The aim of our study was to examine how apical prolapse is surgically managed in Flanders.

An online questionnaire using Qualtrics was sent to all Gynaecologists practicing in Flanders, Belgium. If the participant indicated never to perform any Urogynaecological surgery, the survey was stopped immediately. Furthermore, we examined whether the results obtained were comparable with the regional collected data (MZG Database) on ICD10-diagnosis (International Classification of Diseases 10th revision) and performed procedure at the time of hospitalization. MZG (Minimal Hospital Data) is the obligated registration for all non-psychiatric hospitals in Belgium on their administrative, medical, and nursing data to the federal public service.

Response rate was 25.7%, 140 out of 545 questionnaires were collected. 72.1% of the respondents were female. Mean age and years of expertise were 45 (SD 10.1) and 20 (SD 10.0) respectively. Only 66 (47.1%) of the participants performs pelvic floor surgery, with mean 51 surgeries annually. Of the overall group, 18 (12.9%) had done Urogynaecology subspecialty training. Respectively 36 (25.7%) and 34 (64.2%) participants were working in a tertiary center and discussed patients in a multidisciplinary meeting preoperatively. Table 1 and 2 reflect the variety of surgical techniques used.
Sacrospinous fixation (SSF) is performed by 34 (51.5%) participants. Of those performing SSF, 17 (50.0%) use an open technique, while 8 (23.5%) use I-Stitch. Respectively 6 (17.6%), 5 (14.7%) and 4 (11.8%) participants use Capio, Miya Hook and Anchorsure. Another device is used by 5 (14.7%) respondents. Most surgeons (19, 55.9%) places two stitches on the sacrospinous ligament the remainder 15 (44.1%) utilize one stitch on the sacrospinous ligament. Non-absorbable, delayed absorbable, absorbable and the combination of an absorbable with a non-absorbable suture was used by 16 (47.1%), 11 (32.4%), 5 (14.7%) and 2 (5.9%) participants respectively. Most participants use a suture size 1 (19, 55.9%), followed by size 0 (11, 32.4%) and 2-0 (4, 11.8%). 
Uterosacral ligament suspension (USL) was only used by less than a fourth (16, 24.2%). Most surgeons (8, 50%) utilize absorbable sutures, while 4 (25%) use delayed absorbable sutures. Non-absorbable and the combination of a non-absorbable with an absorbable suture is used by 2 (12.5%) and 2 (12.5%) respectively. Suture size 0, 1 and 2-0 was used by 3 (18.8%), 12 (75%) and 1 (6.2%) participant respectively.
Sacral colpopexy (SCP) is practiced by 24 (36.4%) participants. Promontofixation is performed by a non-absorbable tacker by 12 (50%) participants. Of the surgeons performing SCP, 11 (45.8%), 9 (37.5%), 7 (29.2%) and 6 (25.0%) uses non-absorbable sutures, combination of non-absorbable and absorbable sutures, delayed absorbable and absorbable sutures, respectively. Suture size 0, 1 and 2-0 was used by 7 (29.2%), 11 (45.8%) and 6 (25.0%) participants, respectively.
Mean confidence score on “How confident are you about your answers” regarding surgical technique and suture choice was 7.4/10. Respectively 31.5%, 41.6%, 10.7%, 3.6% and 12.6% stated that their answer was based on their own experience, education, hospital regulations, local guidelines, and research. The choice of surgical technique was chosen by the surgeon and the patient in 79.2% and 20.8% respectively. The MZG showed no data on the different surgical techniques, nor the correlation between the ICD10-diagnosis and the performed surgery.

Apical compartment pelvic floor disorders are common and may require a multidisciplinary team approach for evaluation and management. Apical prolapse can be managed with a variety of different surgical techniques. However, the level of evidence behind those different techniques is variable. 
Practice variation (PV) is an important target for clinical systems improvement. Although some variation in clinical practice is justified, unwarranted variation that is not explained based on illness, patient risk factors or patient preferences, is common. This can lead to underuse of effective care, overuse of non-beneficial services, and emphasis on physician opinions rather than patient preferences. Unwarranted variation has been linked to suboptimal outcomes and to inefficient care [1]. Currently, no local guidelines exist regarding the surgical management of apical prolapse.
Our study showed a wide range in practice variation in Flanders regarding the surgical management of apical prolapse. Although Urogynaecology is not a recognized subspecialty in Belgium, most Gynaecologists in this survey did not treat Urogynaecological patients. Decision about surgical technique should be a clinician guided joined process.
The regional MZG lacks in sufficient data collection and should be optimized.

Implementation of international clinical guidelines might be recommended to ameliorate patient care and surgical outcomes. The need for Urogynaecological subspecialty training in Belgium might be considered.

Cook, D.A., et al., Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS One, 2018. 13(1): p. e0191943.