Low minimally invasive sling rates in UK elderly women.

Abstract

Surgery rates for stress urinary incontinence (SUI) in elderly women have remained low for the past 20 years, despite the availability of bulking agents and now minimally invasive slings (MIS). Hesitancy may persist with any form of surgery at this age. As the authors quote, epidemiological data show a third of women over 65 years of age with leakage have isolated SUI, a symptom that should not require urodynamic evaluation (Nager N Engl J Med 2012;366:1987–97), and where MIS intervention should be straightforward. It may not be so. Studies showing excellent MIS outcomes often have a mean participant age of 50 years. Over the age of 75 careful case selection may be needed, with symptoms being more difficult to interpret. Even with urodynamic assessment (Serati et al. BJU International 2013;112:E344–50), we have no accurate way to measure ageing female detrusor function (Van Koeveringe et al. Neurourology & Urodynamics 2011;30:723–8). Incontinence in the elderly is different. Bladder function changes dramatically (Zimmern et al. J Urology 2014;192:464–8). Sensory function may deteriorate. Detrusor overactivity may progres to detrusor underactivity. There is risk of significant retention. Delayed urethrolysis may lead to irreversible bladder dysfunction (Leng et al. J Urology 2004;172:1379–81). Complex concurrent morbidities compound difficulties. Internationally, a large influx of new operators performing MIS caused rates to soar from 1999, and then to plateau and in some cases fall, around 2004. For all Australian women over 85 years of age, population growth adjusted MIS increased 850%, and bulking agents increased 400%, from 2001 up to 2009. The proportion of all MIS performed in elderly women aged over 74 year was higher than figures for the UK up to 2011, growing from 11.2 to 15.6% in this period; MIS rose 279% for this group. Direct comparison with Gibson and Wagg's data is impossible because they quote gross MIS procedures performed, not adjusted for population growth. But for women over 75 years of age, gross UK MIS rates rose 335% over the period 2001–2011. Despite omitting the effect of population growth, this represented a slight fall in the proportion of all MISs performed in this age group, from 6.8 to 5.4%. So, total population-adjusted Australian MIS rates in this age group in 2009 were three times higher than crude rates in the UK in 2011: 7.8/10 000 versus 2.25/10 000. In the Australian private sector, data for the UK time period 2001–2011 show again a higher MIS rate rise in women over 74 years of age, rising from 3.7 to 8.6/10 000: a rise of 261%. This represents not only 4 times higher adjusted rates but also a much higher adjusted rise in the proportion of MISs performed in this age group, rising from 12.3 to 22.6%, contrasting again with the crude fall in the UK. In Belgium, over the period 1997–2007, proportional rates of total SUI surgery for women aged 70 years or older remained unchanged at 21%, despite generally soaring MIS rates. Overall, internationally, population-adjusted MIS rates in the elderly female population remained lower than in younger cohorts, and rates rose more modestly. The very low rates reported in the UK could represent a concerning lack of access for the elderly in the UK, disappointment with surgical outcomes in this group or an excessive, inappropriate rate of MIS performed in Australia and elsewhere. This large reported UK discrepancy in MIS rates suggests the need for research into the appropriateness of surgery among this growing group. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.