The changing face of stress urinary incontinence and vaginal prolapse surgery in Australia, 2008-2018
Dr Janelle Brennan (1), (2), Dr Rebecca Mathieson (1), Dr Todd Manning (1), A/Prof Rebecca Kippen (3)
(1) Bendigo Health, Bendigo, Australia, (2) St Vincent’s Hospital, Melbourne , Fitzroy, Australia, (3) School of Rural Health, Monash University, Bendigo, Australia
The introduction of the tension-free vaginal tape (TVT) in 1995 (1) heralded a new approach for the management of stress urinary incontinence (SUI) worldwide and led to a substantial increase in the total number of incontinence procedures being performed. In Australia, mid-urethral slings (MUS) quickly became the standard option for surgical management of SUI (2). In more recent years, there has been heightened publicity regarding the complications of vaginal mesh for both SUI and pelvic organ prolapse (POP) procedures, culminating in an Australian Senate Inquiry into transvaginal mesh implants (3). The current paper seeks to identify the latest trends in the management of SUI and POP and assess whether the recent negative publicity surrounding the use of mesh products will have impacted the utilisation of such procedures in Australia.
The number and type of surgical procedures for the management of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) from July 2008 to June 2018 was obtained from the Australian Government Department of Human Services (DHS) database using the relevant Medicare Benefits Schedule (MBS) item numbers. The data extracted was limited to females, 25 years and older. This data was then standardized to the age structure of the 2011 Australian population to be able to accurately analyze trends in the usage of different procedures.
Rates declined for most SUI procedures over time (MUS, colposuspension, fascial slings) except urethral bulking agents. The absolute number of MUS implanted in 2008/9 was 5729, which decreased to 3129 in the 2017/18 financial year. Over the decade the annual rate for MUS implantation per 100,000 population halved from 78 to 36 (Figure 1). Over this same period, the rate of usage of bulking agents doubled (Figure 2), although represented a low volume of procedures (overall numbers increased from 304 to 638 representing an increase from 4 to 8 procedures per 100,000 population). The age-specific peak rate for MUS and Burch colposuspension changed over the decade from 55-64 years to 65-74 years suggesting that women are deferring surgical treatment until later in life. Over the last decade the total number of surgical procedures performed in Australia to treat SUI has decreased markedly from 6812 to 4279. This represents a significant decrease in the annual rate per 100,000 population from 93 to 49. Declines are also evident in procedures for anterior vaginal repair, posterior vaginal repair and combined anterior & posterior vaginal repair. Rates of procedures per 100,000 have decreased from 25 to 15, 27 to 23 and 59 to 45, respectively. Collectively, the procedures had a peak in 2013/14 with a combined total of 12722 cases, which decreased to 10450 in the 2017/18 financial year. Over the same time period there has been a marginal increase in laparoscopic or abdominal pelvic floor procedures, from a total of 456 cases in 2008/09 to 1381 in 2017/18, but this still represents an overall decline in the total number of surgical procedures for treatment of POP.
Rates of procedures for both SUI and POP have experienced a decline during the past decade, with notable changes in 2014/15 and 2017/18. This coincides with the Australian Government Department of Health's Therapeutic Goods Administration releasing results of a review into urogynaecological mesh implants (August 2014) and subsequently removing the use of transvaginal mesh implants for pelvic organ prolapse (December 2017). There are clear trends demonstrating a change in the volume of procedures being performed for both SUI and POP in Australia. With the removal of single incision mini slings, well-publicised class actions relating to MUS and increased regulation for surgeons using mesh, it is likely that other operative alternatives will continue to gain popularity with surgeons and patients. Surgeons must seek to engage patients and educate them regarding the safety of not only mid-urethral slings but also other SUI and POP modalities. This must be done to mitigate the risk of patients suffering from under-treatment of potentially debilitating incontinence and prolapse conditions.