Hypothesis / aims of study
During the time-frame evolution for the past 2 decades, midurethral sling (MUS) has become the standard-of-care female stress urinary incontinence (SUI) surgery. During this paradigm shifts, we tried to evaluate difference variables among bio-psycho-social domains with time-frame comparisons.
Study design, materials and methods
This was a retrospective cohort study based on Taiwan’s National Health Insurance Research Database (NHIRD). We divided female SUI surgeries into four time-frames: 1st period (1999−2003), 2nd period (2004−2008), 3rd period (2009−2013), and 4th period (2014−2018). There were recruited eight variables (i. to viii.) within 3 domains (i.e. bio-, psycho- social- domains). They were: bio- domains: i. surgical trends among different SUI surgeries; (retropubic urethropexy, RPU; pubovaginal sling PVS; MUS); ii. primary vs repeat surgery; iii. surgical volume-outcome effects; surgeon surgical volume (high ≥30, median 5-29, low <5); Psycho- domains: iv. surgeon surgical volume shifts; v. same-specialty and patient-surgeon same-gender preference; vi. elderly women participation; Social- domains: vii. time-frame comparison of MUS versus RUP, and PVS; viii. hospital level shift; (hospital level: medical center, regional and local hospital).
Results
A total of 51,018 patients who received SUI surgeries were identified. Our results showed:
1. Bio- domains: i. chronological surgical trend study indicated MUS, became the standard-of-care SUI surgeries, as compared with RPU, PVS; MUS had better, at least similar, surgical outcome; ii. primary vs repeat surgery: although MUS had higher reoperation rate, as compared with PVS, it is still most frequently used for repeat surgery; iii. surgical volume-outcome effects: high surgical volume surgeon had better surgical outcome and less complication rates.
2. Psycho- domains: iv. surgeon surgical volume shifts: the proportion of surgical volume shifted from high- to medium- and low-volume, but it reversed in the 4th period, which means the bandwagen effect does not exist; v. there were same-specialty preference, i.e. uro-to-uro, gyn-to-gyn surgeon; more women are willing to visit female surgeon due to psycho or cultural reasons; vi. elderly women participation: there were more elderly women who receive SUI surgery, which indicated not only due to society aging effect, but also the willingness of elderly women.
3. Social- domains: vii. time-frame comparison study indicated MUS increased dramatically and significantly during first three periods, which is associated with the decrease of PVS, RPU, followed by a slightly decreased in the 4th period; viii. hospital level generalization, but not centralization; the proportion of SUI surgeries decreased in medical centers, is associated with the increases of regional and local hospitals.
Interpretation of results
First, the increasing number of elderly patients undergoing SUI procedures reflects a growing acceptance of surgical treatment, which deserved attention to appropriate patient selection and perioperative management.
Second, same-gender preference among patients, and increasing participation of female surgeons is reshaping the workforce. A gender friendly environment is needed, including limited mentorship, work-life balance difficulties, more comprehensive supportive and inclusive training environments.
Third, establishing standardized, evidence-based volume benchmarks will be crucial for designing effective training curricula and ensuring long-term surgical quality.
Fourth, the importance of integrating cost-effectiveness analyses (CEA) into SUI surgical decision-making will help reimbursement models, optimize care delivery, and support equitable access to high-quality treatment across diverse healthcare settings.
Concluding message
MUS became the standard-of-care SUI surgeries during our 20 years time-frame cohort study. There were significant changes among eight variables, including different surgical type shifts, surgical volume shifts, hospital levels shifts, same-specialty, and patient-surgeon gender preference. This implied the spreading of surgical skills and performance, as well as the characters of health providers. A bio-psycho-social domains of SUI surgery paradigm shift draws our attention to many variables, in addition to patient biologic variables within bladder and urethra. This may have great influences on patient and healthcare provider for the choice of SUI surgery.