Uro-Gynaecology From

Cambridge to UAE?
May 2018 UAE
Are there any existing Abu Dhabi
Uro-Gynaecology Services?

Detailed Google search:

22 centres in Abu Dhabi cited as providing
treatment for incontinence and prolapse

On analysis of the cited specialists and services:

• There is no dedicated Uro-Gynaecology and Female
Pelvic Floor Disorders unit in Abu Dhabi

• There are no subspecialist accredited

Urogynaecology consultants
What is a Uro-Gynaecologist?
Uro-Gynaecology (UG): Sub-speciality of gynaecology dealing
with benign disorders of the lower urinary and genital tract,
mainly urinary incontinence and genital prolapse.

A Uro-Gynaecologist:
1. Has evidence of training in a specialist unit, providing the full range of investigations and
treatments required for practice as a subspecialist.
2. Has advanced urodynamics experience (e.g. Special Skills Training).
3. Provides >2 urodynamic sessions per month (in person or a supervisory capacity).
4. Provides 3 general clinical sessions in UG per week.
5. Provides a minimum of 1 specialist combined UG clinic per month as part of an MDT
(e.g. Childbirth trauma, combined colorectal, combined functional and neuro-urology).
6. Undertakes at 1-2 major UG procedures associated with pelvic floor dysfunction
(i.e. incontinence and prolapse) per week per year.
7. Audits their practice (e.g. BSUG surgical audit).
8. Undertakes annual appraisal demonstrating a proportion of CME in UG.
Career background
From Locum Consultant Gynaecologist Urogynaecology, Paediatric Adolescent Gynaecology and Reproductive
02/2017 Medicine Cambridge University Teaching Hospital(s) NHS Foundation Trust (CUHFT), Cambridge UK.

2003-2016 Consultant Urogynaecologist, Reconstructive Pelvic Surgeon, Perineal/Childbirth Injury, Paediatric Adolescent
Gynaecology, St. George’s University Hospitals NHS Foundation Trust and St George’s University of London.

2005-2015 Preceptor for RCOG/BritSPAG and RCOG/BSUG Advanced Training Skills Modules (ATSMs).

Honorary Senior Lecturer for Obstetrics and Gynaecology, at SGUL, London, UK.
2003-2016

2003-2012 Uro-Gynaecology subspecialty RCOG Training Program Director based at St George’s Hospital, London, UK.

2002-2003 Completed a subspecialty training at SGUH FT and accreditation for Urogynaecology by the RCOG.

1999-2002 Subspecialty training programme completed. Accreditated with Diploma Urogynaecology awarded by
RANZCOG.
2000-2001 Consultant Gynaecologist, Mercy Hospital & Austin Repatriation Medical Centre Victoria, Australia.
Senior Lecturer University of Melbourne Australia

2000 Doctorate of Medicine (MD) for research awarded by the National University of Ireland. Michelle Checinska-Fynes MB BAO BCH (Hons) MD (Research) MRCOG DU DipUS
2000 Diploma Advanced Ultrasound (DipUS), RCOG and Royal College of Radiology (RCR), London, UK. Dual subspecialist accredited Uro-Gynaecologist
RANZCOG 2002 and RCOG 2003
1997-1999 Senior Lecturer Obstetrics & Gynaecology, Cambridge University, Cambridge, UK.
RCOG Subspeciality Training Programme Director 2003-12
Service Lead for Uro-Gynaecology 2003-2012
1996 Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG).
1995 Lecturer Obstetrics & Gynaecology, University College Dublin, National Maternity Hospital, Ireland. Specialist Paediatric Adolescent Gynaecology
14.5 years experience NHS Consultant Uro-Gynaecologist
What should a subspecialist Urogynaecology and
Pelvic Floor Disorders Unit comprise?
Core medical team Clinical space and equipment
• Lead Uro-Gynaecologist • Dedicated clinical space
• Clinical Nurse specialist • Urodynamics equipment
• Physiotherapist • Ultrasound (TVUS Endo-anal) and Bladder scanner
• Perineal Care Midwife • Outpatient cystoscopy (for diagnostics, Botox, bulking)
• Link to colorectal services • Anal manometry and basic EMG
• Link to neurology services • Capacity to undertake minor outpatient surgical procedures
• Link to pain anaesthetist • Capacity to undertake outpatient local pain blocks
• IT access and medical physics support
What spectrum of conditions does a subspecialist
Uro-Gynaecology and Pelvic Floor Disorders Unit treat?
Sexual dysfunction (e.g. dyspareunia, vaginismus, loss of libido)
Females of all ages with Urinary Incontinence Childbirth injury (e.g. Obstetric Anal Sphincter Injury [OASI], fistula)
and Urogenital Prolapse
Bowel disorders
Other Lower Urinary Tract Disorders • Incontinence
• Recurrent urinary infection • Defecatory difficulty
• Overactive bladder
• Painful bladder disorders These problems are effectively treated within specialist clinics
• Difficulty with bladder emptying provided by the Urogynaecology & Pelvic Floor Disorders Team
• Urogenital fistula
• Urethral diverticula

Complications POP and UI surgery (e.g. mesh)

Urogenital pain disorders
Why does Abu Dhabi need a Subspecialist Uro-Gynaecology and
Pelvic Floors Disorders unit?
Urinary Incontinence (UI) affects
10-20% women aged 15-64 years
30-40% >60 years
50% in long-term care facilities
1 in 8 women will have surgery for urinary incontinence

Pelvic Organ Prolapse (POP) affects

50% women >50 years of age
30-50% lifetime prevalence
10% lifetime risk surgery
13% 2nd operation within 5 years
30% have further surgery for POP/SUI in their lifetime

‘Effective care requires a broad and detailed understanding of normal and

abnormal bladder bowel and pelvic floor muscle function in order to
PUBLISHED FACT: Subspecialist Uro-Gynaecology and
provide the right care package (e.g. surgery), at the right time, for the Pelvic Floor Disorders centres with accredited consultant
right patient, by the right doctor. UAE websites typically offer the
procedure (e,g, we undertake TVT) rather than the package of care.‘
providers have better outcomes, fewer complications and
can offer a wider variety of treatments.
What would an
enhanced subspecialist
Uro-Gynaecology and
Pelvic Floor Disorders
unit look like?
 Vision for a UAE based subspecialist service
Health Clinic Referrals
Referrals from other
Family Doctor (GP)
maternity services
In-house referrals Postnatal referrals from the
along agreed pathways Corniche Hospital ward or other maternity
Non-childbirth related: hospital services
Adolescent Uro-Gynaecology and
Premenopausal Childbirth related antepartum
Postmenopausal Female Pelvic Floor Disorders Unit or first six months postpartum
Elderly care medicine

A&E or
Referrals from antental
self referrals
or booking clinics
Referrals from
Adolescent or physiotherapy on agreed
paediatric urology Referrals from other pathways
referrals or transition SEHA and non-SEHA
cases referrals Hospitals

Referrals screened triaged to the correct care pathway and clinic;

General Uro-Gynaecology (primary incontinence and prolapse),
Childbirth Injury (OASI), Sexual Difficulties,
Complex or combined (e.g. bowel incontinence, recurrent prolapse, mesh complication)

Nurse Led Women’s Health Triage Complex cases or red flags as indicated on the First line triage
for the Pelvic Floor Diagnostics Unit flow chart and care pathway
Assessment
Diagnosis and Treatment
Neuro-Urology and
Hub Uro-Gynaecology
Disorders
First line conservative therapy for 3-6 months minimal investigations
Uro-Gynaecology and Pelvic Floor Specialist Combined
formal assessment of outcome Disorders Service MDT clinic

Referral to appropriate
Uro-Gynaecology
specialist clinic and Colorectal
Disorders Specialist
Combined MDT clinic
Persistent symptoms and or request for
further therapy by patient that is deemed Discussion or
Symptoms resolved or appropriate and in line with care pathways MDT sign-off General
improved and or patient
satisfied Uro-Gynaecology Patient joins
Complex Urology &
Discharge to GP Clinics appropriate ongoing
Paediatric and Uro-Gynaecology Perineal
Secondary assessment clinical evaluation and or Adolescent Uro- Disorders
Childbirth Injury
pathway
diagnostics as indicated by the appropriate care Gynaecology Specialist Combined Clinic
pathways discussion with patient MDT clinic
M Fynes 04/2018
Expanding the
UAE service
referral base?
Care Pathways:
Providing evidence based
care for all Uro-Gynaecology
and Pelvic Floor Disorders
 The role of
care pathways

Care pathway:
First-line management of Urinary Incontinence
Based on NICE Guidelines for management of urinary
incontinence in women 2006.
MMF pathway V2 April 2018
 Care pathway: Management
of Recurrent Stress Urinary
Incontinence (SUI)

The role of
care pathways

1. I have drafted 15 evidenced based care pathways

for the most common conditions referred to the Uro-
Gynaecology and Pelvic Floor Disorders.
2. These optimize success rates and minimize
morbidity whilst promoting patient safety.
3. The pathways may be incorporated into the IT
platform (e.g. EPIC) to facilitate compliance/audit.
Robust Governance:
1. Clinical: Providing evidence based
high quality patient centred care
pathways with measurable and
recorded outcomes (including QoL)
2. Finance
3. Education and Training
 Corniche Hospital
Uro-Gynaecology and Female Pelvic Floor Disorders Unit
Clinical Management, Business Structure, Governance and Quality Assurance

Quality Assurance and Clinical Governance

Financial Governance
1. Regular scheduled meetings with clinical, operational and administrative Specialist Doctors, Nursing, Midwifery PG training, CPD updates, regular
managers, medical and clinical support staff. attendance at relevant meetings
2. Regular meetings including; governance, financial and service planning. 1. Personal and service audit
3. Service utilization audits and exploration options to improve business capture. 2. Demonstrate compliance with service Care Pathways
4. Mandatory attendance at >70% required per annum. 3. Attend regular MDT and divisional governance meetings (>70% per annum)
4. Annual appraisal of team members
5, Formal CPD with regular review to meet local CME requirements
6. Mandatory attendance at UG/PFDs ASM every 1-2 years
7. Participate in service development, pathway updates, audit (patient satisfaction)
Financial Best Practice Care Pathway Costings and Service User Fees
Summary of determined with regular review utilizing:
1. Validate costs include Patient Reported Outcome & Morbidity (PROM) data
Corporate and 2. Utilize Financial and Clinical Governance processes to support tariffs
Staff recruitment for service expansion and training:
Clinical Governance Postgraduates:
aspects of proposed 1. Specialist trainees undertaking RCOG ATSM (1 year fellowship) UG
2. Recruit then to specialist post 2 years higher training (would include audit/
Clear tariff structures:
research component)
Uro-Gynaecology and 1. Individual and family pay as you go
2. Self-pay care packages 3. Recruit consultants from in-house and overseas ‘trained pool’
Pelvic Floor Disorders 3. Insured care packages (agreed with insurance companies)
4. Insured as you go scheme 4. Midwives/CNS: Recruit in-house midwives/ staff nurses to train as continence
Unit 5. Company packages (e.g. direct with airlines, hospitality, engineering) perineal/urodynamic specialists. Advancement and pay rise on completion if stay for
2 years minimum.

5. Attract undergraduates: Special Skills Modules in UG and PFDs

Service Development Promotion and Expansion:

1. Advertisement, brochures, website updates, podcasts
2. Patient Information Leaflets (PILs)
3. Meet the expert public promotion meetings Capital costs equipment, maintenance, consumable costs, patient safety,
4. Ask the experts online Q&A
risk, staff training:
5. Patient service user feedback and testimonials
1. Outpatient flexible cystoscopy equipment
6. Publish favourable audit data
2. Urodynamics equipment
3. Anal physiology equipment
4. Ultrasound (trans-perineal, anal, trans-vaginal transducers)
5. MRI imaging
Lease equipment, replace and upgrade every 5 years, regular maintenance
(contracts), review consumables used and procurement costs regularly (includes
single use theatre devices), regular staff training updates, review equipment
M Fynes V1 2018 related risk incidents, test protocols including sepsis, morbidity and patient safety.
Current and future challenges for
Uro-Gynaecology services:
1. Consent
2. Information Governance (registries)
3. Providing patients with a range of treatment options
4. Managing patient expectations
5. Mesh complications
6. Training the next generation
Consent Uro-Gynaecology surgery:
1. Montgomery ruling
3. Consent form
4. Cooling off period
5. Patient Information Leaflets (PILs)
6. Use of electronic records
7. Patient letters
8. Personal audit versus published audit patient data on
success failure and morbidity
9. Duty of candor
10. What medico-legally constitutes informed consent?
Mesh problems
1. Mesh inserted vaginally for stress urinary
incontinence (e.g. TVT TOT)
2. Mesh inserted for prolapse correction vaginally
(e.g. apogee, prolift kits)
3. Abdominal insertion mesh (sacrocolpopexy)
Training the next generation:
1. Robust 1-year fellowships RCOG ATSM Uro-Gynaecology.
2. Competitive appointment two year fellowships for more
advanced training leading to an MSc for Uro-Gynaecology
or Uro-Obstetrics linked with UAE University Al Ain.
3. Fixed contracts for postgraduate training.
4. Medical students Special Skills Module (SSM) or
equivalent to stimulate interest and research in this area
(linked to the medical school).
5. Regular audit and annual research and study days.
6. Opportunities to work overseas for a fixed period.
Summary

Mapping and monitoring the service:

1. Integrated Governance structures/processes
2. Good communication
3. Robust IT
4. User friendly electronic records platform that is adaptable
and facilitates audit
5. Regularly updated interactive website
6. Involving patients in all aspects of their care and
incorporating their feedback into service changes and
development.
 CEO Corniche Hospital

Overview of
proposed
Corniche Hospital
Uro-Gynaecology
and
Female Pelvic Floor
Disorders service

Corniche Hospital Surgical Care: Ambulatory, Day

Case, or inpatient, under local, regional or general
anaesthesia (preferably dedicated anaesthetist team)

Follow-up at Corniche Follow-up at Corniche

M Fynes iv.2018
 Any
Questions?