Cost-effectiveness of Prophylactic Retropubic Sling at the Time of Vaginal Prolapse Surgery
Authors: Mou Tsung , Cadish Lauren A. , Gray Elizabeth L. , Bretschneider C. Emi 
Published: March 2023

The increasing proportion of elderly Americans has brought about an anticipation of 50% rise in prolapse surgeries by 2050. It is anticipated that 25% to 40% of patients undergoing surgeries will develop de novo stress urinary incontinence (SUI) after prolapse repair. The Outcomes Following Vaginal Prolapse Repair with Midurethral Sling (OPUS) found a 36% reduction in the risk for de novo SUI, but also demonstrated increased risk of bladder perforations, urinary tract infections, and incomplete bladder emptying symptoms (N Engl J Med. 2012;366:2358–2367). As a result, pelvic reconstructive surgeons often vary their approach toward prophylactic MUS at the time of vaginal prolapse repair (VPR). Although a cost-effectiveness analysis found universal MUS placement to be the most cost-effective strategy over both selective and staged strategies (J Urol. 2013;190:1306–1312), this analysis did not include an arm for the less-costly option of using a selective approach via a prolapse-reduced cough stress test (CST). In addition, Richardson analysis of patients undergoing sacral colpopexy lacks generalizability for VPR surgeries (which account for two thirds of all prolapse surgeries). The manuscript described here therefore tested the cost-effectiveness of 3 generalizable MUS utilization strategies for preventing de novo SUI within 1 year post-VPR.

Three approaches were compared: (1) staged strategy performing VPR with later MUS placement only for de novo SUI; (2) universal sling placement at the time of VPR; and (3) selective sling placement with MUS at the time of VPR when occult SUI was observed at the time of preoperative prolapse-reduced CST. A representative population of women with symptomatic pelvic organ prolapse (at least stage II) was modeled. Included in the VPR model was colpocleisis, apical suspension, or anterior colporrhaphy, with or without hysterectomy. The base assumption was that all VPRs were uncomplicated and anatomically successful. Subsequent treatment pathways were formed based on the 3 aforementioned options if de novo SUI was to occur.

A 2017 systematic review by van der Ploeg was used for obtaining literature to gain point estimates concerning the risk for postoperative SUI (Int Urogynecol J. 2016;27:1029–1038). The search was performed via PubMed through January 2017, and exclusionary criteria were as follows: studies examining urodynamics preoperatively, abdominal prolapse repairs, duplicate studies, and studies lacking clear definitions for VPR, MUS, or SUI. Using data from 3 previous studies, for a selective MUS, the authors estimated the rate of de novo SUI after VPR with a negative preoperative CST to be 33.6%. The authors determined the existence of 4 possible adverse outcomes following MUS: (1) persistent SUI, (2) sling lysis required for voiding dysfunction, (3) mesh exposure requiring excision, and (4) anticholinergic medications required for de novo overactive bladder. Information on costs was gathered Physician Fee Schedules from the 2020 Centers for Medicare and Medicaid Services. Incremental cost-effectiveness ratio was the primary outcome modeled, defined as the ratio of the cost difference compared with the difference in quality-adjusted life years between scenarios.

Results indicated that costs were as follows for various approaches: $1051.70 per patient for staged strategy, $1093.75 for selective MUS, and $1125.54 for universal MUS. The incremental cost-effectiveness ratio value for selective MUS calculated at $2664/quality-adjusted life years, rendering it the most cost-effective and preferred strategy.

The variable with the greatest effect on model cost was the proportion of patients experiencing postoperative SUI electing to undergo repeat surgical intervention via MUS placement.

Strengths of the study include its use of high-quality Centers for Medicare and Medicaid Services data for costs and point estimates. Because these data hails from the large portion of older Americans covered by Medicare (the most at risk for prolapse surgery), it avoids the inclusion of large variabilities innate to individual hospital systems. In addition, a 1-way sensitivity analysis was performed based on all case assumptions, thereby demonstrating the robustness of the study model.

Limitations of the study included the expected hindrance of estimations and assumptions about event incidences. A 1-year time horizon was analyzed, although this may be reasonable because risks of complications dwindle over time. Furthermore, the study only considered women with de novo SUI to have the options of no treatment or MUS placement, disregarding costs of alternative procedures such as pelvic floor physical therapy, pessary, repeat MUS, urethral bulking, or other surgical interventions. Finally, all possible common outcomes after VPR were not included, such as urinary tract infections, pain, or postoperative urinary retention requiring short-term catheterization.

In this study, the overall preference for treating de novo SUI via vaginal prolapse surgeries was the selective prophylactic midurethral sling. Patient counseling should occur to inform about the risks and benefits related to prophylactic sling surgeries (including the possibility of de novo SUI after VPR). Decisions regarding treatment strategy ought to be made using each patient’s priorities and treatment goals in discussion with her surgeon.