Study design, materials and methods
Monthly MDT meetings to discuss women who were considering invasive treatment for stress urinary incontinence, overactive bladder or primary prolapse, have been held a university hospital and a local District General Hospital during the study period. These meetings were attended by gynaecologists, urologists, continence nurses, physiotherapists, urodynamicists and administrative staff.
At the meetings, each patient’s condition was discussed in details, looking at presenting symptoms, medical history, concerns, personal choice of treatment, urodynamics diagnosis and proposed treatment plan amongst the multidisciplinary team. This provides a focus of patient-centred care, ensuring each patient receives the highest standard of management for complex conditions that lack evidence of gold standard approaches.
All patient data was collected and anonymised. Age, parity, BMI, primary diagnosis, urodynamics, symptom questionnaires, patient preference and referring consultant preference was analysed alongside the final recommendations from the MDT. The purpose of the study is to assess the impact of the local MDT on patient management including any changes to proposed treatment plans or further involvement with other allied health professionals. SPSS Statistics (version 23) was used to analyse the data.
Results
123 women had their conditions discussed by the MDT. The average age was 54.5 (range 35 – 85 years), the median parity was 2 (range:0 -7) and the mean BMI was 30.8 (range: 21 – 49). No underweight women presented with symptoms during the study period.
The highest incidence of incontinence appears to be within the age range of 49 – 53 years, reflecting the time of menopause and consistent with other studies. The parity also reflects that childbirth was common in our population.Only 2 patients never had children.
Table 1 shows the frequency of patient and MDT choice of the 4 main SUI procedures for 102 out of 123 responses. The most favoured procedure was colposuspension (60.8%) followed by Bulking Agent Injection (28.4%) followed by Autologous Fascial Sling (10.8%). No patient has chosen the mesh tape surgery.
The MDT choice was available for 96 out of 123 patients (78%). MDT choices followed a similar pattern with colposuspension being the favoured procedure (46.9%) closely followed by Bulking Agent Injection (37.5%) and lastly the Autologous Fascial Sling procedure (8.3%). MDT has recommended no surgical intervention in 7 women (7.3%) and, instead, advised further investigation or further conservative treatment. Despite the availability of mesh tape procedures in a nearby hospital, the MDT did not recommend such surgery in any patient.
In 19 instances (15.4%) the MDT has recommended a course of action that was different from the woman’s choice. The MDT has recommended Bulking Agent Injection in 12 instances (63.3%) or continuous conservative treatment or further investigation in 6 instances (31.6%) and,in one occasion, an Autologous Fascial Sling Procedure instead of a Colposuspension procedure because of low urethral pressures.
86 women documented what matters to them in making the choice of SUI procedure. “Cure from leakage” was selected as one of the top 3 values by 83 out of 86 women. While the second most important value was “avoid repeat surgery in the future” with 41 (47.7%) women choosing this value and avoiding mesh complications by 30 women (11.2%). See table 2.
Interpretation of results
The MDT significantly changed the management of patients in 19 (15.4%) cases, mostly to a less invasive intervention. This figure is also in keeping with other regional MDT outcomes and suggests that discussion by a group of cross-specialty experts influences the professional choice of treatment.
This is one of the first studies to analyse the impact of a local MDT which is a real strength of this work. It is in keeping with other studies analysing regional MDTs that suggest it is a beneficial exercise for the patients and specialists involved(3).
This study focused on patient choices and the outcomes of MDT discussions prior to surgical treatment. We are currently analysing the clinical outcomes using patient-reported outcome measures following the proposed MDT recommendation of surgical treatment.
MDTs have been in place since 2014, but due to the lack of data recorded, only evidence from 2017-2019 are included. There is a specific proforma for the local MDT and increasingly the data is being recorded to a higher standard without missing information on patient choices and MDT outcomes. This will help strengthen follow up studies in the future.
The age of the patients in this study are in keeping with other reports suggesting that incontinence and prolapse affect women of all ages, but most commonly around or after the menopause.(3)