Complications following surgical intervention for stress urinary incontinence: A national perspective

In-hospital complications of bilateral salpingo-oophorectomy at benign hysterectomy: a population-based cohort study

OBJECTIVE

The study compared the in-hospital complications and related outcomes between women who underwent bilateral salpingo-oophorectomy at hysterectomy for benign diseases and those who had hysterectomy only.

METHODS

We conducted a population-based, retrospective cohort study using data from Taiwan's National Health Insurance program. Women who underwent concurrent bilateral salpingo-oophorectomy at hysterectomy for benign indications (n = 34,509) were compared with those who had hysterectomy only (n = 176,305). Separate models were estimated to account for the effect of baseline comorbid condition, age, and hysterectomy approach on the relationship between bilateral salpingo-oophorectomy and study outcomes. A secondary analysis was also performed to evaluate the association of inpatient readmission within 30 days and complications among women who underwent bilateral salpingo-oophorectomy.

RESULTS

The addition of a bilateral salpingo-oophorectomy to hysterectomy was associated with a lower risk of surgical complications, a longer length of hospital stay, and an increased risk of inpatient readmission within 30 days. Among women who underwent bilateral salpingo-oophorectomy, women with complications were also more likely to require inpatient readmission within 30 days than those without complications. Our data also suggested that bilateral salpingo-oophorectomy was not associated with an overall risk of medical complications, with the exception of urethral obstruction. The relationships remained even after adjustments by age, surgical indications, hysterectomy approach, and health-related risk factors, such as baseline comorbid condition and status of any prior catastrophic illness.

CONCLUSIONS

Bilateral salpingo-oophorectomy at hysterectomy for benign conditions is not associated with an increased risk of in-hospital complications.

In-hospital complications of vaginal versus laparoscopic-assisted benign hysterectomy among older women: a propensity score-matched cohort study

OBJECTIVE

This investigation compared the outcomes of vaginal and laparoscopic hysterectomies for nonprolapsed benign indications in older women.

METHODS

We conducted a population-based, retrospective propensity score-matched cohort study using data from the Taiwan's National Health Insurance program. Women who were aged 65 years or older with vaginal hysterectomy (n = 290) were compared with women who had laparoscopic hysterectomy for nonprolapsed benign indications (n = 290). Propensity score was calculated based on both patient- (age, socioeconomic status, residential urbanicity, comorbidity, status of any prior catastrophic illness, surgical diagnosis, and year of hysterectomy) and provider-related characteristics (physician's age and sex, hospital accreditation level, and ownership type).

RESULTS

Women undergoing laparoscopic hysterectomy were not associated with increased risk of inpatient readmission within 30 days, in-hospital mortality, and in-hospital (including intraoperative) complications when compared with those who had vaginal hysterectomy. Women in the laparoscopic group had significantly shorter hospital stays than those in the vaginal group. The bleeding complications were mostly due to blood transfusion (2.1% in vaginal and 0.7% in laparoscopic hysterectomy groups) and urinary tract infection (1.0% in vaginal and 1.7% in laparoscopic hysterectomy groups). The surgical injury (intraoperative) complications included mostly surgical laceration of the urinary tract (0.7% in vaginal and 0.3% in laparoscopic hysterectomy groups).

CONCLUSIONS

Advanced age alone should not be the limiting factor for surgical referral of laparoscopic hysterectomy. The shorter hospital stay and low in-hospital complications associated with laparoscopic, as opposed to vaginal hysterectomies, are important attributes of a surgical procedure essential to the postoperative care in older women aged 65 years or more.

Mini Sling (Ophira) versus Pubovaginal Sling for Treatment of Stress Urinary Incontinence: A Medium-term Follow-up

To compare two different procedures, mid-urethral mini sling (Ophira) and autologous rectus fascia sling, according to their medium-term subjective and objective outcome and satisfaction rates in the treatment of stress urinary incontinence in women. One hundred women with the main complaint of stress urinary incontinence were randomized to be treated with either mini sling (Ophira) or autologous rectus facia pubovaginal sling. Preoperative evaluation consisted of: physical examination, blood biochemistry urine analysis and culture, urinary tract ultrasound scan, conventional multi-channel urodynamic study, cystourethroscopy, cough induced stress test and Incontinence Impact Questionnaire (IIQ). The patients were objectively and subjectively re-evaluated at 1, 3, 6 and 12 postoperative months and the last visit and the collected data of more than one year follow-up were compared with preoperative assessments. Seventy two out of one hundred patients were followed for a mean time of 13.8±4.4 months (12-20 months range). Objective cure rate, according to cough-induced stress test was recorded in 88.6% and 89.2% of the mini sling (Ophira) and the rectus facia sling group respectively (P=1.0). Postoperative mean IIQ score decreased to 42.7±11.4 and 50.2±11.1 in the mini sling (Ophira) group versus rectus facia pubovaginal sling (P=0.007). Twenty eight (80%) and 23 (67%) patients in the mini sling (Ophira) and rectus facia pubovaginal sling were satisfied with the operation (P=0.23). There is no significant difference between the mini sling (Ophira) and autologous rectus fascia sling procedure in the treatment of stress urinary incontinence at medium-term follow-up.

Comparison between complication rates of laser prostatectomy electrocautery transurethral resection of the prostate: A population-based study

INTRODUCTION

We compare the complication rates and length of stay (LOS) of laser transurethral resection of the prostate (L-TURP) versus electrocautery transurethral resection of the prostate (E-TURP) in a population-based cohort. L-TURP has shown enhanced intraoperative safety and equivalent efficacy relative to E-TURP in several high volume centres.

METHODS

Relying on the Florida Datafile as part of the Healthcare Cost and Utilization Project State Inpatient Databases (SID) between 2006 and 2008, we identified 8066 men with benign prostate hyperplasia who underwent L-TURP or E-TURP. Chi-square and Mann-Whitney tests were used to compare baseline characteristics. A multivariable linear regression model was used to analyze the effect of L-TURP versus E-TURP on complication rates and LOS.

RESULTS

Overall complication rates did not differ significantly for L-TURP compared to E-TURP in univariable (8.8 vs. 7.4%, p = 0.1) and multivariable analyses (odds ratio [OR]: 1.06, confidence interval [CI]: 0.85-1.32, p = 0.6). Individuals undergoing E-TURP were less likely to experience a LOS in excess of 1 day (46.2 vs. 59.7%, p < 0.001). A lower risk to experience a LOS in excess of 1 day was confirmed for patients undergoing L-TURP after a multivariable linear regression model (OR: 0.37, CI: 0.23-0.58, p < 0.001), but not for a LOS in excess of 2 days (OR: 0.96, CI: 0.83-1.10, p = 0.2).

CONCLUSIONS

Patient characteristics and perioperative safety were similar for L-TURP and E-TURP patients. However, LOS patterns demonstrated a modest benefit for L-TURP compared to E-TURP patients.

Demands and properties of alloplastic implants for the treatment of stress urinary incontinence

Surgical treatment of stress urinary incontinence changed dramatically with the introduction of the tension-free vaginal tape. Owing to its high efficacy and minimal patient discomfort this new minimally invasive procedure quickly obtained widespread acceptance and superseded the abdominal colposuspension as the gold standard. In the course of success of the original method a number of tension-free vaginal tapes flooded the market, varying in approach and material. These variations may strongly influence the safety, efficacy and long-term results of tension-free vaginal tape and its major modification, the transobturator technique. Therefore, it is the aim of this review to closely illuminate available materials and complications associated with this procedure. An extensive Medline search of the published literature up until 2006 on the subject of stress urinary incontinence was carried out. All sources identified were reviewed with particular attention to the method applied, the properties of the mesh materials and clinical complications. Apart from several technical variations, there are marked differences between the different vaginal sling materials, ranging from absorbable collagens over polypropylene to allografts. Although performed globally in substantial and increasing numbers, minimally invasive techniques for the surgical treatment of stress urinary incontinence are lacking sufficient safety data.

Trends in inpatient urinary incontinence surgery in the USA, 1998-2007

INTRODUCTION AND HYPOTHESIS

This study was conducted to assess national rates in stress urinary incontinence (SUI) surgery in the USA from 1998 to 2007.

METHODS

We utilized the 1998-2007 Nationwide Inpatient Sample and assessed women aged 20 years and older who underwent SUI surgery based on the International Classification of Diseases, 9th Revision (ICD-9) procedure and diagnosis codes.

RESULTS

The total number of SUI surgeries performed during this 10-year period was 759,821. The annual number of procedures increased from 37,953 in 1998 to 94,910 in 2007. The type of SUI surgery performed also changed (p < 0.001). In 1998, retropubic suspensions represented 52.3%, decreasing to 13.8% in 2007. "Other repair of SUI" (ICD-9 59.79) comprised 22.4% in 1998, increasing to 75.2% in 2007, likely representing midurethral slings.

CONCLUSIONS

The total number and incidence rates of SUI surgeries have increased from 1998 to 2007. The type of SUI surgery performed has also changed significantly, likely secondary to adoption of midurethral slings.

Impact of surgeon training on outcomes after resective hepatic surgery

BACKGROUND

Higher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon's volume and training had on the outcomes after hepatic resection.

METHODS

Administrative procedure codes were used to identify all adult patients from the fiscal year 1991-1992 to 2003-2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications.

RESULTS

There were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient's sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications.

CONCLUSIONS

This study found surgeon training to be highly predictive of postoperative complications after hepatic resection.

Stress urinary incontinence in women: what options lie between traditional therapies and surgery?

Stress urinary incontinence affects women of all ages, becoming more prevalent with increasing age. While many nonsurgical therapies are available for the treatment of stress urinary incontinence, options are limited for women who fail to respond to these therapies yet may not be candidates for, or wish to avoid, surgery. This limitation prompted efforts to develop less-invasive procedures for treating stress urinary incontinence patients, including bulking-agent injections and a new transurethral, radiofrequency collagen-denaturation system. This new treatment (Renessa((R))) reduces tissue compliance without necrosis or stricture, thus differentiating it from a surgical radiofrequency treatment, transvaginal radiofrequency tissue ablation. The advent of new treatment options for stress urinary incontinence allows physicians to offer their patients a broader choice of treatment options, underscoring the importance of educating patients regarding all available therapies, including success rates and risk for complications. This is particularly important for women who have not responded to prior treatment strategies.

The Role of Preoperative Testing on Outcomes After Sling Surgery for Stress Urinary Incontinence

PURPOSE

In this study we analyzed Medicare claims data to measure the effect of preoperative urodynamics and cystoscopy on outcomes after sling surgery.

MATERIALS AND METHODS

We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of beneficiaries. Women who underwent sling procedures between July 1, 1999 and December 31, 2000 were identified on the basis of the presence of CPT-4 code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify type of preoperative studies performed (urodynamics and cystoscopy) and for 12 months after surgery to assess short-term complications.

RESULTS

Of 1,356 subjects 24.8% underwent preoperative cystoscopy and 27.4% underwent preoperative urodynamic testing. In postoperative year 1, 32.4% of subjects underwent cystoscopy and 30.5% underwent urodynamics. Patients who underwent preoperative urodynamics were more likely to be newly diagnosed with urge incontinence after surgery (21.9% vs 12.7%, p <0.0001). Those who underwent preoperative cystoscopy were significantly more likely to be diagnosed with (9.4% vs 6.1%, p <0.043) or treated for (10.6% vs 7.2%, p <0.047) outlet obstruction postoperatively than those who did not. Multivariate analysis revealed that subjects who underwent preoperative urodynamics were significantly less likely to undergo postoperative urodynamics than those who did not (OR 0.34, 95% CI 0.24-0.48).

CONCLUSIONS

Our findings of worse outcomes among women who underwent preoperative testing may be due in part to case selection. Our finding that women who underwent preoperative urodynamics were only a third as likely to undergo postoperative urodynamics as those who did not supports the use of urodynamics in the preoperative setting. However, the true effect of urodynamics on sling outcomes remains controversial.

Variations in stress incontinence and prolapse management by surgeon specialty

PURPOSE

Numerous studies have documented a relationship between provider specialty and outcomes for surgical procedures. In this study we sought to determine the effect of surgeon specialty on outcomes of sling surgery for women with stress urinary incontinence.

MATERIALS AND METHODS

We analyzed the 1999 to 2001 Medicare claims data from a 5% national random sample of Medicare beneficiaries. Women 65 years or older who underwent a sling procedure between July 1, 1999 and December 31, 2000 were identified on the basis of CPT-4 codes and tracked for 12 months. Key complications were identified using CPT-4 and ICD-9 revision codes for relevant procedures and diagnoses. Outcomes were compared between urologists and gynecologists.

RESULTS

A total of 1,356 sling procedures were performed. Of them 1,063 (78.4%) were performed by urologists, while 246 (18.1%) were performed by gynecologists. Urologists performed concomitant prolapse repairs in 29.1% of cases, and gynecologists performed prolapse repairs in 55.7% (p <0.0001). In the 12 months following sling surgery, urologists were more likely than gynecologists to perform a repeat incontinence procedure (9.3% vs 4.9%, p = 0.024) and prolapse repair (26.0% vs 12.2%, p <0.0001). The 2 surgical specialties did not differ in postoperative outlet obstruction, urological complications, or nonurological complications.

CONCLUSIONS

Early prolapse management by gynecologists corresponded to fewer prolapse repairs in the year following the sling. Our findings suggest that gynecologists are more likely to identify and manage prolapse at the time of the evaluation of urinary incontinence, a strategy that appears to avoid the morbidity and cost of repeat surgery.

Predictors of Clostridium difficile colitis infections in hospitals

Hospital-level predictors of high rates of 'Clostridium difficile-associated disease' (CDAD) were evaluated in over 2300 hospitals across California, Arizona, and Minnesota. American Hospital Association data were used to determine hospital characteristics associated with high rates of CDAD. Significant correlations were found between hospital rates of CDAD, common infections and other identified pathogens. Hospitals in urban areas had higher average rates of CDAD; yet, irrespective of geographic location, hospital rates of CDAD were associated with other infections. In addition, hospitals with 'high CDAD' rates had slower turnover of beds and were more likely to offer transplant services. These results reveal large differences in rates of CDAD across regions. Hospitals with high rates of CDAD have high rates of other common infections, suggesting a need for broad infection control policies.

Is Burch colposuspension ever cost-effective compared with tension-free vaginal tape for stress incontinence?

OBJECTIVE

This study was undertaken to evaluate the cost-effectiveness of Burch colposuspension compared with tension-free vaginal tape.

STUDY DESIGN

A Markov decision model was developed to compare costs (2005 US dollars) and effectiveness (quality-adjusted life years) of Burch and tension-free vaginal tape for stress urinary incontinence over 10 years from a health care system perspective. After surgery, outcomes included cure, persistent stress urinary incontinence followed by second surgery, and persistent stress urinary incontinence and mesh erosion after tension-free vaginal tape. An incremental cost-effectiveness ratio of less than $50,000 per quality-adjusted life year was considered cost-effective.

RESULTS

For the base-case, the Burch strategy cost more than tension-free vaginal tape ($9320 vs $8081), but was slightly more effective (7.260 vs 7.248 quality-adjusted life years). The incremental cost-effectiveness ratio was $98,755 per quality-adjusted life year. The incremental cost-effectiveness ratio was less than $50,000 per quality-adjusted life year when the relative risk of cure after Burch to tension-free vaginal tape was greater than 1.09.

CONCLUSION

Burch colposuspension was not cost-effective compared with tension-free vaginal tape. However, if the tension-free vaginal tape failure rate was to increase over time, Burch may become cost-effective.

The Role of Provider Volume on Outcomes After Sling Surgery for Stress Urinary Incontinence

PURPOSE

Studies of various surgical procedures have documented a relationship between provider volume and outcomes, suggesting that providers who perform a high volume of procedures provide better quality of care. We ascertained whether this relationship held in sling surgery for urinary incontinence.

MATERIALS AND METHODS

We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services for a 5% national random sample of beneficiaries. Women undergoing pubovaginal sling procedures between July 1, 1999 and December 31, 2000 (the index period) were identified and followed for 12 months. The number of slings performed was stratified empirically by cumulative surgeon volume. Main outcomes measures included postoperative complications, concomitant or delayed prolapse repair, outlet obstruction and repeat incontinence surgery.

RESULTS

Among the 5% of Medicare beneficiaries analyzed during the index period 1,356 sling procedures were performed. This extrapolates to 27,120 slings in the entire Medicare population. High volume providers (upper 24th percentile) performed significantly more prolapse repairs at the time of sling surgery than did low volume providers (40.8% vs 32.4%, p <0.006). Subsequently low volume providers performed almost twice the number of prolapse repairs during the first postoperative year following the index sling procedure (p <0.0001). There was no significant difference in complication rates or repeat anti-incontinence procedures between high and low volume providers.

CONCLUSIONS

High volume surgeons were more likely to perform concomitant prolapse surgery at the time of sling surgery, whereas low volume providers had higher reoperation rates to correct prolapse during the first postoperative year. This suggests that high volume providers are more likely to diagnose and manage prolapse at the time of the sling, obviating the need for a second operation.

Complications of sling surgery among female Medicare beneficiaries

OBJECTIVE

To analyze Medicare claims data to determine short-term complications after sling surgery among female beneficiaries aged 65 years and over.

METHODS

We analyzed the 1999-2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries. Women undergoing sling procedures between January 1, 1999, and July 31, 2000, (the index period) were identified by Physicians Current Procedural Terminology Coding System (4th edition) and tracked for 12 months. Main outcome measures were complications as identified by International Classification of Diseases (9th revision) (ICD-9) diagnosis codes and Current Procedural Terminology procedure codes in the first postoperative year.

RESULTS

A total of 1,356 sling procedures were performed during the index period. In the 3 months after the procedure, 12.5% of women developed surgical or urologic complications, and 33.6% were diagnosed with urinary tract infections. Within 1 year of the procedure, 6.9% of subjects had a new diagnosis of outlet obstruction, and 8.0% underwent treatments to manage outlet obstruction. There was a high incidence of new diagnoses of urge incontinence (15.2%) and treatment of pelvic prolapse (23.2%). Both cystoscopy and urodynamic testing, which may serve as indicators of possible complications, were performed frequently during the first year after surgery (32.4% and 30.5%, respectively). Patient race, age, and comorbidity each had a significant influence on outcomes.

CONCLUSION

Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse.

LEVEL OF EVIDENCE

III.

Treatment options for patients with suboptimal response to surgery for stress urinary incontinence

BACKGROUND

Many women with stress urinary incontinence (SUI) undergo surgery to relieve their symptoms. Currently, tension-free vaginal tape or transobturator tape sling procedures are the surgical treatments of choice. Although these procedures are often successful, a growing number of women experience suboptimal results ranging from improvement without cure to postoperative failure. Follow-up surgery often improves residual or recurrent symptoms but generally carries lower success rates and higher complication risks. Additionally, many women with suboptimal results are reluctant to undergo further surgery.

SCOPE

A PubMed literature search for studies of SUI treatment options published from 1986 to 2006 was performed.

FINDINGS

The literature revealed a gap in published studies addressing non-surgical options for patients with failed SUI surgeries. Studies of non-surgical treatments for SUI often exclude women who have had prior surgeries, or do not analyze this subgroup. It is, therefore, difficult to assess non-surgical treatment options for women with failed surgeries. Women whose residual or recurring SUI is attributable to intrinsic sphincter deficiency may instead elect the injection of a bulking agent. Bulking agents are associated with a low rate of complications but frequently require several injections to be successful. Women experiencing suboptimal surgical results whose SUI is attributable to hypermobility may select a new non-surgical treatment, radiofrequency collagen denaturation. This non-invasive procedure has also demonstrated a low rate of complications.

CONCLUSIONS

Considering the effect of SUI symptoms on women's quality of life, and with more women experiencing suboptimal results after surgery for SUI, it is important to assess alternatives to further surgery.

Efficacy, safety and hospital costs of tension-free vaginal tape and pubovaginal sling in the surgical treatment of stress incontinence

AIM

The efficacy, safety and hospital costs of the tension-free vaginal tape procedure were compared with the pubovaginal sling operation.

METHODS

A total of 60 women urodynamically diagnosed as having stress or mixed urinary incontinence were operated on using either the tension-free vaginal tape or pubovaginal sling operation in a prospective manner. Preoperative characteristics of the women were not significantly different for the groups. The women were followed for up to 24 months.

RESULTS

In the tension-free vaginal tape group, the operation time was shorter, numbers of analgesics postoperatively required were less and hospital charges were less expensive compared to those in the pubovaginal sling operation (P < 0.01). Kaplan-Meier survival analysis showed a marginal significant difference (P = 0.059) in the objective cumulative cure rates at 24 months between the groups receiving the former (70.3%) and latter (48.3%) procedures. Subjective cure rates were not significantly different (P = 0.101). In both groups, an improvement in quality of life was significant and surgical complications were identical. De novo urge incontinence developed in 6% and 10% in the former and latter, respectively.

CONCLUSIONS

The tension-free tape was significantly superior to the pubovaginal sling in terms of operation time, postoperative pain, and hospital charges, but not in cure rates. A longer follow up with a larger sample size is necessary to draw definite conclusions.