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Obstetrics and Gynecology, Naval Med. Ctr. Portsmouth, Portsmouth, VA.

Introduction: Between 2010 and 2050 the number of women undergoing surgery for stress urinary incontinence (SUI) is projected to increase by 47%1. Prior studies of complications after sling surgery excluded the large number of women in military treatment facilities within the United States.
Objective: To characterize the 12-month post-operative complication rates after sling surgery for SUI within military treatment facilities in the United States.
Methods: Study design: Retrospective cohort study. Study population: Women, aged 18 years and older, who were enrolled in the U.S. military healthcare system, TRICARE Prime, between January 1, 2011, and December 31, 2013. Inclusion criteria: Had either an outpatient or inpatient mid-urethral sling placement for SUI in any military treatment facility in the United States between January 1, 2011, and December 31, 2012. The study period was selected to ensure we had 12-month follow up data for every patient. Women were identified based on the presence of the ICD-9 code for SUI (625.6), intrinsic sphincter deficiency (599.81), and/or urethral hypermobility (599.82) as a primary or secondary diagnosis. Sling placement was defined by the CPT code 57288 or the ICD-9 procedure codes 59.4, 59.71, and 59.79. Exclusion criteria: Left the military system after their procedure; had a sling procedure at a non-military facility; 12-month follow-up data was not available; had a procedure for pelvic organ prolapse within 30 days of the sling procedure; diagnosis of pelvic pain within the 12 months prior to the procedure; and women with slings placed laparoscopically. Data source: The Military Health System Management and Analysis Reporting Tool and the Military Health System Data Repository database. Outcome variables: Primary outcome variable was a composite variable “Any post-operative complication.” This was defined in way identical to that used by others2,3. The specific complications used to construct this composite variable included: infectious complications; urologic complications; new diagnosis of urgency; new diagnosis of pelvic pain; new diagnosis of bladder outlet obstruction and the need for a repeat incontinence procedure. These were all defined by CPT and ICD-9 codes consistent with prior studies.
Results: During the study period, 348 surgeons performed 1,632 slings. The average patient age was 47.2 years. In terms of surgical characteristics, 22.4% of the patients had a concomitant pelvic organ prolapse procedure. Overall, 45.5% of subjects had at least one post-operative complication. Of the specific complications, urologic infectious complications were the most frequent, occurring in 25.2% of patients. Overall, only 0.9% of patients underwent a repeat incontinence procedure within 12 months. In multivariate analyses, concomitant pelvic organ procedure was associated with an increased risk of bladder outlet obstruction and non-infectious urologic complications. Those with a Charlson score of 1 or more were more likely to have an infectious complication and a new diagnosis of pelvic pain. Women older than the median age were less likely than those below to have a repeat incontinence procedure and a new diagnosis of pelvic pain (within 12 months).
Conclusions: The population of women undergoing sling surgery for SUI at military treatment facilities in the US is a much younger population compared to Medicare beneficiaries. Complication rates after sling surgery among TRICARE beneficiaries at military treatment facilities compare favorably with documented rates among Medicare beneficiaries. However, the absolute rates of complications (particularly for infectious complications) are still high, indicating opportunities for quality improvement measures.
References: 1. Obstet Gynecol. 2009;114(6):1278-1283. 2. Obstet Gynecol. 2013;122(3):546-552. 3. Obstet Gynecol. 2007;109(3):707-714.