Trends in pelvic organ prolapse management in Latin America

Specialty-Specific Trends in Surgery for Apical Pelvic Organ Prolapse Post Vaginal Mesh

IMPORTANCE

Since transvaginal mesh (VM) kits for apical pelvic organ prolapse (APOP) were labeled "high-risk" in 2016 and subsequently banned in 2019 by the U.S. Food and Drug Administration, the most common remaining surgical options include abdominal mesh-augmented sacrocolpopexy (AS) and transvaginal native tissue suspension (VN).

OBJECTIVE

The objective of this study was to determine temporal trends in APOP procedures for urologists and gynecologists.

STUDY DESIGN

Between 2011 and 2020, the American College of Surgeons National Surgical Quality Improvement Program database was queried for AS, VM, and VN.

RESULTS

There were 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with more medical comorbidities. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists ( P < 0.0001). Transvaginal mesh utilization has decreased over time for both specialties ( P < 0.05); nonsignificant trends toward increasing AS ( P = 0.1646) in urologists and VN ( P = 0.0913) in gynecologists concurrently occurred. Significant independent predictors of the operating surgeon being a urologist were surgery being performed in the latter half of the cohort (2016-2020; odds ratio [OR], 1.22), non-White patient race (OR < 1 for all), a concomitant sling being placed (OR = 0.89), the surgery being VM (OR = 2.95) or AS (OR = 4.36), the patient being older (OR > 1 for each age range), and having a higher frailty index score (OR = 1.16).

CONCLUSIONS

Significant differences in APOP repair choices exist between specialties. Urologists operate on older, more medically complex patients while demonstrating a strong preference for mesh-augmented compared with transvaginal native tissue repairs.

Trends in Urogynecology-Transvaginal Mesh Surgery in Germany

BACKGROUND

Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for managing POP has been a subject of extensive debate. Globally, trends in TVM surgery experienced significant shifts subsequent to warnings issued by the FDA.

METHODS

This study aims to explore temporal patterns in transvaginal mesh surgery in the German healthcare system. A comprehensive analysis was conducted on in-patient data from the German Federal Statistical Office spanning 2006 to 2021. A total of 1,150,811 operations, each associated with specific codes, were incorporated into the study. Linear regression analysis was employed to delineate discernible trends.

RESULTS

The trends in transvaginal mesh surgery within the anterior compartment exhibited relative stability (p = 0.147); however, a significant decline was noted in all other compartments (posterior: p < 0.001, enterocele surgery: p < 0.001). A subtle increasing trend was observed for uterine-preserving transvaginal mesh surgery (p = 0.045).

CONCLUSION

Surgical trends over the specified timeframe demonstrate how POP management has evolved globally. Notably, despite observed fluctuations, transvaginal mesh surgery remains a viable option, particularly for specific cases with a high risk of relapse and contraindications to alternative surgical approaches.

Functional urology: Practice patterns and training aspirations among urologists in Brazil

PURPOSE

Urology has rapidly evolved during the last decades, incorporating new technologies faster than most specialties. The challenge to maintain a competent workforce that is prepared to deliver proper contemporary treatment has become increasingly difficult and newly graduated urologists throughout the world typically lack the skills to practice many urological subspecialties. We performed a survey to evaluate the practice patterns and educational aspirations in functional urology (FU) among Brazilian urologists.

METHODS

A web-based survey was sent to board-certified Brazilian urologists to collect data on clinical practice and training aspirations in four subareas of FU: female urology, urodynamics, postprostatectomy incontinence (PPI), and neurourology. We evaluated urologists' clinical and surgical workload in each subarea and investigated educational training aspirations to identify areas and training formats of interest.

RESULTS

A total of 366 urologists (mean age 47.7 + 10.7 years) completed the survey. Mean time since completion of residency was 17.9 + 11.9 years. Of the respondents, 176 (53%) perform urodynamics, 285 (83.1%) SUI surgeries, 159 (47.6%) PPI surgeries, 194 (58.1%) third line OAB procedures, 168 (48.9%) pelvic organ prolapse (POP), and 88 (26.3%) bladder augmentation. Mid-urethral sling is the most performed SUI surgery and transobturator is the preferred route (64.0%). For those performing POP surgery, 40.5% use mesh in at least 50% of their cases, and the vaginal route is used in most cases (75.4%) for apical prolapse. For PPI, 64.6% use artificial sphincter in most surgeries and only 8.1% perform at least 5 surgeries/year. Being fellowship-trained and working in an academic hospital are associated with a higher chance of being active in FU. Most urologists are interested in receiving training in PPI, female SUI, and POP and a hands-on course is the preferred educational method (81%).

CONCLUSIONS

Most urologists in Brazil are involved in the evaluation and treatment of FU patients, but few have a large volume of patient visits and surgical procedures. Completing a fellowship program and working in an academic practice are associated with a higher chance of being a FU practitioner. There is a high interest in training for PPI, female SUI, and POP.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists

OBJECTIVES

To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020.

MATERIALS AND METHODS

A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states.

RESULTS

Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012).

CONCLUSIONS

COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.

The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse

Vaginal length and caliber are necessary for satisfactory vaginal coitus. Surgical treatment of pelvic organ prolapse (POP) can include preservation of vaginal length and caliber, or shortening and narrowing of the vagina (constrictive and obliterative surgery). The latter option is proven to have fewer complications and a lower risk of recurrence of POP. Women undergoing surgical intervention for POP who are not coitally active and choose not to be coitally active for the rest of their lives should be offered constrictive and obliterative surgery.