Why is this study important?
Robinson et al 2003 is the first study that explored how women choose surgery for stress urinary incontinence. The study was conducted soon after mesh surgery, the retropubic Tension-free Vaginal Tape (TVT), became the most commonly performed continence procedure in the UK.
How was the study conducted?
The team in King's College London studied the questionnaire responses of 100 women over a two-month period in 2003. The study addressed what women perceive as "cure" by correlating incontinence severity (using the King's Health questionnaire), with
1) the pre-treatment expectation,
2) the acceptable interventions and
3) the post-treatment symptom acceptability (using a purpose-built questionnaire).
Women completed the questionnaires before seeing a clinician, removing potential clinician’s bias. The questionnaire did not mention the procedure by name, removing potential patient’s bias.
What are the findings?
Most of the 100 women (mean age of 47.5 years) have realistic expectations from treatment, with 66% expecting improvement and only 17% expecting cure.
Acceptability of Treatments:
*The major operation was colposuspension, the minor operation was retropubic Tension-free Vaginal Tape (TVT), and the clinic procedure was Urethral Bulking Agent (UBA) injections.
**The authors stated that the success and complication rates were approximated on the basis of the available literature and are in line with their own results, where these three techniques are offered.
What are the study’s implications?
The study represented the standard clinical practice by the responsible body of (uro)gynecologists at the time. Colposuspension, retropubic Tension-free Vaginal Tape (TVT) and Urethral Bulking Agent (UBA) injections were the reasonable surgical alternatives offered to women in 2003.
Women seeking continence surgery value safety and recovery more than efficacy. Regardless of symptom severity, a safe minor clinic procedure (UBA injection) that improves quality of life was more acceptable and more popular among women, compared to a relatively risky major (colposuspension) or minor (TVT) operation that can cure urine leakage.
The authors stated they were not surprised that less invasive surgery was more attractive, even if this meant a potential "trade-off" in terms of lower success rates. The authors suggested that such findings may prove helpful when counselling patients regarding management of bladder symptoms. Subsequent studies Ong 2019 SUI-PDA and Dwyer et al reported similar results.
Women tolerate stress incontinence much more than urgency and urgency incontinence, and nocturia was found unacceptable to the majority of women. Therefore, an intervention that can cure the stress incontinence but has a risk of new (de novo) urgency incontinence and nocturia may not be acceptable to the majority of women. Indeed, previous studies demonstrated that quality of life is lower in women with urgency incontinence compared to those with stress incontinence.
Women with higher leakage severity and those with long standing condition did not choose differently i.e. the severity and the duration of the condition did not determine the treatment women accept / choose.
As the cure rate and risks were similar, reducing the invasiveness of a major operation (colposuspension) to a minor one (TVT) increased acceptability by only 15% (from 23% to 38%).
Question for future research:
If an intervention was accepted by only 38% of women, how did it become the most commonly performed (90%) in the UK?