Clear communication resolves incontinence nightmares

The first case

Prof. Veronique Phé (FR) presented the first patient case which involved a 66-year-old female patient who was referred to her academic centre due to a refractory overactive bladder in 2022.

In 2019, the patient complained about urgency but not stress urinary incontinence (SUI). The first surgeon, who was from a different centre, placed a synthetic suburethral sling. There was no medical report but the patient recalls a bladder perforation during the surgery for which she was re-operated.

The patient underwent flexible cystoscopy which was performed by the second surgeon, a urologist, who is also from another centre. The surgeon discovered a bladder neck stone. In his report, he stated that there was no erosion.

The patient disclosed the following urinary symptoms:

• Daytime frequency of one void per hour
• She drank two cups of coffee per day
• Numerous episodes of urgency/days without incontinence
• No SUI and pad usage
• No recurrent urinary tract infections
• No gross haematuria

The surgeon gave the patient a physical examination. He stated that there was pain on the palpation of the posterior surface of the urethra and no vaginal erosion. Flexible cystoscopy was not repeated.

To help in the investigation, in 2022 he prescribed pelvic MRI and pelvic ultrasound. The pelvic MRI showed no visualised complication (particularly signs in favour of urethral, bladder, or vaginal erosion), and equivocal oval formation of 6mm located opposite the right anterior vaginal wall in spontaneous T1 hypersignal and frank T2.

The pelvic ultrasound showed a hypoechoic material (possibly calculus or incarcerated mesh material) in the bladder neck of approximately 5mm without a true posterior shadow cone.

The third surgeon, who is from Prof. Phé’s centre, performed a cystoscopy under general anaesthesia with the aim to do a standard bladder stone removal. After the removal and upon closer inspection, the surgeon discovered the sling underneath the bladder stone. He had no experience in sling removal. The patient was not informed about the potential removal of the sling and the consequences that would incur. The sling removal did not proceed since the patient was uninformed. The fourth surgeon, Prof. Phé who is a functional expert surgeon, consulted with the patient and rescheduled the surgery.

Prof. Phé performed the removal of the suburethral portion of the sling by a vaginal approach. At first, there were no issues but then the patient had 14 days of indwelling catheterization. She currently complains about SUI. Prof. Phé stated that the patient is pleased with the surgery in general and that her recurrent SUI will be treated.

Lessons learned

Mr. Leigh analysed the case and underscored the importance of procuring the medical reports, especially from the first surgeon because he was from a different centre than Prof. Phé and also because the patient recalled bladder perforation during the surgery which made the case more complicated.

Prof. Phé explained that she and her team did write a letter to the first surgeon via email requesting the report. However, in response, he only sent them the hospital stay report but not the operating notes. Mr. Leigh rebutted, “I understand that this is a standard procedure and that there should be an evidence trail of communication, but someone in your team should have called the surgeon. You needed to be assiduous to know what happened to your patient the first time.”

Adding to what Prof. Phé stated that women do not generally develop bladder or urethral stones spontaneously, Mr. Leigh said that this should have been suspicious to her team and that they should have approached her or another specialist in the centre before removing the stone.

Furthermore, Mr. Leigh suggested that instead of giving patients leaflets about their conditions, it is more beneficial to send patients letters containing information relevant and specific to their circumstances.

To check if patients understand what was explained about their conditions, the treatment options available to them, and the implications of procedures they have to undergo, Mr. Leigh suggested that patients should be guided in using an online programme/form that would verify their understanding and confirm their consent.

The case presentation and deliberations highlighted the importance of clear communication among team members, with peers from different institutions, and with patients.

To (re)watch the full panel discussion and other cases from the Plenary Session, please visit EAU On Demand on the Virtual Platform.