and robot-assisted sacrocolpopexy rates increased. Urethral sling surgery predominated as second surgery. Surgical procedure selection and surgical rate varied by region.
What does this add to what is known?
As in Western countries, transvaginal mesh surgery application decreased, while minimally invasive surgery became more widespread in Japan. Surgical procedure diversification engendered regional differences in procedure selection.
CRediT authorship contribution statement
Maika Nariai: Writing – original draft, Visualization, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Osamu Wada-Hiraike: Writing – review & editing, Supervision, Project administration, Funding acquisition. Yusuke Sasabuchi: Writing – review & editing, Supervision, Software, Resources, Project administration, Methodology, Formal analysis, Data curation. Hideo Yasunaga: Writing – review & editing, Supervision, Resources, Methodology, Funding acquisition, Data curation. Miyuki Harada: Writing – review & editing, Supervision. Yasushi Hirota: Writing – review & editing, Supervision.
Acknowledgments
We would like to thank Editage (www.editage.com) for English language editing.
Glossary
- Halban colporrhaphy
Anterior vaginal wall repair.
- ICD-10
International Classification of Diseases 10th Revision, a standardized coding system for diagnoses and health conditions.
- LeFort colpocleisis
Central vaginal closure, a surgical procedure in which the vaginal canal is closed centrally, typically in women who are no longer sexually active.
- LSC
Laparoscopic sacrocolpopexy, a surgical procedure in which the vaginal apex or uterine cervix is fixed to the sacrum using mesh via laparoscopy.
- Manchester repair
Cervical amputation with uterine suspension, typically in women who wish to preserve uterus.
- POP
Pelvic organ prolapse, descent or protruding of pelvic organs (bladder, uterus, rectum, etc.) into the vaginal canal due to weakness of the pelvic floor.
- RSC
Robot-assisted sacrocolpopexy, a robot-assisted laparoscopic procedure in which the vaginal apex or uterine cervix is fixed to the sacrum using mesh.
- TVM
Transvaginal mesh surgery, a surgical technique using mesh inserted through the vagina to support pelvic organs.
- Urethral sling surgery
A procedure in which a synthetic or biological sling is placed under the urethra to treat stress urinary incontinence.
- Vaginal vault suspension
Sometimes called native tissue repair (NTR), a surgical procedure in which vaginal apex is elevated after hysterectomy without using mesh, for example, suturing to the uterosacral ligament.
Footnotes
Funding: This work was supported by a grant from the Ministry of Health, Labour and Welfare, Japan (23AA2003 and 24FB1001), and Mochida Pharmaceutical Company. The funding sources had no role in the study design, data collection, analysis, reporting, or the decision to submit this article.
Tweetable statement: Japan’s first national study on pelvic organ prolapse found a drop in transvaginal mesh repair and hysterectomy, with rising sacrocolpopexy. Despite spread to rural areas, procedure selection varies by region.
Conflicts of interest: H.Y. reports an institutional grant from the Ministry of Health, Labour and Welfare, Japan (23AA2003). Y.S. reports all support for the present manuscript from DeSC Healthcare, Inc. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
Data availability: The data underlying this article were provided by DeSC Healthcare, Inc under license. Data will be shared on request to the corresponding author with permission of DeSC Healthcare, Inc.
Supplementary material associated with this article can be found, in the online version at doi:10.1016/j.xagr.2026.100613.
Appendix. Supplementary materials
Figure S1. Annual trends in the proportion of each surgical procedure stratified by age group. (A) 40 to 64 years old at the first surgery; (B) 65 to 74 years old at the first surgery; (C) 75 to 79 years old at the first surgery; (D) 80 years or older at the first surgery.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1. Annual trends in the proportion of each surgical procedure stratified by age group. (A) 40 to 64 years old at the first surgery; (B) 65 to 74 years old at the first surgery; (C) 75 to 79 years old at the first surgery; (D) 80 years or older at the first surgery.