Does specialty affect sling complication rate?

Author(s):

Gynecologists derive higher complication rates than urologists during the first 30 days following sling procedures for urinary incontinence, according to a multicenter study presented at the European Association of Urology annual congress in Munich, Germany.

Munich, Germany-Gynecologists derive higher complication rates than urologists during the first 30 days following sling procedures for urinary incontinence, according to a multicenter study presented at the European Association of Urology annual congress in Munich, Germany.

Commentary: Urologists, GYNs demonstrate slings' safety

However, the difference was small and most complications were slight-primarily post-procedure urinary tract infections.

The authors arrived at these findings by delving into data amassed by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). They reviewed 10,508 sling procedures for stress urinary incontinence conducted between 2006 and 2013.

Procedures performed by gynecologists (5,970) were associated with a higher rate of UTIs (3.6%) compared to the 2.3% rate seen in 4,538 procedures conducted by urologists (OR: 1.55, 95% CI: 1.23-1.97, p<.0001). Gynecologists also had a higher rate of overall complications than urologists: 4.1% vs. 2.9% (OR: 1.42, 95% CI: 1.15-1.76, p=.001).

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“Large sample sizes can make small differences statistically significant. The question is whether they are clinically meaningful,” first author Björn Löppenberg, MD, a research fellow at Brigham and Women’s Hospital, Boston, told Urology Times.

Next: Overall complication rate was 3.5%

The overall complication rate was 3.5%, with the majority (84.3%) of complications being UTIs. Thirty-day postoperative outcomes, including cardiovascular, pulmonary, thrombotic, septic, renal, wound, and bleeding complications, did not differ between the two specialties. Reoperation and readmission rates were also similar.

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The above rates were similar despite differing patient characteristics. Patients treated by urologists tended to be older with a greater incidence of comorbidity and higher American Society of Anesthesiologist scores (ASA ≥3, p=.05).

Dr. LoppenbergIt is possible the complication rates are under-reported, noted Dr. Löppenberg, who worked on the study with Quoc-Dien Trinh, MD, and co-authors.

“The NSQIP database codes only for complications that occur within 30 days of the procedure. We cannot account for long-term adverse events such as chronic pain and erosion, among others,” said Dr. Löppenberg, who explained that these complications would not be registered in the NSQIP database.

Some 17.1% of the patients in the dataset underwent an additional procedure. Gynecologists performed twice as many additional procedures as urologists, 22.2% versus 10.5% (p<.0001), despite the higher comorbidity rates seen among patients being treated by urologists.

“We are not able to identify the underlying reason for this finding. The majority of these additional procedures were cystoscopies, and the majority were performed by gynecologists. It is possible that these findings simply reflect differences in surgical technique and approach,” Dr. Löppenberg said.

Next: Independent predictors of reoperation, readmission

Independent predictors of reoperation and readmission rates were ASA scores ≥3 (OR: 1.6%, 95% CI: 1.2-2.0; p=.001), prolonged operative time in the 75th percentile or higher (OR: 1.9, 95% CI: 1.5-2.3), and a gynecologist-conducted procedure (OR: 1.5, 95% CI: 1.2-1.9; p<.0001).

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Dr. Löppenberg said the study was prompted when Dr. Trinh and co-author Christian Meyer, MD, were asked to comment on a December 2015 JAMA Surgery article that examined factors associated with synthetic mesh removal following surgical interventions for stress urinary incontinence (study, JAMA Surg 2015; 150:1167-75; comment, 1175-6). That study found that over a 10-year span, complications were not significantly influenced by the specialty of the surgeon conducting the procedure.

Specialists at the Henry Ford Hospital Health System, Vattikuti Institute of Urology, Center for Outcomes Research, Analytics and Evaluation, Detroit, participated in the study. It will be presented again in a poster session at the AUA annual meeting in San Diego.