Towards patient centered care in female stress urinary incontinence

Abstract

This thesis focussed on the treatment of stress urinary incontinence in women. It comprises the results of the PORTRET study (Physiotherapy OR Tvt Effectiveness Trial). Currently, pelvic floor muscle training is advised as initial treatment for all women with stress urinary incontinence. We questioned whether all stressincontinent women should initially be treated with pelvic floor muscle training or if slingsurgery could be a good initial treatment option too. We reviewed literature on the effect of pelvic floor muscle training and midurethral slingsurgery on Health Related quality of life. Both pelvic floor muscle training and midurethral slingsurgery Improve health related quality of life. However improvement seemed higher after midurethral slingsurgery. We presented the main and secondary outcomes of the PORTRET study. The primary outcome was subjective improvement, at 12 months. We randomly assigned 230 women to the slingsurgery group and 230 women to the physiotherapy group. In the physiotherapy group 49.0% crossed over to the alternative treatment compared to 11.2% of women in the surgery group. Subjective improvement was reported by 90.8% of women in the slingsurgery group versus 64.4% of women in the physiotherapy group (95% confidence interval [CI], 18.1 to 34.5). The rates of subjective cure were 85.2% in the slingsurgery group and 53.4% in the physiotherapy group (95% CI, 22.6 to 40.3); rates of objective cure were 76.5% and 58.8%, respectively (95% CI, 7.9 to 27.3). A post hoc per-protocol analysis showed that women who crossed over to the slingsurgery group had outcomes similar to those initially assigned to slingsurgery and that both these groups had outcomes superior compared to women who did not cross over to slingsurgery. We concluded that initial midurethral slingsurgery, as compared with initial physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 12 months follow up. Furthermore we developed a prediction rule for the chance of slingsurgery after initial physiotherapy in stress urinary incontinent women. Prognostic factors for undergoing slingsurgery after physiotherapy were: age <55 years at baseline higher educational level and severe incontinence at baseline according to the Sandvik index and Urogenital Distress Inventory. We concluded that in women with moderate to severe stress incontinence, individual prediction for slingsurgery after initial physiotherapy is possible, and enables shared decision making for the choice of initial management for stress urinary incontinence.

We also performed an incremental cost-utility analysis of pelvic floor muscle training and slingsurgery. The incremental cost per quality adjusted life years i.e. incremental cost-effectiveness ratio (ICER) was calculated. The incremental cost for initial slingsurgery was €1091. The mean ICER for initial slingsurgery was € 54.377 with a 74% probability of the ICER remaining below the Dutch threshold of €80.000 per QALY gained.

We demonstrated that initial midurethral slingsurgery is a cost effective treatment approach compared to initial pelvic floor muscle training for moderate to severe urinary stress incontinent women. From a cost perspective and taking in account objective and subjective outcomes of treatment, both options should be considered as initial treatment approach for SUI.