PIG Meeting: 29th April 2021

53-year-old lady for cystoscopy and intravesical botox for urge incontinence

  • BMI 48
  • COPD. Current smoker. 40 pack years
  • PFTs showed normal lung volumes but reduced TLCO (likely in keeping with her known pulmonary hypertension)
  • NIDDM. Poor glycaemic control. HbA1c = 9.9%
  • HFpEF and moderate pulmonary hypertension
  • Uncontrolled hypertension
  • Non-obstructive CAD
  • T-cell lymphoma – currently in remission since chemotherapy and stem-cell harvest but moderate prognosis disease with 43% 5-year mortality rate
  • Extremely poor exercise tolerance, resting every 10-20 steps
  • NASH


  • Consult in clinic and advised on multiple areas for optimisiation including.
    • Weight loss and dietician via GP
    • Smoking cessation
    • Diabetes optimisation
    • Sleep studies
  • Patient had pursued none of these recommendations, citing social stressors.
  • Surgeon contacted to request a further 3mth delay.
  • Surgeon decided to cancel the procedure, believing conservative measures were more appropriate and that her other health problems were far more important to optimise.


Was this the right decision?

  • Should we be more compassionate regarding the contribution of her social stressors to her health inertia?
    • Is an incontinence procedure likely to be effective in a morbidly obese smoker? Thought to be low value healthcare.
    • Could this procedure be done under LA (group consensus was no, based on previous experience).
    • Is this paternalistic?
    • Possible that the surgical team requested a ‘consult’ in the hopes that we would say no?
  • Ideally the decision to cancel should have been communicated by the surgical team, rather than via periop clinic.
  • A letter was sent to the GP which clearly outlines ownership of the decision.