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1.
BJOG ; 127(1): 18-26, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31538709

RESUMO

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/economia , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Meta-Análise em Rede , Prolapso de Órgão Pélvico/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária/economia , Resultado do Tratamento
2.
Int J Urol ; 25(7): 655-659, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29729035

RESUMO

OBJECTIVE: To compare nationwide outcomes of tension-free vaginal mesh surgery and laparoscopic sacrocolpopexy for the treatment of pelvic organ prolapse in Japan. METHODS: Using the Diagnosis Procedure Combination database, we collected data on female patients who underwent tension-free vaginal mesh surgery or laparoscopic sacrocolpopexy for pelvic organ prolapse from April 2014 to March 2015. We compared the proportion of perioperative adverse events, duration of anesthesia, total costs and postoperative length of stay between the groups. Univariate and multivariate analyses were carried out for age, comorbidity, mesh volume, additional concomitant surgery and hospital volume. RESULTS: We identified 3023 patients, including 2388 who underwent tension-free vaginal mesh surgery, and 635 who underwent laparoscopic sacrocolpopexy. The median age at the time of surgery was significantly higher in the tension-free vaginal mesh group (71 vs 66 years; P < 0.001). The tension-free vaginal mesh group had a higher proportion of all adverse events (7.1% vs 1.8%; P < 0.001) and a higher proportion of genitourinary complications (5.7% vs 1.1%; P < 0.001). The median duration of anesthesia was shorter in the tension-free vaginal mesh group (150 vs 286 min; P < 0.001). The total cost was significantly lower in the tension-free vaginal mesh group. CONCLUSIONS: Both procedures offer favorable results for surgical treatment of pelvic organ prolapse. Overall, the tension-free vaginal mesh procedure seems to represent a good option for high-risk women, such as elderly patients, whereas laparoscopic sacrocolpopexy is useful for younger patients with a higher level of sexual activity.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Laparoscopia/efeitos adversos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Telas Cirúrgicas/efeitos adversos , Fatores Etários , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Japão/epidemiologia , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Período Perioperatório , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Telas Cirúrgicas/economia , Resultado do Tratamento
3.
Obstet Gynecol ; 131(3): 484-492, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29420405

RESUMO

OBJECTIVE: To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis. RESULTS: Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively. CONCLUSION: Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/tendências , Seguro Saúde , Prolapso de Órgão Pélvico/cirurgia , Padrões de Prática Médica/tendências , Utilização de Procedimentos e Técnicas/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Estudos Retrospectivos , Telas Cirúrgicas , Estados Unidos , United States Food and Drug Administration
4.
Int Urogynecol J ; 29(8): 1161-1171, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29480429

RESUMO

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a common diagnosis that imposes high and ever-growing costs to the healthcare economy. Numerous surgical techniques for the treatment of POP exist, but there is no consensus about which is the ideal technique for treating apical prolapse. The aim of this study was to estimate hospital costs for the most frequently performed operation, vaginal hysterectomy with uterosacral ligament suspension (VH) and the uterus-preserving Manchester-Fothergill procedure (MP), when including costs of postoperative activities. METHODS: The study was based on a historical matched cohort including 590 patients (295 pairs) who underwent VH or MP during 2010-2014 owing to apical prolapse. The patients were matched according to age and preoperative prolapse stage and followed for a minimum of 20 months. Data were collected from four national registries and electronic medical records. Unit costs were obtained from relevant departments, hospital administration, calculated, or estimated by experts. The hospital perspective was applied for costing the resource use. RESULTS: Total costs for the first 20 months after operation were 3,514 € per VH patient versus 2,318 € per MP patient. The cost difference between the techniques was 898 € (95% confidence interval [CI]: 818-982) per patient when analyzing the primary operation only and 1,196 € (CI: 927-1,465) when including subsequent activities within 20 months (p < 0.0001). CONCLUSIONS: The MP is substantially less expensive than the commonly used VH from a 20-month time perspective. Healthcare costs can be reduced by one third if MP is preferred over VH in the treatment of apical prolapse.


Assuntos
Custos Hospitalares , Histerectomia Vaginal/economia , Tratamentos com Preservação do Órgão/economia , Prolapso de Órgão Pélvico/cirurgia , Estudos de Coortes , Dinamarca , Feminino , Humanos , Histerectomia Vaginal/métodos , Ligamentos , Tratamentos com Preservação do Órgão/métodos , Tratamentos com Preservação do Órgão/estatística & dados numéricos , Prolapso de Órgão Pélvico/economia , Resultado do Tratamento
5.
Actas urol. esp ; 41(2): 117-122, mar. 2017. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-160621

RESUMO

Objetivos. El objetivo del estudio es realizar un análisis comparativo de los costes directos de la reparación del prolapso de órganos pélvicos mediante colposacropexia laparoscópica (CL) o malla transvaginal (MTV). La hipótesis inicial es que la corrección del prolapso de órganos pélvicos mediante CL presentaría al menos un coste por procedimiento similar a la corrección mediante MTV. Material y métodos. Análisis retrospectivo comparativo del coste medio por procedimiento de los primeros 69 procedimientos consecutivos de CL frente a los primeros 69 procedimientos consecutivos de MTV. Para cada procedimiento, se determinaron los costes directos: gastos estructurales, personal, ocupación de quirófano, estancia hospitalaria, material fungible e inventariable y el material protésico implantado. Se determinó el coste medio por procedimiento para cada uno de los grupos, con el intervalo de confianza al 95%. Resultados. Mientras que el grupo de CL incurrió en un mayor gasto en relación con un mayor tiempo quirúrgico, ocupación de quirófano y anestesia, el grupo de MTV incurrió en un mayor gasto en relación con una mayor estancia hospitalaria y un coste mayor del material protésico implantado. De forma global, si bien el grupo de CL presentó un coste medio por procedimiento menor que el grupo de MTV (5.985,7 Euros ± 1.550,8 Euros vs. 6.534,3 Euros ± 1.015,5 Euros), esta diferencia no alcanzó la significación estadística. Conclusiones. En nuestro medio, la corrección del prolapso de órganos pélvicos mediante CL presenta al menos, un coste por procedimiento similar a la corrección del mismo mediante MTV (AU)


Objectives. The objective of this study is to compare direct costs of repairing pelvic organ prolapse by laparoscopic sacrocolpopexy (LS) against vaginal mesh (VM). Our hypothesis is the correction of pelvic organ prolapse by LS has a similar cost per procedure compared to VM. Material and methods. We made a retrospective comparative analysis of medium cost per procedure of first 69 consecutive LS versus first 69 consecutive VM surgeries. We calculate direct cost for each procedure: structural outlays, personal, operating room occupation, hospital stay, perishable or inventory material and prosthetic material. Medium cost per procedure were calculated for each group, with a 95% confidence interval. Results. LS group has a higher cost related to a longer length of surgery, higher operating room occupation and anesthesia; VM group has a higher cost due to longer hospital stay and more expensive prosthetic material. Globally, LS has a lower medium cost per procedure in comparison to VM (5,985.7 Euros ± 1,550.8 Euros vs. 6,534.3 Euros ± 1,015.5 Euros), although it did not achieve statistical signification. Conclusions. In our midst, pelvic organ prolapse surgical correction by LS has at least similar cost per procedure compared to VM (AU)


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Prolapso de Órgão Pélvico/cirurgia , Prolapso de Órgão Pélvico , Laparoscopia/economia , Laparoscopia/métodos , Custos Diretos de Serviços , Custos e Análise de Custo/economia , Custos e Análise de Custo/métodos , Telas Cirúrgicas/economia , Telas Cirúrgicas , Estudos Retrospectivos , Intervalos de Confiança
6.
Int Urogynecol J ; 28(8): 1183-1195, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28091710

RESUMO

INTRODUCTION AND HYPOTHESIS: Hysterectomy is often performed at the time of pelvic organ prolapse (POP) surgery; yet, there is insufficient evidence regarding the specific effect of hysterectomy on outcomes. We sought to determine the outcomes and associated short-term complications of mesh-based POP surgery with and without concurrent hysterectomy. METHODS: We utilized the New York Statewide Planning and Research Cooperation System (SPARCS) database to identify patients under 55 years of age undergoing surgeries for POP with mesh between 2009 and 2014. Patients who had a hysterectomy at the time of mesh-based POP surgery were compared with those who underwent mesh-based POP surgery without hysterectomy. Outcome measures of the patient groups before and after propensity score matching were compared. We assessed the difference Chi-squared tests and log-rank tests in the entire cohort and Mantel-Haenszel stratified Chi-squared tests and Prentice-Wilcoxon tests in the matched cohort. RESULTS: A total of 1,601 women underwent mesh-based POP surgery. 921 patients underwent concurrent hysterectomy, whereas 680 had mesh-based uterine-preserving POP surgery. After propensity score matching, there was no difference in reintervention rates between groups for up to 3 years. Concurrent hysterectomy with mesh-based POP repair was consistently associated with longer hospitalization (20.0% vs 12.8% stayed longer than 2 days) and higher charges (median charges were $22,689 vs $19,273). CONCLUSIONS: Concurrent hysterectomy during mesh-based POP surgery in patients under 55 years led to more expensive charges and a longer stay compared with uterine-preserving mesh surgery. There was no difference in reintervention rates between groups for up to 3 years.


Assuntos
Histerectomia Vaginal/métodos , Tratamentos com Preservação do Órgão/métodos , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas , Vagina/cirurgia , Adulto , Estudos de Coortes , Terapia Combinada , Custos e Análise de Custo/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Humanos , Histerectomia Vaginal/economia , Tempo de Internação , Pessoa de Meia-Idade , New York , Tratamentos com Preservação do Órgão/economia , Prolapso de Órgão Pélvico/economia , Resultado do Tratamento , Útero/cirurgia
7.
Menopause ; 23(12): 1307-1318, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27504918

RESUMO

OBJECTIVE: We investigated the effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training (PFMT) in women with pelvic organ prolapse over a 2-year period. METHODS: Randomized controlled trial with women (≥55 y) with symptomatic pelvic organ prolapse, identified by screening. Participants were recruited from 20 primary care practices (October 2009-December 2012). Primary outcome was the difference in change of pelvic floor symptoms (PFDI-20 score) between groups over 24 months. Secondary outcomes included prolapse, urinary, and anorectal symptoms; quality of life; costs; sexual functioning; prolapse stage; pelvic floor muscle function; and participants' perceived symptom improvement. RESULTS: There was a nonsignificant difference in the primary outcome between pessary treatment (n = 82) and PFMT (n = 80) with a mean difference of -3.7 points (95% CI, -12.8 to 5.3; P = 0.42) in favor of pessary treatment. A significantly greater improvement in the prolapse symptom score was, however, seen with pessary treatment (mean difference -3.2 points [95% CI, -6.3 to -0.0; P = 0.05]). Direct medical costs over the 2-year study were $309 and $437 per person for pessary treatment and PFMT, respectively. CONCLUSIONS: In older women with symptomatic prolapse, there was no significant difference between pessary treatment and PFMT in reducing pelvic floor symptoms, but specific prolapse-related symptoms did improve more with pessary treatment. Pessary treatment was preferable in the cost-effectiveness analysis. When counseling women for prolapse treatment it should, however, be taken into account that pessary fitting fails in a considerable portion of women and that pessary treatment was associated with more side effects compared with PFMT.


Assuntos
Análise Custo-Benefício , Terapia por Exercício/economia , Prolapso de Órgão Pélvico/terapia , Pessários/economia , Atenção Primária à Saúde/economia , Idoso , Terapia por Exercício/métodos , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Diafragma da Pelve/fisiopatologia , Prolapso de Órgão Pélvico/economia , Resultado do Tratamento
8.
Int Urogynecol J ; 27(11): 1619-1632, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27379891

RESUMO

INTRODUCTION AND HYPOTHESIS: This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management. METHOD: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee. RESULTS: There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited. CONCLUSION: The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.


Assuntos
Prolapso de Órgão Pélvico/diagnóstico , Prolapso de Órgão Pélvico/terapia , Consenso , Tratamento Conservador , Feminino , Humanos , Prolapso de Órgão Pélvico/economia , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva
9.
Female Pelvic Med Reconstr Surg ; 22(2): 103-10, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26571432

RESUMO

OBJECTIVE: This study aimed to assess trends and factors affecting inpatient hospital costs and length of stay (LOS) in surgical treatment of pelvic organ prolapse in the United States. METHODS: A retrospective cross-sectional study along with longitudinal trend analysis from the 2001 to 2011 National Inpatient Sample included subjects who underwent inpatient prolapse repairs. The primary outcomes were inpatient mean cost per admission and LOS. We compared unadjusted differences in primary outcomes for each patient and hospital characteristic using 2011 data with analysis of variance. Multivariable regression estimated proportional change in cost and LOS associated with each characteristic. RESULTS: Unadjusted analysis revealed increased LOS with age of 80 years or older, African American race, uninsured status, lower income, and lower surgical volume hospitals (≤75%) as well as increased costs in the West and public hospitals. On multivariable analyses, African Americans had 1.09 (95% confidence interval [CI], 1.05-1.13; P < 0.001) times longer LOS compared with Caucasians, and the uninsured had 1.15 (95% CI, 1.01-1.30; P = 0.032) times longer LOS compared with those privately insured. Comorbidities associated with 20% increase in LOS and costs were pulmonary circulation disorders, metastatic cancer, weight loss, coagulopathy, and electrolyte/fluid imbalance (P < 0.001). Congestive heart failure and blood loss/deficiency anemia lead to 20% longer LOS (P < 0.001). In 2001-2011, mean LOS declined from 2.42 days (95% CI, 2.37-2.47) to 1.79 days (95% CI, 1.71-1.87) (P < 0.001), whereas mean total cost increased from $6233 (95% CI, $5859-$6607) to $9035 (95% CI, $8632-$9438) (P < 0.001). CONCLUSIONS: Inpatient surgical costs for prolapse increased despite decreasing LOS. Some patient and hospital characteristics are associated with increased inpatient costs and LOS.


Assuntos
Tempo de Internação/economia , Prolapso de Órgão Pélvico/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Custos e Análise de Custo , Estudos Transversais , Feminino , Custos Hospitalares , Humanos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Estudos Retrospectivos , Estados Unidos
10.
Int Urogynecol J ; 27(2): 233-7, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26282093

RESUMO

INTRODUCTION AND HYPOTHESIS: For the surgical correction of apical prolapse the abdominal approach is associated with better outcomes; however, it is more expensive than the transvaginal approach. This cost-effectiveness analysis compares abdominal sacral colpopexy (ASC) with sacrospinous ligament fixation (SSLF) to determine if the improved outcomes of ASC justify the increased expense. METHODS: A decision-analytic model was created comparing ASC with SSLF using data-modeling software, TreeAge Pro (2013), which included the following outcomes: post-operative stress urinary incontinence (SUI) with possible mid-urethral sling (MUS) placement, prolapse recurrence with possible re-operation, and post-operative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per quality-associated life year (QALY). Base-case, threshold, and one-way sensitivity analyses were performed. RESULTS: At the baseline, ASC is more expensive than SSLF ($13,988 vs $11,950), but is more effective (QALY 1.53 vs 1.45) and is cost-effective (ICER $24,574/QALY) at 2 years. ASC was not cost-effective if the following four thresholds were met: the rate of post-operative SUI was above 36 % after ASC or below 28 % after SSLF; the rate of MUS placement for post-operative SUI was above 60 % after ASC or below 13 % after SSLF; the rate of recurrent prolapse was above 15 % after ASC or below 4 % after SSLF; the rate of post-operative dyspareunia was above 59 % after ASC or below 19 % after SSLF. CONCLUSIONS: Abdominal sacral colpopexy can be cost-effective compared with sacrospinous ligament fixation; however, as the post-operative outcomes of SSLF improve, SSLF can be considered a cost-effective alternative.


Assuntos
Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos em Ginecologia/economia , Prolapso de Órgão Pélvico/cirurgia , Análise Custo-Benefício , Dispareunia/etiologia , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/economia , Anos de Vida Ajustados por Qualidade de Vida , Recidiva , Slings Suburetrais/efeitos adversos , Slings Suburetrais/economia , Incontinência Urinária por Estresse/etiologia , Vagina/cirurgia
11.
Fertil Steril ; 102(4): 933-8, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25274486

RESUMO

The robotic platform is a tool that has enabled many gynecologic surgeons to perform procedures by minimally invasive route that would have otherwise been performed by laparotomy. Before the widespread use of this technology, a larger percentage of hysterectomies and sacrocolpopexies were completed via the open route because of the lack of training in traditional laparoscopic suturing, knot tying, and retroperitoneal dissection. Additional deterrents of traditional laparoscopic surgery adoption have included the lengthy learning curve associated with development of advanced laparoscopic skills; and surgeon preference for the open route because of surgical ergonomics, decreased operative time, and more experience with laparotomy. Level I evidence regarding robotic-assisted laparoscopy in benign gynecology is sparse, with most of the data supporting robotic surgery comprised of retrospective cohorts. The literature demonstrates the safety and efficacy of robotic-assisted laparoscopy for hysterectomy and pelvic organ prolapse repair; however, most level I data show increased operative time and cost. The true indications for robotic-assisted laparoscopy in benign gynecology have yet to be discerned. A review of the best available evidence is summarized.


Assuntos
Histerectomia/métodos , Laparoscopia , Prolapso de Órgão Pélvico/cirurgia , Robótica , Cirurgia Assistida por Computador , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde , Humanos , Histerectomia/economia , Laparoscopia/economia , Prolapso de Órgão Pélvico/diagnóstico , Prolapso de Órgão Pélvico/economia , Robótica/economia , Cirurgia Assistida por Computador/economia , Resultado do Tratamento
13.
BJOG ; 120(2): 217-223, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23240800

RESUMO

OBJECTIVES: To assess the cost-effectiveness of a mesh-augmented anterior vaginal wall repair compared with a non-mesh fascial plication repair. DESIGN: Cost-utility analysis. SETTING: Data for outcomes of different surgical techniques were derived from systematic reviews and recent publications. METHODS: A decision-analytic Markov model, developed in TreeAge Pro 2007(®) , was used to compare the cost-utility of mesh and non-mesh anterior vaginal wall repairs. Sensitivity analysis was used to assess the impact of different scenarios and assumptions on results from the model. MAIN OUTCOME MEASURE: Health outcomes were expressed in terms of quality-adjusted life years (QALYs). RESULTS: Under base case assumptions at 5 years, the incremental cost-effectiveness ratio (ICER) for mesh-augmented anterior repairs was £15 million per QALY. Sensitivity analysis found no plausible model inputs that could make a mesh repair cost-effective by conventional criteria. This was mostly because of the extra costs associated with the price of the mesh, treating mesh erosion and difficulty finding data that support a lower reoperation rate for mesh anterior wall repairs. CONCLUSIONS: This model suggests that the use of mesh is not cost-effective.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/economia , Vagina/cirurgia , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Custos de Cuidados de Saúde , Humanos , Cadeias de Markov , Modelos Econômicos , Modelos Estatísticos , Prolapso de Órgão Pélvico/economia , Complicações Pós-Operatórias/economia , Anos de Vida Ajustados por Qualidade de Vida , Recidiva , Reoperação/economia , Resultado do Tratamento , Reino Unido
14.
Int Urogynecol J ; 24(3): 363-70, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22930214

RESUMO

Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon's audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.


Assuntos
Colposcopia/métodos , Laparoscopia/métodos , Prolapso de Órgão Pélvico/epidemiologia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas , Auditoria Clínica , Análise Custo-Benefício , Medicina Baseada em Evidências , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Prevenção Secundária , Resultado do Tratamento
15.
Eur J Obstet Gynecol Reprod Biol ; 164(2): 221-6, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22771224

RESUMO

OBJECTIVE: To compare midterm clinical outcome using modified pelvic floor reconstructive surgery with mesh (MPFR) vs Prolift devices for the treatment of pelvic organ prolapse (POP). STUDY DESIGN: This prospective observational cohort study involved 223 women with POP stages III-IV who were assigned to either MPFR (n=131) or Prolift device (n=92). Outcomes were analyzed at 6 and 12 months and the last follow-up visit postoperatively. Main outcome measures included pelvic organ prolapse quantification measurement, Short Form-20 Pelvic Floor Distress Inventory (PFDI-20), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) questionnaires, perioperative outcomes, complications, and a personal interview about urinary and sexual symptoms. Statistical analysis included comparison of means (Wilcoxon test or Student's t-test) and proportions (Chi-square test). Multivariate analysis was carried out using Cox proportional hazard model. RESULTS: At follow-up (median, 36 months; range, 17-58 months), anatomic success for MPFR and Prolift was 87.07% and 93.41%, respectively (P=0.1339). Both operations significantly improved quality of life, and PFDI-20 scores were lower in the Prolift group than the MPFR group (P=0.03). Complication rates did not differ significantly between the two groups and the prevalence of urinary symptoms decreased postoperatively in both groups. The cost of operation, however, was RMB ¥11,882.86 yuan for MPFR and ¥23,617.59yuan for Prolift (P=0.00). CONCLUSIONS: MPFR and Prolift had comparable anatomic outcomes, Prolift had better functional outcomes than MPFR, but MPFR is much cheaper than Prolift. MPFR is an alternative, cheap and effective surgical treatment option to mesh-kits for the management for POP.


Assuntos
Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Dispositivos de Fixação Cirúrgica , Telas Cirúrgicas , Vagina/cirurgia , Idoso , China/epidemiologia , Estudos de Coortes , Feminino , Doenças Urogenitais Femininas/epidemiologia , Doenças Urogenitais Femininas/etiologia , Seguimentos , Custos de Cuidados de Saúde , Humanos , Incidência , Teste de Materiais , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Prolapso de Órgão Pélvico/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Prevalência , Estudos Prospectivos , Qualidade de Vida , Dispositivos de Fixação Cirúrgica/efeitos adversos , Dispositivos de Fixação Cirúrgica/economia , Telas Cirúrgicas/efeitos adversos , Telas Cirúrgicas/economia , Inquéritos e Questionários , Equivalência Terapêutica
16.
Curr Opin Obstet Gynecol ; 24(4): 253-8, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22614674

RESUMO

PURPOSE OF REVIEW: This review is aimed to provide an update on the surgical techniques and complications of sacrocolpopexy procedures, and determine the role of minimally invasive techniques based on the most recent evidence. RECENT FINDINGS: The minimally invasive laparoscopic and robot-assisted alternatives to open abdominal sacrocolpopexy offer faster recovery, less complications and better cosmesis. However, this is suggested predominantly by retrospective comparative studies and no high-level evidence is available to date. Robot-assisted sacrocolpopexy (RASC) has enabled surgeons to overcome the steep learning curve associated with laparoscopic sacrocolpopexy at the expense of a higher cost. Recent data, testing its potential advantages of reduced operative time and postoperative pain, have revealed contradictory results. A novel, totally retroperitoneal sacrocolpopexy procedure aimed to eliminate complications associated with transperitoneal access may become an option in patients unsuitable for minimally invasive techniques, but warrants further investigation. SUMMARY: The benefits of RASC must be weighed against the lack of current evidence to prove its superiority over conventional procedures in terms of faster recovery and cost-effectiveness. There is a need for better reporting of complications associated with these novel techniques and for long-term, randomized comparative data.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Laparoscopia , Prolapso de Órgão Pélvico/cirurgia , Robótica , Sacro/cirurgia , Adulto , Idoso , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Pessoa de Meia-Idade , Satisfação do Paciente , Prolapso de Órgão Pélvico/economia , Prolapso de Órgão Pélvico/fisiopatologia , Robótica/economia , Robótica/métodos , Cirurgia Assistida por Computador , Resultado do Tratamento
17.
Int Urogynecol J ; 22(5): 507-15, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21360216

RESUMO

INTRODUCTION AND HYPOTHESIS: To compare the relative cost effectiveness of treatment decision alternatives for post-hysterectomy pelvic organ prolapse (POP). METHODS: A Markov decision analysis model was used to assess and compare the relative cost effectiveness of expectant management, use of a pessary, and surgery for obtaining months of quality-adjusted life over 1 year. Sensitivity analysis was conducted to determine whether the results depended on specific estimates of patient utilities for pessary use, probabilities for complications and other events, and estimated costs. RESULTS: Only two treatment alternatives were found to be efficient choices: initial pessary use and vaginal reconstructive surgery (VRS). Pessary use (including patients that eventually transitioned to surgery) achieved 10.4 quality-adjusted months, at a cost of $10,000 per patient, while VRS obtained 11.4 quality-adjusted months, at $15,000 per patient. Sensitivity analysis demonstrated that these baseline results depended on several key estimates in the model. CONCLUSIONS: This analysis indicates that pessary use and VRS are the most cost-effective treatment alternatives for treating post-hysterectomy vaginal prolapse. Additional research is needed to standardize POP outcomes and complications, so that healthcare providers can best utilize cost information in balancing the risks and benefits of their treatment decisions.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Laparoscopia/economia , Prolapso de Órgão Pélvico/terapia , Pessários/economia , Robótica/economia , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Cadeias de Markov , Prolapso de Órgão Pélvico/economia , Medição de Risco
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