title: To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis.
abstract: OBJECTIVE
  We compare the cost-effectiveness of 3 strategies for the use of a mid urethral sling to prevent occult stress urinary incontinence in patients undergoing abdominal sacrocolpopexy.
  
  
  METHODS
  Using decision analysis modeling we compared cost-effectiveness during a 1-year postoperative period of 3 treatment approaches including 1) abdominal sacrocolpopexy alone with deferred option for mid urethral sling, 2) abdominal sacrocolpopexy with universal concomitant mid urethral sling and 3) preoperative urodynamic study for selective mid urethral sling. Using published data we modeled probabilities of stress urinary incontinence after abdominal sacrocolpopexy with or without mid urethral sling, the predictive value of urodynamic study to detect occult stress urinary incontinence and the likelihood of complications after mid urethral sling. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost-effectiveness ratio per quality adjusted life-years gained. In addition to base case analysis, 1-way sensitivity analyses were performed.
  
  
  RESULTS
  In our model, universally performing mid urethral sling at abdominal sacrocolpopexy was the most cost-effective approach with an incremental cost per quality adjusted life-year gained of $2,867 compared to abdominal sacrocolpopexy alone. Preoperative urodynamic study was more costly and less effective than universally performing intraoperative mid urethral sling. The cost-effectiveness of abdominal sacrocolpopexy plus mid urethral sling was robust to sensitivity analysis with a cost-effectiveness ratio consistently below $20,000 per quality adjusted life-year.
  
  
  CONCLUSIONS
  Universal concomitant mid urethral sling is the most cost-effective prophylaxis strategy for occult stress urinary incontinence in women undergoing abdominal sacrocolpopexy. The use of preoperative urodynamic study to guide mid urethral sling placement at abdominal sacrocolpopexy is not cost-effective.
authors.affiliation: Stanford University School of Medicine, Stanford, California.
authors.forename: Monica L
authors.initials: ML
authors.lastname: Richardson
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Elliott
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Shaw
authors.forename: Craig V
authors.initials: CV
authors.lastname: Comiter
authors.forename: Bertha
authors.initials: B
authors.lastname: Chen
authors.forename: Eric R
authors.initials: ER
authors.lastname: Sokol
mesh_terms: D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007432:Intraoperative Period; D056887:Pelvic Organ Prolapse / Q000601:surgery*; D053825:Suburethral Slings / Q000191:economics*; D014550:Urinary Incontinence, Stress / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*
keywords: ASC; ICER; MUS; QALY; SUI; UDS; abdominal sacrocolpopexy; costs and cost analysis; incremental cost-effectiveness ratio; mid urethral sling; pelvic organ prolapse; quality adjusted life-year; stress; stress urinary incontinence; suburethral slings; urinary incontinence; urodynamic study