The cost of urogynaecological treatments: which are more cost-effective?

AIMS: To determine the cost-effectiveness of four urogynaecological treatments. MATERIALS: Two prospective trials were performed in which 205 women with urinary incontinence underwent urogynaecological treatments. The cost incurred and the improvement in quality of life (QOL) as a result of treatment was calculated as cost/quality-adjusted life year (QALY) and then ranked in order of cost-effectiveness. RESULTS: The Nurse Continence Advisor (NCA) group (N = 73) and the Urogynaecologist (UG) group (N = 72) both had significant improvements in leaks per week and incontinence score. QOL improvement was also similar (1.5% vs 1.2%). The economic data found a similar improvement in pad usage costs ($A2.90 vs $A3.52). The clinician costs were significantly lower for the NCA group ($A60.00 vs $A105.00) (P < 0.0001). The cost per QALY was significantly lower for the NCA group ($A28,009 vs $A35,312) (P = 0.03). Both groups had significant improvements in pad testing and leaks per week. The cure/improvement rates were also similar at three months (100% vs 89%). There was no significant difference in the improvement in QOL between the laparoscopic colposuspension (LC) and open colposuspension (OC) groups (2.09% vs 1.54%). The economic data found a similar improvement in pad usage costs ($A11.74 vs $A16.17). The theatre costs were significantly higher for the LC group ($A403.45 vs $A266.94) (P < 0.0001), however the overall costs were significantly lower ($A4,668 vs $A6,124) (P < 0.0001). The cost/QALY was lower for the LC group ($A63,980 vs $A134,069), however this did not reach significance. CONCLUSIONS: Overall, on comparison of the cost/QALY's, conservative treatment of urinary incontinence by a NCA was the most cost-effective.

TVT and Sparc suburethral slings: a case-control series.

Two midurethral slings, TVT and Sparc, are the subject of this case-control series aimed at assessing sling placement, voiding function, bladder symptoms and patient satisfaction. Thirty-seven Sparc and 69 TVT patients were matched for age, body weight, pre-existing urge incontinence, preoperative voiding, concomitant surgery and length of follow-up (mean 0.6, range 0.1-1.5 years). There were no significant differences for subjective cure/improvement, satisfaction or symptoms of incontinence. The clinical stress test was positive in 8/37 Sparc vs 4/69 TVT patients ( p=0.019). The TVT had a more negative effect ( p=0.001) on postoperative voiding. The Sparc was situated more cranially at rest and further from the symphysis pubis, and was more mobile ( p<0.001) on Valsalva. There are significant differences in medium-term outcomes after TVT and Sparc, affecting tape placement, mobility, effect on voiding function and objective stress continence. Patient satisfaction and subjective cure rates seem similar.

Laparoscopic colposuspension in women with previously failed anti-incontinence surgery.

OBJECTIVES: To assess the effectiveness of laparoscopic colposuspension after previously failed anti-incontinence surgery. METHODS: Retrospective review of 10 cases, all with urodynamically proven grade 2 genuine stress incontinence. RESULTS: All patients were subjectively cured at 3 months or more follow-up. The mean hospital stay was 2.9 days, the mean time until normal voiding was 1.7 days, and the mean blood loss was 39 ml. CONCLUSION: Laparoscopic colposuspension may be useful after failed anti-incontinence surgery. However, larger numbers are needed with objective longer term follow-up.

External cephalic version from 34 weeks under tocolysis: factors influencing success.

External cephalic version (ECV) was performed on 72 patients from 34 weeks of gestation under tocolysis, with ultrasound control and cardiotocograph surveillance. Successful ECV was associated with multiparity, decreased lower segment caesarean section (LSCS) rate, and earlier discharge home. ECV was successful in 51.4% of patients overall, with the success rate being 35% in primigravidas and 71.4% in multiparas (p < 0.005). The LSCS rate was reduced from 91.4% to 0% (p < 0.0001) on comparing the unsuccessful and the successful ECV groups, while breech presentation was reduced from 94.3% to 0% (p < 0.0001). There were no significant fetal complications.

Stage 1 endometrial cancer: treatment modalities and factors influencing recurrence.

One hundred and nineteen patients treated for FIGO Stage 1 endometrial adenocarcinoma were reviewed retrospectively to determine if adjuvant radiotherapy reduced disease recurrence. The patients had all been treated in the Hunter Region of New South Wales over a 10-year period from 1978 to 1988. Median follow up was 82 months with a range of 24 to 163 months. Treatment consisted of surgery alone (75.6%), surgery and brachytherapy (17.6%), surgery and megavoltage therapy (4.2%), and surgery with both brachytherapy and megavoltage therapy (2.5%). The overall recurrence rate was 10.1%. Recurrence at the vaginal vault alone occurred in 3.4%. The median time to recurrence was 25.0 months. A statistically significant correlation was found between overall recurrence risk and poorly differentiated lesions (p < 0.0001). Just failing to reach statistical significance were age over 70 years (p < 0.06) and patient weight less than 70 kg (p = 0.06). Depth of myometrial invasion (p = 0.17), use of adjuvant radiotherapy (p = 0.17) and uterine cavity size (p = 0.48) were not significantly correlated with risk of recurrence. The 5-year survival rate was 93.8%.

Review of obstetric operative intervention rates.

The trends in obstetric operative intervention at a major teaching hospital in Sydney, Australia, were reviewed during the decade 1979-1989. While the caesarean section rate has increased by 36.4%, forceps deliveries have decreased. The normal delivery rate has remained constant at 67%.