Background
Prophylactic midurethral sling placement at the time of prolapse repair significantly
reduces the risk for de novo stress urinary incontinence, but it is associated with
some small but significant morbidities. Because there has not been a standardized
approach to midurethral sling utilization, decision analysis provides a method to
evaluate the cost and effectiveness associated with varying midurethral sling placement
strategies in addressing the risk for de novo stress urinary incontinence.
Objective
We aimed to compare the cost effectiveness of the 3 midurethral sling utilization
strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse
repair. The 3 approaches are (1) staged strategy in which prolapse repair is done
without prophylactic midurethral sling placement, (2) universal sling placement in
which prolapse repair is accompanied by prophylactic midurethral sling placement,
and (3) selective sling placement in which prolapse repair is accompanied by prophylactic
midurethral sling placement only in patients with a positive prolapse-reduced cough
stress test.
Study Design
We created a decision analysis model to compare staged strategy, universal sling placement,
and selective sling placement. We modeled probabilities of de novo stress urinary
incontinence, patients choosing subsequent midurethral sling surgery for de novo stress
urinary incontinence, and outcomes related to midurethral sling placement. De novo
stress urinary incontinence rates were determined for each strategy from published
data. The likelihood of patients with de novo stress urinary incontinence choosing
midurethral sling surgery as their first-line treatment was also determined from the
literature, and this scenario was only applied to patients without prophylactic midurethral
sling placement at their index prolapse repair. Finally, outcomes related to midurethral
sling placement, including recurrent or persistent stress urinary incontinence, voiding
dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive
bladder requiring medications, were all derived from publicly available data. All
midurethral sling placement procedures were assumed to be retropubic. The costs for
each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services
Physician Fee Schedule or from previous literature with convertion to 2020 equivalent
US dollar prices using the Consumer Price Index. The primary outcome was modeled as
the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity
analyses to assess model robustness.
Results
The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient,
followed by $1093.75 for selective sling placement and $1125.54 for universal sling
placement. The selective sling approach, however, had the highest health utility value;
therefore, universal sling placement was dominated by selective sling placement because
it is both less costly and more effective. When compared with the staged strategy,
selective sling placement was cost effective with an incremental cost-effectiveness
ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold.
In multiple 1-way sensitivity analyses, the variable with the largest effect was the
percentage of patients electing to undergo subsequent midurethral sling surgery for
de novo stress urinary incontinence after the index surgery. Only when this proportion
exceeded 62% did universal sling placement become the cost-effective option because
selective sling placement surpassed the predetermined incremental cost-effectiveness
ratio threshold and became dominated.
Conclusion
Selective sling placement was the preferred and cost-effective strategy in treating
de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons
should counsel their patients preoperatively regarding the possibility of de novo
stress urinary incontinence after prolapse repair, as well as on the benefits and
risks of prophylactic midurethral sling placement surgery.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Obstetrics & GynecologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050.Am J Obstet Gynecol. 2011; 205: 230.e1-230.e5
- Urinary incontinence after surgery for pelvic organ prolapse.Neurourol Urodyn. 2013; 32: 455-459
- A midurethral sling to reduce incontinence after vaginal prolapse repair.N Engl J Med. 2012; 366: 2358-2367
- Variability in practice patterns in stress urinary incontinence and pelvic organ prolapse: results of an IUGA survey.Int Urogynecol J. 2017; 28: 735-744
- To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis.J Urol. 2013; 190: 1306-1312
- Surgical trends and patient factors associated with the treatment of apical pelvic organ prolapse from a national sample.Int Urogynecol J. 2019; 30: 603-609
- Prolapse surgery with or without incontinence procedure: a systematic review and meta-analysis.BJOG. 2018; 125: 289-297
- Incidence of stress urinary incontinence following vaginal repair of pelvic organ prolapse in objectively continent women.Neurourol Urodyn. 2011; 30: 390-394
- Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial.Int Urogynecol J. 2016; 27: 1029-1038
- Mid-urethral sling operations for stress urinary incontinence in women.Cochrane Database Syst Rev. 2015; 7: CD006375
- Incontinence rates after midurethral sling revision for vaginal exposure or pain.Am J Obstet Gynecol. 2016; 215: 764.e1-764.e15
- Release of tension-free vaginal tape for the treatment of refractory postoperative voiding dysfunction.Obstet Gynecol. 2002; 100: 898-902
- Recurrence of stress urinary incontinence after midurethral sling revision: a retrospective cohort study.Female Pelvic Med Reconstr Surg. 2017; 23: 184-187
- Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial.Obstet Gynecol. 2008; 111: 611-621
- Utility scores for chronic conditions in a community-dwelling population.Pharmacoeconomics. 1999; 15: 369-376
- Potential health and economic impact of adding a human papillomavirus vaccine to screening programs.JAMA. 2003; 290: 781-789
- Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study.Int Urogynecol J. 2013; 24: 1679-1686
- Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK: a register linkage study.BMJ Open. 2011; 1e000206
- The demographics of pelvic floor disorders: current observations and future projections.Am J Obstet Gynecol. 2001; 184: 1496-1501
Article Info
Publication History
Published online: May 26, 2022
Accepted:
May 22,
2022
Received in revised form:
May 7,
2022
Received:
March 10,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
The authors report no conflict of interest.
The Department of Obstetrics & Gynecology at Northwestern University provided financial support to conduct statistical analysis for this study.
Cite this article as: Mou T, Cadish LA, Gray EL, et al. Cost-effectiveness of prophylactic retropubic sling at the time of vaginal prolapse surgery. Am J Obstet Gynecol 2022;XX:x.ex–x.ex.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
