By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
SYNOPSIS: Board-certified urogynecologists had higher surgical volumes of stress incontinence surgeries, were more likely to perform perioperative tasks, and had lower readmission rates compared with non-urogynecologists performing anti-incontinence procedures.
SOURCE: Erekson E, Whitcomb EL, Kamdar N, et al. Performance of perioperative tasks for women undergoing anti-incontinence surgery: Developed by the AUGS Quality Improvement and Outcomes Research Network. Urogynecology (Phila) 2023;29:660-669.
The main objective of this study was to identify the practice patterns employed in the surgical treatment of female stress urinary incontinence within North America. The authors hypothesized that the performance of five standardized perioperative tasks was associated with more consistent surgical outcomes. Performance of these tasks and postoperative outcomes were compared by board certification status of the primary surgeon.
This was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013. Charts reviewed were from nine health systems across the United States and in Canada and included 30 hospitals and surgical centers. Inclusion criteria were charts of patients who underwent anti-incontinence procedures alone or with concomitant gynecologic procedures, including those who had had a prior incontinence procedure. Exclusion criteria included concomitant surgery for pelvic organ prolapse, cancer, urethral diverticulum, fistula, or revision of sling or mesh. Additionally, cases were excluded in which the surgeon was identified incorrectly or the certification status for the surgeon was unknown.
Primary outcome measures included the performance of five perioperative tasks. The identified tasks included documentation of having discussed nonsurgical treatment, completion of a standard preoperative prolapse examination, performance of cough stress test, performance of post-void residual, and intraoperative cystoscopy. Additionally, secondary outcomes included intraoperative complications; post-operative complications occurring within 30 days of surgery, including readmission or reoperation; retreatment for stress urinary incontinence; and mesh complication. Cases were identified based on Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code and surgeon national provider identifier numbers. The latter were used to verify surgeon board certification status. Sampling of up to 200 cases was performed at each site. Stratification by board certification was considered for sites that had more than 200 cases, with oversampling of cases performed by non-Female Pelvic Medicine and Reconstructive Surgery (FPMRS) surgeons to ensure adequate representation of this group.
Cases were identified at each of the nine health systems and each health system collected an administrative dataset. The complete dataset contained 2,238 surgical procedures. Surgeries were performed by 243 surgeons at nine sites. Of these, 65 surgeons were FPMRS-certified (eight through obstetrics and gynecology and seven with urology). One hundred seventy-four were non-FPMRS certified and 24 were not certified in any specialty. Cases performed by these 24 surgeons were excluded. Following chart review, 1,021 cases met inclusion criteria and were included in the analysis.
The majority of anti-incontinence procedures performed were midurethral slings (93%), these include retropubic, transobturator, and single incision slings. Small numbers of pubvaginal slings and retropubic urethropexies were performed. Three-quarters of the procedures were performed by FPMRS surgeons. Non-specialist patients were more likely to be premenopausal, post-hysterectomy, and have private insurance, while patients cared for by FPMRS surgeons were more likely to have had prior pelvic floor surgery. FPMRS surgeons performed the majority of mid-urethral slings compared to non-FPMRS surgeons. Non-FPMRS surgeons were more likely to perform single-incision slings. Subspecialty surgeons also were more likely to perform surgery on patients with a history of prior incontinence or prolapse surgery. FPMRS specialists were more likely to perform all five perioperative tasks. Although surgeons in both groups had similar intraoperative complications, FPMRS surgeons had fewer readmissions. Post-operative voiding dysfunction, retreatment for stress urinary incontinence, and mesh complications were similar between the two surgeon types.
COMMENTARY
Anti-incontinence procedures constitute high-volume/low-morbidity procedures. The use of standardized lists of tasks has been proposed to improve quality of care in other fields that perform high-volume/low-morbidity procedures. This retrospective cohort study spanning nine health systems attempted to determine practice patterns for the surgical treatment of incontinence. The authors measured preoperative and intraoperative quality tasks performed by surgeons performing surgery for stress urinary incontinence.
The authors compared surgeons who were subspecialty board-certified (FPMRS) to those who were not and found that board certified FPMRS surgeons were more likely to perform all five selected perioperative tasks and have higher volumes of surgical procedures compared to other surgeons. The authors did not find differences in intraoperative complications, post-operative voiding dysfunction, retreatment for stress urinary incontinence, and mesh complications between surgeon types; however, board-certified FPMRS surgeons were less likely to have readmissions within 30 days of surgery.
The authors found that non-FPMRS specialists were more likely to use single-incision slings (sometimes called mini slings), which are inserted through a single vaginal incision without a suprapubic or groin skin incision. The sling is shorter and is held in place with use of special anchors or tines that are embedded in soft tissue. The single-incision sling does not require a blind passage, and non-specialists may feel more at ease in using the single-incision sling. A recent Cochrane review that included 62 studies concluded that single-incision slings may be as effective as retropubic and transobturator slings for improvement of stress urinary incontinence at 12 months. However, uncertainty still exists regarding the long-term outcomes and effectiveness of single-incision slings compared to other mid-urethral slings. Although overall complication rates for slings are low, prior studies have identified that high surgeon volume is associated with a decreased rate of reoperation for slings.1,2 This study found that FPMRS subspecialty surgeons had higher volumes and were more likely to use the tasks consistently. The tasks selected for this study either were existing quality measures or were being considered as quality measures. The tasks included offering nonsurgical treatment options, including referral to physical therapy or trial of an incontinence pessary; assessment of pelvic organ prolapse by a preoperative Pelvic Organ Prolapse Quantification (POP-Q) examination; visual confirmation of stress urinary incontinence by preoperative cough stress test; assessment of preoperative voiding by documenting postvoid residual; and assessment of intraoperative lower urinary tract injury with intraoperative cystoscopy.
Although the importance of the tasks or the unique value of each task is unclear, the five tasks do offer a context/framework for surgeons performing incontinence surgery. High-volume surgeons have the opportunity to develop a standardized perioperative approach to the surgery. The decreased variability between individual surgeries in turn may contribute to the improved outcomes documented for high-volume surgeons across surgical fields. Perioperative standardization can include not only the standardization of surgical steps but also standardization in the evaluation and management of women with incontinence and the selection of surgical candidates.
The five tasks used in this study may provide a framework for standardized quality of care for any surgeon performing mid-urethral slings. This care involves informed consent including a discussion of all treatment types for stress incontinence, assessment of coexisting prolapse, confirmation of the urine leakage under direct visualization, assessment of preoperative voiding function, and intraoperative evaluation for bladder injury. Maintaining a consistent perioperative approach can improve post-operative outcomes.
REFERENCES
- Berger AA, Tan-Kim J, Menefee SA. Surgeon volume and reoperation risk after midurethral sling surgery. Am J Obstet Gynecol 2019;221:523.e1-523.e8.
- Welk B, Al-Hothi H, Winick-Ng J. Removal or revision of vaginal mesh used for the treatment of stress urinary incontinence. JAMA Surg 2015;150:1167-1175.
