Hypothesis / aims of study
Due to aging population the need for treatment of pelvic organ prolapse (POP) has become a great challenge for medical professionals and health care system. In Poland, 15.4 % of the whole population is over 65 years old, and, as of 2015, life expectancy at birth was 77.5 years. In January 2016, after previous warnings in 2009 and 2011, the US Food and Drug Administration (FDA) reclassified surgical mesh for transvaginal repair of pelvic organ prolapse into class 3. Since then, the global use of mesh in vaginal surgeries has significantly decreased. Thus it is of great interest to know how did this trend overall affected the performance of urogynecological surgeries. Major pelvic floor disorders that require the use of mesh are: midurethral sling (MUS) procedures- tension-free vaginal tape (TVT) and transobturator tape (TOT) for stress urinary incontinence; transvaginal mesh (TVM) for POP and transabdominal mesh for POP. Throughout the years, various approaches have been introduced to treat POP, still, the type of surgery may depend on several factors including type and degree of POP, patient characteristics and surgical expertise.
The aim of this study was to investigate trends in POP and UI surgeries in Poland between year 2009-2017.
Study design, materials and methods
A retrospective analysis of data from the National Health Fund Information Centre websites has been performed [1]. Prevalence of pelvic organ prolapse, urinary incontinence as well as vaginal hysterectomies, has been investigated. Annual reports from 2009 to 2017 were analyzed. Reasons of hospitalization and type of procedures were identified using ICD-9 classification. The same codes were used for each year of the study period. Linear regression models were constructed for observed trends. P<0.05 was considered statistically significant
Ethics approval was not required because we used public domain and anonymous data.
Results
Between 2009-2017- 327294 hospitalizations were considered in this analysis. The majority (n=265147, 81%) was due to POP. Incomplete uterovaginal prolapse was the most common diagnosis (n=64786, 19%). Complete prolapse was diagnosed in 25288 cases (7%). During the study period, 29821 (9%) vaginal hysterectomies (VH) were performed. The number of hospitalizations due to urinary incontinence (UI) reached 32326 (9.8%) comprising stress urinary incontinence (SUI) 23137 and ‘other’ (n=9189).
During the study period the most common procedure for POP was anterior and posterior colporrhaphy (n=64895). Suspension and fixation of the vagina using a mesh was performed in 47887 patients, while 24204 women had posterior colporrhaphy and 13336 anterior colporrhaphy. Finally, 7349 cervical excision with simultaneous vaginoplasty for POP were performed. Between the year 2009 and 2015 a rapid increase in the number of POP procedures was observed (r2=0.94, b=1711, p<0.001). The following years were characterized by a marked decline in the number of POP surgeries (Figure 1, Table 1). Prediction based on the trend between 2009 and 2015 revealed that in 2017 number of procedures should reach 37505 95% CI (34775-40234), whereas only 30200 was performed. The number of vaginal suspension with mesh dropped by 24.7%, posterior and anterior repair by 8.5%, posterior repair by 7.5% and vaginoplasty with cervix removal by 6.5%. The number of anterior repair procedures raised slightly by 1.5%. Moreover, between 2015 and 2017 number of vaginal hysterectomies (performed for all indications) decreased by 9.0%. Number of UI surgeries raised between 2011 and 2015 and then remained at a relatively stable level. A similar trend was observed for tape procedures, whereas popularity of colposuspension has declined noticeably (Table 1).
Interpretation of results
Since 2016 a trend towards decrease in the number of POP surgeries has been observed. Although it has been a general tendency, the most marked decline has been observed in mesh surgeries. The number of UI procedures overall and surgeries with tape has remained at a similar level since 2015, while colposuspension has been increasingly rare.