ObjectiveThe aim of this study was to perform a cost-effectiveness analysis comparing the management for ongoing voiding dysfunction after midurethral sling placement, including early sling loosening and delayed sling lysis.MethodsA Markov model was created to compare the cost-effectiveness of early sling loosening (2 weeks) versus delayed sling lysis (6 weeks) for the management of persisting voiding dysfunction/retention after midurethral sling placement. A literature review provided rates of resolution of voiding dysfunction with conservative management, complications, recurrent stress urinary incontinence, or ongoing retention, as well as quality-adjusted life years (QALYs). Costs were based on 2020 Medicare reimbursement rates. Incremental cost-effectiveness ratios were compared using a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed.ResultsAt 1 year, early sling loosening resulted in increased costs ($3,575 vs $1,836) and higher QALYs (0.948 vs 0.925) compared with delayed sling lysis. This translated to early sling loosening being the most cost-effective strategy, with an incremental cost-effectiveness ratio of $74,382/QALY. The model was sensitive to multiple variables on our 1-way sensitivity analysis. For example, delayed sling lysis became cost-effective if the rate of voiding dysfunction resolution with conservative management was greater than or equal to 57% or recurrent stress urinary incontinence after early loosening was greater than or equal to 9.6%. At a willingness-to-pay threshold of 100,000/QALY, early sling loosening was cost-effective in 82% of microsimulations in probabilistic sensitivity analysis.ConclusionsEarly sling loosening represents a more cost-effective management method in resolving ongoing voiding dysfunction after sling placement. These findings may favor early clinical management in patients with voiding dysfunction after midurethral sling placement.
Vaginal hysterectomy is considered the preferred approach for benign hysterectomy due to its cost-effectiveness, safety, and low morbidity. Efforts to increase vaginal hysterectomy utilization, including endorsement by the American College of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists, has had limited impact on national trends. Marketing from companies and shifts in practice patterns along with lack of resident education have exacerbated the problem. Deeply engrained, though unfounded, perceived contraindications to a vaginal approach (e.g., prior surgery, nulliparity, uterine size, and risk factors for extrauterine disease) limits consideration of this approach further. This review presents evidence against these commonly perceived contraindications and provides a peer-reviewed algorithm that can be implemented to increase vaginal hysterectomy utilization safely. As minimally invasive technologies continue to evolve, surgeons have the responsibility to seek candidates that would benefit from the original-and most minimally invasive-approach to benign hysterectomy.
Purpose of reviewPelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer.
Recent findingsWe review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted.
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