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Re: What is the Best Surgical Intervention for Stress Urinary Incontinence in the Very Young and Very Old? An International Consultation on Incontinence Research Society Update
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
information available to counsel their patients, care and outcomes should be improved. However, this depends on whether the clinician and the patient feel that the extra information provided by the investigation translates into better outcomes and so would be worth the associated risks and costs of urodynamics.” All of this notwithstanding, the article by Reynolds et al documents that the use of urodynamics in the female Medicare program increased substantially between 2000 and 2010. The rate of women undergoing urodynamics per 100,000 female beneficiaries increased by 29%, from 422 to 543 per 100,000 beneficiaries, between 2000 and 2010. White women accounted for a higher rate of urodynamic utilization than nonwhites but use of urodynamics for both groups increased similarly during the study period (from 448 to 580 per 100,000 white beneficiaries and from 268 to 340 per 100,000 nonwhite beneficiaries). Perhaps most interesting is that although urologists performed the most urodynamics during the study period, the rate of utilization declined by 3% (from 326 to 316 per 100,000 beneficiaries), while the rate for gynecologists increased by 144% (from 77 to 188 per 100,000 beneficiaries). Alan J. Wein, MD, PhD (hon)
Re: What is the Best Surgical Intervention for Stress Urinary Incontinence in the Very Young and Very Old? An International Consultation on Incontinence Research Society Update D. Robinson, D. Castro-Diaz, I. Giarenis, P. Toozs-Hobson, R. Anding, C. Burton and L. Cardozo Department of Urogynaecology, Kings College Hospital, London, Department of Urogynaecology, Birmingham Women’s Hospital, Birmingham, and Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth, United Kingdom, Department of Urology, Hospital Universitario de Canarias Universidad de La Laguna, Canary Islands, Spain, and Department of Neurourology, Rheinische Friedrich-Wilhelms-Universitaet Bonn, Bonn, Germany Int Urogynecol J 2015; 26: 1599e1604. doi: 10.1007/s00192-015-2783-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26202394 Editorial Comment: This report represents the consensus of a think tank after a review and discussion of the existing literature regarding surgery for stress incontinence in the young and old at the International Consultation on Incontinence Research Society meeting. “Very young” refers to premenopausal women younger than 40 years and particularly to those who have still not completed their families. “Very old” seems to refer to patients over the age of 75. As an informed and experienced clinician might expect, there is really no consensus, but simply a statement of general principles. In general it is believed that continence surgery should be deferred until after the completion of childbearing, although there are few data regarding the outcome of continence surgery following subsequent childbirth and delivery. Both colposuspension and retropubic tape procedures seem to be safe and effective, with reported objective cure rates being higher for tapes, with objective cure rates of 90% at up to 17 years of followup. In addition, there seems to be no negative impact on sexual function after tape insertion in young women. Worrisome is the number of tape related complications, and the authors cite a 2010 article pegging this at a minimum of 4%. Urethral bulking agents, with a very low risk of complications, are an acceptable option but, as with the other options, the authors bemoan the lack of data at even 2 years or more. Questions to be answered concern whether synthetic tape should be used at all in very young patients, or should colposuspension or autologous fascial slings be the choice. Data on the effect of pregnancy and childbirth on continence status following stress urinary incontinence surgery are lacking. With respect to the very elderly, there seems to be little reported difference in the safety and efficacy in mid urethral sling surgery for these patients as opposed to younger women. Questions that need to be answered in this age group include: What is the role of bulking agents? What is the role of single incision minitapes as compared to standard mid urethral tapes? Is there a role for perioperative vaginal estrogen therapy? Are there subsets (in the very young as well as the very old) for which more definitive recommendations can be formulated? Alan J. Wein, MD, PhD
3
information available to counsel their patients, care and outcomes should be improved. However, this depends on whether the clinician and the patient feel that the extra information provided by the investigation translates into better outcomes and so would be worth the associated risks and costs of urodynamics.” All of this notwithstanding, the article by Reynolds et al documents that the use of urodynamics in the female Medicare program increased substantially between 2000 and 2010. The rate of women undergoing urodynamics per 100,000 female beneficiaries increased by 29%, from 422 to 543 per 100,000 beneficiaries, between 2000 and 2010. White women accounted for a higher rate of urodynamic utilization than nonwhites but use of urodynamics for both groups increased similarly during the study period (from 448 to 580 per 100,000 white beneficiaries and from 268 to 340 per 100,000 nonwhite beneficiaries). Perhaps most interesting is that although urologists performed the most urodynamics during the study period, the rate of utilization declined by 3% (from 326 to 316 per 100,000 beneficiaries), while the rate for gynecologists increased by 144% (from 77 to 188 per 100,000 beneficiaries). Alan J. Wein, MD, PhD (hon)
Re: What is the Best Surgical Intervention for Stress Urinary Incontinence in the Very Young and Very Old? An International Consultation on Incontinence Research Society Update D. Robinson, D. Castro-Diaz, I. Giarenis, P. Toozs-Hobson, R. Anding, C. Burton and L. Cardozo Department of Urogynaecology, Kings College Hospital, London, Department of Urogynaecology, Birmingham Women’s Hospital, Birmingham, and Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth, United Kingdom, Department of Urology, Hospital Universitario de Canarias Universidad de La Laguna, Canary Islands, Spain, and Department of Neurourology, Rheinische Friedrich-Wilhelms-Universitaet Bonn, Bonn, Germany Int Urogynecol J 2015; 26: 1599e1604. doi: 10.1007/s00192-015-2783-9
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26202394 Editorial Comment: This report represents the consensus of a think tank after a review and discussion of the existing literature regarding surgery for stress incontinence in the young and old at the International Consultation on Incontinence Research Society meeting. “Very young” refers to premenopausal women younger than 40 years and particularly to those who have still not completed their families. “Very old” seems to refer to patients over the age of 75. As an informed and experienced clinician might expect, there is really no consensus, but simply a statement of general principles. In general it is believed that continence surgery should be deferred until after the completion of childbearing, although there are few data regarding the outcome of continence surgery following subsequent childbirth and delivery. Both colposuspension and retropubic tape procedures seem to be safe and effective, with reported objective cure rates being higher for tapes, with objective cure rates of 90% at up to 17 years of followup. In addition, there seems to be no negative impact on sexual function after tape insertion in young women. Worrisome is the number of tape related complications, and the authors cite a 2010 article pegging this at a minimum of 4%. Urethral bulking agents, with a very low risk of complications, are an acceptable option but, as with the other options, the authors bemoan the lack of data at even 2 years or more. Questions to be answered concern whether synthetic tape should be used at all in very young patients, or should colposuspension or autologous fascial slings be the choice. Data on the effect of pregnancy and childbirth on continence status following stress urinary incontinence surgery are lacking. With respect to the very elderly, there seems to be little reported difference in the safety and efficacy in mid urethral sling surgery for these patients as opposed to younger women. Questions that need to be answered in this age group include: What is the role of bulking agents? What is the role of single incision minitapes as compared to standard mid urethral tapes? Is there a role for perioperative vaginal estrogen therapy? Are there subsets (in the very young as well as the very old) for which more definitive recommendations can be formulated? Alan J. Wein, MD, PhD
3