Surgery for urinary incontinence in women 65 years and older: a systematic review

Sacral and Implantable Tibial Neuromodulation for the Management of Overactive Bladder: A Systematic Review and Meta-analysis

INTRODUCTION

Implantable tibial neuromodulation (iTNM) systems have recently become commercially available in the US, and offer a new method of neurostimulation for the treatment of overactive bladder (OAB). In the absence of head-to-head studies, the aim of this meta-analysis was to indirectly compare the efficacy and safety of sacral neuromodulation (SNM) and implantable tibial neuromodulation (iTNM) for the treatment of OAB.

METHODS

A comprehensive search was performed using terms for OAB and neuromodulation. Primary efficacy measures included a ≥ 50% reduction in urgency urinary incontinence (UUI) episodes, urinary frequency, and/or OAB symptoms. Primary safety measures included the rate of device-related adverse events (AEs).

RESULTS

A total of 20 studies met selection criteria, encompassing 1416 patients treated with SNM and 350 patients treated with iTNM. No comparative or placebo-controlled studies for SNM and iTNM were identified, and therefore the analysis was completed using single-arm results. Weighted averages showed that the UUI responder rate was similar for both SNM and iTNM (71.8% and 71.3%, respectively). Similarly, weighted averages of OAB responder rates were 73.9% for SNM and 79.4% for iTNM. Similar rates of device-related AEs were also observed.

CONCLUSIONS

This meta-analysis found similar efficacy and safety of SNM and iTNM for the treatment of OAB and UUI, including UUI and OAB symptom response rates, reduction in UUI episodes, significant improvements in quality-of-life (QoL), and low rates of procedure and device-related adverse events. Notably, this comparable efficacy was seen without the use of a trial phase of neuromodulation in the iTNM studies versus SNM studies.

Mortality and Reoperation Following Midurethral Sling Versus Urethral Bulking in Older Women

OBJECTIVE

To examine differences in mortality, retreatment rates, and comorbidities that may be risk factors for retreatment among Medicare beneficiaries (age 65+) undergoing midurethral sling vs urethral bulking.

MATERIALS AND METHODS

This was a retrospective cohort study using the 5% limited data set from the Center for Medicare and Medicaid Services between 2010 and 2018. Beneficiaries age 65 or older who underwent sling or bulking without concomitant surgery from 2011 to 2014 were included and followed until reoperation or retreatment, loss of Medicare, death, or December 31, 2018. Repeat procedures for ongoing stress incontinence or complication were included. Associations between index treatment and need for a secondary procedure were evaluated using Cox proportional hazards models.

RESULTS

Median follow-up time was 5.7 years for 1,700 patients undergoing sling and 5.2 years for 875 patients undergoing bulking. Within 5 years, 10.2% of sling patients and 23.2% of bulking patients had died. When controlling for age, race, and comorbidities, bulking patients were 1.73 times more likely than sling patients to die during the study period. Bulking patients were significantly more likely to have 12 of the 16 of the medical comorbidities evaluated. By 5 years, 6.7% of sling patients had been retreated for stress urinary incontinence (SUI) compared with 24.6% of bulking patients. Apart from hypertension, none of the comorbidities evaluated was associated with a difference in the risk of a subsequent surgical procedure. Members of racial and ethnic minority groups were less likely to be retreated.

CONCLUSION

Older adults undergoing bulking are notably sicker and have shorter life expectancy as compared with those undergoing sling, suggesting these factors heavily guide patient selection. Comorbidities do not predispose patients to reoperation or retreatment.

Long-term functional outcomes of artificial urinary sphincter (AMS 800™) implantation in women aged over 75 years and suffering from stress urinary incontinence caused by intrinsic sphincter deficiency

PURPOSE

To assess the outcomes after artificial urinary sphincter (AUS) implantation in older women aged over 75 years.

METHODS

A monocentric retrospective study included all non-neurological women aged over 75 years suffering from stress urinary incontinence (SUI) due to intrinsic sphincter deficiency and undergoing an AUS placement between 1991 and 2015. Early postoperative complications were reported according to Clavien-Dindo classification. Continence, defined as no pad use, was assessed at the end of follow-up. Explantation, revision and deactivation rates of the AUS were reported. A Kaplan-Meier survival curve was generated to evaluate the survival rate of the device without revision or explantation.

RESULTS

Among 393 AUS implantations, a total of 45 patients, median age 77 years (IQR 75-79), were included. Twenty-six early postoperative complications occurred in 18 patients (40%) patients. All were minor Clavien grades (I-II) except one (grade IVa). Median follow-up was 36 months (IQR 16-96). Overall, 32 women (71.1%) still had their AUS in place at the end of the follow-up, without revision or explantation. The AUS was definitively removed in four (8.9%). The AUS required revisions in nine (20%) women. The 5- and 10-year survival rates of the device without revision or explantation were 78 and 50%, respectively. Three patients (6.7%) had their AUS deactivated. At last follow-up, in an intention-to-treat analysis, the continence rate was 68.9%.

CONCLUSION

In women aged over 75-years-old, suffering from SUI, the AUS provides satisfactory functional results comparable to the general population.

What a mesh! An Australian experience using national female continence surgery trends over 20 years

PURPOSE

To review the evolution of female continence surgical practice in Australia over the last 20 years and observe whether vaginal mesh controversies impacted these trends.

MATERIALS AND METHODS

From January 2000 to December 2019, medicare benefit schedule codes for female continence procedures were identified and extracted for: mesh sling, fascial sling, bulking agent, female urethral prosthesis, colposuspension, and removal of sling. Population-adjusted incidences per 100,000 persons were calculated using publicly available demographic data. Three discrete phases were defined over the study time frame for analysis: 2000-2006; 2006-2017, and 2017-2019. Interrupted time-series analyses were conducted to assess for impact on incidence at 2006 and 2017.

RESULTS

There were 119,832 continence procedures performed in Australia from 2000 to 2019, with the mid-urethral sling (MUS) the most common (72%). The majority of mesh (n = 63,668, 73%) and fascial sling (n = 1864, 70%) procedures were in women aged < 65 years. Rates of mesh-related procedures steeply declined after 2017 (initial change: -21 cases per 100,000; subsequent rate change: -12 per 100,000, p < 0.001). Non-mesh related/bulking agents increased from + 0.34 during 2006-2017 to + 2.1 per 100,000 after 2017 (p < 0.001). No significant change in mesh extraction was observed over 2006-2017 (+ 0.06 per 100,000, p = 0.192). There was a significant increase in mesh extraction procedures after 2017 (0.83 per 100,000, p < 0.001).

CONCLUSION

Worldwide, controversy surrounding vaginal mesh had a significant impact on Australian continence surgery trends. The most standout trends were observed after the 2017 Australian class-action lawsuit and Senate Inquiry.

Variation in availability and use of surgical care for female urinary incontinence: a mixed-methods study

Background

Urinary incontinence affects between 25% and 45% of women. The availability and quality of services is variable and inequitable, but our understanding of the drivers is incomplete.

Objectives

The objectives of the study were to model patient, specialist clinician, primary and secondary care, and geographical factors associated with referral and surgery for urinary incontinence, and to explore women’s experiences of urinary incontinence and expectations of treatments.

Design

This was a mixed-methods study.

Setting

The setting was NHS England.

Participants

Data were collected from all women with a urinary incontinence diagnosis in primary care data, and all women undergoing mid-urethral mesh tape surgery for stress urinary incontinence were included. Interviews were also carried out with 28 women from four urogynaecology clinics who were deciding whether or not to have surgery, and surveys were completed by 245 members of the Royal College of Obstetricians and Gynaecologists with a specialist interest in urinary incontinence.

Data sources

The sources were patient-level data from Hospital Episode Statistics, the Clinical Practice Research Datalink and the Office for National Statistics mortality data linked to Hospital Episode Statistics. Interviews were conducted with women. An online vignette survey was conducted with members of the Royal College of Obstetricians and Gynaecologists.

Main outcome measures

The main outcome measures were the rates of referral from primary to secondary care and surgery after referral, the rates of stress urinary incontinence surgery by geographical area, the risk of mid-urethral mesh tape removal and reoperation after mid-urethral mesh tape insertion.

Results

Almost half (45.8%) of women with a new urinary incontinence diagnosis in primary care were referred to a urinary incontinence specialist: 59.5% of these referrals were within 30 days of diagnosis. In total, 14.2% of women referred to a specialist underwent a urinary incontinence procedure (94.5% of women underwent a stress urinary incontinence procedure and 5.5% underwent an urgency urinary incontinence procedure) during a follow-up period of up to 10 years. Not all women were equally likely to be referred or receive surgery. Both referral and surgery were less likely for older women, those who were obese and those from minority ethnic backgrounds. The stress urinary incontinence surgery rate was 40 procedures per 100,000 women per year, with substantial geographical variation. Among women undergoing mid-urethral mesh tape insertion for stress urinary incontinence, the 9-year mesh tape removal rate was 3.3%. Women’s decision-making about urinary incontinence surgery centred on perceptions of their urinary incontinence severity and the seriousness/risk of surgery. Women judged urinary incontinence severity in relation to their daily lives and other women’s experiences, rather than frequency or quantity of leakage, as is often recorded and used by clinicians. Five groups of UK gynaecologists could be distinguished who differed mainly in their average inclination to recommend surgery to hypothetical urinary incontinence patients. The gynaecologists’ recommendations were also influenced by urinary incontinence subtype and the patient’s history of previous surgery.

Limitations

The primary and secondary care data lacked information on the severity of urinary incontinence.

Conclusions

There was substantial variation in rates of referrals, surgery, and mesh tape removals, both geographically and between women of different ages and women from different ethnic backgrounds. The variation persisted after adjustment for factors that were likely to affect women’s preferences. Growing safety concerns over mid-urethral mesh tape surgery for stress urinary incontinence during the period from which the data are drawn are likely to have introduced more uncertainty to women’s and clinicians’ treatment decision-making.

Future work

Future work should capture outcomes relevant to women, including ongoing urinary incontinence and pain that is reported by women themselves, both before and after mesh and non-mesh procedures, as well as following conservative treatments. Future research should examine long-term patient-reported outcomes of treatment, including for women who do not seek further health care or surgery, and the extent to which urinary incontinence severity explains observed variation in referrals and surgery.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Variation in surgical treatment advice for women with stress urinary incontinence: a study using clinical case vignettes

Introduction

The aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics.

Methods

Two hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 ‘certainly not’ to 5 ‘certainly yes’. Mean scores were used to calculate the relative impact (‘weight’) of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way.

Results

The gynaecologists’ overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0.

Conclusions

Surgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Electronic supplementary material

The online version of this article (10.1007/s00192-020-04295-4) contains supplementary material.

Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study

OBJECTIVE

To examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS).

DESIGN

National cohort study.

SETTING

NHS hospitals.

PARTICIPANTS

27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure.

METHODS

Multilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation.

PRIMARY OUTCOME MEASURE

Rate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44).

RESULTS

The rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs.

CONCLUSIONS

Substantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.

Mixed feelings: general practitioners' attitudes towards eHealth for stress urinary incontinence - a qualitative study

BACKGROUND

Stress urinary incontinence (SUI) is the most prevalent subtype of urinary incontinence and is a bothering condition in women. Only a minority of those with SUI consult a general practitioner (GP). EHealth with pelvic floor muscle training (PFMT) is effective in reducing incontinence symptoms and might increase access to care. The role of the GP regarding such an eHealth intervention is unknown. The aim of the study is to gain insight into the attitudes towards a PFMT internet-based, eHealth, intervention for SUI.

METHODS

A qualitative study was conducted. Data were collected through semi-structured interviews among purposively sampled GPs. Audio records were fully transcribed, and analysed thematically.

RESULTS

Thirteen GPs were interviewed, nine females and four males. Three themes emerged: appraisal of eHealth as a welcome new tool, mixed feelings about a supportive role, and eHealth is no cure-all. GPs welcomed eHealth for SUI as matching their preferences for PFMT and having advantages for patients. With eHealth as stand-alone therapy GPs were concerned about the lack of feedback, and the loss of motivation to adhere to the intervention. Therefore, GPs considered personal support important. The GP's decision to recommend eHealth was strongly influenced by a woman's motivation and her age. GPs' treatment preferences for elderly are different from those for young women with SUI; both PFMT and eHealth are perceived less suitable for older women.

CONCLUSION

EHealth with PFMT fits into the GPs' routine practice of SUI and adds value to it. Although there is evidence that eHealth as a stand-alone intervention is effective, GPs consider personal support important to supplement the perceived shortcomings. Probably GPs are not aware of, or convinced of the existing evidence. Training should address this issue and should also focus on common misunderstandings about regular care for women with SUI, such as the idea that PFMT is not suitable for the elderly. Improving GPs' knowledge that eHealth can be a stand-alone therapy for SUI facilitates the implementation in daily care.

Are suburethral slings less successful in the elderly?

INTRODUCTION AND HYPOTHESIS

We aimed to evaluate the success of suburethral slings in women ≥70 years of age.

METHODS

This was a retrospective cohort study of women who underwent suburethral sling placement. Subjects were separated into three groups: ≤50 years of age (group 1), 51 to 69 years of age (group 2), and ≥70 years of age (group 3). The primary aim was to evaluate success as defined by ≥ improved on a validated patient improvement satisfaction score and a negative postoperative standardized stress test.

RESULTS

There were 1,464 subjects. Mean age was 44.51 ± 4.25 (n = 296) for group 1, 60.5 ± 5.28 (n = 680) for group 2, and 77.68 ± 5.41 (n = 488) for group 3. The median follow-up was 26 (6-498) weeks, 45 (6-498) weeks, and 42 (6-543) weeks, for groups 1, 2, and 3 respectively. Multiple logistic regression analysis demonstrated no difference in sling success according to age stratification. Lower success was associated with having had a previous sling (adjusted OR 0.25, 95 % CI 0.12-0.5), having detrusor overactivity (adjusted OR 0.44, 95 % CI 0.28-0.69), and having a history of urge urinary incontinence (UUI) for ≥ 4 years (adjusted OR 0.54, 95 % CI 0.31-0.95).

CONCLUSIONS

There is no difference in sling success between the elderly and younger populations. However, those with previous sling surgery or a long standing history of UUI may be at a higher risk of failure.