Comparative outcomes of open versus laparoscopic sacrocolpopexy among medicare beneficiaries

Introduction and hypothesis

Since the first reported laparoscopic sacrocolpopexy in 1991, a limited number of single-center studies have attempted to assess the procedure’s effectiveness and safety. Therefore, we analyzed a national Medicare database to compare real-world short-term outcomes of open and laparoscopically assisted (including robotic) sacrocolpopexy in a United States sample of patients.

Methods

Public Use File data for a 5 % random national sample of all Medicare beneficiaries aged 65 and older were obtained from the Centers for Medicare and Medicaid Services for the years 2004–2008. Women with pelvic organ prolapse were identified using ICD-9 diagnosis codes. CPT-4 procedure codes were used to identify women who underwent open (code 57280) or laparoscopic (code 57425) sacrocolpopexy. Individual subjects were followed for 1 year post-operatively. Outcomes measured, using ICD-9 and CPT-4 codes, included medical and surgical complications and re-operation rates.

Results

Seven hundred and ninety-four women underwent open and 176 underwent laparoscopic (including robotic) sacrocolpopexy. Laparoscopic sacrocolpopexy was associated with a significantly increased rate of re-operation for anterior vaginal wall prolapse (3.4 % vs 1.0 %, p?=?0.018). However, more medical (primarily cardiopulmonary) complications occurred post-operatively in the open group (31.5 % vs 22.7 %, p?=?0.023). When sacrocolpopexy was performed with concomitant hysterectomy, mesh-related complications were significantly higher in the laparoscopic group (5.4 % vs 0 %, p?=?0.026).

Conclusion

Laparoscopic sacrocolpopexy resulted in an increased rate of reoperation for prolapse in the anterior compartment. When hysterectomy was performed at the time of sacrocolpopexy, the laparoscopic approach was associated with an increased risk of mesh-related complications.     

Population-based trends in ambulatory surgery for urinary incontinence

Introduction and hypothesis

Surgical procedures for stress urinary incontinence (SUI) have become progressively less invasive and easier to perform with the development of new technologies such as the midurethral sling. For these reasons, it seems logical to conclude that midurethral slings would supplant other surgical treatments for incontinence. The purpose of this study was to assess the impact of this technology on trends in ambulatory surgery for incontinence over the past decade.

Methods

We searched Current Procedure Terminology codes and the State Ambulatory Surgery Database from 2001 through 2009 to identify all ambulatory procedures for incontinence. Next, we calculated age-adjusted rates separately for each procedure. We then fit a multilevel model to characterize patient and regional factors associated with the preferential use of midurethral slings over alternative treatments.

Results

Midurethral slings and submucosal injections comprised >90 % of all ambulatory procedures for SUI during the time period examined. Age-adjusted rates of midurethral slings increased dramatically, from 2.36 to 9.45/10,000 population (p?<?0.001), whereas rates of submucosal injections remained relatively stable, from 1.75 to 1.41/10,000 population (p?=?0.226). Not surprisingly, older ([odds ratio (OR) 0.61; 95 % confidence interval (CI) 0.56–0.66] and more infirm patients (OR 0.60; CI 0.44–0.83) were more likely to receive submucosal injection therapy than to receive midurethral slings.

Conclusions

Rates of midurethral slings have increased significantly by fourfold. Rates of submucosal injections, however, have remained fairly stable during this time period, suggesting that sling dissemination has led to an increase in rates of incontinence procedures as opposed to replacing old technologies in the ambulatory setting.     

Medico-legal considerations for Morel-Lavallée lesions

Forensic Science, Medicine and Pathology - The Morel-Lavallée lesion is an infrequent traumatic lesion that the forensic physician may need to evaluate during examination of a victim. Using a...