If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Reprint requests: J. S. Sandhu, M.D., Department of Surgery and Urology, Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate and Urologic Cancers, 353 East 68th Street, New York, NY 10065.
To investigate contemporary trends in the use of midurethral sling procedures for the surgical correction of female stress urinary incontinence over the past decade.
Methods
Annualized case log data for female incontinence surgeries from certifying and recertifying urologists were obtained from the American Board of Urology. Descriptive analysis of the number and type of cases per year was performed. Associations between surgeon characteristics and the use of female incontinence procedures were evaluated.
Results
A total of 6355 nonpediatric urologists applied for certification or recertification between 2003 and 2012. Two-thirds (4185) reported performing any procedures for female incontinence. Procedures sharply increased from 4632 in 2003 to 7548 in 2004, then remained relatively stable between 2005 and 2012 (range, 8014-10,238 cases). Traditional procedures decreased from 17% of female incontinence procedures in 2003 to 5% in 2004 to <1% since 2010 (P <.0005). Midurethral sling procedures have risen sharply from 3210 procedures in 2003 to 7200 in 2012 (P <.0005). Endoscopic injection treatments have remained stable.
Conclusion
Midurethral slings have been widely adopted by urologists over the last decade. Increase in sling usage coincided with a drastic decline in traditional repairs, implying that the newer midurethral slings were replacing these traditional procedures for the treatment of female incontinence. In addition, the fact that the use of periurethral injections did not change significantly during this time period indicates that increased sling usage is responsible for most of the decline in traditional repairs.
The medical, psychological, social, and economic burden of female stress urinary incontinence (SUI) is significant.
Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States.
The management of female SUI is a common problem faced by urologists. After a trial period of nonoperative measures, including behavioral modification and pelvic floor muscles exercises, there is an array of surgical therapies available.
Several of these treatment modalities have been shown to be safe and efficacious for the treatment of female SUI. These treatments vary from traditional repairs, such as Burch colposuspension or Marshall-Marchetti-Krantz repairs,
which can be done as outpatient procedures. The more minimally invasive options have gained popularity because of their procedural ease and likely decreased rates of complications.
With the apparent proliferation of midurethral slings, we sought to determine the changes in practice pattern of urologists surgically managing SUI in the United States. We conducted an analysis of annual case logs submitted to the American Board of Urology (ABU) for certification and recertification between 2003 and 2012.
Materials and Methods
Study Cohort and Data Source
Data came from the case logs of urologists applying for certification or recertification by the ABU between 2003 and 2012. The process of ABU certification and data acquisition has previously been described.
Applicants provided 6 months of billing data as a case log. These case logs are submitted for original certification and recertification every 10 years thereafter. These data represent approximately 10% of certified urologists. Urologic specialty was self-reported. Urologists were excluded from analysis if they self-reported a pediatric subspecialty because pediatric incontinence is etiologically different from adult incontinence. Surgeons were not excluded if they performed any female incontinence procedures on patients younger than 19 years; however, these cases were excluded from analysis. Case logs for 6 months were annualized for this study. The Current Procedural Terminology (CPT) code 57288 for sling operation for stress incontinence (ie, fascia or synthetic) was used for midurethral slings. Supplementary Table 1 lists the CPT codes analyzed and provided as part of this study.
Statistical Methods
Using data from case logs submitted for ABU certification, we characterized the trends in the treatment of female incontinence. We hypothesized that the total number of female incontinence procedures would increase over time. We also posited that midurethral slings would replace traditional repairs. We further hypothesized that the increase in sling procedures would be driven by younger urologists applying for original certification, whereas older recertifying surgeons would continue to use endoscopic injections and traditional repairs (ie, Burch, Marshall-Marchetti-Krantz). We also aimed to assess the association between surgeon characteristics, such as age, gender, and specialty, and practice trends. In addition, we analyzed the practice trends of those urologists who performed more than 24 midurethral sling procedures annually (the 80th percentile and above) to characterize the group of physicians who performed the highest volume of this newer procedure. All analyses were conducted using Stata 12.0 (Stata Corp., College Station, TX).
Results
A total of 6355 nonpediatric urologists submitted case logs for certification or recertification between 2003 and 2012. Two-thirds of these urologists (4185) reported performing at least 1 procedure for the treatment of female incontinence. Median ages for first certification and first, second, and third recertifications were 34, 42, 51, and 60 years, respectively. See Supplementary Table 2 for surgeon characteristics.
The total number of female incontinence procedures reported in the case logs for 2012 was 8574, nearly double the number of cases in 2003 (4632). The number of slings placed followed the same trend, with 7200 sling procedures performed in 2012, compared with 3210 in 2003. In 2003, slings represented 69% of female incontinence procedures performed; this increased to 83% by 2012.
As seen in Figure 1, slings were by far the most commonly used procedure for female incontinence between 2003 and 2012. The median annual sling caseload for urologists who performed any sling procedures was 10 slings (interquartile range [IQR] 4-20), whereas urologists who used slings exclusively reported a median annual caseload of 8 (IQR 4-16; Table 1) . Urologists who performed >24 sling procedures in 1 log year were in the top 20% of sling users. As seen in Table 2, urologists in this group of high-volume sling users were slightly older than lower sling volume urologists and significantly more likely to be female and to report a specialty of “female urology”. The urologists with the highest sling volume also reported median annual caseloads for female incontinence procedures that were >4 times the median annual caseloads for the lower volume sling users (Table 2).
Figure 1Trends in the use of female incontinence procedures among certifying urologists between 2003 and 2012. Bottom bar (dark gray), periurethral injections; middle bar (light gray), midurethral slings; top bar (medium gray), traditional procedures. Urethrolysis procedures have been excluded because of low case volume.
Despite the significant drop in the number of traditional repairs over time, the use of endoscopic injection has remained fairly constant from 2003 to 2012 (Fig. 2). Injections accounted for an average of 15% of all studied female incontinence procedures each year. Urethrolysis, one of many procedure codes used for the revision of midurethral slings, was reported relatively few times. The use of this procedure was first reported in 2004 (20 cases) and it has increased, as the use of midurethral slings has increased. The volume of urethrolysis cases peaked in 2007 with 226; there were 180 cases reported in 2012.
Figure 2Total number of each female incontinence procedure type among certifying urologists between 2003 and 2012. Dashed line, traditional procedures (urinary repositioning); dotted line, periurethral injections; solid line, midurethral slings. Urethrolysis procedures have been excluded because of low case volume.
The large increase in the use of sling procedures over the past decade, combined with the relatively stable number of periurethral injections, indicates that traditional repairs have been almost entirely replaced by midurethral sling procedures. Between 2003 and 2012, the number of traditional procedures fell from 784 (17% of the total) to just 56 (<1%).
Of all urologists treating female incontinence, 3878 (93%) reported any use of slings and 2216 (53%) reported using slings exclusively. In contrast, 1545 (37%) reported any use of endoscopic injections, and 431 (10%) reported any use of traditional repairs. Only 185 (4%) and 85 (2%), respectively, reported using exclusively injections or exclusively traditional repairs.
Urologists who reported using traditional repairs or injections, whether exclusively or nonexclusively, were older than those who did not use these 2 procedure types (P <.0001). As well, older recertifying urologists performed more endoscopic injections and traditional repairs (median of 4 for both procedures) than younger surgeons certifying for the first time (median of 2; P <.0001 for both procedures). Those urologists who reported exclusive or nonexclusive sling use were younger than those who did not (P <.0001). Urologists who reported sling use were also more likely to be applying for original certification, as opposed to those doctors reporting no sling use, who were more likely to be applying for recertification (P <.0001). The trends in sling use based on age and recertification carried over to the use of urethrolysis: urologists reporting this procedure were younger and more likely to be applying for original certification (P = .001). These data support the hypothesis that older recertifying surgeons are using traditional repairs and endoscopic injections more than younger initially certifying surgeons, who predominantly use midurethral slings.
However, the total increase in sling procedures does not seem to be entirely driven by younger urologists applying for initial certification. Although younger urologists tend to use slings more than older urologists, it appears that the trend in sling procedures during the last decade has been driven mostly by the highest volume urologists, regardless of age. Applicants for initial certification who placed any slings reported a median of 8 (IQR 4-16) annually, whereas recertifying applicants who placed slings reported an annual median of 12 (IQR 6-24). Among the urologists in the top 10% by caseload volume, >75% were recertifying, meaning they had been in practice for at least 10 years.
Only 117 urologists (3%) reported using all 3 procedure types. Surgeons performing all 3 procedure types had significantly higher annual caseloads for both female incontinence procedures and all female urology procedures (P <.0001). However, although both age and recertification status were predictive of any use of each type of procedure individually, neither were predictive of whether a surgeon reported using all 3 types of procedures (P = .8).
Of the 4185 urologists who reported performing female incontinence procedures, nearly half performed 10 or fewer of these procedures each year. Among urologists who reported placing midurethral slings, only the top 25% of surgeons perform more than 20 of these procedures each year. This trend continued for each of the 3 procedure types, with most urologists performing very few, if any, of the 3 categories of female incontinence procedure in any given year.
In January 2004, CPT code 53500 for urethrolysis was introduced (Supplementary Table 1).
It describes the procedure performed through a vaginal incision and involves dissection, lysis, and removal of periurethral scar tissue and mobilization of the urethra away from the surrounding fibrous tissue resulting from a previous urethral suspension procedure. Use of urethrolysis was relatively rare, with only 8% of urologists (n = 326) reporting any use of the procedure. There were 10 urologists (<1%) who reported only performing urethrolysis for female incontinence.
We chose not to study CPT code 57287, “Removal or revision of sling for stress incontinence (eg, fascia or synthetic),” which is applied if the patient needs to return to an operating room for a sling revision or excision where the sling material has to be removed and/or removed and replaced because the use of this code is dependent on when the sling was placed. It is only applied after the 90-day global period, and there are a host of other codes including CPT code 10120, “Incision and removal of foreign body, subcutaneous tissues; simple,” that can be used if the sling is incised. The more invasive procedure code of urethrolysis was used as a surrogate for efficacy of incontinence procedures.
Comment
Over the past decade, urologists have had to adapt to new techniques for the management of SUI. There was nearly a doubling in the number of procedures for SUI in 2012 compared with 2003. This likely reflects the growth of the aging population, the proliferation of the midurethral sling, and greater awareness among patients and physicians of treatment options. The specialty of female pelvic medicine and reconstructive surgery has also led to an increased number of urologists who self-classify themselves as female pelvic medicine and reconstructive surgery surgeons and an increased number who have undertaken specialty training. In addition, slings composed 69% of the procedures for SUI in 2003; whereas in 2012, slings increased to 86%. It is interesting to note that the rate of periurethral bulking injections remained relatively low and stable over this period of time. Unfortunately, because of the limitations of this dataset, we do not have any further information on the patients who received these procedures. In a population-based analysis by Suskind et al,
the authors reviewed the Florida State Ambulatory Surgery Database from 2001 to 2009. They also found that the use of periurethral injections remained stable over the study period and that they were more commonly used among older and sicker patients. Anger et al
evaluated a 5% random sample of female Medicare beneficiaries who were diagnosed with urinary incontinence. In the decade before 2001, there was a doubling of surgeries for female urinary incontinence and sharp rise in the use of sling procedures as the technique became less invasive. These data show that the increase has continued, and procedures for female SUI have nearly doubled over a 10-year period.
The management of SUI has evolved dramatically since its inception. Several surgical options have come into favor, only to fall out of favor again relatively quickly. There are few trials that compare each treatment strategy to one another leading to the use of many different procedures. The present study, which evaluates data form the ABU, shows that midurethral slings and urethral bulking agents are the only procedures performed currently for female SUI, with 5 times as many midurethral slings performed as urethral bulking agents. The Food and Drug Administration recently released a safety communication “UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse (July 2011),” which stressed the safety concerns associated with using transvaginal mesh products.
FDA, FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse, in Safety Communications, FDA, Editor 20122.
Midurethral synthetic slings used for female SUI were noted to be safe in this communication; however, the Food and Drug Administration did note that single-incision slings, which have become more popular of late, need further study.
FDA, FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse, in Safety Communications, FDA, Editor 20122.
Predictive factors that influence treatment outcomes of innovative single incision sling: comparing TVT-Secur to an established transobturator sling for female stress urinary incontinence.
If any unforeseen changes in the use of synthetic midurethral slings as an inadvertent result of the safety communication take place, these changes would likely be seen starting in data collected from 2013 or 2014.
The strengths of this study include the fact that this is a contemporary analysis of urologist practice across all geographic locations and practice types in the United States. Several other publications have used this approach to report on other procedures and practice patterns. The study design and dataset allow for self-reported differences in surgeon characteristics. However, an important limitation of this study is that the dataset lacks information on case mix. In addition, all analyses were based on single CPT codes, which might have been performed as part of multiple procedures.
Conclusion
The treatment for female SUI has evolved over the past decade. The overall number of midurethral slings cases performed for female SUI has doubled. An increased awareness of the problem, an aging population, and the proliferation of synthetic midurethral slings all likely contributed to this trend. Concurrently, there has been a decline in the number of traditional repairs reflecting current urologic training.
Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States.
FDA, FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse, in Safety Communications, FDA, Editor 20122.
Predictive factors that influence treatment outcomes of innovative single incision sling: comparing TVT-Secur to an established transobturator sling for female stress urinary incontinence.
Data were acquired under a Data-Use agreement by the American Board of Urology.
Financial Disclosure: The authors declare that they have no relevant financial interests.
Funding Support: This study was supported by the Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, NY.
00963-1&id=gr1.jpg){kind=link}
00963-1&id=gr2.jpg){kind=link}