Trends Outcomes and Multivariable Analysis of Continence Surgery
Trends, Outcomes and Multivariable Analysis of Continence Surgery from the BSUG Database Miss Fiona Bach Mr Philip Toozs-Hobson
Conflicts of interest • Fiona Bach - Nil • Philip Toozs-Hobson - Boston Scientific, Contura • Funding for stats: BSUG grant
Objectives • BSUG database - Trends, patient characteristics, outcomes - Stress urinary incontinence surgical treatments - Retropubic tapes Bulking agents Autologous slings Colposuspension (18726) (3574) (355) (1054)
Methods Multivariable analysis Multiple imputation for inputs
Trends
Baseline characteristics Age categories, n(%) Age less than 50 Age between 50 -79 Age 80 and over Missing Age (years), mean (SD) BMI categories Underweight Healthy weight Overweight - lower Overweight - upper Obese Missing BMI, mean (SD) Pelvic floor exercises, n(%) Yes No Missing Tapes n=18726 Bulking n=3574 8767(46. 80) 9187(49. 10) 273(1. 50%) 499(2. 70) 51. 98(11. 54) 21(0. 10) 2339(12. 50) 3352(17. 90) 2044(10. 90) 981(5. 20) 9989(53. 30) 28. 47(4. 94) 14861(79. 40) 1758(9. 40) 2107(11. 30) 1285(36. 00) 1896(53. 00) 270(7. 60%) 123(3. 40) 56. 35(15. 52) 3(0. 10) 263(7. 40) 393(11. 00) 257(7. 20) 168(4. 70) 2490(69. 70) 29. 19(5. 37) 2598(72. 70) 418(11. 70) 558(15. 60) Autologous sling n=355 170(47. 90) 169(47. 60) 1(0. 30%) 15(4. 20) 50. 77(10. 96) 0(0. 00) 26(7. 30) 48(13. 50) 28(7. 90) 15(4. 20) 238(67. 00) 28. 94(5. 10) 259(73. 00) 48(13. 50) Colposuspension n=1054 510(48. 40) 495(47. 00) 7(0. 70%) 42(4. 00) 50. 05(10. 73) 0(0. 00) 116(11. 00) 168(15. 90) 127(12. 00) 51(4. 80) 592(56. 20) 28. 72(4. 71) 820(77. 80) 130(12. 30) 104(9. 90)
Baseline characteristics Tapes n=18726 Pre-op urodynamic diagnosis, n(%) USI and voiding dysfunction Normal Mixed and voiding dysfunction DOA Voiding dysfunction Missing Incontinence Surgery Type, n(%) Primary Repeat Missing Grade of operator, n(%) Consultant Associate Specialist Subspec Trainee (SST) Speciality Trainee (ST) Other Missing Intra-operative bladder injury, n(%) Yes No Missing Bulking Autologous sling n=3574 n=355 13267 (70. 80) 2275(63. 70) 433 (2. 30) 95(2. 70) 442 (2. 40) 86(2. 40) 2685 (14. 30) 526(14. 70) 94 (0. 50) 17(0. 50) 75 (0. 40) 23(0. 60) 5 (0. 03) 8(0. 20) 1725 (9. 20) 544(15. 20) 17174 (91. 7%) 2459 (68. 8%) 1066 (5. 7%) 906 (25. 3%) 486(2. 60) 209(5. 80) 14566(77. 80) 3061(85. 60) 125(0. 70) 4(0. 10) 1036(5. 50) 155(4. 30) 2368(12. 60) 192(5. 40) 381(2. 00) 55(1. 50) 250(1. 30) 107(3. 00) 681 (3. 6%) 2 (0. 1%) 17806 (95. 1%) 3531 (98. 8%) 239(1. 30) 41(1. 10) 244(68. 70) 9(2. 50) 2(0. 60) 55(15. 50) 1(0. 30) 2(0. 60) 0(0. 00) 42(11. 80) 203 (57. 2%) 126 (35. 5%) 26(7. 30) 292(82. 30) 1(0. 30) 42(11. 80) 8(2. 30) 1(0. 30) 11(3. 10) 14 (3. 9%) 335 (94. 4%) 6(1. 70) COLPO n=1054 803(76. 20) 24(2. 30) 11(1. 00) 98(9. 30) 6(0. 60) 1(0. 10) 110(10. 40) 765 (72. 6%) 221 (21. 0%) 68(6. 50) 887(84. 20) 3(0. 30) 105(10. 00) 42(4. 00) 5(0. 50) 12(1. 10) 37 (3. 5%) 1005 (95. 4%) 12(1. 10)
Raw outcomes Autologous sling n=355 Non concomitant Tapes Bulking COLPO n=18726 n=3574 n=1054 Global Impression of Improvement for Incontinence, n(%) Better 10821(57. 80) 1068(29. 90) 133(37. 50) 504(47. 80) No change 1130(6. 00) 834(23. 30) 16(4. 50) 76(7. 20) Missing 6775 (36. 2%) 1672 (46. 8%) 206 (58. 0%)474 (45. 0%) Stress incontinence symptoms, n(%) Cured or Improved 10757(57. 40) 1282(35. 90) 134(37. 70) 531(50. 40) No change or Worse 397(2. 10) 478(13. 40) 4(1. 10) 24(2. 30) Missing 7572 (40. 4%) 1814 (50. 8%) 217 (61. 1%)499 (47. 3%) Urgency/Urge incontinence (Patients that had sypmtoms previously), n(%) (n=18482) Cured or Improved 4084(28. 45) 380(12. 78) 31(10. 00) 145(17. 18) No change or Worse 2501(17. 42) 642(21. 59) 54(17. 42) 174(20. 62) Missing 7769 (54. 1%) 1952 (65. 6%) 225 (72. 5%)525 (62. 2%) Urgency/Urge incontinence (Patients did not have sypmtoms previously), n(%)(n=15698) New symptoms 427(3. 52) 19(0. 74) 4(1. 48) 26(3. 54) Never present 3945(32. 49) 581(22. 77) 41(15. 19) 184(25. 03) Missing 7769 (63. 9%) 1952 (76. 4%) 225 (83. 3%)525 (71. 4%)
Outcomes excluding missing values Global Impression of Improvement for Incontinence Better No change or Worse Stress incontinence symptoms Cured or Improved No change or Worse Urgency/Urge incontinence (Previous OAB) Cured or Improved No change or Worse Urgency/Urge incontinence (No previous OAB) New symptoms Never present Tapes 11951 90. 5% 9. 5% OR p value 11154 96. 4% 3. 6% OR p value 6585 62% 38% OR p value 4372 9. 80% 90. 20% OR p value Bulking 1902 56. 20% 43. 80% 0. 13(0. 12, 0. 15) <0. 001 1760 72. 80% 27. 20% 0. 10(0. 09, 0. 11) <0. 001 1022 37. 20% 62. 80% 0. 36(0. 32, 0. 42) <0. 001 600 3. 20% 96. 80% 0. 30(0. 19, 0. 48) <0. 001 Autologous sling 149 89. 20% 10. 70% 0. 87(0. 51, 1. 46) 0. 595 138 97. 10% 2. 90% 1. 24(0. 46, 3. 36) 0. 677 85 36. 50% 63. 50% 0. 35(0. 23, 0. 55) <0. 001 45 8. 90% 91. 10% 0. 90(0. 32, 2. 53) 0. 844 Colposuspension 580 86. 90% 13. 10% 0. 69(0. 54, 0. 89) 0. 004 555 95. 70% 4. 30% 0. 82(0. 54, 1. 24) 0. 346 319 45. 50% 54. 50% 0. 51(0. 41, 0. 64) <0. 001 210 12. 40% 87. 60% 1. 31(0. 86, 1. 99) 0. 216
Multivariate analysis: Tapes PGI-I (N=6017) Characteristics BMI Age (Decades) Pelvic floor exercises Pre-operative Urodynamics diagnosis USI and voiding dysfunction Normal Mixed and voiding dysfunction DOA Voiding dysfunction Incontience surgery type Primary Repeat Grade of operator Consultant Associate Specialist Subspec Trainee (SST) Speciality Trainee (ST) Other Intraoperative bladder injury Number of imputations – 63 OR (95% CI) 0. 95(0. 93, 0. 96) 0. 85(0. 79, 0. 91) 1. 11(0. 85, 1. 45) Reference 0. 48(0. 30, 0. 75) 0. 55(0. 31, 0. 96) 0. 50(0. 41, 0. 62) 0. 29(0. 10, 0. 82) 0. 16(0. 06, 0. 46) Omitted Reference 0. 61(0. 44, 0. 84) Reference 0. 37(0. 09, 1. 56) 0. 80(0. 53, 1. 19) 0. 94(0. 71, 1. 25) 0. 76(0. 46, 1. 25) 0. 61(0. 39, 0. 94) p-value <0. 001 0. 463 0. 001 0. 035 <0. 001 0. 021 0. 001 0. 003 0. 176 0. 274 0. 678 0. 281 0. 024
Multivariate analysis: Others PGI-I Bulking OR (95% CI) 1. 01(0. 98, 1. 05) 1. 05(0. 96, 1. 15) p-value 0. 523 0. 274 Pelvic floor exercises Pre-operative Urodynamics diagnosis USI and voiding dysfunction Normal 1. 03(0. 64, 1. 66) 0. 894 Reference 0. 86(0. 42, 1. 74) 0. 68(0. 27, 1. 71) 0. 666 0. 409 Mixed and voiding dysfunction DOA Voiding dysfunction Incontience surgery type Primary Repeat Grade of operator Consultant Associate Specialist Subspec Trainee (SST) Speciality Trainee (ST) Other Bladder damage 0. 89(0. 63, 1. 25) 3. 62(0. 41, 31. 90) Omitted BMI Age (Decades) Reference 0. 83(0. 60, 1. 16) Omitted* 0. 493 0. 246 0. 104 n=925 Number of imputations - 77 Autologous sling OR (95% CI) p-value 0. 69(0. 36, 1. 32) 0. 253 1. 44(0. 31, 6. 58) 0. 64 Colposuspension OR (95% CI) p-value 1. 02(0. 92, 1. 12) 0. 728 0. 87(0. 64, 1. 19) 0. 398 0. 92(0. 04, 21. 56) Omitted 1. 14(0. 46, 2. 81) Reference 1. 17(0. 13, 10. 19) Omitted 3. 23(0. 73, 14. 26) 0. 121 Omitted Reference 1. 19(0. 50, 2. 82) 0. 69 Reference Omitted 0. 70(0. 24, 2. 10) 0. 529 1. 14(0. 13, 9. 78) 0. 902 Omitted 0. 25(0. 06, 1. 02) 0. 053 n=301 Number of imputations=70 Reference 0. 14(0. 00, 5. 24) Omitted 0. 958 0. 284 0. 02(0. 00, 25. 10) 0. 288 n=51 Number of imputations=81 0. 779 0. 888
SUI trends + clinical utility BSUG (3424) BSUG Pause (1374) 0% 10% 20% 30% 40% 50% 60% 70% 80% Retropubic MUS TOT Single Incision Tape Colposuspension - open/lap Anterior repair + BNB Pubovaginal Slings Peri-urethral Injection BNI (Bulkamid) Bulking BSUG SUI Cure/improved = 72% Mikkola SUI Cure/improved = 92% 90% 100%
Strengths • Real life data • Large numbers • Multicentre
Limitations • Non mandatory • Missing data - multiple imputations to fill in missing data • Short term outcomes • Clinician completed
Conclusion • Overall good success rates • Lower complications with bulking • Tapes Less successful - Increasing age and BMI - Non USI diagnosis • Databases are important - Personal outcomes - Benchmarking - Adjunct to clinical trials
Thank you to BSUG for the grant and for approving the research idea Thank you to the efforts of the membership to fill out the database Questions?
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