Urinary incontinence in women: Study of surgical practice in France

25 avril 2013

Auteurs : D. Desseauve, F. Pierre, X. Fritel
Référence : Prog Urol, 2013, 4, 23, 249-255




 




Introduction


Stress urinary incontinence (SUI) in women is a public health problem on account of its prevalence, its consequences on quality of life and its costs. SUI affects an estimated three to six million women in France [1, 2, 3]. Reduction of the frequency and consequences of female urinary incontinence is figures among the 100public health objectives defined in 2004 by the French parliament.


Among the widely used surgical treatments, abdominal retropubic colposuspension (the Burch procedure) [4] was the technique of reference through the end of the 1990s. The suburethral slings or strips (SUS) that appeared at the end of the 1990s for retropubic procedures [5] and at the outset of the 2000s for transobturator procedures [6] have facilitated surgical treatment that is less invasive than and just as efficient as Burch colposuspension [7]. The simple use and low morbidity associated with curative SUS techniques have helped to boost their circulation. Scholarly organizations such as the French national college of gynecologists and obstetricians and the French urology association, of which the recommendations were recently assessed [8] recommend SUS as first-line treatment because the postoperative period is particularly short and easy to manage [9, 10]. A recent study has shown that these recommendations have been widely distributed to health care professionals, but the conclusions of this study should be carefully weighted on account of the low rate of reply among the professionals (22%) [11]. What is more, there are few data on surgical practices in France with regard to SUI, except in the Paris areas, where as early as the outset of the 2000s, nearly 85% of SUI-related procedures were carried out with a SUS [12]. At the same time, there seems to exist a trend favoring the transobturator route [13].


In order to precisely indicate the apportionment in France of surgical interventions for female urinary incontinence, it is necessary to possess an exhaustive database bringing together the data from private as well as public and “mixed” public health establishments. Since no specific register exists, we deemed it pertinent to interrogate the 2009 medical information system program (PMSI), which is readily accessible on the site of the French technical hospital information agency (www.atih.sante.fr/).


Materials and methods


Subsequent to enactment of the 31 July 1991 French hospital reform law, a medical information system program known as PMSI was put into place, and it is aimed at describing hospital activity through the coding of diagnoses and medical acts or procedures. Hospital stays are considered according to their classification in terms of diagnosis-related groups (DRGs, known in French as GHM). Attendant complications or associated morbidities, length of stay and age are the elements defining the four DRG levels, which are numbered from 1 to 4.


The statistics available on the ATIH site have been compiled in terms of main diagnosis, medical act specific to the procedure being studied (“classifying procedure”) and DRG. Construction of a DRG is based on an algorithm to which several inputs contribute. A DRG is composed of an aggregate of hospital stays with a number of diagnoses and classifying procedures in common. As we study the construction of this algorithm, we may identify the diagnosis-related groups in which the classifying procedures we are striving to describe may be classified. Cross-referencing of the procedure database and the group database allowed us to define 3 DRGs of interest with regard to urinary incontinence surgery in cases grouped the heading of CMD13 (disorder of the female genital apparatus). To summarize, most of the time surgery for female urinary incontinence (cervicocystopexy) takes place when a patient is classified 13 in the diagnosis-related groups 13C17 (cervicocystopexy), 13C03 (hysterectomy), or 13C04 (procedure aimed at repairing the female genital apparatus).


For each DRG of interest, we have combined the distribution results by procedure for the four DRG levels and thereby spelled out the distribution of operations on the female urinary tract.


We verified the exhaustiveness of our data collection through cross-referencing of the data by diagnosis and by DRG. With this in mind, we conducted a search on the ATIH site for the number of hospital stays listed in the 2009 database corresponding to diagnosis of SUI “N393”; at the same time and so as to have an idea of the distribution of this diagnosis in other DRGs, we counted the number of “N393” diagnoses in the 3 DRGs of interest. The results are expressed in terms of number of stays and percentage.


Results


As regards the “cervicocystopexy” DRG, average length of stay was 1.9days, while average age of patient was 56.5years (Table 1). As regards the surgical techniques employed, 97.7% of the cervicocystopexies were carried out by SUS. In this DRG, Burch colposuspension by laparotomy or laparoscopy represented less than 1% of the procedures. Sixty percent of cervicocystopexy hospitalizations took place in the private sector.


As regards the “procedures aimed at repairing the female genital apparatus” DRG, average age of patient was 62.3years and average length of stay was 4.5days (Appendix A). On account of associated procedures, the total number of medical acts included in Table S1 is higher than 100%. And in this DRG, the vaginal route was by far the most widely used, with 18,274 classifying procedures reported (70%) versus 12,103 for laparoscopy (45%) and only 1879 (7.1%) for laparotomy. In 32.7% of the surgical operations for genital prolapse, SUS installation was associated. Whatever the route, use of Burch colposuspension remained lower than 1%. As regards this DRG, 62% of the activity took place in the private sector. Infra-urethral plication with vaginal approach was marginal, accounting for only 4.5% of the procedures carried out, and 82% of the time, it took place in the private sector.


As regards the “hysterectomy” DRG, average age was 52.9years and average length of stay was 5.3days (Appendix A). In this group, the vaginal route appeared to be privileged. As concerns the non-vaginal route, in terms of number of stays laparotomy remained higher than laparoscopy. Cervicocystopexia by SUS was associated with 9.2% of the reported hysterectomies, which meant that in this group, it was the procedure the most frequently employed in cases of SUI. Urinary incontinence treatment by non-vaginal route was rare, representing less than 2% of the cumulative cases. Close to 50% of the hysterectomies were carried out in the private sector, with statistical distribution in terms of approach routes similar to that observed in the public sector. A few marginally employed procedures, such as bladder neck support by intraurethral myoplasty via the vaginal route and Burch colposuspension, were carried out primarily in the private sector (respectively 74% and 77% of the reported procedures).


A few of the treatment procedures for urinary incontinence pertained to other diagnosis-related groups having little to do with urinary incontinence, but fewer than 10 women were involved. The one exception was DRG 11C041 Other bladder interventions with the exception of transurethral interventions”, which involved some 1315 cervicocystopexies by SUS. Unlike the three other DRGs under consideration, the grouping function for this DRG 11C041 did not discriminate by gender, and it was consequently difficult to know whether the persons having undergone treatment were women or men.


Comprehensive analysis shows that the number of hospital stays subsequent to a diagnosis of SUI “N393” inventoried in the 2009 ATIH database was 28,021. At the same time, the number of “N393” diagnoses in our three DRGs of interest was 27,087. Subtraction shows that 934 “N393” SUI diagnoses, approximately 3% of the overall total, were assigned to other DRGs, and thus did not correspond to our description.


Table 2 provides an overall picture of the number of SUI surgical procedures listed by the PMSI in the 2009 ATIH database. The actions mentioned correspond to the most frequent cervicocystopexy procedures in the framework of our three DRGs of interest, and are found in the A-293 list compiled by the PMSI. These procedures are considered as classifying procedures in accordance with the CMD 13 algorithm (disorders of the female genital apparatus). This table also includes SUI surgical procedures associated with a hysterectomy and not included in list A-293. It enumerates 42,223 procedures in France of which 38,929 (92%) were carried out by SUS, all establishments included. Sixty-two percent (62%) of the operations involving SUS were performed in the private sector. As for Burch colposuspension by laparotomy (JDDA002), it represented only 564 procedures, of which 68% took place in the private sector. As for the Bologna technique, which consists in support of the bladder neck by vaginal wall sling [14], it was only marginally used, and of the 199 procedures listed, 48% took place in the private sector. The overall classification of cervicocystopexies according to DRGs was 24,464 (58%) for the DRG “Cervicocystopexy”, 11,483 (26%) for the DRG “Procedure aimed at repairing the female genital apparatus” and 6671 (16%) for the DRG “Hysterectomy”.


Discussion


In all, in 2009 more than 42,000 surgical procedures consisting of cervicocystopexy for SUI took place in France, and 92% of them were carried out by SUS. In over half of the cases (58%) they were isolated (“cervicocystopexy” DRG), while in the other cases, the procedures were associated with static pelvic intervention (26%) or a hysterectomy (16%). As regards the “cervicocystopexy” DRG, the mean age of the women having been operated was 56.5years, and the mean duration of their stay was 1.9days.


Even though more extreme values were reported, most studies have drawn the conclusion that among female adults in the general population, the prevalence of urinary incontinence ranges from 25% to 45% [2], which means that in 2009, there were around 4 million incontinent women in France. The annual incidence rate of surgery for SUI, a rate translating the per-year percentage of incontinent women in France undergoing an operation, whatever the method employed, was according to our estimate, about 1%. Even though the literature on this subject is inadequate, the recent study by Wu et al . [15] show that in the United States in 2010, a comparable estimate came to 1.6% (13 million incontinent women and 217,000 interventions).


The figures published in this work translate the incidence in France of surgical treatment for female urinary incontinence in 2009. Since a dedicated register does not yet exist, the PMSI is one of the only databases in France allowing for a relatively precise estimate to be carried out. A PMSI-based approach is open to criticism from a methodological standpoint since it was not initially intended to be used as it is nowadays, and yet for 20years it has effectively helped researchers to apply a measuring stick to the occurrence of a number of diseases [16]. While any diagnosis-based approach is controversial on account of its high degree of code dependency, the classifying procedure approach may be relatively comprehensive to the extent that all of the concerned medical establishments require coding in order to ensure their overall annual financing; what is more, numerous controls by social security inspectors serve to verify the exactness of the data received.


However, the database will always be dependent on the coding, and one on the limits of our study consists in the fact that in the 2009 PMSI data collection, we were unable to distinguish Trans-Obturator Tape (TOT) from Trans Vaginal Tape (TVT). It would have been interesting to compare the two procedures in terms of how many times they were carried out, and it is worth noting that as of 2012, given the introduction in June 2011 of the code JDDB005 for the trans-obturator route and the introduction in January 2012 of the code JDDB007 for the retropubic procedure, it is henceforth possible to make the necessary distinction.


Another source of code error resides in the withdrawal or removal of the vaginal prostheses. While there do exist specific and detailed codes pertaining to the removal or ablation of the SUS (from JRGA001 to JRGA004, JRGC001, and JRPA001), there exists no code denoting removal of a subvesical prosthesis that could be analogically coded by using the code employed for SUS removal. In the present study, we lacked the means to control this classification bias.


In order to verify the internal validity of our study we have tried to evaluate the frequency of code errors in our comprehensive analysis and come to an estimate of 3%, a rate remaining acceptable for this type of study, in which it must imperatively remain lower than 10%.


Several external criteria of validity have confirmed the interest of our methodology. For example, the mean age of the women operated for urinary incontinence was 56.5years, and this figure is comparable to the mean ages found in other large-scale epidemiological studies based on other sources, particularly direct questioning of large segments of the population [17]. The mean ages of the female patients significantly differed (supplementary analysis not presented here) between the three DRGs of interest: 62.7years for procedures aimed at repairing the female genital apparatus, 56.5years for cervicocystopexies and 52.9years for hysterectomies. These mean ages are in agreement with results in the literature showing that the peak frequency for urinary incontinence is found at ages ranging from 45 to 64years [18].


Our work also serves to confirm the near-disappearance of approaches such as the Burch or Bologna procedures, which have been replaced by cures for urinary incontinence involving a suburethral tape or sling. Our data are in agreement with trends recently noted in other countries such as the United States. In a study methodologically comparable to ours, Oliphant et al. have observed a 46% diminution between 1979 and 2004 in recourse to Burch-type procedures [17]. On a parallel track, Oliphant reported a 93% increase in the implementation of SUS-type procedures. The trend was confirmed in 2002 in an essay by Ward, who showed that while the respective techniques do not differ in terms of effectiveness, a SUS operation is much simpler to carry out than the Burch procedure [7]. That said, enthusiasm for SUS may be tempered by results such as those of Fialkow et al., who observed in a large retrospective cohort a higher rate of re-operation for urinary incontinence in patients with a sling than in patients having undergone the Burch procedure [19]. However, a recent meta-analysis reviewing more than 40 randomized controlled trials and comparing SUS to the Burch technique concluded that the rate of objective and subjective cure was higher in the SUS patients [20]. Several long-term follow-up cohort studies have facilitated assessment of the effectiveness and durability of SUS, and 10years after surgery, 94% of the one-time patients have declared themselves satisfied with the result [21]. On the other hand, the risk of bladder perforation is five times higher with SUS than with Burch [20].


As some authors recommend, SUS can be introduced on an outpatient basis [22]. Unfortunately, our study did not enable us to answer questions pertaining to the possibility of ambulatory care and treatment for urinary incontinence. Boyles et al . have confirmed the existence of a trend in favor of ambulatory care by showing that in the United States, instances of this type of treatment doubled between 1994 and 1996 [23].


Sixty per cent of the SUS procedures are carried out in the private sector. This is slightly higher than the percentage of surgical interventions (55%) carried out in France in 2008 [24].


As regards care for female genital prolapsus, predominance of the vaginal route and a preference of laparoscopy to laparotomy have been observed. When a urinary procedure is called for, SUS has remained the most widely used. And as for hysterectomies, our study confirms the predominance of the vaginal route.


Conclusion


Recent literature has demonstrated the equivalent effectiveness, at least in the medium term, of SUS and Burch colposuspension. However, Burch colposuspension is still considered the reference technique when it comes to curing female SUI. Study of contemporary French surgery techniques shows that less than 1% of today’s interventions are carried out according to the above indication. 10years after its introduction in France, SUS represents by far the most widely used type of intervention.


Disclosure of interest


The authors declare that they have no conflicts of interest concerning this article.



Appendix A. Supplementary data


(483 Ko)
  
(145 Ko)
  



 Level of evidence: 4.
 French version of this article is available online (Appendix).





Table 1 - Distribution of the main urinary incontinence procedures for the cervicocystopexy DRG.
  Cervicocystopexy DRG (13C171 to 13C174) 
  Common name  CCAM code  Public+ESPIC+Private 
% Private Activity 
Description             
Participants          24,387  60.0 
Mean age (years)      56.49       
Standard deviation Age      11.69       
Mean hospital stay (MHS) in days      1.88       
Standard deviation MHS      1.17       
Deaths           
 
Urinary incontinence procedure          24,464  60.0 
Cervicocystopexy by sling with vaginal approach  TVT/TOT  JDDB001/JDDA003  97.7%    23,821  60.5 
Indirect CCPX of pectineal ligament (Cooper’s) by laparotomy  Burch  JDDA002  <1%    132  62.9 
Indirect CCPX of pectineal ligament (Cooper’s) by laparoscopy  Burch  JDDC002  <1%    39  30.8 
Direct CCPX with infra-urethral sling by laparotomy, or through transvaginal route  Göbell - Stöckel  JDDA006  1.1%    274  43.1 
Direct CCPX with infra-urethral prosthetic sling by laparotomy  Sling  JDDA005  <1%    78  29.5 
Direct CCPX with fascial infra-urethral sling by laparotomy  Sling  JDDA004  <1%    27  7.4 
Indirect CCPX with pedunculated vaginal sling by laparotomy and vaginal approach  Bologna  JDDA007  <1%    48  54.2 
Indirect CCPX with vaginal approach and by abdominal route, with endoscopic guidance  Raz  JDDA008  <1%    45  24.4 



Légende :
CCPX: Cervicocystopexy; ESPIC: établissement de santé privé d’intérêt collectif (private health establishment of public interest), CCAM: classification commune des actes médicaux (common classification of medical procedures); TVT/TOT: Tension free Vaginal Tape/Trans-Obturator Tape.



Table 2 - Number of cervicocystopexy procedures listed in 2009 according to the ATIH.
  Common name  CCAM code  Public+ESPIC+Private 
% Private Activity 
      n =42,223 
   
Cervicocystopexy with infra-urethral sling by vaginal route  TVT/TOT  JDDB001  32,929    38,929  62.1  61.7 
Cervicocystopexy by sling with vaginal approach+transcutaneous    JDDA003  6000      60.0   
Indirect cervicocystopexy of pectineal ligament (Cooper’s) by laparotomy  Burch  JDDA002    564    68.4   
Direct cervicocystopexy with infra-urethral sling, by laparotomy and transvaginal route  Göbell-Stöckel  JDDA006    433    42.0   
Indirect cervicocystopexy of pectineal ligament (Cooper’s) by laparoscopy  Burch  JDDC002    330    60.6   
Indirect cervicocystopexy with pedunculated vaginal sling, by laparotomy and with vaginal approach  Bologna  JDDA007    199    48.2   
Direct cervicocystopexy with prosthetic infra-urethral sling, by laparotomy  Sling  JDDA005    196    35.7   
Indirect cervicocystopexy with vaginal approach and by abdominal route, with endoscopic guidance  Raz  JDDA008    184    39.7   
Direct cervicocystopexy with fascial infra-urethral sling, by laparotomy  Sling  JDDA004    54    13.0   
 
Subotal HT posterior suspension of uterine cervix (colposuspsension) and indirect cervicocystopexy of pectineal ligament by laparotomy    JKFA012    164    70.7   
Subtotal HT with unilateral or bilateral adnexectomy and with posterior suspension of uterine cervix and indirect cervicocystopexy of pectineal ligament, by laparotomy    JKFA029    235    56.6   
 
Suspension of vaginal dome (Promontofixation) with indirect cervicocystopexy of the pectineal ligament (Cooper’s)    JLDA004    257    81.3   
Suspension of vaginal dome (Promontofixation) with direct cervicocystopexy by infra-urethral sling    JLDA003    247    64.4   
Posterior hysteropexy (Promontofixation) with indirect cervicocystopexy of the pectineal ligament (Cooper’s)    JKDA002    243    83.5   
Posterior hysteropexy (Promontofixation) with direct cervicocystopexy of the pectineal ligament (Cooper’s)    JKDA001    188    80.3   



Légende :
PMSI: programme de médicalisation des systèmes d’information (medical information system program); ESPIC: établissement de santé privé d’intérêt collectif (private health establishment of public interest); CCAM: classification commune des actes médicaux (common classification of medical procedures), TVT/TOT: Tension free Vaginal Tape/Trans-Obturator Tape.


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