Between 2006 and 2013, gynecologists in the United States performed four times more sling procedures for stress urinary incontinence (SUI) than urologists, as well as a larger number of concomitant pelvic floor procedures such as prolapse repair and hysterectomy, a study found.
Analysis of an American College of Surgeons (ACS) database also showed that during the same period, urologists performed more autologous fascial sling procedures than gynecologists (66 versus 10 cases, P<0.001), and tended to have older patients with more comorbidities, including hypertension.
“These findings demonstrate that although gynecologists perform a greater number of surgeries, urologists treat a unique population of patients who require operative management of stress urinary incontinence,” Doreen E. Chung, MD, of Columbia University Medical Center in New York City, and colleagues wrote online in The Journal of Urology.
These practice differences may reflect differences in training, the investigators said, noting that urologists treat more patients with complex issues such as neurogenic bladder, who have a history of previous treatment failure, and who have mesh complications.
Although the retrospective nature of the study did not allow the team to determine causality, it did generate unique and generalizable data, the researchers said.
For the analysis, patient and operative characteristics were compared in a cohort of 22,192 sling procedures from the ACS National Surgical Quality Improvement Program. Of these, 16,474 (74.2%) sling procedures were performed by gynecologists and 5,718 (25.8%), by urologists. A total of 8,664 patients (44.1%) underwent concomitant prolapse repair: 7,710 (46.8%) were treated by gynecologists, and 954 (16.7%) were treated by urologists.
Patients who underwent surgery performed by a urologist were more likely to have a physical status of 3 or 4 on the American Society of Anesthesiologists (ASA) classification system.
In addition, 77.5% of patients who underwent surgery performed by a urologist were overweight or obese, 37% had hypertension, 15% were smokers, and 10% had diabetes.
The significant differences in the patient profiles of gynecologists compared with urologists may be the result of different referral patterns, Chung et al wrote. “For example, primary care gynecologists may diagnose incontinence in younger patients during routine preventive visits and refer those patients to their colleagues. Urologists may have more referrals from internal medicine physicians who see patients for other medical problems such as hypertension.”
In an accompanying editorial comment, Kathleen C. Kobashi, MD, of Virginia Mason Medical Center in Seattle, said that the findings may be a bit misleading, since the greater number of slings performed by gynecologists compared with urologists is a reflection of the number of clinicians who practice in the U.S. — i.e., gynecologists outnumber urologists four to one (40,826 versus 9,711), and performed four times as many sling procedures.
Similarly, the trend towards the two disciplines treating distinct patient populations may not be as pronounced in clinicians who are fellowship-trained, regardless of whether their primary focus was urology or gynecology, Kobashi said, noting that fellowship training was not specifically addressed in the study.
Previous studies indicate that urologists tend to dismiss prophylactic sling placement and treat more medically complex patients based on lower urinary tract functional characteristics.
Anatomy-focused gynecologists still embrace the procedure, noted Kobashi, who is first author of the American Urological Association (AUA) clinical guideline on treatment of SUI in women, which was published in October.
“Perhaps the most important implication, given the recent increase in emphasis on pelvic floor medicine in urological training and the AUA Core Curriculum, is the need for more resolute attention to training urologists in the management of prolapse,” she wrote. “Similarly, gynecologists might more purposefully consider the influence of function. This landscape presents a fine opportunity for the two disciplines to collaborate, share thinking, and learn from each other.”
The melding of the urology and gynecology into “urogynecology” with board certification of clinicians in female pelvic medicine and reconstructive surgery (FPMRS) may already be helping: Clinicians with FPMRS board certification — which is overseen by the joint boards of urology and obstetrics and gynecology — “may be more likely to have a broader outlook on the patient with a pelvic floor disorder, incorporating both function and anatomy at an advanced level,” Kobashi told MedPage Today.
“Clearly, there is always more to learn about any condition, and the collective efforts to advance the field and increase our knowledge and understanding should ultimately benefit the patients.”
None of the authors noted any potential conflicts of interest.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner