Older sling patients need extra counseling

Los Angeles-Older women who are candidates for sling surgery to treat stress incontinence need more intensive counseling than younger patients do. That is the conclusion from a study presented at the AUA annual meeting in Anaheim, CA, that shows older women have worse outcomes following sling surgery than do younger women. Women age 75 years and older are more likely to suffer treatment failure following sling surgery and significantly more likely to have a new diagnosis of urge incontinence within 12 months of sling surgery.

"Older women are more likely to experience a variety of complications following sling surgery," said lead author Jennifer Anger, MD, MPH, assistant professor of urology at the UCLA David Geffen School of Medicine here. "The data suggest that counseling for older women should include the possibility of these complications. We would not necessarily tell women not to have slings, but we need to have appropriate counseling before surgery so we know women understand these risks and are willing to take them."

Dr. Anger and colleagues analyzed Medicare claims from a random national sample of 1,356 women who underwent sling surgery between July 1, 1999, and Dec. 31, 2000. The sample represents 5% of beneficiaries, which extrapolates to 27,120 sling procedures performed nationwide during the 18-month study period.

"About 65% of the slings were performed on women 74 years old or younger," Dr. Anger said. "The younger women were divided into two age cohorts: 65 to 69 years old and 70 to 74 years old. In general, outcomes were more favorable among women in both of the younger age groups than for women 75 and older."

The researchers examined nonurologic complications (including pulmonary embolism and cardiac events), new diagnosis of urge incontinence, treatment failure as measured by a repeat procedure for stress incontinence, outlet obstruction, and urinary obstruction.

The results should help settle ongoing discussions over the role that age may play in urinary surgical outcomes. While age generally correlates with increased surgical risk, Dr. Anger noted, several recently published case series suggest older women who undergo slings for stress incontinence may have outcomes similar to those of younger patients. These retrospective national data suggest the opposite.

"We found in multivariate analysis that outcomes in women 75 and older were worse than in both of the younger groups," Dr. Anger said.

"Older patients are more likely to have a new diagnosis of urge incontinence, more likely to have a repeat incontinence procedure, and more likely to have later outlet obstruction."

Older women are 38% more likely to suffer nonurologic complications compared to women 65 to 69 years old. Even women between the ages of 70 and 74 are 30% less likely to suffer nonurologic complications than are older patients. The numbers are similar for post-surgical urge incontinence. Older women are 66% more likely than 65- to 69-year-olds and 16% more likely than 70- to 74-year-olds to show a new urge incontinence diagnosis following sling surgery.

According to the researchers, older women are 55% more likely to encounter treatment failure than 65- to 69-year-olds and 13% more likely than 70- to 74-year-olds.

Older women are 42% more likely to suffer outlet obstruction after sling surgery than either of the two younger groups, and 41% more likely to suffer urinary obstruction than 65- to 69-year-olds. Rates of urinary obstruction are similar in women 70 to 74 and in the 75-plus group.

"Older women are more likely to have inherent voiding dysfunction and incomplete bladder emptying than younger women," Dr. Anger said. "However, claims-based data do not provide detailed clinical information, and we were not able to determine from these data why the outcomes were worse in older women. Large-scale collaborative efforts to prospectively study women undergoing sling surgery in later years might help us identify predictors of outcomes and help us understand why older women do worse."