Abstract
Introduction and hypothesis
Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.
Methods
ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.
Results
The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.
Conclusions
We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.
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Acknowledgements
The authors wish to acknowledge Alex Lynch for her technical expertise and Dr. Deborah Myers for her content expertise in the development and implementation phases of this study.
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Conflicts of interest
Vivian W. Sung - None
Diane Borello-France - None
Gena Dunivan
Pelvalon: Research funding
Marie Gantz - None
Emily S. Lukacz
Renew Medical, Inc: Research : 2010-2011; Consultant 2012-2015 for study of anal insert for accidental bowel leakage.
Pfizer: Study drug donated for trial on prevention of urinary tract infections.
AMS/Astora: Consultant: clinical events committee member for prolapse study, TOPAS sling for accidental bowel leakage.
Boston Scientific: Research funding for observational study of native tissue vaginal prolapse surgery
Uroplasty: Research funding for observational study of Macroplastique for intrinsic sphincter deficiency
Axonics: Consultant for development of neuromodulation technology
Grants: American Urogynecologic Society fellow research award: 2013 funding for study of prevention of urinary tract infection.
UpToDate – Royalties for chapters on urinary incontinence and perioperative management
NIH/NIDDK: Honoraria and travel for scientific consulting and Principal Investigator in the PLUS (Prevention of Lower Urinary Tract Symptoms) network
Pamela Moalli
ACell-Unrestricted Corporate Research Agreement
Diane K. Newman
Research support: VA, NIH, Wellspect
Holly Richter
Research Grants:
National Institute of Diabetes and Digestive and Kidney Diseases K24 Midcareer Award in Patient Oriented Pelvic Floor Research
Eunice Kennedy Shriver National Institute of Child Health and Human Development - Pelvic Floor Disorders Network
National Institute of Allergy & Infectious Diseases/National Institute of Health/Dept of Health and Human Services
Washington University/National Institutes of Health Pelvalon, Inc
Consultant: Kimberly Clarke, Astellas and Pelvalon, Inc
Royalties: UpToDate
Beri Ridgeway - None
Ariana L. Smith - None
Alison C. Weidner - None
Susan Meikle - None
Funding
Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (U10 HD041261, U10 HD069013, U10 HD054214, U10 HD054215, U10 HD041267, U10 HD069025, U10 HD069010, U10 HD069006, U01 HD069031) and the National Institutes of Health Office of Research on Women’s Health.
Additional information
Clinicaltrials.gov
NCT01959347
Appendix: Pelvic Floor Disorders Network contributors
Appendix: Pelvic Floor Disorders Network contributors
Cleveland Clinic
Mathew D. Barber, Principal Investigator
J. Eric Jelovsek, Co-Investigator
Marie Fidela R. Paraiso, Co-Investigator
Mark D. Walters, Co-Investigator
Beri Ridgeway, Co-Investigator
Brooke Gurland, Co-Investigator
Massarat Zutshi, Co-Investigator
Geetha Krishnan, Research Nurse Clinician
Ly Pung, Research Nurse
Annette Graham, Research Nurse Clinician
Alpert Medical School of Brown University-Women & Infant’s Hospital of Rhode island
Vivian W. Sung, Principal Investigator
Deborah L. Myers, Co-Investigator
Charles R. Rardin, Co-Investigator
Cassandra Carberry, Co-Investigator
B. Star Hampton, Co-Investigator
Kyle Wohlrab, Co-Investigator
Ann S. Meers, Research Nurse Coordinator
Duke University
Anthony Visco, Principal Investigator
Cindy Amundsen, Co-Investigator
Alison Weidner, Co-Investigator
Nazema Siddiqui, Co-Investigator
Ingrid Harm-Ernandes, Interventionist
Jennifer Maddocks, Interventionist
Shantae McLean, Research Coordinator
University of Alabama at Birmingham
Holly Richter, Primary Investigator
Alayne Markland, Co-Investigator
R. Edward Varner, Co-Investigator
Robert Holley, Co-Investigator
L. Keith Lloyd, Co-Investigator
Tracy S. Wilson, Co-Investigator
Alicia Ballard, Co-Investigator
Jeannine McCormick, Research Nurse Clinician
Velria Willis, Research Nurse Coordinator
Nancy Saxon, Research Nurse Coordinator
Kathy Carter, Research Nurse
Julie Burge, Research Coordinator
NIH Project Scientist
Susan Meikle, Primary Investigator
University of California, San Diego
Charles Nager, Principal Investigator
Michael Albo, Co-Investigator
Emily Lukacz, Co-Investigator
Cindy Furey, Interventionist
Patricia Riley, Interventionist
JoAnn Columbo, Research Coordinator
Sherella Johnson, Research Coordinator
Kaiser Permanente–San Diego
Shawn Menefee, Co-Investigator
Karl Luber, Co-Investigator
Keisha Dyer, Co-Investigator
Gouri Diwadkar, Co-Investigator
Jasmine Tan-Kim, Co-Investigator
University of New Mexico
Rebecca G. Rogers, Primary Investigator
Yuko Komesu, Co-Investigator
Gena Dunivan, Co-Investigator
Peter Jeppson, Co-Investigator
Sara Cichowski, Co-Investigator
Christy Miller, Interventionist
Barbara White, Interventionist
Sue Lee, Research Coordinator
Julia Middendorf, Research Nurse
RTI
Dennis Wallace, Primary Investigator
Marie G. Gantz, Co-Investigator
University of Pennsylvania
Lily Arya, Principal Investigator
Ariana Smith, Co-Investigator
Heidi Harve, Co-Investigator
Uduak Umoh Andy, Co-Investigator
Pamela Levin, Co-Investigator
Diane K. Newman, Co-Investigator
Mary Wang, Interventionist
Donna Thompson, Interventionist
Teresa Carney, Interventionist
Michelle Kingslee, Research Coordinator
Lorraine Flick, Research Nurse
University of Pittsburgh
Halina Zyczynski, Principle Investigator
Pam Moalli, Co-Investigator
Gary Sutkin, Co-Investigator
Jonathan Shepherd, Co-Investigator
Michael Bonidie, Co-Investigator
Steven Abo, Co-Investigator
Janet Harrison, Co-Investigator
Lori Geraci, Research Coordinator
Judy Gruss, Research Coordinator
Karen Mislanovich, Research Coordinator
Ellen Eline, Interventionist
Beth Klump, Interventionist
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Sung, V.W., Borello-France, D., Dunivan, G. et al. Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial. Int Urogynecol J 27, 1479–1490 (2016). https://doi.org/10.1007/s00192-016-3031-7
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DOI: https://doi.org/10.1007/s00192-016-3031-7