The multi-disciplinary team (MDT) approach is an increasingly familiar aspect across many different surgical specialties. The most recent National Institute of Clinical Excellence (NICE) guidelines on “The Management of Urinary Incontinence in Women” in 2015 (1) recommend that invasive therapy is offered for stress urinary incontinence (SUI) and/or overactive bladder (OAB) only after MDT review. They also recommend that such teams should include representation from: urogynaecology, urology, physiotherapy, colorectal surgery, and geriatrics. The MDT should be working within an established regional clinical network.

In this study, we aim to audit the evolution and activity of the monthly Pelvic Floor MDT of a regional referral centre in North West England. It was initially set up as a small “urodynamic meeting” in 2009 and has grown into its current form today. More specifically, we aimed to identify the patient case load as well as their outcomes following MDT review.

We retrospectively sampled patients discussed at the local Pelvic Floor MDT from October 2014 to October 2018 which consisted of patients from 3 different sites. We retrospectively analysed paper and electronic documentation as per our aims. Advantis Clinical Documentation System (CDS) was the primary source of data as well as MDT attendance sheets.

694 patients were included in our study with a male:female ratio of 1:141.9 and a mean average age of 56.0 years (median = 56, SD = 14.1 years). The attendance rate varied across specialties (Fig. 1) with the highest being gynaecology (total 128 attendances) followed by physiotherapy (total 102) and urology (total 95). There was a low attendance for colorectal surgery (total 21) and no attendance was documented for geriatrics. The main source of patient referral was from gynaecology (66.7%) followed by urology (29.9%). The most common reason for referral (Fig. 2) was primary SUI (25.6%) followed by pelvic organ prolapse (14.9%). 406 (58.5%) patients had urodynamic studies and 47 (6.8%) patients had defecating proctograms reviewed at MDT. 45 (6.5%) patients were referred to another specialty following MDT discussion. Surgical management was advised in 72% of patients discussed at MDT. Overall, the MDT concurred with 79% of pre-MDT management plans.

We have demonstrated the pelvic floor MDT’s progressive evolution since its inception in 2009 (only 21 patients discussed that 12-month period). A wide range of pathology was discussed with referrals from many different specialties although the highest were from gynaecology. The vast majority of patients discussed were middle aged women. The MDT forum promotes cross-speciality discussion in order to ensure best practice for complex incontinence, pelvic organ prolapse and rarer pelvic floor pathology. Attendance did not meet NICE guidelines with respect to colorectal surgeons and geriatricians. However, although colorectal surgery is very relevant for pelvic organ prolapse management, the value added to discussions purely regarding incontinence, for example is limited. Both surgical and conservative measures were advocated by the MDT and over a fifth of management plans had changed after MDT review.

The pelvic floor MDT continues to evolve into a multi-specialty regional pelvic floor dysfunction network as per NICE guidelines. Moving forward, MDT activity should be continually audited and more specific data concerning individual meetings and their attendances can also be analysed in future studies. We also eagerly await the latest NICE guidelines concerning “Urinary incontinence (update) and pelvic organ prolapse in women: management” (2) which are due to be published on 2nd April 2019 and whether the MDT can adapt to any new recommendations. Furthermore, we believe there is a strong business case to advocate for an administrative role within the MDT to help in its organisation and running. The recent Independent Medicines and Medical Devices Safety Review (3) chaired by Baroness Cumberlege advised that all stress incontinence procedures are to be collated and all mesh procedures should be registered. Regular audited MDT meetings provide an ideal setting for this to take place. The MDT is an important part of the decision-making process for complex pelvic pathology patients and we have shown that it regularly alters management plans after review. We believe that this pelvic floor MDT provides a benchmark for how such patients should be managed within a cross-specialty framework across all hospital Trusts.

https://www.nice.org.uk/guidance/cg171 - NICE Guideline - Urinary Incontinence in Women: Management
https://www.nice.org.uk/guidance/indevelopment/gid-ng10035- NICE Guideline - Urinary incontinence (update) and pelvic organ prolapse in women: management
http://www.immdsreview.org.uk/index.html - The Independent Medicines and Medical Devices Safety