Comparison of Perioperative Adverse Events Following Suburethral Sling Placement Using Synthetic Mesh, Autologous Rectus Fascia, and Autologous Fascia Lata in a National Surgical Registry

Abstract

The involuntary loss of urine due to effort activities such as coughing, sneezing, or athletic exertion, better known as stress urinary incontinence (SUI), is common for adult women, with anywhere from 4% to 35% of the population being affected. Surgical placement of suburethral sling is a highly effectivemethod of treatment, with up to an 89.2% success rate at 3 years. Suburethral slings can be fashioned from either synthetic mesh or the patient's own autologous fascia tissue. The predominant types of slings currently placed in United States are currently mesh, with the advantages including shorter operative times, reduced surgical dissection, and avoidance of tissue harvesting. A mere 2% of surgeries involving synthetic mesh result in extrusion or exposure. Despite this, concerns regarding mesh have resulted in the resurgence of autologous fascial slings, especially for those with high risk for adverse events or previously failed synthetic mesh operations. Because a current lack of literature comparing both methods of SUI repair exists, this study primarily aimed to utilize a national database in order to identify the incidence of adverse events following the 30-day perioperative period after sling with syntheticmesh, autologous fascia lata, and autologous rectus fascia. Secondary aims of the study included comparison of risk of adverse events due to sling type, as well as description of the most common adverse events. Utilizing the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database, a retrospective cohort study was performed for patients who experienced synthetic or fascial suburethral sling between 2008 and 2021. This database contained clinical characteristics, patient demographics, and intraoperative events from over 700 US hospitals. Data were abstracted from medical records via trained clinical reviewers. Current Procedural Terminology (CPT) code 57288 was used to identify cases (this code includes all SUI sling operations). Presence of CPT codes of 20922/20920 (fascia lata harvest) and 15769/ 20926 (rectus fascia harvest) were used to differentiate between patients who underwent sling placement with synthetic mesh versus autologous fascia. Patients undergoing concomitant procedures aside fromcystoscopy (CPT 5200) or fascial harvest were excluded. Patient clinical characteristics and demographic information such as body mass index, age, smoking status, race, American Society of Anesthesiologists class, hypertension requiring medical intervention, diabetic history, severe chronic obstructive pulmonary disease, bleeding disorders, and congestive heart failure were all included, as well as the subspecialty of the surgeon performing the procedure. The composite rate of adverse events within 30 days postsurgical procedure was the primary outcome. Included in the adverse events category were various surgical site infections (SSIs), urinary tract infection (UTI), septic shock or sepsis, blood transfusion, renal failure, pneumonia, myocardial infarction, deep vein thrombosis, pulmonary embolism, stroke or cerebral vascular accident, and unplanned reoperation or readmission. Two comparisons took place: (1) between those who underwent autologous fascial sling versus those undergoing synthetic sling placement and (2) among the autologous fascial slings, a comparison of rectus fascia versus fascia lata harvest group. Results of the study found that of 41,533 patients who underwent suburethral sling placement, 41,292 (99.4%) received a synthetic mesh sling, and only 241 (0.6%) received an autologous fascial sling. Within the autologous fascial sling cohort, two-thirds underwent rectus fascia harvest. Synthetic mesh slings had the lowest composite adverse event rate (6.2%), with the highest rates occurring for fascia lata (23.5%) and rectus fascia (12.5%). The most common perioperative adverse events included blood transfusions (0.3%), superficial SSIs of either the harvest site or sling site (0.5%), and UTIs (4.4%). Total operative time was roughly 3 times as long for fascial slings. Similarly, length of stay was significantly longer for fascial slings. Furthermore, the UTI rate was higher for fascia lata autologous slings when compared with rectus fascia harvest (14.8% vs 5.0%). Overall, the risk of 30-day adverse events from autologous fascia surgical methods was 3.6 times higher than sling surgery using synthetic mesh. Strengths of the study include its use of a large patient cohort from a validated national database, as well as its exclusive focus on sling-related adverse events through exclusion of cases that featured concomitant procedures. Furthermore, the ACS-NSQIP database includes both inpatient and outpatient procedures. These 3 points all compare favorably to previous published analyses. Limitations of the study include the 30-day limitation of surgical outcomes being recorded in the ACS-NSQIP database, as well as a lack of recording any sling-related adverse events occurring with patients prior to sling surgical approaches (ie, bladder injury, mesh extrusion or exposure, urinary retention, hematoma, and urinary retention). The database also failed to capture patient-centered outcomes regarding prior procedures for incontinence. Data discerning whether SSIs occurred at the harvest site or sling site were lacking. Additionally, because the CPT code 57288 encompasses all SUI-related sling operations via synthetic material or fascia, it also includes slings derived from nonsynthetic mesh implants and cadaveric fascia. Finally, infrequent use of autologous fascial slings in the United States may render this study underpowered to detect differences between autologous fascial slings, despite the analysis including one of the largest patient cohorts subject to this procedure. This study definitively identified a lower rate of 30-day adverse events using synthetic mesh for surgical SUI treatment as compared with autologous fascial methods. With autologous facial slings, the use of fascia lata was twice as likely to be associated with adverse events (although the exclusion of UTIs yielded similar composite rates of adverse events). Both physicians and patients can find this information useful when determining the optimal SUI surgical treatment. More informed decisions regarding sling type and site for harvest will overall lead to improved patient care.