Sling procedures for the treatment of stress urinary incontinence: Comparison of national practice patterns between urologists and gynecologists: Beyond the Abstract

Sling procedures have become the dominant surgical treatment for stress urinary incontinence (SUI) in the modern era, representing over 80% of all surgical procedures for the treatment of SUI. Both urologists and gynecologists perform sling procedures, and both specialties have fellowships and board certification in female pelvic medicine and reconstructive surgery (FPMRS).

While much literature has focused on general trends in the surgical management of SUI, few studies have investigated differences in provision of care between urologists and gynecologists. We sought to compare national practice patterns of sling procedures by specialty using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a contemporary, validated, national data registry containing prospectively collected preoperative through 30-day postoperative data on patients in both academic and non-academic centers. Using Current Procedural Terminology codes, we identified patients who underwent sling procedures as their primary procedure, then compared patient and operative characteristics between those operated on by urologists, and those operated on by gynecologists.

Of the 22,192 patients identified, urologists performed only 25.8% of the sling procedures. Gynecologists performed the overwhelming majority of sling procedures in our study, however, it is worth noting that practicing gynecologists nationwide outnumber practicing urologists about 4:1. Interestingly, the proportion of sling procedures performed by urologists grew over the study period. The majority of autologous fascial slings were performed by urologists. 

The two specialties appear to perform sling procedures in distinct populations, with urologists treating more medically complex patients, and gynecologists performing more concomitant procedures. Nearly 40% of the cohort underwent concomitant pelvic organ prolapse (POP) repair, with gynecologists accounting for 90% of those cases. This may reflect a difference in the practice of prophylactic sling placement, a practice that remains controversial as prophylactic sling placement has been shown to result in higher rates of adverse events. Perhaps a greater emphasis on management of prolapse is needed in the future training of urologists.

In our study, patients who had surgery performed by urologists had higher comorbidity. Reasons could be differing referral patterns. Urologists may have more referrals from internal medicine physicians seeing patients for other medical problems, while gynecologists may be diagnosing incontinence in younger patients during routine preventative visits. Further studies into differences in referral patterns and patient selection are needed. We also found that urologists performed a greater proportion of autologous fascial slings than gynecologists, a practice difference that may reflect differences in training and a more complex patient population.

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Written By: Doreen E. Chung and Maxwell James