Pre-operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence

Which parameters, related to the female urethra and pelvic floor, determine therapy selection for recurrent female stress urinary incontinence: ICI-RS 2023?

INTRODUCTION

The evidence basis for therapy selection in women who have failed primary stress urinary incontinence (SUI) surgery is limited. The ICI-RS group discussed the available data at its meeting in June 2023, particularly the anatomical characteristics as assessed using magnetic resonance imaging (MRI) and ultrasound (US) modalities, functional characteristics associated with storage and voiding urodynamic assessment, as well as the patient characteristics that might influence outcomes. This paper summarizes the evidence base that supported these discussions and offers the basis for research proposals for future groups.

METHODS

A literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed, and the data is presented. Research questions are based on the knowledge gaps highlighted.

RESULTS

Possible MRI parameters that may influence outcomes were striated urethral sphincter volume, bladder and proximal urethral funneling, pubo-urethral ligament integrity, distance of the bladder neck below the pubococcygeal line, posterior urethra-vesical angle, and bladder neck to levator ani distance. US parameters included sling distance to the urethral lumen and pubis, sling position, bladder neck mobility, and lateral arm asymmetry, twisting, or curling. Urodynamic parameters included detrusor overactivity, Valsalva leak point pressure, maximum urethral closure pressure, and bladder outlet obstruction. Important patient parameters included body mass index, age, and previous interventions.

CONCLUSIONS

Identifying and quantifying causative factors in patients with recurrent SUI, that allow clinicians to modify subsequent treatment choices and techniques may help reduce treatment failure and complications. Formulating algorithms is the next step in optimizing patient counseling, surgical selection, and healthcare allocation.

Twenty-Five Years of the Midurethral Sling: Lessons Learned

Midurethral slings (MUS) are widely accepted for the surgical treatment of stress urinary incontinence (SUI) in cases where conservative treatment has failed. They have been shown to be a safe and effective surgical treatment for the management of SUI. However, there have recently been growing concerns regarding the safety profile of mesh procedures, generating international debate and leading to national inquiries into the effectiveness and safety of mesh implants. A multitude of clinical, technical, manufacturer-related, and other health jurisdictional factors are involved in the outcomes of MUS. Appropriate patient selection and informed consent to all treatment options, with proper guidance from healthcare providers, are critical for empowering women to choose an appropriate treatment option based on a personalized decision.

A randomized, placebo-controlled clinical development program exploring the use of litoxetine for treating urinary incontinence

AIMS

To investigate the safety and efficacy of litoxetine, a serotonin reuptake inhibitor, in treating urinary incontinence (UI) and mixed urinary incontinence (MUI).

METHODS

Two randomized, double-blind, placebo-controlled clinical trials (RCT1 and RCT2) were conducted. RCT1, which included 196 women aged 18-75 with MUI randomized 1:1:1:1 to receive 10, 20, or 40 mg litoxetine or placebo orally twice daily (BID) for 12 weeks, investigated the efficacy (including changes in patient reported outcomes) and safety of litoxetine compared to placebo. RCT2, which included 82 men and women aged 18-70 with any UI type randomly assigned 2:1 to receive 30 mg litoxetine or placebo orally BID for 8 weeks including a 2 week dose titration period, investigated the safety (including psychiatric safety) and efficacy of litoxetine compared to placebo. Efficacy was measured as the change in number of incontinence episodes per week and assessed using an analysis of covariance with missing data imputed by Predictive Mean Matching. Safety was assessed by adverse events (AEs) and physical examinations and analyzed using descriptive statistics.

RESULTS

The 30-mg and placebo groups in RCT2 showed no difference in frequency of AEs, and litoxetine reduced the number of incontinence episodes per week compared to placebo. Although RCT1 suffered an unexpectedly high placebo response, and therefore did not meet the primary efficacy endpoint, 71% of participants receiving 40 mg litoxetine reported a clinically meaningful improvement in the King's Health Questionnaire.

CONCLUSIONS

Litoxetine may be a safe, effective and well-tolerated treatment for patients with UI.

Urodynamic predictors of de novo overactive bladder after single-incision sling

OBJECTIVE

To identify urodynamic predictors for de novo overactive bladder (OAB) after single-incision sling implantation.

METHODS

This retrospective study analyzed women with pure, urodynamically proven stress urinary incontinence, without OAB, between 2008 and 2015, in a university hospital. De novo OAB was investigated during clinical interviews.

RESULTS

A total of 192 patients were analyzed; 21 patients with de novo OAB were considered as group A while 171 control patients formed group B. Univariate analysis demonstrated that patients with de novo OAB have the first desire to void at a lower bladder volume (124 mL versus 160 mL, P = 0.0052), smaller maximum cystometric capacity (357 mL versus 406 mL, P = 0.0061), lower maximum flow (17 mL/s versus 23 mL/s, P = 0.0006), and higher bladder outlet obstruction index (BOOI; -11 versus -23, P = 0.0022) compared with controls. According to multivariate analysis, maximum cystometric capacity (parameter estimate [PE] =0.008, P = 0.04) and BOOI (PE = -0.029, P = 0.01) were independent urodynamic predictors of de novo OAB. The final model showed good predictive accuracy (area under the curve =0.81).

CONCLUSION

The present study identified maximum cystometric capacity and BOOI as independent predictors of de novo overactive bladder after single-incision sling implantation. Therefore, preoperative urodynamics may be useful to improve preoperative counseling and to tailor surgical treatment.

Comparison of Urodynamics and Perineal Ultrasonography for the Diagnosis of Mixed Urinary Incontinence in Women

OBJECTIVES

This study aimed to compare urodynamic studies (UDS) and perineal ultrasonography (US) for the assessment of mixed urinary incontinence (MUI) in women in China.

METHODS

Adult women with MUI and healthy control participants were enrolled from 2 centers in China (Zhejiang and Beijing) between September 2010 and April 2017. Baseline clinical characteristics were recorded. The MUI type was categorized by the King's Health Questionnaire: stress-predominant, urge-predominant, or equal predominance. Urodynamic studies were performed, followed within 1 week by perineal US. Tolerability of the investigations was compared by a 3-point scale: better than, worse than, or equal to.

RESULTS

For UDS parameters, compared with controls, the urge-predominant MUI group had a lower maximal flow rate, smaller bladder volume, higher detrusor pressure at urethral opening, higher detrusor pressure at maximal flow, and higher incidence of detrusor overactivity; the stress-predominant MUI group had a lower maximal urethral closure pressure and functional urethral length; and the equal MUI group had a higher detrusor pressure at maximal flow and lower maximal urethral closure pressure (P < .05). For US parameters, compared with controls, the stress-predominant MUI group had a greater dynamic posterior urethral angle, dynamic angle of urethral inclination, descent of the bladder neck, and dynamic pubourethral distance; the urge-predominant MUI group had a greater detrusor thickness; and the equal MUI group had a greater descent of the bladder neck (P < .05). All UDS and US parameters differed significantly between the stress-predominant and urge-predominant groups (P < .05). The dynamic angle of urethral inclination, descent of the bladder neck, and dynamic pubourethral distance were inversely correlated with detrusor pressure at maximal flow and functional urethral length, while detrusor wall thickness was positively correlated with detrusor pressure at maximal flow and functional urethral length. Perineal US was better tolerated than UDS.

CONCLUSIONS

Perineal US parameters show good correlations with UDS parameters. Ultrasonography is better tolerated than UDS and provides additional morphologic data. Perineal US could facilitate the diagnosis of urge-predominant MUI.

Overactive bladder symptoms after midurethral sling surgery in women: Risk factors and management

INTRODUCTION

Overactive bladder syndrome (OAB) including urgency and urgency urinary incontinence (UUI) occurs frequently after stress urinary incontinence (SUI) surgery. It is important to identify the risk factors for the occurrence of OAB symptoms in order to adequately inform the patient before surgery. Furthermore, when facing OAB after sling surgery it is crucial to know how to manage these symptoms.

METHODS

We conducted a literature review in order to assess the risk factors and management of OAB symptoms after SUI surgery. We searched for relevant articles in PubMed that specifically addressed the topic of OAB symptoms after midurethral sling surgery.

RESULTS

The incidence of de novo and persistent urgency and UUI is reported around 15% and 30%, respectively. Several studies demonstrated that women with mixed incontinence who have a predominant urge component will have worse outcomes after surgery. Older age was also found to be a predictive factor in three studies. Furthermore, urodynamic signs of overactive bladder (eg, DO, low bladder capacity, elevated detrusor pressure) can predict postoperative urgency or UUI. The management of OAB symptoms after SUI surgery is essentially the same as in idiopathic OAB. However, before commencing therapy it is crucial to rule out other factors than can cause urgency, including bladder outlet obstruction, urinary tract infection, or sling erosion.

CONCLUSIONS

OAB symptoms are frequently reported after sling surgery. Women with mixed incontinence and older women are at risk of developing post-operative OAB symptoms. We have proposed an algorithm for the treatment of these symptoms which can be useful in clinical practice.

The long term predictive value of preoperative pressure flow studies in the resolution of overactive bladder after insertion of a retropubic midurethral sling

AIMS

To identify if the short term association of pressure flow rates with resolution of overactive bladder (OAB) is maintained in the long term in patients with mixed urodynamic incontinence treated with a retropubic midurethral sling. To assess if other demographic factors are associated with the long term resolution of OAB.

METHODS

This was follow up study of a consecutive case series of 100 patients treated with a MUS at a single center followed up with questionnaires. Preoperative pressure flow studies were compared to the resolution of urgency and urgency incontinence after surgery.

RESULTS

A total of 6.25 years after surgery, resolution of urgency and urgency incontinence was associated with a higher preoperative flow rate (26.7 mL/s vs 19.1 mL/s P = 0.02) and a higher flow rate centile (33.1 vs 14.0 P = 0.01). No other demographic parameters were associated with resolution of OAB.

CONCLUSIONS

The long term outcome and resolution of urgency and urgency incontinence can be predicted by preoperative pressure flow studies over 6 years after surgery.

Diagnosis, Evaluation, and Treatment of Mixed Urinary Incontinence in Women

Mixed urinary incontinence (MUI) is a common clinical problem in the community and hospital setting. The broad definition of the term makes it difficult to diagnose, as well as determine effective treatment strategies. There are no current guidelines recommended for physicians. The estimated prevalence of this condition is approximately 30% in all women with incontinence. It has also been suggested that patients with MUI report more bothersome symptoms than either stress or urge incontinence; approximately 32% of 40- to 64-year-olds with MUI report symptoms of depression. The authors examine the diagnosis, evaluation, and treatment of patients with MUI.

[Intrinsic sphincter deficiency and female urinary incontinence]

OBJECTIVE

Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article.

MATERIAL AND METHODS

This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association.

RESULTS

Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary.

CONCLUSION

Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

Does preoperative urodynamic testing improve surgical outcomes in patients undergoing the transobturator tape procedure for stress urinary incontinence? A prospective randomized trial

Purpose

Urodynamic studies are commonly performed as part of the preoperative work-up of patients undergoing surgery for stress urinary incontinence (SUI). We aimed to assess the extent to which these urodynamic parameters influence patient selection and postoperative outcomes.

Materials and Methods

Patients presenting with SUI were randomly assigned to two groups: one undergoing office evaluation only and the other with a preoperative urodynamic work-up. Patients with unfavorable urodynamic parameters (detrusor overactivity [DO] and/or Valsalva leak point pressure [VLPP]<60 cm H₂O and/or maximum urethral closure pressure [MUCP]<20 cm H₂O) were excluded from the urodynamic testing group. All patients in both groups underwent the transobturator midurethral sling procedure. Evaluation for treatment success (reductions in urogenital distress inventory and incontinence impact questionnaire scoring along with absent positive stress test) was done at 6 months and 1 year postoperatively.

Results

A total of 72 patients were evaluated. After 12 patients with any one or more of the abnormal urodynamic parameters were excluded, 30 patients were finally recruited in each of the "urodynamic testing" and "office evaluation only" groups. At both the 6- and the 12-month follow-ups, treatment outcomes (reduction in scores and positive provocative stress test) were significantly better in the urodynamic testing group than in the office evaluation only group (p-values significant for all outcomes).

Conclusions

Our findings showed statistically significantly better treatment outcomes in the urodynamic group (after excluding those with poor prognostic indicators such as DO, low VLPP, and MUCP) than in the office evaluation only group. We recommend exploiting the prognostic value of these urodynamic parameters for patient counseling and treatment decisions.

Mixed urinary incontinence: international urogynecological association research and development committee opinion

BACKGROUND AND AIM

The definition as well as the treatment of women with mixed urinary incontinence (MUI) is controversial. Since women with MUI are a heterogeneous group, the treatment of MUI requires an individual assessment of the symptom components: stress urinary incontinence, urinary urgency, urgency urinary incontinence, urinary frequency, and nocturia. The purpose of this paper is to summarize the current literature and give an evidence-based review of the assessment and treatment of MUI.

METHODS

A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the diagnosis and management of MUI was drafted based on a literature review. After evaluation by the entire IUGA R&D Committee, revisions were made, and the final document represents the IUGA R&D Committee Opinion on MUI.

RESULTS

This R&D Committee Opinion reviews the literature on MUI and summarizes the assessment and treatment with evidence-based recommendations.

CONCLUSIONS

The diagnosis of MUI encompasses a very heterogeneous group of women. The evaluation and treatment requires an individualized approach. The use of validated questionnaires is recommended to assess urinary incontinence symptoms and effect on quality of life. Conservative therapy is suggested as a first-line approach; if surgery is contemplated, urodynamic investigation is recommended. Women undergoing surgical treatment for MUI need to be counselled about the possibility of persistence of urinary urgency, frequency and urge incontinence even if stress urinary incontinence is cured.

Clinical and urodynamic differences among women with overactive bladder according to the presence of detrusor overactivity

INTRODUCTION AND HYPOTHESIS

We tried to determine whether clinical and urodynamic differences exist between women with and without detrusor overactivity (DO) using a large database of overactive bladder (OAB) patients.

METHODS

We reviewed the medical records of 513 women who underwent urodynamic studies for OAB symptoms without neurogenic or anatomical conditions that affect micturition function. Clinical symptoms were evaluated using a 3-day frequency-volume chart (FVC) including the Urinary Sensation Scale and American Urological Association Symptom Index (AUA-SI). All clinical and urodynamic findings were compared between women with and without DO.

RESULTS

The patients' mean age was 58.9 years. DO was identified urodynamically in 167 (32.6 %) women. Those with DO were older (62.9 vs 57.0 years, p < 0.001); however, no differences in AUA-SI, episodes of daytime voiding, and episodes of nocturia were observed between the groups. Functional bladder capacity was smaller in women with DO; however, this difference did not reach statistical significance. Women with DO had significantly more urgency incontinence symptoms than those without DO (55.1 vs 29.5 %, p < 0.001). In urodynamic parameters, the volumes at first desire to void and strong desire to void and maximum cystometric capacity were significantly smaller, and detrusor pressure at the opening was significantly higher in women with DO compared to subjects without DO (26.2 vs 21.2 cmH(2)O, p = 0.004).

CONCLUSIONS

Our findings suggest a more severe disturbance of bladder function when DO exists, although no differences were observed in symptom scores and 3-day FVC parameters among women with OAB symptoms according to the presence of DO.

Mid-urethral slings in female incontinence: Current status

The advent of the mid-urethral sling (MUS) 15 years ago has drastically changed the surgical management of stress urinary incontinence (SUI). Both retropubic and transobturator MUS can be placed in the ambulatory setting with excellent results. The tension-free vaginal tape (TVT) sling has the most robust and long-term data, but more recent literature suggests that the transobturator tape sling may offer comparable efficacy in appropriately selected patients. Single incision sling (SIS) is the newest addition to the MUS group and was developed in an attempt to minimize morbidity and create an anti-incontinence procedure that could be performed in the office. The efficacy of SIS remains unknown as the current literature regarding SIS lacks long-term results and comparative trials. The suprapubic arc sling appears to have equally effective outcomes in at least the short-term when compared with TVT. Although evolution of the SIS has led to a less invasive procedure with decreased post-op pain and reduced recovery time, durability of efficacy could be the endpoint we are sacrificing. Until longer-term data and more quality comparison trials are available, tailoring one's choice of MUS to the individual patient and her unique clinical parameters remains the best option.

Defining the role of urodynamics in predicting voiding dysfunction after anti-incontinence surgery: a work in progress

PURPOSE OF REVIEW

To evaluate the role of preoperative urodynamics in predicting postoperative voiding dysfunction in patients undergoing anti-incontinence surgery.

RECENT FINDINGS

Voiding dysfunction after anti-incontinence procedures is not an uncommon finding, along with being a difficult one to treat. Many patients undergo preoperative urodynamics in an attempt to further characterize their incontinence preoperatively and possibly provide information regarding prognosis postoperatively. However, the role of routine urodynamics in patients undergoing anti-incontinence surgery is somewhat controversial, with mixed findings in regard to support of this practice being found in the literature.

SUMMARY

The literature on the role of preoperative urodynamics in predicting voiding dysfunction after anti-incontinence surgery is reviewed.

Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is a coexistence of stress (SUI) and urgency urinary incontinence (UUI). There is conflicting evidence on the effectiveness of midurethral slings (MUS) in this condition. The objective of this study is to evaluate the effectiveness of MUS in women with MUI by systematic review of the literature.

METHODS

Systematic literature search was carried (June 2010) using relevant search terms in Medline, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis was performed with random effects model using STATA 8.

RESULTS

There were six randomised trials and seven prospective studies with average to good quality included in this systematic review. There was heterogeneity in outcomes reported. The overall subjective cure from seven prospective nonrandomised studies that included patients with symptomatic ± urodynamically proven MUI was found to be 56.4% (95% confidence interval 45.7-69.6%) at 34.9 ± 22.9 months follow-up. The overall cure of urgency and UUI component was 30-85% at a follow-up of few months up to 5 years. Most of the studies described that this cure does not persist over the time. The cure rate of SUI following MUS varies from 85% to 97%. On meta-analysis of five RCTs which included women with MUI symptoms, the odds of overall subjective cure with TVT versus transobturator tapes are similar at 6-33 months follow-up (OR, 0.9; 95% CI, 0.63-1.27). This was true when a subgroup analysis was performed on women with MUI who were negative for DO on UDS (OR, 1.21; 95% CI, 0.7-2.08)

CONCLUSIONS

There is evidence of persistent and good cure of stress component following MUS in women with MUI. The cure of the urge component is variable but less than stress component. Methodologically sound RCTs of retropubic and transobturator tapes with long-term follow-up are needed specifically for women with urodynamically proven and symptomatic mixed incontinence.

The association of changes in opening detrusor pressure with the resolution of overactive bladder symptoms after repair of pelvic organ prolapse

AIMS

To evaluate whether changes in opening detrusor pressure (ODP) are associated with resolution of overactive bladder symptoms in women undergoing surgical correction of pelvic organ prolapse.

METHODS

Forty women with DO and OAB together with anterior wall prolapse who underwent a repair between 2003 and 2007 were studied. Each woman was assessed pre- and post-operatively with a clinical assessment and cystometry. Opening pressures were recorded pre- and post-operatively for each patient by retrospective review of the pressure flow traces. Patients were divided into those who experienced resolution of OAB symptoms and those with persistent OAB symptoms. Wilcoxon matched pairs signed rank test was used to assess any change in opening pressures between these groups.

RESULTS

Resolution of urgency with an anterior repair was associated with a significant fall in ODP from a mean of 27.9 to 11.7 cmH(2)O (P = 0.01). There was no significant pre-operative difference in ODP between women in whom urgency resolved and those in whom it did not.

CONCLUSION

These results suggest that a fall in ODP is associated with resolution of urgency in women undergoing prolapse surgery. This may imply that decreased urethral resistance is of importance in symptom resolution.

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesis

The aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.

Methods

Opening detrusor pressure, detrusor pressure at maximum flow (p_det Q_max), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.

Results

There were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.

Conclusions

We found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Can we predict if overactive bladder symptoms will resolve after sling surgery in women with mixed urinary incontinence?

Persistent overactive bladder and urgency urinary incontinence after sling surgery (pubovaginal sling or midurethral sling) in women with mixed urinary incontinence (MUI) is devastating to patients and frustrating to surgeons who perform anti-incontinence surgery. To better predict the outcomes of sling surgery in women with MUI, preoperative parameters need to be examined to accurately predict postsurgical outcomes. In this review article, we will explore recent literature exploring possible preoperative predictors of persistent overactive bladder and urgency urinary incontinence after sling surgery in women with MUI.

Transperineal ultrasound to assess the effect of tension-free vaginal tape position on flow rates

OBJECTIVE

To determine whether the position of the tension-free vaginal tape (TVT) has an effect on postoperative flow rates and voiding function in women successfully cured of urodynamic stress incontinence.

METHODS

Postoperatively 72 women who had undergone TVT surgery had a transperineal ultrasound examination to assess the position of the TVT on the urethra. The tape was categorized as proximal, mid or distal urethral. The effect on voiding was assessed using the maximum flow rate (MFR) centiles corrected for voided volume and detrusor pressure at maximum flow.

RESULTS

Forty-six women had distal tapes and 26 mid-urethral tapes. A tape lying on the mid urethra was associated with a fall in MFR centile (P = 0.04) while a tape lying on the distal urethra did not cause a fall in the MFR centile (P = 0.52). There was no significant change in the detrusor pressure at maximum flow between mid and distally placed tapes.

CONCLUSIONS

Distally placed tapes cause less alteration in flow rates than do mid-urethrally placed tapes. This may be beneficial in certain patient groups.

Are multichannel urodynamics required prior to surgery in a woman with stress urinary incontinence?

The National Institute for Clinical Excellence recommends that cystometry need not be performed before conservative therapy for incontinence in women, nor is cystometry routinely recommended in the small group of women with a clearly defined diagnosis of pure stress incontinence. Nonetheless, it is frequently utilized in the assessment of women with stress urinary incontinence in the hope that results will shed light on preoperative risk factors for failure or postoperative voiding dysfunction. The ability of urodynamic studies to characterize these parameters reliably remains under investigation. Because urodynamic studies are invasive, costly, and not always available, it is imperative that its benefit be carefully explored. This review highlights the recent arguments for and against this recommendation.

When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

Introduction and hypothesis

Development of a model that can predict in which group of women pre-operative urodynamics can be safely omitted.

Methods

Three hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20 cm H₂O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics.

Results

Women are likely to benefit from pre-operative urodynamics if they (1) are 53 years of age or older or (2) have a history of prior incontinence surgery and are at least 29 years of age or (3) have nocturia complaints and are at least 36 years of age.

Conclusion

If urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29%.