Trends in Primary surgery and Re-operation for Female Stress Urinary Incontinence in Taiwan: a descriptive nationwide study Yi-Yin Liu1, Ming-Ping Wu1 1Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital, Tainan, Taiwan

Jonsson Funk M,et al. Gynecol 2012;120:83–90. Introduction Urinary incontinence affects 14–25% of all women About 200 different surgical procedures have been described for over 100 years Post-operative SUI recurrence is a common problem A health-care database survey in the United States showed a 14.5% 9-year cumulative incidence rate for repeat SUI surgery 8.8% lifetime risk of reoperation rate for SUI in the UK form a registry linkage study Jonsson Funk M,et al. Gynecol 2012;120:83–90. Abdel-fattah M, et al. BMJ Open 2011;1:e000206. doi:10.1136/bmjopen-2011-000206

Aims of study Using the National Health Insurance database in Taiwan to identify The changing trends of primary surgery The rate and associated factors for re-operation of female stress urinary incontinence

MATERIALS AND METHODS

Study Subjects Primary surgery: Female patient received surgeries for SUI in Taiwan from 1996 to 2010 Reoperation: Primary surgery for SUI from Jan, 2000 to Dec, 2006 Followed till December 2010 or the time when reoperation occurred 研究對象為患有應力性尿失禁,且曾經在2000年一月到2006年12月期間接受第一次手術治療的女性病人, 追蹤到2010的12月底或是再次手術發生的時間。手術的方式分成五大類,分別是

Data source NHIRD The in-patient expenditure file The contracted medical facility The registry of medical personnel Itemized hospital bills Dates of admission and discharge Codes for diagnosis Treatment Surgeries Patient demography Accreditation level Geographical location The attending physician’s Age Sex Medical specialty 在健保資料庫中,住院病人的檔案可收集包含各項醫療花費,住院的日期,診斷編碼,治療方式,手術方式,區域等資訊..合作醫療機構的層級和地區,執業醫師的年齡,性別,專科等資料

Types of anti-incontinence surgeries Study Subjects Types of anti-incontinence surgeries Retropubic urethropexy (RPU, ICD-9-CM code 59.5) Pubovaginal sling (PVS, ICD-9 CM code 59.4) Mid-urethral sling (MUS, ICD-9-CM code 59.79) Vaginal procedures (ICD-9-CM code 59.3, 59.6) Periurethral injection (ICD-9-CM code 59.72) Anti- incontinence surgeries Marshall-Marchetti-Krantz procedure Burch colposuspension Kelly plication (ICD-9-CM code 59.3) Needle suspension (ICD-9-CM code 59.6) Pubovaginal sling:  In the autologous sling procedure,  a harvested strip of rectus fascia is placed transvaginally at the level of the proximal urethra. The fascial strip is secured superiorly to the rectus fascia with permanent sutures

RESULT

Surgical types for stress urinary incontinence by year RPU (59.5) PUS (59.4) MUS (59.79) Kelly (59.3) Needle (59.6) Injection (59.72) Total 1996 38.08% 11.11% 11.38% 12.87% 26.56% 100.00% 1997 38.07% 9.29% 19.27% 10.44% 22.94% 1998 56.35% 8.08% 22.63% 5.23% 7.70% 1999 52.19% 9.50% 24.90% 6.97% 6.44% 2000 44.56% 14.94% 28.81% 5.31% 6.38% 2001 44.78% 20.24% 24.01% 3.82% 7.15% 2002 44.11% 25.27% 20.38% 4.80% 5.43% 2003 45.41% 21.10% 24.09% 3.79% 4.22% 1.39% 2004 47.89% 14.90% 27.95% 4.58% 2.50% 2.17% 2005 41.69% 12.89% 34.38% 4.28% 2.98% 3.78% 2006 29.68% 9.33% 53.09% 3.07% 2.18% 2.64% 2007 22.22% 6.96% 65.46% 2.03% 1.08% 2.25% 2008 20.44% 68.81% 2.22% 0.81% 2.42% 2009 17.48% 4.03% 74.60% 1.47% 0.56% 1.85% 2010 12.99% 3.46% 78.74% 2.00% 0.97% 1.84% 33.54% 11.01% 45.89% 3.84% 4.18% 1.55%

Surgical Trend for SUI 1996-2010

↓2.3X ↑2.7X The surgical skills and knowledge spread from medical centers into regional hospitals.

The Reoperation Rate Among Different Types of Primary Surgeries 研究結果在2000~2006年間總共有14613名女性接受第一次應力性尿失禁手術, 手術的平均年齡是54歲，其中以RPU最多佔4成,其次是MUS佔3成,再來是PVS,vaginal procedure 和 peri-urethral injection。初次尿失禁手術約30%同時進行hysterectomy。 Mean age 54 y/o Mean F/U period: 86.28 ± 26.76 month

The Reoperation Rate Among Different Types of Primary Surgeries 在再次手術率方面, 總共的再手術率為 3.85% Injection procedures有最高的再手術率為35.64%, Overall reoperation rate: 3.85 % (563/14613) Incidence rate: 54.37 per 10000 person year.

The Reoperation Rate Among Different Types of Primary Surgeries Mean interval: Injection Procedure MUS Kelly plication PVS Needle suspension RPU 15.74 mo 30.42 mo 32.49 mo 33.94 mo 44.27 mo 47.86 mo 再次手術平均是發生在第一次手術後36個月, 兩次手術期間相隔最短的是 injection group (平均15個月), 其次是MUS (30個月), 最長的是RPU(47.89 個月). Mean interval 36 mo

Predictive Variables for Reoperations Primary surgical types Surgery volume Year Surgeon gender Accreditation level * 1.3 * 針對可能影響再次手術的因素 如初次手術的術式,醫師的手術經驗,醫師的專科, 性別,進行手術的年份,等等進行分析,發現初次手術的術式中,採取injection的手術 方式, 之後再次手術的hazard ratio (HR) 最高, 與RPU相比為 11.86倍, , 初次手術 採取MUS的group,再手術的ＨR也顯著高於RPU是1.30.

Predictive Variables for Reoperations Primary surgical types Surgery volume Year Surgeon gender Accreditation level 手術量大的醫師有比較低的再手術率, 泌尿科專科醫師的再手術率比婦科專科醫 師高,HR 1.5 有統計學上的意義。其他像是醫師性別,初次手術的年分, 醫院的規 模層級與再次手術的機率無顯著相關。

The Choice of Surgery for Reoperations 當進行第二次尿失禁手術時,選擇的術式又有怎樣的變化呢？研究發現,半數以上會選擇不同的術式, 43%選擇相同術式, MUS是再次手術時占的比例最多的術式,依序是lapa RPU,injection,PVS,vaginal procedure 和RPU LSC。 第一次手術是MUS或Injection的人,之後若再次手術,大部分都會選擇相同的術式。

Primary surgery types Injection of bulking agents had the highest cumulative incidence of reoperation (35.64%) 94.03% still chose the same treatment, possibly due to the preference of less invasive procedures MUS had higher reoperation risks relative to RPU Agreed with previous findings Fialkow et al, lower reoperation rate of Burch than slings (4.2 vs. 6.7 /1000) Jonsson et at. 9-yr 28% higher reoperation rate for slings than Burch 如果第一次手術是用injection of bulking agent的方式,再手術率是最高的約35%, 但第二次手術時仍有94％選擇同樣用injection的方式,也許是因為偏好較不invasive 的procedure導致。 MUS 相對RPU有較高的再手術率,這項結果也和其他的study相似。 13

Conclusion

Primary surgery MUS was the most common primary surgical type (45.89%) MUS significantly increased up to 78 % in 2010 SUI surgeries increased in patients aged ≥60, surgeons aged≥50, and in regional hospitals Less younger women received operation for SUI; more women of advanced age were willing to seek healthcare and receive surgery. Minimally invasive, easy-to-use, high success rate, and had a rapid convalescent period Reimbursement of TVT by the NHI system in Taiwan may explain the transition during 2005–2006

Reoperation for SUI Substantial number of patients in Taiwan need reoperation for SUI Overall reoperation rate: 3.85 % (563/14613) Incidence rate of repeat SUI surgery: 54.37 per 10,000 PY Choice of primary surgery type and surgical volume may affect the reoperation rates Mid-urethral sling is the most common reoperation choice 我們統計出來的 Reoperation rate較低  shorter follow-up duration but cumulative incidence 則是類似 US, 2000~2009, population-based cohort study, cumulative incidence: 14.5% (All) Washington, 1987~2005, cumulative rate: 0.55% (Burch and sling) UK, the Scottish Morbidity Records database, 8.8%, median interval 2.8yrs (All) Jonsson Funk M, Siddiqui NY, Kawasaki A, et al. Long-term outcomes after stress urinary incontinence surgery. Obstet Gynecol 2012;120:83–90. Fialkow M, Symons RG, Flum D. Reoperation for urinary incontinence. Am J Obstet Gynecol 2008;199:546 54e1–8.Abdel-Fattah M, Familusi A, Fielding S, et al. Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK: A register linkage study. BMJ Open 2011;1:e000206.

Strength and limitation NIH database, a population-based sample of the whole country Limitation Lack of detailed clinical information: type or severity of incontinence Lack of information about other risk factors: BMI, parity Unable to identify the exact method within the same category such as retropubuic, trans-obturator, or single-incision MUS MUS 的 type TVT, TOT, single incision sling Reoperation 不等於 recurrence rate

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Reference Ming-Ping Wu, Cheng-Yu Long, Ching-Chung Liang, Shih-Feng Weng, Yat-Ching Tong: Trends in reoperation for female stress urinary incontinence: A nationwide study. Neurourol Urodynam 2015 Sep;34(7):693-8 Chia-Jen Wu, Yat-ChingTong, Sheng-Mou Hsiao, Ching-Chung Liang, So-Jung Liang, Shih-FengWeng, Ming-Ping Wu*(Corresponding): The surgical trends and time-frame comparison of various approaches for stress urinary incontinence, 2006-2010 vs. 1997-2005: A population-based nation-wide follow-up descriptive study. Int Urogynecol J. 2014;Dec:25(12):1683-1691. Ming-Ping Wu & Kuan-Hui Huang & Cheng-Yu Long & Kuo-Feng Huang & Ken-Jen Yu & Chao-Hsiun Tang: The distribution of different surgical types for female stress urinary incontinence among patients’ age, surgeons’ specialties and hospital accreditations in Taiwan: a descriptive 10-year nationwide study. Int Urogynecol J (2008) 19:1639–1646 Pei-Yang Hsu, Cheng-Yu Long, Kuan-Hui Huang, Chao-Hsiun Tang, Ming-Ping Wu* (Corresponding): The vicissitudes of open and laparoscopic retropubic urethropexy for stress urinary incontinence in Taiwan: an 11-year nationwide analysis. Gynecol Minim Invasive Therapy 2013;Feb:1:22-26. Ming-Ping Wu, Kuan-Hui Huang, Cheng-Yu Long, Kuo-Feng Huang, Ken-Jen Yu, Chao-Hsiun Tang: The distribution of different surgical types of stress urinary incontinence among the patients’ age, surgeons’ specialties and hospital accreditation in Taiwan: A descriptive ten-year nationwide study. Int Urogynecol J 2008;Dec:19(12):1639-1646.

Factors affecting the SUI reoperation rate Speciality Higher reoperation rate for urologists than gynecologists. ( HR 1.5, 95% CI 1.20~1.86) more injection, less RPU less surgical experience 泌尿專科醫師的再手術率比婦科醫師高，可能的原因第一是婦科醫師在第一次手術的選擇就較多是採取再手術率低的術式,如RPU,只有很少的婦科醫師會採用再手術率高的Injection作為手術治療的方式,第二個原因可能是泌尿科醫師的手術經驗較少導致。

Primary Surgeon’s Preference and Experience Gynecologist did more RPU, MUS, and vaginal procedure Higher surgical volume in GYN than Uro The average surgery count was higher in gynecologist than urologist GYN:Uro = 26:13 The average percentage of specilists who performed anti-incontinence surgeries was smaller in the gynecologist group. for the year 2006, Gynecologist 19.4% (461/2382) Urologist 31.5% (209/664) 研究發現,在台灣,婦科醫師在做尿失禁手術時 比較多採取RPU, MUS, vaginal procedure的術式但比較少做PVS和injection。 雖然婦科醫師進行尿失禁手術的 總手術量比泌尿科醫師多,但比較兩個專科中有做女性尿失禁手術的醫師比率,婦 科醫師有19.4％在做尿失禁手術,泌尿專科醫師則比較多,有31%在做。 Given the numbers of registered gynecologists (2,382) and urologist (664) in Taiwan for the year 2006, the estimated percentage of specialists who performed anti- incontinence surgeries was smaller in the former group: gynecologists 19.4% (461/2382); urologists 31.5% (209/664).

The Choice of Surgeon for Reoperations 研究另外有一個有趣的發現,病患在選擇第二次手術的醫師,忠誠度頗高, 近8成病患會選擇相同專科,近5成會找同一位醫師, High degree of loyalty - Majority remained in the same specialty - Half chose the same doctor 17