Urethral Sling Procedures Research Articles

Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism

The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism. A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent). Fifteen children (ten boys, five girls, mean age of 7.6years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients. Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.

Comparing Trends in Urethral Sling Procedures Performed by Urologists and Gynecologists: Is There Anything Significantly Different?

INTRODUCTION: Sling procedures, the most common surgical treatment for stress urinary incontinence, are performed by both urologists and gynecologists. Our study aims to examine differences in operative times and surgical metrics based on surgeon subspecialty training. METHODS: This study is a retrospective review of the 2005 to 2015 National Surgical Quality Improvement Program database. Patients who underwent a sling operation as their primary procedure were identified. Chi-square analysis and independent t-tests were used for statistical comparisons. RESULTS: A total of 21,040 patients were included. Urologists completed 38.8% of the cases, and gynecologists completed 61.2%. Urologists had shorter operative times (45.93 vs 54.21 minutes; p < 0.001; 95% CI –9.66 to –6.91), were more likely to complete the procedure outpatient (85.4% vs 83.5%; p < 0.001), and performed fewer concomitant procedures (16.1% vs 32.3%; p < 0.001) such as pelvic prolapse repairs. Length of hospital stay was similar between specialties (0.40 vs 0.46 days; p = 0.078). Patients under 60 years saw gynecologists more frequently, while those 61 to 80 years saw urologists more often (p < 0.001). Urological patients had increased likelihood of having comorbidities, including obesity, diabetes, hypertension, smoking history, dyspnea, decreased functional status, chronic obstructive pulmonary disease, and chronic steroid use (p < 0.001; Table). Urologists were less likely to have a resident or fellow present (37.3% vs 42.8%; p < 0.001). CONCLUSION: Urologists were associated with shorter operative times for midurethral slings. They were more likely to operate outpatient, while gynecologists were more likely to perform concomitant procedures and have a trainee present. Urologists operated on older patients who tended to have more comorbidities and had similar lengths of hospital stay. Table. - Comparison of Patient Comorbidities Variable Urology (%) Gynecology (%) p Value Obesity 50.6 47.5 <0.001 Diabetes 12.3 9.5 <0.001 Hypertension 38.9 33.0 <0.001 Current Smoker 15.9 13.0 <0.001 Dyspnea 6.1 4.2 <0.001 Decreased functional status 0.9 0.4 <0.001 COPD 3.8 2.3 <0.001 Chronic steroid use 2.1 1.4 <0.001

PD34-07 PREDICTORS OF SLINGS AFTER URETHRAL DIVERTICULECTOMY: A 5-YEAR LARGE POPULATION ANALYSIS

You have accessJournal of UrologyCME1 May 2022PD34-07 PREDICTORS OF SLINGS AFTER URETHRAL DIVERTICULECTOMY: A 5-YEAR LARGE POPULATION ANALYSIS Allison Sih, Seth Cohen, Fornati Bedell, Karyn Eilber, Victoria Scott, and Kai Dallas Allison SihAllison Sih More articles by this author , Seth CohenSeth Cohen More articles by this author , Fornati BedellFornati Bedell More articles by this author , Karyn EilberKaryn Eilber More articles by this author , Victoria ScottVictoria Scott More articles by this author , and Kai DallasKai Dallas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002585.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Management of female urethral diverticula can be challenging and can result in stress urinary incontinence (SUI). Currently there is no consensus on management strategy to perform placement of a urethral sling concomitantly or at a delayed interval. In efforts to further elucidate this, we aimed to characterize those patients who went on to further surgical intervention for SUI after urethral diverticulectomy. METHODS: All women undergoing urethral diverticulectomy in California between January 2013 through December 2018 were identified using the Office of Statewide Health Planning and Development data sets (CPT 53230). Women who underwent a urethral sling procedure for SUI, either autologous fascial or synthetic, were identified from this cohort (CPT 57288). Women who had undergone concomitant sling at time of urethral diverticulectomy were excluded. Patient demographics such as age, race/ethnicity, payor type and comorbidities (diabetes mellitus, hypertension, obesity) were identified. Univariate (t-test and chi-square test) and multivariate analysis (multivariable logistic regression) were performed among the patient factors above and the risk of a future sling procedure. RESULTS: A total of 525 women (mean age 47.2 years) underwent a urethral diverticulectomy during this time period. Of these, 43 (8.2%) underwent a subsequent urethral sling. Limiting the analysis to women who had at least two years of follow up after diverticulectomy, this rate increased to 12.2%. Women of older age (51.6 vs. 41.9, p<0.001), and women with obesity (14.9% vs. 7.1%, p=0.024) were more likely to undergo a subsequent sling procedure. These effects were significant under multivariate analysis, controlling for all other factors. There was no significant effect of patient race or payor status on rates of subsequent sling procedure. CONCLUSIONS: The rate of SUI after treatment of urethral diverticulum for which patients subsequently underwent a urethral sling procedure is not insignificant (12.2% in those with at least two years of follow up). Given that some women with SUI will not elect for surgical intervention, this suggests that an even higher number of women have bothersome incontinence. Women of older age or with obesity have a higher rate of SUI necessitating surgical treatment. Consideration of these factors for sling placement at the time of urethral diverticulum repair may avoid secondary procedures. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e562 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Allison Sih More articles by this author Seth Cohen More articles by this author Fornati Bedell More articles by this author Karyn Eilber More articles by this author Victoria Scott More articles by this author Kai Dallas More articles by this author Expand All Advertisement PDF DownloadLoading ...

Cost Value Analysis of Single Incision Midurethral Sling Insertion in the In Office Vs. Hospital Setting

<h3>Study Objective</h3> Patient outcomes between Mid-urethral slings in office setting vs hospital setting based on average total patient encounter time, total procedure time, total patient cost. The secondary outcomes were adverse events, unexpected outcomes, and urgent evaluation. <h3>Design</h3> Retrospective, double-arm study, 1 physician implanted a mid-urethral single-incision sling with the clinical diagnosis for urethral hypermobility or stress urinary incontinence. <h3>Setting</h3> Office setting and hospital-based setting. <h3>Patients or Participants</h3> 78 women underwent sling placement in an office setting and 47 patients underwent sling placement in a hospital-based setting. <h3>Interventions</h3> Patients were evaluated at 2 and 6 weeks after surgery. A validated Surgical Satisfaction Questionnaire (SSQ-8) was collected at the 6-week post-operative visit. Patients that did not complete the SSQ-8 were contacted by phone. All women with the diagnosis of urethral hypermobility or stress urinary incontinence. <h3>Measurements and Main Results</h3> Between January 2016 until August 2020 a total of 125 women underwent a single incision mid urethral sling procedure. Hospital-based setting: The average SSQ-8 score totaled 39.17 out of 40. The average total patient encounter time was 344.702 minutes. The average total time in the OR was 50.06 minutes. 5 total patients reported one adverse event, 13 patients reported 6 unexpected outcomes. No patients were seen for emergent evaluation. Office-based setting: The average SSQ-8 score totaled 39.48 out of 40. The average total patient encounter time was 53.76 minutes. The average total time in the OR was 22.05 minutes. 5 total patients reported one adverse event, 25 patients reported 27 unexpected outcomes. 1 patient was seen for emergent evaluation. No statistically significant differences in patient satisfaction. <h3>Conclusion</h3> The findings have shown considerable favor office-based setting in comparison to the hospital setting. There is a significant difference in the financial cost and the total patient encounter time. The office-based setting would be the more advantageous option for patients. The office-based setting is cost-effective, less time-consuming, and is safe.

Transvaginal subfascial synthetic mesh sling in female stress urinary incontinence: A Novel technique

The object of this paper is to assess the treatment outcome and overall efficacy of a novel technique of transvaginal subfascial synthetic mesh for female stress urinary incontinence. The study included 53 patients of female stress urinary incontinence managed at our institution between March 2005 and December 2015. Preoperative evaluation included a detailed history, base-line investigations and cystoscopic examination including stress test, uroflometry with residual urine was done in all cases. Lower urinary tract imaging and urodynamic evaluation was done in selected cases . patients with concomitant pelvic organ prolapse and severe BMI were excluded from the study. All patients underwent a transvaginal subfascial sling procedure under regional anesthesia. Urethral catheter was removed the day after procedure. Post procedure results were assessed in terms of improvement in stress urinary incontinence, procedure related complications, and overall satisfaction of the patient. Mean age of the patients was 43.5 years (25-63 years). All patients were multiparous. Complete resolution of symptoms in 49 patients (92.4%) while in 4 patients (7.5%) had some degree of SUI. Urinary retention in 3 (5.6%), increased frequency in 5 (9.4%) patients and urge incontinence in 2 (3.7%) One (1.8%) had mesh erosion at 3 months after the procedure. None of the patient had any sexual dysfunction on follow up. Overall success rate of the procedure was around 93%.However patients with preoperatively urge incontinence needs anticholinergics in post operative period for 1-2 months. Operative time was 30-45 minutes. Three patients (5.6%) who experience transient postoperative retention had no symptoms of SUI on follow up. Transvaginal subfascial sling is a modification of the original mid urethral sling procedure with an advantage of being less invasive, simpler to learn and achieve similar results compared to other sling procedures.

Do urodynamics predict urinary retention after sling placement in the complex patient: the value of reproducing symptoms on urodynamics.

To examine urinary retention (UR) after female urethral sling placement in patients with or without detrusor underactivity (DU) or Valsalva voiding whose urodynamics (UDS) accurately reproduced voiding symptoms to determine whether the reproduction of voiding symptoms on UDS in those with DU is predictive of UR after sling placement. We performed a review of patients undergoing urethral sling procedures for stress urinary incontinence (SUI) looking specifically at the occurrence of short- and long-term urinary retention. Preoperative UDS data were obtained from a prospectively acquired UDS database in which patients were directly queried at the time of the UDS study about whether the filling and/or storage phase of the study reproduced their usual symptoms. Of the 141 women who had a urethral sling procedure, 124 (87.9%) had preoperative UDS. Of those who had UDS, 41 (33%) had de novo UR at some point postoperatively. Compared to those without DU, patients with DU and/or Valsalva voiding were more likely to have UR (75.6% vs. 56.6%, p = 0.04). There was no difference in association of UR in patients with DU/Valsalva voiding whose UDS reproduced voiding symptoms compared to those with DU/Valsalva voiding whose UDS did not reproduce symptoms (OR 1.01, CI 0.32-3.19, p 0.98). This study found that patients with DU/Valsalva voiding had an increased association with UR but did not find reproduction of symptoms on UDS to correlate with UR in either those with DU/Valsalva voiding or with normal bladder contractility.

Risk Factors for Intraoperative Bladder Perforation at the Time of Midurethral Sling Placement

To evaluate patient-specific and perioperative factors that may be predictive of bladder perforation during midurethral sling placement. A retrospective chart review of women who underwent a midurethral sling procedure at our institution between 2013 and 2017 was completed. All cases with bladder perforation were included. Patient demographics and perioperative factors were explored for associations with perforation. Bivariate analysis was used to compare baseline characteristics between those with and without perforation. Logistic regression modeling was used to identify predictors of perforation and associations between bladder perforation and postoperative sequelae. Four hundred and ten women had a urethral sling procedure at our institution between 2013 and 2017. Of these, 35 (9%) had evidence of bladder perforation on cystoscopy. This rate was higher for retropubic slings (15%) compared to transobturator slings (2%). Those with a perforation were younger (54 vs 61 years, P= .004) and had a lower average BMI (24.1 kg/m2 vs 26.3 kg/m2, P=.022). Other risk factors included lack of pre-existing apical prolapse (11% vs 4%, P=.012) and concomitant urethrolysis (27% vs 8%, P=.024). In multivariable analysis, age, BMI, and sling type were significantly associated with perforation. In univariate analysis, perforation was associated with postoperative lower urinary tract symptoms (OR 2.3, P=.21) and urinary tract infection within 30 days of surgery (OR 2.2, P=.047). Intraoperative bladder perforation was associated with younger patient age and lower BMI. Additionally, bladder perforation is a risk factor for postoperative urinary tract infection and lower urinary tract symptoms.

Long-Term Safety with Sling Mesh Implants for Stress Incontinence.

We examined long-term risks and predictors of mesh erosion and reoperation following mid urethral sling procedure for stress urinary incontinence. Women aged 18 years or older who received a mid urethral sling for stress urinary incontinence between 2008 and 2016 in outpatient surgical settings in New York State were included in our study. Those who underwent concomitant mesh pelvic organ prolapse repair were excluded. Primary outcomes were post-implantation time to erosion and reoperations. Kaplan-Meier analysis and Cox proportional hazard models were used to assess the risks of erosion diagnosis and reoperation. Our cohort included 36,195 women with a mean±SD age of 53.7±12.4 years. Estimated risks of erosions and reoperations at 7 years after sling procedures were 3.7% and 6.7%, respectively. Older age (≥65 vs <65: HR 0.83, 95% CI 0.70-0.99) and high volume facilities (high vs low: HR 0.79, 95% CI 0.68-0.92) were associated with a lower risk of erosion. History of hysterectomy was associated with a higher risk of erosion (HR 1.62, 95% CI 1.36-1.92). Predictors of reoperation included concurrent abdominal or native tissue transvaginal prolapse repair, previous hysterectomy and depression. One in 27 women had sling erosions and 1 in 15 had invasive reoperations at 7 years after sling procedures. The highest erosion cases were observed among younger White women treated at low volume facilities. Continued and vigilant surveillance of mesh in stress urinary incontinence repairs, the nature and burden of stress urinary incontinence recurrence, different types of re-treatment, patient reported outcomes and information about treating surgeons are crucial.

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery.

Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p< 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.

The Use of a Vaginal Pessary to Decide Whether a Mid Urethral Sling should be Added to Prolapse Surgery.

Women with pelvic organ prolapse are at risk for stress urinary incontinence after prolapse surgery. Combining pelvic organ prolapse repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing only pelvic organ prolapse repair leads to under treatment. Is a vaginal ring pessary a useful tool when deciding whether a mid urethral sling should be added to prolapse surgery? We performed a retrospective cohort study in women with symptomatic pelvic organ prolapse but without bothersome stress urinary incontinence who underwent vaginal prolapse repair between January 1, 2008 and December 31, 2017. Preoperatively a pessary was inserted in all women to detect occult stress urinary incontinence. If the pessary revealed bothersome stress urinary incontinence, a concomitant mid urethral sling was proposed. The primary outcome at followup was de novo stress urinary incontinence. Included in study were 220 women. After pessary insertion 132 women (60%) remained continent, 20 (9%) reported nonbothersome stress urinary incontinence and 68 (31%) had bothersome stress urinary incontinence. The latter group was offered combined surgery. At followup bothersome stress urinary incontinence was present in 12 of the 132 women (9%) who had been continent preoperatively and in 7 of the 20 (35%) who had had nonbothersome stress urinary incontinence. In 132 women who were continent with the pessary a total of 11 mid urethral sling procedures would have been needed to prevent postoperative stress urinary incontinence in 1 (number needed to treat was 11). In the 20 women who had nonbothersome stress urinary incontinence only 3 mid urethral sling procedures would have been necessary (number needed to treat was 3). In women with symptomatic pelvic organ prolapse a pessary is a useful tool when deciding whether to add a mid urethral sling.

Can Urethral Bulking Agents Salvage Failed Slings?

ObjectiveTo evaluate the efficacy of urethral bulking agents for stress urinary incontinence (SUI) in the setting of prior failed sling. MethodsThis is a retrospective review of patients who underwent urethral bulking agent injections for a primary complaint of SUI following prior failed sling surgery. The outcomes assessed were patient reported improvement, need for further interventions for incontinence and validated questionnaires. Values for questionnaires were obtained from the patient's preprocedure visit, at the first visit following their last injection and at their most recent visit within our system. ResultsOver the study period, 73 patients underwent urethral bulking agent injection following failed sling. Thirty-eight patients received Macroplastique injections and 35 had collagen injections. On average, patients underwent 2.6 injections. Seventy-one percent of patient reported at least partial symptom resolution at first postinjection follow-up. Validated questionnaire responses also improved at short-term follow-up (mean difference in American Urological Association Symptom Index-3.8, Michigan Incontinence Symptom Index-5.1, P <.01). Forty patients had long-term follow-up data available (mean 39.6 months postinjection). Statistically significant improvement persisted on the stress incontinence and quality of life domains of the validated questionnaires. ConclusionIn our cohort of patients with persistent or recurrent SUI following urethral sling procedure, 71% experienced short-term improvement or resolution of symptoms following urethral bulking agent injections, with SUI-specific improvement persisting at an average of 35 months in patients with available data.

MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2018MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL Annah Vollstedt, Rachel Moses, and E. Ann Gormley Annah VollstedtAnnah Vollstedt More articles by this author , Rachel MosesRachel Moses More articles by this author , and E. Ann GormleyE. Ann Gormley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.882AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American Urologic Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) Guideline outlines the evaluation and treatment of stress urinary incontinence (SUI) and state that urodynamic (UDS) testing may be omitted in healthy females who have not undergone a prior SUI procedure. This recommendation is largely based on the data reported in the seminal Value of Urodynamic Evaluation (ValUE) trial. We sought to investigate the rates of UDS testing in those undergoing a SUI procedure before and after the ValUE trial publication. METHODS Using the Dartmouth Institute’s Atlas Rate Generator exploring a 100% Medicare claims data, we identified females with a diagnosis of SUI by ICD-9 codes and a CPT code for either urethral bulking or urethral sling procedure, within 306 hospital referral regions (HRR). We then identified the proportion of those who also had a CPT code for UDS within one year prior to their SUI procedure. RESULTS Complete 2011 and 2013 data was available for 151 of the 306 HHRs. The national percentage of pre-operative UDS evaluation was 53% (16020/30131) in 2011, compared to 55% (11,772/21579) in 2013, after the publication of the ValUE trial (p=0.157). In 2011, the highest percentage of UDS testing in was performed in Monroe, LA at 81% (48/59) and the lowest in Jonesboro, AR at 22% (14/64). In 2013, the highest percentage of UDS testing was performed in Longview, TX at 88% (43/49) and the lowest in Springfield, MO at 22% (22/99). Only 40% (61/151) of HHRs decreased their use of UDS, while 52% (79/151) increased UDS rates, and 8% (11/151) HHRs stayed the same. CONCLUSIONS There is significant regional variation in utilization of UDS in those undergoing a SUI procedure. Nationally, the overall rates of UDS, diagnostic testing did not change significantly after the publication of the ValUE trial. When evaluating at the HRR level, a larger proportion of HRRs demonstrated increased or unchanged rates between 2011 and 2013. Further research is needed to investigate the differences in UDS testing after the distribution of the SUI AUA/SUFU guidelines as well the rates of UDS testing in populations other than Medicare beneficiaries. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e347 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Annah Vollstedt More articles by this author Rachel Moses More articles by this author E. Ann Gormley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cost Analysis of Vaginal Mid Urethral Sling Suburethral Removal

IntroductionFor cost analysis of mid urethral sling surgery there is a lack of data on costs associated with long-term complications. Therefore, we studied the costs related to a vaginal suburethral synthetic sling removal procedure over 2 consecutive years. MethodsFrom a prospectively maintained database of consecutive women who underwent 1 vaginal suburethral synthetic sling removal only, we analyzed the cost of suburethral synthetic sling removal for 2013 and 2014. Costing data were obtained for operating room expenses, medical and surgical supplies, pharmacy, anesthesia supplies, and room and bed. Professional fees for the suburethral synthetic sling removal procedure were obtained from the Medicare fee-for-service schedule. Costs for 2013 were adjusted by 3% to match 2014 costs. ResultsFrom 2013 to 2014 a total of 46 women underwent suburethral synthetic sling removal. Mean ± SD length of surgery was 62 ± 22 minutes and median length of stay was 1 day (range 0 to 2). Costs for medical and surgical supplies decreased significantly from 2013 to 2014 while operating room and total cost increased during that time. No significant differences were found among payer types. With the 3% inflation adjustment for 2013 the mean total cost based on these factors was $3,714 ± $941, with a median cost of $3,556. Of the 46 women 13 were treated on an outpatient basis and the median cost was reduced at $3,030. ConclusionsAt our tertiary care center the mean total cost of suburethral synthetic sling removal was $3,714, with a slight total cost increase from 2013 to 2014 but a cost saving for those treated as outpatients. This information will be useful for inclusion in the overall cost of mid urethral sling procedures.

Racial and Socioeconomic Disparities in Short-term Urethral Sling Surgical Outcomes

To evaluate the association of racial and socioeconomic factors with the risk of adverse events in the first 30 days following urethral sling placement. We accessed nonpublic data from the Office of Statewide Health Planning and Development in California from 2005 to 2011. All female patients who underwent an ambulatory urethral sling procedure in the entire state of California over the study period were identified (Current Procedural Terminology 57288). Our main outcome was any unplanned hospital visits within 30 days of the patient's surgery in the form of an inpatient admission, revision surgery, or emergency department visit. A total of 28,635 women who underwent outpatient urethral sling placement were identified. Within 30 days, 1628 women (5.7%) had at least 1 unplanned hospital visit. In the adjusted multivariate model, black race and Medicaid insurance status were both independently associated with increased odds of having an unplanned hospital visit (odds ratio 1.80, P < .01 and odds ratio 1.53, P < .01, respectively). This significance persisted even when controlling for patient comorbidities, demographics, and facility characteristics. We found that, similar to what has been reported in other fields, disparities in outcomes exist between socioeconomic and racial groups in the field of urogynecology.

MP40-05 USING DATA FROM THE CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) TO DETERMINE THE 30-DAY COMPLICATION RATE FROM URETHRAL-SLING PLACEMENT.

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy I1 Apr 2017MP40-05 USING DATA FROM THE CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD) TO DETERMINE THE 30-DAY COMPLICATION RATE FROM URETHRAL-SLING PLACEMENT. Kai Dallas and Christopher Elliott Kai DallasKai Dallas More articles by this author and Christopher ElliottChristopher Elliott More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1252AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgical intervention for stress urinary incontinence is common with 200,000 repairs annually. The most common repair is mid-urethral sling placement. Although the long-term complication rate after a sling procedure has been rigorously studied, the short -term (30 day) complication rate has been incompletely assessed. We sought to evaluate unplanned hospital visits within 30 days of sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. METHODS With approval from the California Protection of Human Subjects committee, we accessed non-public data from the Office of Statewide Health Planning and Development (OSHPD) in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (CPT 57288) were identified, excluding other procedures aside from cystoscopy. All emergency department visits, inpatient admissions, and sling revision operations within 30 days of the original surgery were identified. We also examined the most common primary diagnoses associated with emergency department visits. RESULTS 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure (aside from cystoscopy). 1,630 patients had at least one unplanned hospital visit (5.7%) within 30 days. This included 1,327 emergency department visits (4.7%), 295 inpatient admissions (1.0%) and 79 sling revisions (0.28%). The hospital visit rate was significantly higher in patients undergoing a third or fourth sling placement (14.3%) as compared to a first or second sling placement (5.7%) (p=0.02) (table 1). Urinary retention and Foley catheter problem were the most common emergency department visit diagnoses (18.7% of ER visits), followed by urinary tract infection (9.3% of ER visits). CONCLUSIONS One in eighteen females will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits. Our findings can be used to improve patient counseling and suggest target areas to decrease unnecessary emergency department visits in the early postoperative period. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e524-e525 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Kai Dallas More articles by this author Christopher Elliott More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Where do Women go for Revision Surgeries? Geographic Migration Patterns after Urethral Sling Placement in California

IntroductionAlthough long-term rates of sling revision after urethral sling placement have been well studied, details of these revisions have not been addressed. In this study we explore the timing, location and migration of patients from one facility to another for revision procedures. MethodsUsing data from the Office of Statewide Health Planning and Development (OSHPD) for the state of California (2005 to 2011), all females who underwent index outpatient urethral sling procedures at nonfederal facilities were identified (CPT 57288). Cases requiring eventual sling revision or urethrolysis were subsequently identified. Location, distance traveled and factors associated with seeking a new facility for revision were explored. ResultsOf the 44,605 patients undergoing urethral sling surgery 842 (1.9%) underwent sling revision, with 178 (22.5%) at a new facility. Facilities in the top 10% of surgical volume placed 41% of the slings and performed more than 50% of revisions. Patient proximity to multiple facilities and increased time between procedures were associated with an increased odds of changing facilities for revision (OR 2.11, p <0.0001 and OR 1.05 per month, p <0.0001, respectively). Placement at a high volume center was associated with decreased odds of changing facilities for revision (OR 0.32, p <0.0001). Patients migrated toward larger centers in urban areas for revision. ConclusionsOverall 78% of sling revisions are performed at the facility where the initial placement was performed. This suggests that the majority of facilities where urethral slings are placed also have the capability of sling revision surgery.

71: Predictors of urinary tract infection and need for sling revision due to obstructive symptoms after sub urethral sling procedures

71: Predictors of urinary tract infection and need for sling revision due to obstructive symptoms after sub urethral sling procedures

Unplanned Hospital Visits in the First 30 Days After Urethral Sling Procedures

To evaluate unplanned hospital visits within 30 days of urethral sling placement in the form of emergency department visits, inpatient admissions, or repeat surgery. We accessed nonpublic data from the Office of Statewide Health Planning and Development in the state of California for the years 2005-2011. All female patients who underwent an ambulatory urethral sling procedure (Current Procedural Terminology 57288) without concomitant surgery (other than cystoscopy) were included. Any subsequent emergency department visit, inpatient admission, or sling revision operation within 30 days of the original surgery were then examined. A total of 28,635 women were identified who underwent outpatient urethral sling placement as a sole procedure. Within 30 days, 1630 women (5.7%) had at least 1 unplanned hospital visit. This included 1327 emergency department visits (4.7%), 295 inpatient admissions (1.0%), and 79 sling revisions (0.28%). Urinary retention and Foley catheter problems were the most common emergency department visit diagnoses (18.7% of visits), followed by urinary tract infection (9.3% of visits). One in 18 women will have an unplanned hospital visit within 30 days of urethral sling placement, the majority of which are emergency department visits (~81%). Our findings can be used to improve patient counseling and suggest areas that one might target to decrease unnecessary emergency department visits in the early postoperative period.

Repeat Surgical Intervention for Stress Urinary Incontinence after a Failed Mid Urethral Sling

IntroductionWe determined the incidence of stress urinary incontinence surgery performed after mid urethral sling procedures and the impact of physician volume on mid urethral sling failure. MethodsAdministrative data were used to identify all women who underwent a mid urethral sling procedure in Ontario, Canada between 2002 and 2013. The primary outcome was subsequent stress urinary incontinence surgery. The primary exposure was surgeon mid urethral sling case volume with high volume defined as greater than the 75th percentile. ResultsA total of 59,556 women with a median age of 52 years (IQR 45–63) received a mid urethral sling, of whom 3.3% underwent additional stress urinary incontinence operations. The most common secondary surgery was a repeat mid urethral sling in 78.3% of cases and a pubovaginal sling in 5.8%. The cumulative incidence of repeat stress urinary incontinence surgery at 10 years of followup was 5.2% (95% CI 4.9–5.5). On multivariable survival analysis the effect of surgeon mid urethral sling volume on subsequent stress urinary incontinence surgery was nonsignificant (HR 0.89, 95% CI 0.76–1.03). Younger patient age, lower comorbidity and simultaneous hysterectomy decreased the hazard of future stress urinary incontinence surgery. In this cohort 1,425 women (2.4%) required surgical revision or removal of the initial mid urethral sling, of whom 215 (15%) underwent a simultaneous or subsequent incontinence procedure. The most common procedure was still a mesh sling, which was placed in 159 women (74.0%). ConclusionsSecondary stress urinary incontinence surgery after mid urethral sling placement was observed in 3.3% of women. The majority of women with recurrent incontinence were treated with a repeat mid urethral sling. There is a nonsignificant trend toward higher mid urethral sling provider volume being correlated with a reduced risk of future stress urinary incontinence surgery.

Utilization of Preoperative Laboratory Testing for Low-risk, Ambulatory Urologic Procedures

To determine the clinical significance of preoperative laboratory testing for low-risk ambulatory urologic procedures. The National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2013 was queried for urethral sling procedures, cystoscopic procedures, and scrotal procedures. Multivariate analysis was used to assess for independent predictors of preoperative laboratory testing utilization and for postoperative complications. Overall, 7378 procedures were identified, with 73.9% undergoing 1 or more laboratory tests, including 37.9% who had no comorbidities. Patients who were tested were older, had a higher American Society of Anesthesiologists class, and had more preoperative comorbidities. Of these procedures, only 2.9% resulted in any complication. Most laboratory tests were drawn within 1 week of the procedure. On multivariate analysis of testing utilization, increasing age and medical comorbidities were predictive of testing. Multivariate analysis of postoperative outcomes showed that abnormal test laboratory findings were not predictive of postoperative complications in those with and without NSQIP-defined comorbidities. Abnormal preoperative laboratory testing was not a significant independent predictor of postoperative complications. Almost 40% of patients received preoperative testing despite having no NSQIP-detected comorbid conditions. A multidisciplinary approach should be taken to define procedures in which preoperative laboratory testing may be eliminated.