Impact of the availability of midurethral slings on treatment strategies for stress urinary incontinence: a cost-effectiveness analysis.

OBJECTIVE: To perform a cost-effectiveness analysis for the surgical and non-surgical management of stress urinary incontinence (SUI) with and without the availability of midurethral sling. DESIGN: Cost-effectiveness analysis. SETTING: USA, 2019. POPULATION: Women with stress urinary incontinence. METHODS: We modelled SUI treatment pathways with and without the availability of midurethral slings, including no treatment, incontinence pessary, pelvic floor muscle physical therapy, urethral bulking injection, open and laparoscopic Burch colposuspension, and pubovaginal autologous sling. Time horizon was 2 years after initial treatment. MAIN OUTCOME MEASURES: Costs (2019 US$) included index surgery, surgical retreatment, and complications including urinary retention, de novo urgency and mesh exposure. The incremental cost-effectiveness ratio (ICER) was calculated for non-dominated treatment strategies. RESULTS: The least costly treatment strategies were incontinence pessary, pelvic floor physical therapy, no treatment and midurethral sling, respectively. Midurethral slings had the highest effectiveness. The strategy with the lowest effectiveness was no treatment. The three cost-effective strategies included pessary, pelvic floor muscle physical therapy and midurethral slings. No other surgical options were cost-effective. If midurethral slings were not available, all other surgical options were still dominated by pelvic floor muscle physical therapy. Multiple one-way sensitivity analyses confirmed model robustness. The only reasonable threshold in which outcomes would change, was if urethral bulking costs decreased 12.6%. CONCLUSIONS: The midurethral sling is the most effective SUI treatment and the only cost-effective surgical option. TWEETABLE ABSTRACT: Midurethral sling is the only cost-effective surgical treatment option for stress urinary incontinence.

Baseline renal function and renal ultrasound findings in patients with obstetric fistulas (RENFRU): a prospective cohort study.

OBJECTIVE: To describe and compare baseline renal anatomy and renal function in patients with obstetric fistulas, and to evaluate whether preoperative renal testing and imaging may aid with operative decision making. DESIGN: A prospective cohort study. SETTING: Fistula Care Centre in Malawi. POPULATION: Women with an obstetric fistula. METHODS: Baseline creatinine testing and renal ultrasounds were performed. Surgeons completed a short questionnaire on the usefulness of creatinine and renal ultrasound on operative decision making. MAIN OUTCOME MEASURES: Baseline creatinine and renal ultrasound findings. RESULTS: Four surgeons performed operations on 85 patients. The mean creatinine in patients with vesicovaginal fistulas (VVF) was 0.60 ng/ml versus patients with uretero-vaginal fistulas (UVF) (0.79 ng/ml, P = 0.012). When a grade 3 or more hydronephrosis is absent on renal ultrasound, the negative predictive value of the presence of UVF is 93.3% (95% confidence interval [CI] 88.6-96.2) with a specificity of 97.2% (95% CI 90.3-99.6). In cases of UVF, surgeons found the renal ultrasound results useful or very useful 87.5% of the time, and the creatinine useful or very useful 75% of the time. CONCLUSION: In this pilot study, most patients with obstetric fistulas presented with a normal creatinine. In the absence of a grade 3 hydronephrosis or above on renal ultrasound, the probability of not having a UVF is 93.3%. Surgeons should consider performing preoperative renal ultrasound testing in all patients with an obstetric fistula, particularly in women with a prior laparotomy, as this population has risk factors for ureterovaginal fistula. TWEETABLE ABSTRACT: Most patients with obstetric fistulas have normal renal function. Preoperative renal ultrasounds should be performed.