The subspecialty of female pelvic medicine and reconstructive surgery (FPMRS) obtained recognition by the American Board of Medical Specialties with an official accreditation in 2011.¹ Subsequently, the American Board of Urology (ABU) subspecialty board certification for FPMRS began in 2013.² The subspecialty field incorporates issues such as male and female urinary incontinence, neurogenic lower urinary tract dysfunction, pelvic organ prolapse (POP), recurrent urinary tract infection, painful bladder syndrome, genitourinary fistula, and voiding dysfunction.

Case log data submitted to the ABU are a rich source of data that previously have been used to assess the surgical practice patterns of general and subspecialist urologists.^3,4 As the initial year of subspecialty certification by the ABU, 2013 was the first year that FPMRS practice logs could be submitted, and as such, criteria for FPMRS designation that year were not based on any specific level of prior FPMRS training, but rather having an FPMRS-focused practice with case logs that met a minimum level of FPMRS-related care, as determined by the ABU. These same urologists who took the initial FPMRS certifying examination in 2013 were eligible for FPMRS recertification in 2020. These 2 time points provided unique insight. Case logs from 2013 provided information on those individuals “grandfathered” into the subspecialty;⁵ 2020 provided information both on urologists undergoing recertification as well as those who were ready for initial certification after completion of their ACGME-approved FPMRS fellowship.

We identified a total of 229 unique self-designated FPMRS providers in the case log data from 2013 and 2020—131 FPMRS urologists in 2013 and 98 FPMRS urologists in 2020. Of those 229 individual surgeons, 57.2% submitted case logs in 2013, for a total of 41,456 cases between the 2013 and 2020 log years. We stratified cases based on procedure type and whether they were traditionally FPMRS-specific procedures, which included anti-incontinence procedures, abdominal and vaginal approaches for prolapse repair, vesicovaginal fistula repair, and mesh excision/removal. In 2013, of a total of 19,309 cases, 6,882 were FPMRS cases and 12,427 were non-FPMRS cases. There were 22,237 cases in 2020, of which 7,790 were FPMRS-specific and 14,447 were non-FPMRS cases. Overall, non-FPMRS-specific cases were less likely among surgeons who performed a high volume of FPMRS-specific procedures (P < .01).

Anti-incontinence procedures consistently constituted 46% of the subspecialty-specific cases in certification logs from both 2013 and 2020. The overwhelming majority (>90%) of procedures performed for management of stress urinary incontinence were sling procedures with either synthetic mesh or autologous fascia. There was a slight increase in sling placement as a proportion of anti-incontinence procedures from 2013 to 2020 (95.6% vs 98.2%), similarly observed as a proportion of overall cases (44% vs 45%). However, based on the case rate adjusted for the number of surgeons per certification year, the number of sling cases per surgeon decreased between the 2 case log years (31.3 in 2013 vs 26.8 in 2020). The remainder of anti-incontinence procedures included transvaginal urethropexy, abdominal/laparoscopic urethropexy, and laparoscopic sling placement.

Mid-urethral sling placement has previously been shown to be the most commonly performed anti-incontinence procedure amongst certifying urologists, regardless of specialty type.⁶ The relative increase in the share of sling procedures as a proportion of anti-incontinence procedures without an overall change in total anti-incontinence procedures during the 2 case certification years suggests that factors specific to sling placement may be influencing the sling placement rates, such as a balance between concerns about mesh use and data supporting the higher efficacy of sling placement as compared to other anti-incontinence procedures. Additionally, there may be changes in the proportion of autologous fascia vs synthetic mesh use which is not captured by case logs.

Surgical management of POP similarly changed between the 2013 and 2020 case logs, perhaps another indication of attitudes toward mesh use. Prolapse repair procedures were one of the most common procedure types performed by FPMRS-certifying urologists comprising 45% of submitted cases in 2013 and 2020. The total number of transvaginal mesh/prosthetic graft placement cases in 2013 (741 cases) vs 2020 (338 cases) represents 11% and 4% of total cases performed by FPMRS urologists in 2013 and 2020, respectively. The share of transvaginal mesh/prosthetic graft placement cases for POP as a proportion of transvaginal prolapse repair decreased by half, from 30% to 15%, from 2013 to 2020. Over this same time period, there was an increase in the use of abdominal mesh for prolapse repair, as abdominal mesh increased as both a proportion of total FPMRS cases (from 9% to 15%) and overall prolapse repair procedures (from 24% to 30%). These trends were similar for non-FPMRS providers, likely related to the uptake of robot-assisted laparoscopic sacrocolpopexy among all urologists. Interestingly, the rates of mesh excision did not change between 2013 and 2020, staying at 8% of all procedures.

The identified CPT (Current Procedural Terminology) codes for transvaginal mesh/prothesis placement bundle transvaginal mesh and prosthetic graft (xenografts, biologic graft) use, limiting the ability to distinguish between the 2 case types. However, as the 2013 case logs included cases from as early as 2011, it is reasonable to assume that transvaginal mesh kits were used in a significant proportion of these cases, and the subsequent decrease in these cases was at least partially in response to consecutive U.S. Food and Drug Administration (FDA) statements about transvaginal mesh use. In 2019, the FDA banned the distribution of transvaginal mesh kits for POP repair, a follow-up to earlier FDA communications questioning the use of transvaginal mesh for the surgical management of POP, reducing the likelihood that transvaginal mesh was used in these repairs, especially in the case logs submitted for certification in 2020.

As the practice of urology continues to become more subspecialized, it is important to appreciate the impact of subspecialty certification on practice patterns for cases that are considered specific to a certain subspecialty. While highlighting the diversity of FPMRS practice, the data also demonstrate the impact of external factors—FDA communications on transvaginal mesh and training experience—on practice patterns among subspecialists.