RESUMO
OBJECTIVE: Our objective was to perform a 5-year cost-effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse. DESIGN: A decision analytic model assessed the cost-effectiveness of the surgical intervention over a 5-year horizon. SETTING: This model was constructed using TreeAge® software. POPULATION OR SAMPLE: Healthy women undergoing surgery for uterine prolapse were modeled. METHODS: A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed. MAIN OUTCOME MEASURES: The primary outcome was the incremental cost-effectiveness ratio (ICER) of <$100 000 per quality-adjusted life year (QALY). RESULTS: Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP-SS and HP-US are cost-effective at a willingness-to-pay (WTP) threshold of <$100 000 per QALY. The incremental cost-effectiveness ratio (ICER) for HP-US compared to HP-SS is $90 738.14, while VH-US and VH-SS are both dominated strategies. HP-US is the optimal cost-effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost-effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000. CONCLUSION: Hysteropexy surgical strategies are cost-effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost-effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost-effectiveness relationship between these different surgical approaches.
Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Histerectomia Vaginal , Prolapso Uterino/cirurgia , Análise Custo-Benefício , Análise de Custo-Efetividade , Resultado do Tratamento , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos em Ginecologia , HisterectomiaRESUMO
PURPOSE: To identify factors associated with urinary incontinence (UI) in women of various Hispanic/Latina backgrounds. MATERIALS AND METHODS: We analyzed data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a multicenter, community-based cohort study which includes a health-related questionnaire assessing presence and type of UI. Complex survey logistic regression analysis was used to assess the cross-sectional association of Hispanic/Latina backgrounds and other factors of UI. All estimates accounted for HCHS/SOL survey design. RESULTS: Of 5027 women, 33.4% answered "yes" to UI. Rates of any UI ranged from approximately 21.9% to 40.3% in women of Dominican and Puerto-Rican background, respectively. Any UI and UI subtypes were associated with age older than 65 years, increasing body mass index, smoking status, any alcohol use, parity ≥3, and postmenopausal status. After controlling for covariates and when compared with women of Mexican background, women of Dominican background were less likely to have any UI (OR = 0.42, 95% CI 0.30-0.57), as were women of Cuban (OR = 0.48, 95% CI 0.37-0.62), Puerto-Rican (OR = 0.79, 95% CI 0.62-1.0), and mixed (OR = 0.62, 95% CI 0.39-0.99) background; and women of every other background except for South American were less likely to have stress UI. In addition, women of Cuban (OR = 0.53, 95% CI 0.32-0.86) and mixed (OR = 0.38, 95% CI 0.16-0.87) background were less likely to have urge UI than women of Mexican background. CONCLUSIONS: Our study demonstrates differences in UI by Hispanic/Latina background, suggesting collective designation of Hispanics/Latinas as a single ethnic group does not adequately describe UI among this diverse group.
Assuntos
Hispânico ou Latino , Saúde Pública , Humanos , Estados Unidos/epidemiologia , Feminino , Idoso , Estudos Transversais , Estudos de Coortes , Incontinência Urinária de Urgência , Fatores de Risco , PrevalênciaRESUMO
PURPOSE: We sought to determine the association between socioeconomic factors, procedural costs, and postoperative complications among patients who underwent sacrocolpopexy. METHODS: The 2016-2017 US National Inpatient Sample from the Healthcare Cost and Utilization Project was used to identify females > 18 years of age with an ICD10 diagnosis code of apical prolapse who received open or laparoscopic/robotic sacrocolpopexy. We analyzed relationships between socioeconomic factors, procedural costs, and postoperative complications in these patients. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs, respectively. RESULTS: We identified 4439 women who underwent sacrocolpopexy, of which 10.7% had complications. 34.6% of whites, 29.1% of Blacks, 29% of Hispanics, and 34% of Others underwent a laparoscopic/robotic procedure. Hispanic patients had the highest median charge associated with surgical admission for sacrocolpopexy at $51,768, followed by Other ($44,522), White ($43,471), and Black ($40,634) patients. Procedure being within an urban teaching hospital (+ $2602), laparoscopic/robotic (+ $6790), or in the West (+ $9729) were associated with a significantly higher median cost of surgical management. CONCLUSIONS: In women undergoing sacrocolpopexy, the protective factors against postoperative complications included private insurance status, a laparoscopic approach, and concurrent hysterectomy. Procedures held within an urban teaching hospital, conducted laparoscopically/robotically or in the West are associated with significantly higher costs of surgical management. Hispanic patients observe significantly higher procedure charges and costs, possibly resulting from the large number of this ethnic group living in the Western United States.
Assuntos
Laparoscopia , Prolapso de Órgão Pélvico , Humanos , Feminino , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos em Ginecologia/métodos , Prolapso de Órgão Pélvico/cirurgia , Pacientes Internados , Disparidades Socioeconômicas em Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Laparoscopia/métodos , Estudos RetrospectivosRESUMO
PURPOSE OF REVIEW: To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery. RECENT FINDINGS: Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.
Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Prolapso de Órgão Pélvico/cirurgia , Prolapso de Órgão Pélvico/etiologia , Prolapso Uterino/cirurgia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Qualidade de Vida , Útero/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION AND HYPOTHESIS: Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. METHODS: All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. RESULTS: In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p < 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). CONCLUSIONS: Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.
Assuntos
Prolapso de Órgão Pélvico , Slings Suburetrais , Incontinência Urinária por Estresse , Incontinência Urinária , Feminino , Humanos , Prolapso de Órgão Pélvico/cirurgia , Reoperação , Slings Suburetrais/efeitos adversos , Incontinência Urinária/epidemiologia , Incontinência Urinária/cirurgia , Incontinência Urinária por Estresse/cirurgiaRESUMO
OBJECTIVES: Our primary objective was to determine rectal prolapse (RP) and pelvic organ prolapse (POP) reoperation rates and postoperative < 30-day complications after combined RP and POP surgery at a single institution. METHODS: This was an IRB-approved retrospective cohort study of all female patients who received combined RP and POP surgery at a single tertiary care center from 2008 to 2019. Recurrence was defined as the need for subsequent repeat RP or POP surgery at any point after the index surgery. Surgical complications were separated into Clavien-Dindo classes. RESULTS: Sixty-three patients were identified, and 18.3% (12/63) had < 30-day complications (55% Clavien-Dindo grade 1; 27% Clavien-Dindo grade 2; 18% Clavien-Dindo grade 4). Of patients undergoing combined abdominal RP and POP repair, no postoperative < 30-day complications were noted in the MIS group compared to 37.5% of those patients in the laparotomy group (p < 0.01). Overall, in those patients who underwent combined RP and POP surgery, the need for subsequent RP surgery for recurrent RP was 14% and the need for subsequent POP surgery for recurrent POP was 4.8% (p = 0.25). CONCLUSION: In this cohort of women undergoing combined RP and POP surgery, a higher proportion required subsequent RP surgery compared to those requiring subsequent POP surgery, although this was not statistically significant. Almost one-fifth of patients undergoing combined RP and POP surgery experienced a < 30-day surgical complication, regardless of whether the approach was perineal or abdominal. For those patients undergoing abdominal repair, < 30-day complications were more likely in those patients who had a laparotomy compared to those who had a minimally invasive surgery.
Assuntos
Prolapso de Órgão Pélvico , Prolapso Retal , Feminino , Humanos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reto , Reoperação , Estudos RetrospectivosRESUMO
OBJECTIVE: Sacral nerve stimulation (SNS) is an effective treatment for refractory overactive bladder (OAB). However, advanced age is often cited as a reason to avoid SNS in the elderly. This study evaluates the safety and efficacy of SNS for refractory OAB among our octogenarian population. METHODS: A retrospective review from a single institution was performed on all SNS lead placements from December 1998 to June 2017 for refractory OAB. Octogenarians were characterized as 80 years of age or older at the time of Stage I. Efficacy and safety were determined by the rate of progression to Stage II, subsequent need for multimodal therapy, and rate of surgical revision and explantation. All patients were followed for a minimum of 12 months. RESULTS: Of 374 patients in this study, 37 (9.9%) were octogenarians. There was no difference in gender, race, smoking history, or prior OAB treatment regimens between cohorts. The rate of progression to Stage II was 56.8% for octogenarians compared to 60.5% for nonoctogenarians (p = 0.66). The rate of surgical revision, explantation, and need for multimodal therapy did not differ between groups. Subgroup analysis of octogenarians did not reveal any significant differences between successful and nonsuccessful Stage I patients. CONCLUSIONS: The safety and efficacy of SNS was similar between cohorts. This result suggests that SNS is a safe and effective therapy that should be considered among the treatment options for refractory OAB in octogenarian patients. Further studies are needed to determine predictive factors of Stage I success in elderly patients.
Assuntos
Terapia por Estimulação Elétrica/métodos , Plexo Lombossacral/fisiologia , Bexiga Urinária Hiperativa/diagnóstico , Bexiga Urinária Hiperativa/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Terapia por Estimulação Elétrica/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Bexiga Urinária Hiperativa/fisiopatologiaRESUMO
The objective of the article is to review key guidelines on the management of urinary incontinence (UI) to guide clinical management in a practical way. Guidelines produced by the European Association of Urology (updated in 2014), the Canadian Urological Association (updated in 2012), the International Consultation on Incontinence (updated in 2012), and the National Collaborating Centre for Women's and Children's Health (updated in 2013) were examined and their recommendations compared. In addition, specialised guidelines produced by the collaboration between the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction on overactive bladder and the use of urodynamics were reviewed. The Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument was used to evaluate the quality of these guidelines. There is general agreement between the groups on the recommended initial evaluation and the use of conservative therapies for first-line treatment, with a limited role for imaging or invasive testing in the uncomplicated patient. These groups have greater variability in their recommendations for invasive procedures; however, generally the mid-urethral sling is recommended for uncomplicated stress UI, with different recommendations on the approach, as well as the comparability to other treatments, such as the autologous fascial sling. This 'Guideline of Guidelines' provides a summary of the salient similarities and differences between prominent groups on the management of UI.
Assuntos
Incontinência Urinária , Feminino , Humanos , Guias de Prática Clínica como Assunto , Incontinência Urinária/diagnóstico , Incontinência Urinária/terapia , UrodinâmicaRESUMO
OBJECTIVE: To characterize prevalence and severity of pelvic floor disorders (PFDs) in various health care settings and to examine unmet health-related social needs (HRSN) among minority women. MATERIALS AND METHODS: Minority women with PFDs were recruited from our academic urogynecology clinic, a general urology clinic at our institution's safety net hospital, and a community outreach mobile clinic. Questions from the Urinary Distress Index-6, Pelvic Organ Prolapse Distress Inventory-6, and Female Genitourinary Pain Index were used to identify patients with stress urinary incontinence, overactive bladder (OAB), and chronic pelvic pain syndrome (CPPS). RESULTS: Sixty-one (46.6%) women identified as Hispanic, 53 (40.4%) as Black, and 17 (12.9%) as Other. Overall, self-reported PFDs included stress urinary incontinence in 45%, OAB in 74.8%, and CPPS in 24.4% of women. Hispanic women were more likely to report OAB symptoms, compared to Black women (odds ratio (OR) 3.4 [1.2-10.2], P = .03) or Other women (OR = 5.1 [1.3-20.4], P = .02). Participants held a median of 5 unmet HRSN. Minority women facing issues with family and community support, transportation, and utilities were more likely to report CPPS symptoms, compared to those without psychosocial issues (support OR: 4.8 [1.7-13.7], P = .002; transportation OR: 2.0 [1.0-8.2], P = .05; utility OR: 7.0 [1.9-28.1], P = .005). CONCLUSION: Minority women with PFDs may have several unmet HRSNs which impact their ability to receive appropriate medical care. Our findings may assist in the development of effective strategies to improve health care outcomes for women dealing with PFDs.
Assuntos
Distúrbios do Assoalho Pélvico , Prolapso de Órgão Pélvico , Bexiga Urinária Hiperativa , Incontinência Urinária por Estresse , Feminino , Humanos , Distúrbios do Assoalho Pélvico/epidemiologia , Distúrbios do Assoalho Pélvico/psicologia , Incontinência Urinária por Estresse/epidemiologia , Prevalência , Bexiga Urinária Hiperativa/epidemiologia , Prolapso de Órgão Pélvico/epidemiologia , Prolapso de Órgão Pélvico/psicologiaRESUMO
OBJECTIVE: To assess how race, ethnicity, primary language, clinical and other sociodemographic factors predict surgical treatment for pelvic organ prolapse (POP) in a minority-majority Hispanic population. METHODS: We identified patients with POP ICD-10 codes from Oct 2019 to Dec 2022 at our Urogynecology academic practice. Data were collected by chart review. Covariates were obtained by manual abstraction. Continuous and categorical variables were analyzed using t-test and chi-square test, and Wilcoxon rank-sum test for non-parametric data. A logistic regression model was fitted to identify independent predictors of surgery. RESULTS: Of 943 patients over 38 months, 441 (46.8%) underwent surgery. On univariate analysis, younger age, Hispanic/Latino ethnicity, Spanish as primary language, private insurance, stage of prolapse and obesity correlated with higher rates of surgical treatment. On multivariate regression, only age and prolapse compartment remained significant predictors. Younger age and apical prolapse increased the likelihood of surgery (OR=.98 [.96-.99], P = <.001; R=2.31 [1.13-4.72], P = <.001, respectively). CONCLUSION: Controlling for confounders, age, and apical prolapse compartment predicted surgical treatment for POP in our Hispanic minority-majority population. Previously identified barriers to care including minority status and non-English primary language do not appear to exist in our population. This may be related to linguistic, ethnic, and racial concordance between healthcare staff and patients, alongside protective aspects of ethnic enclaves. Further research is warranted to understand the impact of cultural barriers, such as provider language, on patient-provider dynamics and surgical decision-making.
RESUMO
CONTEXT: Polycystic Ovary Syndrome (PCOS) is a multifaceted endocrine disorder with reproductive and metabolic dysregulation. PCOS has been associated with inflammation and Metabolic Syndrome (MetS); however, the moderating effects of inflammation as measured by C-reactive protein (CRP) and menopause on the PCOS-MetS association have not been studied in Hispanic/Latinas with PCOS who have a higher metabolic burden. OBJECTIVE: We studied the cross-sectional association between PCOS and (i) MetS in 7316 females of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), (ii) subcomponents of MetS including impaired fasting glucose (IFG) and elevated triglycerides (TGL), and (iii) effect modification by menopausal status and CRP. DESIGN: HCHS/SOL is a multicenter, longitudinal, and observational study of US Hispanic/Latinos. Our study sample included females from Visit 2 with self-reported PCOS and MetS (ages 23-82 years). RESULTS: PCOS (prevalence=18.8%) was significantly associated with MetS prevalence (OR=1.41[95% confidence interval: 1.13-1.76]), IFG and TGL (OR=1.42[1.18-1.72], OR=1.48[1.20-1.83] respectively). We observed effect modification by menopausal status (ORpre=1.46, pint=0.02; ORpost=1.34, pint=0.06) and CRP (ORelevated=1.41, pint=0.04; ORnormal=1.26, pint=0.16) on the PCOS-MetS association. We also observed a super-additive interaction between CRP and PCOS, adjusting for which resulted in an attenuated effect of PCOS on MetS (OR=1.29[0.93-1.78]). CONCLUSIONS: Hispanic/Latino females with PCOS had higher odds of MetS, IFG, and elevated TGL, than their peers without PCOS. Interaction analyses revealed that the odds of MetS are higher among PCOS females who have pre-menopausal status or high inflammation. Interventions in Hispanic/Latinas should target these outcomes for effective management of the disease.
RESUMO
INTRODUCTION: To ensure patient satisfaction during the COVID-19 pandemic, hospitals implemented changes to elective surgeries while upholding safety and quality of care. This includes a growing trend toward same-day discharge (SDD) following apical pelvic organ prolapse (POP) repair surgery, which previously involved overnight hospitalization for some institutions. We assessed patient perspectives following SDD after transvaginal and minimally invasive apical POP repair during the pandemic. METHODS: This was a cross-sectional study of women who underwent apical POP surgery. Preoperatively, we assessed preference for SDD. A postoperative survey evaluated perceived safety, pain control and satisfaction using the "Core questionnaire for the assessment of Patient Satisfaction for general Day-care" and the "Patient Global Impression of Improvement." Postoperative complications were identified. RESULTS: Of 36 recruited patients, 83.3% preferred SDD preoperatively. When rating the influence of COVID-19 on their preference (1-10, 10=high), 13 reported level 10 and 11 reported level 1 (mean 5.9±4.0). A total of 34 postoperative surveys were collected, 29 of which were SDD (85.3%); 89.7% of patients reported feeling safer with SDD, and 40% (2/5) of admitted patients would have preferred SDD. Pain control satisfaction for SDD was assessed on a Likert scale (1-10, 10=very satisfied), with a mean of 9.1 (±1.8); 82.8% of SDD patients rated their overall experience as "very satisfied" and consistently rated individual components highly. CONCLUSIONS: During the pandemic, our patient population preferred SDD after an apical POP repair with a high success and satisfaction rate with minimal complications. In the absence of a pandemic, SDD should be considered to increase patient satisfaction.
RESUMO
Numerous studies have investigated the influence of health disparities among women with pelvic floor disorders with varied results. Racial/ethnic disparities, in particular, inconsistently indicate differences in prevalence of disease, disease severity, and treatment outcomes. We aim to review the body of literature examining racial/ethnic disparities in pelvic floor disorders, including overactive bladder, stress urinary incontinence, pelvic organ prolapse, and interstitial cystitis. A better understanding of these disparities may help guide clinicians, researchers, and advocates in providing improved education, outreach opportunities, and access to care in minority women with pelvic floor disorders.
Assuntos
Incontinência Fecal , Distúrbios do Assoalho Pélvico , Prolapso de Órgão Pélvico , Bexiga Urinária Hiperativa , Incontinência Urinária por Estresse , Feminino , Humanos , Prolapso de Órgão Pélvico/epidemiologia , Bexiga Urinária Hiperativa/epidemiologia , Incontinência Urinária por Estresse/epidemiologiaRESUMO
Urinary incontinence is common after spinal cord injury (SCI) due to loss of supraspinal coordination and unabated reflexes in both autonomic and somatic nervous systems; if unchecked, these disturbances can become life-threatening. This manuscript will review normal anatomy and physiology of the urinary system and discuss pathophysiology secondary to SCI. This includes a discussion of autonomic dysreflexia, as well as its diagnosis and management. The kidneys and the ureters, representing the upper urinary tract system, can be at risk related to dyssynergy between the urethral sphincters and high pressures that lead to potential vesicoureteral reflux, urinary tract infections, and calculi associated with neurogenic lower urinary tract dysfunction (NLUTD). Recent guidelines for diagnosis, evaluation, treatment and follow up of the neurogenic bladder will be reviewed and options provided for risk stratification and management. Mechanical, pharmacological, neurolysis and surgical management will be discussed.
RESUMO
Introduction Although women remain vastly underrepresented in urology, the proportion of female urology residents and practicing urologists has steadily increased over the last four decades. However, it remains critical to evaluate the representation of females in the pipeline when examining trainees and practicing urologists. As it pertains to leadership positions, the gender distribution among the board of directors (BOD) and committee chairs in the American Urological Association (AUA) subspecialties has not been studied to date. Therefore, we plan to analyze the proportion of females among the BOD and committee chairs in different subspecialty societies recognized by the AUA over time. Methods We conducted a cross-sectional observational study, quantitatively comparing the composition of gender in BOD and Committee Chair members belonging to different AUA-recognized subspecialty societies from 2014 to 2020. The websites for each subspecialty society were searched and contacted. Results We evaluated BODs from 10 AUA subspecialty societies and committee chair members from 6 AUA subspecialty societies. From 2014 to 2020, the total proportion of female BOD amongst all AUA sub-specialty societies did not change significantly, with a small increase from 10.6% (n = 29) to 13.5% (n = 36). However, female representation among committee chair members significantly increased from 9.8% (n = 20) to 19.2% (n = 44; p = 0.006), along with the total number of women in urology, from 897 (8.9%) to 1,375 (10.3%). Increases in female representation were seen in the Society for the Study of Male Reproduction (SSMR) from 0% to 9% and in the Indian American Urological Association (IAUA) from 4% to 13%. Of note, there were no elected female board members in the Society of Urologic Oncology (SUO) or the Urologic Society for Transplantation and Renal Surgery (USTRS) from 2014 to 2020. Conclusion Females remain a minority in leadership positions at AUA sub-specialty societies despite increased female representation in recent years. Future efforts should promote the advancement of women to positions of leadership to reflect the changing landscape of the urology workforce and surgical specialties.
RESUMO
OBJECTIVE: To determine if racial and/or socioeconomic factors influence advanced therapy utilization for refractory overactive bladder (OAB) among the commercially insured. METHODS: We queried Optum, a national claims database, between 2003 and 2017. Non-neurogenic OAB patients were identified using ICD-9/10 diagnosis codes. Demographic and treatment data were collected, including oral medication therapies (anticholinergic, beta3 agonists), and advanced therapies (OnabotulinumtoxinA [BTX], Sacral Nerve Stimulation [SNS], percutaneous tibial nerve stimulation [PTNS]). Associations between patient sociodemographic factors and advanced therapy utilization were explored. RESULTS: Of 4,229,617 OAB patients, 807,612 (19%) received medical therapies, of which 95% received oral medications only and only 4.7% received advanced therapies. Asians had the lowest use of oral therapy use (14% vs 18%-19% in other races/ethnicities, P <0.05), and advanced therapy use (0.44% vs 0.71%-0.93%, P <0.05). Asians and Hispanics were least likely to utilize SNS therapy and most likely to use PTNS compared to Blacks and Whites. BTX use was similar between races/ethnicities (P <0.05). Female gender (OR 1.65 [CI 1.61,1.69]), younger age (<65) (OR 1.28 [1.25,1.31]), higher annual income ≥$40K (OR 1.09 [1.06,1.12]) and prior use of oral medications (OR 3.30 [3.21,3.38] for 1 medication) were significantly associated with receiving advanced therapies. Non-white race (OR 0.89 [0.87,0.91]), lower education level (less than a bachelor's degree) (OR 0.97 [0.94,0.99]), and Northeast region were associated with a lower likelihood of receiving advanced therapies (P <0.05 for all). CONCLUSION: Among commercially insured, racial and socioeconomic factors predict utilization of advanced OAB therapies, including race/ethnicity, age, gender, education level, and region.
Assuntos
Fármacos Neuromusculares/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde , Estimulação Elétrica Nervosa Transcutânea , Bexiga Urinária Hiperativa , Adrenérgicos/uso terapêutico , Toxinas Botulínicas Tipo A/uso terapêutico , Antagonistas Colinérgicos/uso terapêutico , Feminino , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fatores Sociodemográficos , Estimulação Elétrica Nervosa Transcutânea/métodos , Estimulação Elétrica Nervosa Transcutânea/estatística & dados numéricos , Estados Unidos/epidemiologia , Bexiga Urinária Hiperativa/epidemiologia , Bexiga Urinária Hiperativa/terapiaRESUMO
BACKGROUND: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. METHODS: 91 consecutive patients ≥18 years old diagnosed with external and/or high-grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgment, and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. RESULTS: Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p < 0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with a recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. CONCLUSIONS: With multiple options available for the treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.
Assuntos
Tomada de Decisão Clínica , Cirurgia Colorretal/métodos , Prolapso Retal/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesia/psicologia , Cirurgia Colorretal/psicologia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/psicologia , Índice de Gravidade de Doença , Telas CirúrgicasAssuntos
Artéria Celíaca/anormalidades , Doença Celíaca/diagnóstico , Constrição Patológica/diagnóstico , Fasciite/diagnóstico , Hemossiderose/diagnóstico , Hiperbilirrubinemia Neonatal/diagnóstico , Pneumopatias/diagnóstico , Miosite/diagnóstico , Dor Abdominal/etiologia , Adolescente , Criança , Fasciite/microbiologia , Feminino , Hemoptise/etiologia , Hemossiderose/etiologia , Humanos , Recém-Nascido , Icterícia Neonatal/etiologia , Pneumopatias/etiologia , Síndrome do Ligamento Arqueado Mediano , Limitação da Mobilidade , Miosite/microbiologia , Dor/etiologia , Infecções Estreptocócicas/diagnóstico , Streptococcus pyogenes , Redução de Peso , Hemossiderose PulmonarRESUMO
Several transvaginal mesh products have been marketed to address vaginal vault prolapse. Although data are limited, prolapse recurrence rates and subjective outcome measures seem to be equivalent for vaginal mesh compared with native tissue apical prolapse repair, and the different vaginal meshes have not proven superior to one another. Given the known unique complications specific to vaginal mesh with equivalent outcomes for the apical vaginal prolapse, it is reasonable to reserve mesh use for specific high-risk cases, such as patients with large apical prolapse recurrence after native tissue repair who are not candidates for sacrocolpopexy.