Update on pelvic surgery
The midurethral sling has become the standard treatment for stress urinary incontinence. But are all sling techniques equally effective? Recent studies shed some light on that question.
IN THIS ARTICLE
Also notable in this study is that subjects had relatively high Valsalva leak-point pressures (approaching 100 cm H2O) in both groups.
Which technique is best for SUI with intrinsic sphincter deficiency?
Jeon MJ, Jung HJ, Chung SM, et al. Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency. Am J Obstet Gynecol. 2008;199:76.e1–76.e4.
This retrospective cohort study was designed to evaluate techniques for treating severe SUI. Researchers were mainly interested in patients who had intrinsic sphincter deficiency (ISD), defined as a Valsalva leak-point pressure <60 cm H2O or maximal urethral closure pressure <20 cm H2O.
The pubovaginal (bladder neck) sling (PVS) has been considered the gold standard therapeutic option for patients who have ISD. Recently, however, data have shown satisfactory outcomes using TVT in this setting.2,3 The aim of this study, therefore, was to compare PVS, TVT, and TOT for treating SUI in patients who had ISD. (Note: The researchers used Uratape [Mentor-Purgès] for the transobturator sling.)
The study included 253 subjects who had ISD and who underwent surgical intervention (87, PVS; 94, TVT; 92, TOT); women who had detrusor overactivity and voiding dysfunction were excluded. Follow-up assessments were performed at 1, 3, 6, and 12 months and annually thereafter. Outcomes studied included complications and rates of cure; the latter was defined as 1) the absence of subjective complaints of leakage and 2) a negative cough stress test.
Median follow-up was 36, 24, and 12 months in the PVS, TVT, and TOT groups, respectively. All groups were similar in regard to baseline clinical and demographic characteristics. Bladder perforation was rare (PVS, 1; TVT and TOT, 0). No significant difference was noted across techniques in the rate of de novo urgency, voiding dysfunction, reoperation for urinary retention, and recurrent urinary tract infection.
Two years after surgery, the cure rate for the three procedures differed significantly: PVS and TVT, 87% each; TOT, 35% (p<.0001). A Cox proportional hazards regression model revealed that the risk of treatment failure with PVS was no different than it was for TVT. However, this model demonstrated that the risk of failure was 4.6 times higher for TOT compared with PVS (p<.0001).
This study is subject to the limitations of any retrospective study. It is unique, however, in that investigators focused on a more severe sample of subjects with ISD. In addition, the authors of the study used the appropriate statistical techniques to attempt to control for potential confounders.
Although the rate of cure was higher with TVT than with TOT, the rate of voiding dysfunction (i.e., the need for catheterization longer than 1 month after surgery) and de novo urgency was higher with TVT as well. This finding suggests that TVT provides more compressive force around the urethra than TOT does; on the other hand, it is possible instead that the difference arises in the method of tensioning of various types of sling.
Last, the study surgeon conducted the postoperative evaluations and was not blinded. This may have introduced bias into the assessments.
As more long-term data become available about different approaches to placing a midurethral sling, it’s likely that we will learn that not all techniques are equal. A customized approach—one that takes into account the individual patient’s clinical parameters—may be necessary to yield long-term efficacy with a sling.
Although, as the authors of this Update discuss, there are several surgical approaches to stress urinary incontinence (tension-free vaginal tape, suprapubic urethral support sling, transobturator tape, pubovaginal sling placed at the bladder neck), coding for the procedure is limited to a single Current Procedural Terminology (CPT) code when surgery is performed via a vaginal approach. CPT code 57288 ( Sling operation for stress incontinence [e.g., fascia or synthetic] ) has been assigned 21.59 relative value units in 2008 and should be reported no matter what type of sling is placed or what method is used to place it.
Failed placement
On occasion, sling material erodes or creates other problems for the patient, such that it must be removed or revised. To report correction of this adverse outcome, bill with 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]). If revision must be performed within the global period for the original procedure by the surgeon who placed the sling, append modifier -78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the revision code.
Minimally invasive placement
If you perform a sling procedure laparoscopically, report 51992 (Laparoscopy, surgical; sling operation for stress incontinence [e.g., fascia or synthetic]) instead. No corresponding code exists for laparoscopic revision of a sling procedure; under CPT rules, your only course is to report 51999 (Unlisted laparoscopy procedure, bladder).—MELANIE WITT, RN, CPC-OBGYN, MA
