Methods
To extrapolate data on female POP and continence surgery performed in 2012 throughout the 34 member countries of the OECD, we contacted each of the OECD-listed government health department sources in writing and by electronic mail in September 2013. If data on 2012 were not available, the latest year of available data was used. Data from 2010 to the end of 2012 were extracted if available. If no response was received within a month, a second electronic query was sent. In non–English-speaking countries, we enlisted the expertise of local colleagues to assist in communication and data extraction. We also contacted colleagues in nonresponding countries to determine whether these data could be accessed directly from the health department, national databases, or insurance companies.
We retrieved data from OECD sources in Australia, Canada, England, France, Germany, Ireland, Israel, New Zealand, Portugal, Switzerland, and Spain. Data were retrieved from national or health insurer’s databases in Holland, Denmark, Sweden, and the United States, which totaled 15 responses from 34 OECD countries.
Supplementary Table 1 ( Appendix ) describes the various coding systems used in the 15 OECD countries, the data source that the percentage of the population the data represents, the accessibility of the data, and the rates of private insurance.
To ensure consistency and transparency with data recording, we developed an International Classification of Disease , edition 10 (ICD-10)–compliant Excel spreadsheet (Microsoft Corporation, Redmond, WA) that was used for extracting data. Where possible, data were extracted in OECD, age-specific groups that included 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and ≥80 years and allowed age-related and population prevalence data to be calculated.
Supplementary Tables 2 and 3 describe the allocation of the various procedure codes for each country to our modified ICD-10 descriptor that forms the reporting basis. Procedural code descriptors include all interventions, irrespective of the service being provided as an inpatient or outpatient. No descriptor included reference to practice guidelines or algorithm of management. We attempted to extract not only procedures performed but also the number of women who underwent POP or continence surgery. In English-speaking countries, 2 authors independently extracted the data and entered it onto the ICD-10–compliant spreadsheets. In non–English-speaking countries, a native-speaking coauthor extracted the data and completed the ICD-10–compliant spreadsheet. The data sets were then collated centrally and checked by the lead authors. Discrepancies were resolved by mutual agreement.
No single accessible US source of data for POP and continence interventions is currently available. For the US analysis, we used 2 sources of data to allow us to reflect most accurately the actual status of POP and continence surgery. The 2011 Food and Drug Administration (FDA) estimate of the number of women who underwent POP and continence procedures in 2010 was used as a reliable national source. These data were used for comparisons on national rates of POP and continence interventions. More detailed data were extracted from the MarketScan Commercial Claims and Encounters database and Medicare Supplemental and Coordination of Benefits database (2012; Truven Health Analytics, Sacramento, CA). Individuals who were included in these databases were those with commercial, employment-based insurance (such as employees, their spouses, dependents, and retirees). This database included 53 million Americans in 2011, represents approximately one-sixth of the population, and was used for comparisons of specific surgical interventions and age-related calculations. Changes in transvaginal graft, sacral colpopexy, and midurethral slings that were undertaken between 2010 and 2012 were evaluated in countries that provided multiple years of data. Local ethics committee approval (reference no. 2014.21.127) was obtained on Feb. 2, 2014. Statistical analysis was performed with SPSS software (version 22; SPSS Inc, Chicago, IL). The median and range have been reported because of the asymmetric distribution of the data. A Spearman’s rank-order correlation was run to determine the relationship between private health insurance and the number of POP and continence procedures.
Results
We report on 684,250 POP procedures and 410,352 continence procedures that were performed in 15 OECD countries in 2012 ( Figure 1 ). POP procedures were performed at a median rate of 1.38 per 1000 women (range, 0.51–2.55) and were performed 1.84 times more frequently than continence procedures, which were undertaken at a median rate of 0.75 per 1000 women (range, 0.46–1.65; Figure 2 ). Only 3 countries reported on rates at which women underwent prolapse surgery ( Figure 1 ), and they demonstrated that 1.33 prolapse procedures are performed at each prolapse surgery. From this, we can calculate that women underwent prolapse surgery 1.4 times more frequently than continence surgery in OECD countries.
Interestingly, there was a moderately strong, positive correlation between rates of private health insurance and the number of POP and continence procedures per 1000 women, which was statistically significant (r S = 0.615; P = .025).
Figure 3 shows age-specific data that were provided by 13 of the 15 countries, with the exception of Germany and Switzerland. Although significant variation exists in the rate of interventions between countries, the median rate of continence surgery peaks at 1.3 procedures per 1000 women in the fifth decade and remains relatively constant until the seventh decade. The rate of prolapse procedures also demonstrates significant variation between countries and the median rate peaks at 3.9 procedures per 1000 women in the seventh and eighth decades.
As seen in Figure 4 , 13 of the 15 countries provided data on the various sites of POP interventions (anterior, posterior, or apical); however, Holland and Canada coding did not distinguish between anterior and posterior vaginal repairs; therefore, only apical data were included from these countries in this analysis. Anterior vaginal repairs represented 54% of all POP procedures; posterior repairs represented 43% of all POP procedures, and apical compartment repairs (abdominal or vaginal approach) represented 20% of all POP procedures.
Nine of the 15 countries provided data on graft usage in the anterior and posterior vaginal repairs ( Figure 5 ). The median rate of graft usage was 15.7% in the anterior vaginal compartment that ranged from 3.3% in England to 25.6% in Germany. Median rate of graft usage was 8.5% in the posterior vaginal compartment that ranged from 3.2% in Denmark and England to 17.0% in Spain.
Figure 6 shows that, in the 11 countries that provided data on apical compartment repairs, the repairs were repaired vaginally at a median rate of 70% (range, 35% in France to 95% in Sweden), and sacral colpopexy represented a median rate of 17% (range, 5% Sweden to 65% in France) of apical repairs. Data were insufficient to differentiate between types of vaginal apical procedures that were performed. Sacral colpopexy represented a median rate of 3.3% of all prolapse procedures and ranged from 0.3% in Denmark to a high of 33% in France ( Figure 7 ). Nine countries provided data on the route of sacral colpopexy with a median rate of 60.8% of interventions performed minimally invasively (laparoscopic or robotically), which ranged from 33% in Canada to a high of 94% in Denmark ( Figure 8 ).
As seen in Figure 9 , midurethral slings remain the most frequently performed female continence surgery, with a median rate of 82.4% of continence interventions that ranged from 63.6% in France to 97.8% in Sweden. Other continence surgery includes pubovaginal slings, Stamey needle suspensions, Botox injections, sacral nerve stimulators, and reconstructive bladder interventions that accounted for a median rate of 10.6% of continence interventions that ranged from 1.3% in Holland to 34.3% in France.
