Evaluation of the Effect of Hospital and Physician Factors on Likelihood of Revision After Mid-Urethral Sling Placement

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Objective: To estimate rates of revision surgery after insertion of mesh midurethral slings (MUS) and explore if healthcare attributes such as physician specialty, annual operative volume, or hospital type are risk factors for this outcome. Methods: This study used a population-based retrospective cohort of women who underwent MUS insertion over a 13-year interval (2004–2017) in Alberta, Canada. The main outcome was subsequent surgery for revision of MUS, defined by a composite of surgical procedures. Exposures included annual number of MUS procedures performed by the surgeon, facility type, surgeon specialty, patient age, and concomitant prolapse repair. Mixed-effects logistic regression utilizing linear spines was used to test the a priori hypothesis that annual surgical volume would be inversely related in a non-linear fashion to risk of revision. Results: In a cohort of 19,511 women, cumulative rates of revision surgery were 3.36% (95% CI 3.06–3.68) at 5 years and 4.57% (95% CI 4.00–5.21) at 10 years. The first year after MUS insertion was the most vulnerable window, with 0.39% (95% CI 0.31–0.49) undergoing revision within 30 days and 2.05% (95% CI 1.85–2.26) within a year. Concomitant prolapse repairs (OR = 1.24, 95% CI 1.04–1.48) and surgeon’s annual volume were associated with revision. After 50 cases per year, odds of revision declined with each additional case (OR = 0.991 per case, 95% CI 0.983–0.999; OR = 0.91 per 10 cases, 95% CI 0.84–0.98) and plateaued at 110 cases per year. Surgeon specialty, hospital type, and patient age were not associated with outcome. Conclusions and relevance: Within 10 years, nearly 1 in 20 women underwent revision surgery after MUS insertion. Physician annual surgical volume appears to be a risk factor, with a decline in risk of revision surgery occurring at an annual threshold of >50 cases. Given that annual case volume is a potentially modifiable risk factor, development of policies regarding minimum caseload parameters for surgeons performing MUS procedures may hold potential to improve the quality of MUS surgery.
Brennand, E. A. (2020). Evaluation of the Effect of Hospital and Physician Factors on Likelihood of Revision After Mid-Urethral Sling Placement (Master's thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca.