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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. My name is Ruchika Talwar. Today, I'm really excited to have a group of incredible authors in urology here to speak with us. I'm delighted to introduce Dr. Shreeya Popat, who was a former Virginia Mason fellow, Dr. Jennifer Chyu, who is a current Virginia Mason fellow, and Dr. Una Lee, who really needs no introduction, here with us today to be discussing a really important topic on the impact of mesh sling complications on urologic patient partners, a qualitative analysis study. Dr. Chyu, I will turn it over to you to go ahead and give us an overview of your research project.

Jennifer Chyu: Awesome. Thank you so much for the introduction. I'm really excited to talk about this project. This really came about because mid-urethral slings have been used really commonly and are the gold standard for treatment of stress urinary incontinence in women, but 5% of women actually suffer complications. Some of these complications are really devastating.

Some patients have really awful chronic pain related to the mesh. Some patients have mesh erosions. These complications can require patients to undergo many procedures afterwards. It has a lot of impact on them, their lives, and then their spouses. A lot of other arms of the study have looked at what the patient perspective is from the woman themselves, from the surgeon's perspective. But the spouses have never really been talked to, and that perspective has never really been explored before. There's other research out there in caregiver populations, but not really with spouses, and especially in such a sensitive topic like slings and in such a sensitive location with such an impact on quality of life. We thought it was really important to actually go and characterize the spouses' perspective and hopefully increase understanding of sling complications and how we take care of these patients.

We have actually a pretty large cohort of patients who have had mesh complications at Virginia Mason. A little over 80 patients had mesh complications requiring mesh excisions. We contacted spouses of these patients and asked for their permission to participate in some semi-structured interviews.

We had an interview guide and some prompts that we used to guide the conversation. But we really let them take it away so we could really hear from them and hear their voice. Using inductive content analysis, which is part of qualitative research, the three of us came together, looked at those recorded interviews,, and came up with some themes.

The next slide is about our findings. Ultimately, seven spouses were willing to participate in the interviews. We reached a saturation. We got a lot of the same content over and over, which speaks a lot to what kept coming up and how much the impact was. But we broke that down into three major themes. The first one was patient-surgeon communication. The second was there was a huge multidimensional impact on all of their lives, and then, lastly, the value of having support.

To go into each one of these, with regards to patient-surgeon communication, the spouses were talking about the informed consent process. Some of them had gone to the appointments with their partners but felt like they didn't really understand what the risks they were taking on. They also expressed some regret and some loss of trust in the surgeon, like they wish that if they had known that there were these potential risks and this potential impact that they might not have asked for a sling.

The impact on their lives came down to a lot of different aspects. Definitely intimacy. Pretty much every single partner mentioned that they were not able to have sexual relationships with their partners anymore. There was a huge impact on the marriage and the relationship. They felt socially isolated. They couldn't go out and live their lives. Obviously, there was an impact on, then, their family. A lot of them who had children weren't able to participate in PTA meetings or go out and do household chores. That puts a lot of strain on the spouse, who then has to pick up the rest of the slack. Huge financial impact. There often are multiple procedures, many, many doctor's visits, and time taken away from work.

Then, they lastly talk about the value of support. A lot of the patients themselves are able to find great things like Facebook groups. There's a little group called the Meshies. They're able to find each other and connect. But the spouses also... They didn't have any way. They felt much more isolated because they didn't know that there were other people also going through it. They also found a lot of value in having a supportive healthcare team. Just having surgeons that they trusted to take the mesh out with a lot of really good experience in the community and the trust that they found... That really helped them get through a really difficult time.

I think it's really important that we explore this topic because the spouses of the women who suffered these sling complications are caregivers. They're really impacted by all these outcomes in a lot of different ways. But I think there's important things that we took away. We can definitely be really cognizant, as the surgeons, about how we communicate what a sling impact could be, and what potential outcomes and risks that they're taking on, and the potential impact on their lives, especially when we're counseling on, if a patient did in fact have a complication. Then, the value of support: how can we be there as their surgeon guiding them through the complication, and how we can connect them with other people that can support them through this? This is a great foundation for future work in this area and hopefully continue to improve how patients and spouses experience sling surgery and complications.

Ruchika Talwar: Great. Thank you so much, Dr. Chyu. That was a really thought-provoking overview of this hugely important research topic. Kudos to all of you for not only exploring this subset of patients and their quality of life but really pushing the boundaries for urology as a whole and giving us the idea to really take a look at the experience of a patient's spouse or partner. It's not something that we have published about extensively anywhere in urology. I'd say outside of the... Maybe a bit in the financial toxicity impact of a caregiver, as you alluded to when a patient's going through illness. But really, especially when it comes to intimate issues that urologists face, I think this work is just so important. I really am excited to have y'all here today to pick your brains a bit.

Dr. Lee, let's start with you. This data is really, I think, important. It arms urologists with valuable information to take to their counseling when they're discussing sling surgery with patients. How has this perhaps changed how you counsel patients before mesh sling surgery?

Una Lee: Absolutely. That's a great question. Urinary incontinence is a very common problem. We have great treatment options. We certainly want people to be evaluated and treated for this. That's part of what we do. But I think when it comes to surgery and intimate surgery that affects that delicate area of the body, we have to have a very thorough informed consent process. We build relationships with our patients. That includes the spouse and family for that 1% chance that something negative happens, then you have that foundation. I think that this really brings that out: that surgical complications can happen. We have to embrace them and work with them. At the same time, acknowledge the huge impact it may have on the patient and their family beyond what you think. We think very concretely about the surgery, but there's all these ripple effects. That's what we learned with this study.

Ruchika Talwar: Dr. Popat, would you be able to tell me a bit about how perhaps you would guide urologists in navigating these challenging conversations based on your data?

Shreeya Popat: I think that the quotes that we got from patients' spouses are really helpful. Our paper has a table full of them that really shows what patients want to hear, what their spouses want to hear, things like just simply knowing that this is a possibility, making sure you share that with the patient, and letting them know that you're there for them if one of these complications happen. I think those are the two most important aspects to counsel your patients about and their family and their spouses about before surgery.

Ruchika Talwar: Absolutely. I couldn't agree more. Dr. Chyu, let's get into the nitty-gritty of your methods a little bit. Just for other urologists who might be interested in embarking on qualitative research in other aspects of the field, how did you categorize the themes that were picked up on in your interviews? Was there a specific technique you used? A software? Anything like that?

Jennifer Chyu: There are softwares out there. In order to try to reduce bias, because this is like a non-hypothesis-driven type of research, we each actually independently go through the transcripts. All the interviews get recorded and then transcribed verbatim. We each independently go through them and start coming up with themes ourselves. It actually takes quite a bit of time to go through each of the transcripts and try to sort out what things keep coming up over and over again, and then try to make them into themes.

Then, we all come together with what we each independently look at and see what overlap there is. Because we all have a lot of experience in this type of research and this methodology, we are actually able to have a lot of overlap. That goes to show that what we're interpreting is very much true to the spouse perspective.

Ruchika Talwar: It's really interesting that despite the fact that you had a pretty large cohort of 80 patients, you were able to narrow it down to three main domains. Even within those domains, the themes that you explored, or I should say, identified, were easily common between so many different spouses. I think that's interesting. I think that a lot of times, especially spouses of patients, as you alluded to, have less of a robust support system, so they often feel they're alone and that they're going through this challenging situation without... Or perhaps I should say it's a situation in which they feel that is unique to them when it really isn't.

I think one big takeaway here is focusing on how we as physicians can create networks of support groups just like we do for bladder cancer patients, for sling complication patients, et cetera. We should be thinking about the spouses as well. If there's a patient and their spouse who are willing to be vocal and share their story, perhaps they can serve as a resource to other patients. Dr. Lee, is that ever something that you've thought about doing or perhaps something you already have implemented?

Una Lee: I think that's very important. That's exactly the kind of work that needs to be done. I mean, they do feel very alone. They are important stakeholders in their wives or their partner's lives. I know online there are groups for the women, but there really aren't for the spouses. That's what this is bringing up, is that there is a need out there. If you think about the millions of women who've had slings and the small percentage who've had problems, there's a huge number of people out there who would appreciate that. Just like there's, like you said, caregivers of cancer patients, there's Al-Anon for alcoholics. This impacts families. I'm really happy to put a spotlight on that.

Ruchika Talwar: Yeah. As an oncologist, with my biased lens, I really found myself thinking about my prostate cancer patients after hearing about your study and reading it initially and thinking, "Wow, what a big untapped world of information there must be out there from patient partners who have a loved one who underwent prostate cancer surgery from an incontinence and a sexual functioning standpoint. Again, I just want to thank you all for making time to chat with us today. This work is hugely important. I think it's hopefully the first of many articles exploring qualitative analysis in spouses and partners of urologic patients. To our audience, thank you so much for joining us today. We look forward to seeing you at our next Health Policy Center of Excellence Chat.