UTILITY AND CRITICISM OF TELEMEDICINE IN UROGYNECOLOGY: A PROSPECTIVE STUDY

In the last years telephone interview has been proposed as tool to follow-up patients after surgery in the home environment without transportation and loosing of time. Limits of these studies were: retrospective evaluation, selection of no complicated cases, lack of comparison between the telemedicine result and the objective evaluation in a clinic setting. We prospectively compared telephone follow-up and in-clinic evaluation in a no selected population of women treated for stress urinary incontinence (SUI) and/or cystocele. MATERIALS AND METHODS A prospective crossover blind comparative study was done involving women referring to our outpatient clinic from December 2015 to December 2017 following surgery for cystocele and/or stress urinary incontinence. First patients’ evaluation was done with a telephone interview. Telephone interview included a checklist of questions (figure 1) and validated questionnaires as The Patient Global Impression of Improvement (PGI-I), and Patient Perception of Bladder Condition (PPBC). At the end of the phone call all patient were scheduled for a conventional outpatient clinic setting for the next 7–12 days. In the in-clinic setting all women have been investigated with an interview and the same validated questionnaires. In-clinic setting allowed also objective outcome. Success rate of MUS at the phone call was considered when patient referred no episode of SUI. Nevertheless, at the office evaluation this data was checked by stress test. Objective cure of cystocele was defined in case of asymptomatic POP with the midline anterior vaginal wall inferior to the POP-Q 2nd stage. Correspondence between telephone and office follow-up was obtained with statistical evaluation by Cohen test. RESULTS A total of 297 women have been enrolled in the study. Characteristics of the population are reported in table 1–2. All surgical procedures were performed in our Department from 2000 to 2017, and were as follow: (i) synthetic MUS; (ii) anterior vaginal wall repair; (iii) synthetic MUS associated to anterior vaginal wall repair. In women with MUS 22% reported SUI recurrence at the phone interview. This group at in-clinic follow-up has shown a real SUI recurrence only in 13.5%, while part of the women misinterpreted urge urinary incontinence for IUS recurrence. No patient reported vaginal discharge nor the suspect of vaginal extrusion at telephonic and in-clinic follow-up. Patients with objective tape and/or mesh extrusion were 13. In the group treated for POP all women were able to refer by telephone interview a prolapse recurrence and if it was symptomatic. No statistical significant difference was found analyzing PGI-I and PPBC questionnaires when administered by telephone or in clinic follow-up. Statistical analysis by Cohen test showed a “substantial agreement” (K = 0.782) between the two methods of follow-up. Data reported in table 3. INTERPRETATION OF RESULTS Telephonic follow-up was successful assessing an anterior vaginal POP recurrence in all the women due to the fact that all women experienced the cystocele before surgery. Moreover, also in the case of dry women the detection rate was comparable in both follow-up. A first limits of telemedicine was the missed diagnosis of tape/mesh extrusion due to the lack of symptoms. Indeed, al women were no sexual active and with no tape infection. In these cases only an objective evaluation can lead to a correct diagnosis. The second limit was the overestimation of IUS recurrence due to the presence of de-novo urge incontinence not adequately interpreted by patients. The use of a dedicated checklist is suggested to focus the main clinical problems saving time. CONCLUSIONS Our data suggests that telephone follow-up can be a useful tool with some criticism: the missing diagnosis of tape/mesh extrusion and the overestimation of IUS recurrence. An appropriate counseling both preoperatively and at the telephonic controls may limit part of these criticisms.