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Tarcan T, Finazzi-Agrò E, Kessler TM, Serati M, Solomon E, Rosier PFWM. How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence? Neurourol Urodyn 2023; 42:1639-1646. [PMID: 37638391 DOI: 10.1002/nau.25273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
AIMS Since formal evidence demonstrating the value of urodynamic studies (UDS) in functional urology remains elusive, we aimed to consider how best to design robust research for this purpose in female urinary incontinence. METHODS An expert group was convened to debate the following considerations: (a) precedents for formally proving the value of a gold standard diagnostic test, (b) key research principles, (c) defining a study population, (d) selecting endpoints, (e) defining interventional and controls arms, (f) blinding, (g) powering the study, and (h) duration of follow-up. In each case, we considered the strengths and weaknesses of different approaches in terms of scientific validity, ethical acceptability, practicality, and likelihood of bias. RESULTS We agreed that unlike evaluating therapies, attempting to judge the value of a diagnostic test based on eventual treatment success is conceptually flawed. Nonetheless, we explored the design of a hypothetical randomized controlled trial for this purpose, agreeing that: (1) the study population must sufficiently reflect its real-world counterpart; (2) clinical endpoints should include not only continence status but also other lower urinary tract symptoms and risks of management; (3) participants in the interventional arm should receive individualized management based on their UDS findings; (4) the most scientifically valid approach to the control arm-empiric treatment-is ethically problematic; (5) sufficient statistical power is imperative; and (6) ≥ 2 years' follow-up is needed to assess the long-term impact of management. CONCLUSIONS Although a perfect protocol does not exist, we recommend careful consideration of our observations when reflecting on past studies or planning new prospective research.
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Affiliation(s)
- Tufan Tarcan
- Department of Urology, Marmara University School of Medicine and Koç University School of Medicine, Istanbul, Turkey
| | - Enrico Finazzi-Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and UOSD Urologia, Policlinico Tor Vergata, Rome, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | | | - Peter F W M Rosier
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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Leandro A, Marta L, Gracia G, Ariel M, Pablo VJ, Bengió Rubén G. Prevalence of "uncomplicated" and "complicated" stress urinary incontinence in Argentinian women: Assessing the role of the urodynamic study. Eur J Obstet Gynecol Reprod Biol 2020; 256:466-470. [PMID: 33162151 DOI: 10.1016/j.ejogrb.2020.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/05/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the percentage of Argentinian patients with "uncomplicated" and "complicated" stress urinary incontinence (SUI) in whom preoperative urodynamics study (UDS) was performed. The secondary objective of the study was to evaluate differences between clinical observation and urodynamics in both groups of women. METHODS A retrospective study of women with IOE derivatives for UDS prior to surgical treatment is performed. The analyzed patients were classified in complicated and not complicated according to the criteria of the study VALUE. The prevalence of different urodynamics observations was assessed in patients with complicated and uncomplicated SUI. RESULTS We studied 792 patients with SUI derivatives for UDS. Of the patients studied, 313 (39.5%) were considered as uncomplicated SUI and 479 (60.5%) as complicated SUI. The Urodynamics observation was considered different from the clinical data in 415/792 (52.4%), although in greater proportion in SUI complicated (59.9% vs. 40.9%, p < 0.001). There was a higher incidence of voiding dysfunction in patients with complicated SUI (32.4% vs. 14.7%, p < 0,001). CONCLUSIONS Patients with uncomplicated SUI represent 39% of patients studied with SUI. The differences between clinical evaluation and urodynamics are higher in patients with complicated SUI contributing new information in 60% of the cases.
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Affiliation(s)
- Arribillaga Leandro
- Centro Urológico Profesor Bengió, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina.
| | - Ledesma Marta
- Centro Urológico Profesor Bengió, Córdoba, Argentina
| | | | | | | | - Bengió Rubén G
- Centro Urológico Profesor Bengió, Córdoba, Argentina; Clínica Universitaria Reina Fabiola, Córdoba, Argentina
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Pilsetniece Z, Vjaters E. Can conventional urodynamic variables help to predict the necessity of overactive bladder symptomatic therapy in women after transobturator tape surgery? Cent European J Urol 2020; 73:315-320. [PMID: 33133659 PMCID: PMC7587482 DOI: 10.5173/ceju.2020.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/22/2020] [Accepted: 08/23/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction The aim of this study was to find out if there are any conventional urodynamic (UDS) variables that would help to predict the necessity of overactive bladder (OAB) symptomatic therapy in women after transobturator tape surgery (TOT). Material and methods A total of 487 females after TOT were enrolled in this retrospective study. Inclusion criteria (UDS before surgery, follow-up visit within 2–6 month after TOT) were met in 169 women. Based on patient history, questionnaires and physical examination, two groups were distinguished: pure stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (MixUI). A statistical analysis was performed including age and UDS variables. T-test was used for continuous data and Chi-squared test for categorical data. Combinations of these factors were analyzed using binary logistic regression and surgery outcome as the target variable. Results Significant correlations between the probability of a need for OAB therapy after TOT were observed with age (higher age increases OAB therapy necessity, p <0.001) and such UDS variables as cystometric capacity (CC) p <0.001; maximum flow rate (Qmax) p <0.001; detrusor contractility index (DCI) p <0.015 – higher value decreased the need for OAB therapy. Critical limit for these values: 60 years for age, 300 ml for CC, 15 ml/s for Qmax, but no specific value for DCI was observed. Binary logistic regression showed that the UI Group (p <0.01) and CC (p = 0.01) allow correctly classify 78.9% of TOT outcome (increased CC and SUI group are factors for TOT normal outcome). Conclusions UI group, age, CC, Qmax, DCI can help to predict the necessity of OAB symptomatic therapy in women after TOT.
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Affiliation(s)
- Zane Pilsetniece
- Pauls Stradins Clinical University Hospital, Department of Urology, Riga, Latvia
| | - Egils Vjaters
- Pauls Stradins Clinical University Hospital, Department of Urology, Riga, Latvia
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Al Mousa RT, Al Dossary N, Hashim H. The role of urodynamics in females with lower urinary tract symptoms. Arab J Urol 2019; 17:2-9. [PMID: 31258939 PMCID: PMC6583751 DOI: 10.1080/2090598x.2019.1589931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/31/2019] [Indexed: 01/22/2023] Open
Abstract
Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used. Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society. Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS. Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity. Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; PdetQmax: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence
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Affiliation(s)
- Riyad T Al Mousa
- Department of Urology, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Nader Al Dossary
- Department of Urology, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Ong HL, Kuo HC. Bladder dysfunction does not affect long-term success rate of the retropubic suburethral sling procedure in women with stress urinary incontinence. Low Urin Tract Symptoms 2018; 11:O168-O173. [PMID: 30484955 DOI: 10.1111/luts.12244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 10/15/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE This study investigated the long-term success rate of retropubic suburethral sling in the treatment of women with stress urinary incontinence (SUI) and different bladder function. METHODS Surgical outcomes of women with SUI undergoing a retropubic suburethral sling procedure between October 1989 and November 2014 were analyzed retrospectively. Bladder function was evaluated in every patient preoperatively using videourodynamic studies. Patients were classified as having stable bladder, detrusor overactivity (DO), or detrusor underactivity (DU). Baseline urodynamic parameters were analyzed and long-term therapeutic outcomes were compared among these three groups. RESULTS In all, 403 patients underwent sling procedure for SUI. Of these, 291 (72.2%) had a stable bladder, 78 (19.4%) had DO, and 34 (8.4%) had DU. Mean (± SD) patient age was 60.2 ± 11.8 years, and the median follow-up was 97 months (interquartile range 24-325 months). Postoperatively, the overall continence rate was 83.4% (336/403). After surgery, 71 patients (17.6%) complained of dysuria, 14 (3.5%) complained of urgency incontinence, 25 (6.2%) had recurrent SUI requiring a secondary sling procedure, and urethrolysis was performed in 13 (3.2%). In the stable bladder, DO, and DU groups, the 5-year continence rates were 88.6%, 84.1%, and 79.4%, respectively (P = 0.59), whereas the 10-year continence rates were 83.8%, 72.9%, and 79.4%, respectively. Kaplan-Meier survival analysis indicated that the long-term success rate was similar among the three groups (P = 0.39). CONCLUSIONS The overall continence rate was 83.4% and the 10-year continence rate was satisfactory in all bladder function subgroups. Treatment outcomes were the same for women with SUI but different bladder function.
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Affiliation(s)
- Hueih Ling Ong
- Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
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Stangel-Wójcikiewicz K, Migdał M, Skotniczny K, Hessel T, Chłosta P. Urodynamics and diagnosis of urinary incontinence. BIO-ALGORITHMS AND MED-SYSTEMS 2018. [DOI: 10.1515/bams-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
The urinary incontinence diagnostic process should include a medical history focused on ailments related to it and their impact on the quality of patient’s life. The lack of proper control over the function of the lower urinary tract creates a lot of troubles for sufferers and prevents them from living an active professional, social, and family life. The patient with a suspicion of urinary incontinence is recommended to record in a voiding diary the number of mictions per day, the volume of urine, and episodes of incontinence. The invasive test called urodynamics is based on cystometry, profilometry, and uroflowmetry. A urodynamic examination performed in patients with incontinence allows for correct diagnosis and proposal of specific surgical or pharmacological treatment.
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Finazzi-Agro E, Gammie A, Kessler TM, van Koeveringe G, Serati M, Solomon E, de Wachter S, Kirschner-Hermanns R. Urodynamics Useless in Female Stress Urinary Incontinence? Time for Some Sense-A European Expert Consensus. Eur Urol Focus 2018; 6:137-145. [PMID: 30061075 DOI: 10.1016/j.euf.2018.07.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/15/2018] [Accepted: 07/20/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Routine use of urodynamics (UDS) for the assessment of female stress urinary incontinence (SUI) appears to be in decline across Europe. The reasons for this trend appear multifactorial, but the implications are of significant concern. OBJECTIVES To achieve an expert consensus viewpoint on the value of UDS in female SUI and current barriers to its use. METHODOLOGY A multidisciplinary group of UDS experts from six European countries was convened, and a modified version of the Delphi method was utilised to reach a consensus viewpoint structured around five key questions. RESULTS Consensus was achieved on all five questions. The group was unanimous that the decline in routine use of UDS is unjustified and misguided, driven by restrictions in funding and accelerated by the publication-and subsequent influence-of two trials that had major limitations. LIMITATIONS The authors comprised a selected group of UDS experts and the analysis is not a formal systematic review. CONCLUSIONS Extensive experience and observational studies have demonstrated the value of UDS for the assessment of female SUI and the dangers of empiric management. This evidence base should not be eclipsed by the findings of two randomised controlled trials that had numerous shortcomings. PATIENT SUMMARY A group of experts were worried that, even though the cause of incontinence varies, doctors seem to be skipping a diagnostic test called urodynamics (UDS) in some patients and just providing treatment-even surgery-without knowing exactly what is wrong. These experts analysed the situation in detail and reached agreement that UDS testing should not be skipped.
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Affiliation(s)
- Enrico Finazzi-Agro
- Department of Experimental Medicine and Surgery, Unit for Functional Urology, Tor Vergata University Hospital, Rome, Italy
| | - Andrew Gammie
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Thomas M Kessler
- Neuro-urology, Spinal Cord Injury Center & Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
| | - Gommert van Koeveringe
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maurizio Serati
- Department of Obstetrics and Gynaecology, Urogynaecology Unit, University of Insubria, Varese, Italy.
| | | | - Stefan de Wachter
- Department of Urology, University Hospital Antwerpen, University of Antwerp, Belgium
| | - Ruth Kirschner-Hermanns
- Neuro-urology/Urology, University Clinic, Friedrich Wilhelms University Bonn and Neurological Rehabilitation Centre, Bonn, Germany
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Homer T, Shen J, Vale L, McColl E, Tincello DG, Hilton P. Invasive urodynamic testing prior to surgical treatment for stress urinary incontinence in women: cost-effectiveness and value of information analyses in the context of a mixed methods feasibility study. Pilot Feasibility Stud 2018; 4:67. [PMID: 29588862 PMCID: PMC5865344 DOI: 10.1186/s40814-018-0255-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 02/19/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?) was a mixed methods study to assess the feasibility of a future randomised controlled trial of invasive urodynamic testing (IUT) prior to surgery for stress urinary incontinence (SUI) in women. Here we report one of the study's five components, with the specific objectives of (i) exploring the cost-effectiveness of IUT compared with clinical assessment plus non-invasive tests (henceforth described as 'IUT' and 'no IUT' respectively) in women with SUI or stress-predominant mixed urinary incontinence (MUI) prior to surgery, and (ii) determining the expected net gain (ENG) from additional research. METHODS Study participants were women with SUI or stress-predominant MUI who had failed to respond to conservative treatments recruited from seven UK urogynaecology and female urology units. They were randomised to receive either 'IUT' or 'no IUT' before undergoing further treatment. Data from 218 women were used in the economic analysis. Cost utility, net benefit and value of information (VoI) analyses were performed within a randomised controlled pilot trial. Costs and quality-adjusted life years (QALYs) were estimated over 6 months to determine the incremental cost per QALY of 'IUT' compared to 'no IUT'. Net monetary benefit informed the VoI analysis. The VoI estimated the ENG and optimal sample size for a future definitive trial. RESULTS At 6 months, the mean difference in total average cost was £138 (p = 0.071) in favour of 'IUT'; there was no difference in QALYs estimated from the SF-12 (difference 0.004; p = 0.425) and EQ-5D-3L (difference - 0.004; p = 0.725); therefore, the probability of IUT being cost-effective remains uncertain. The estimated ENG was positive for further research to address this uncertainty with an optimal sample size of 404 women. CONCLUSIONS This is the largest economic evaluation of IUT. On average, up to 6 months after treatment, 'IUT' may be cost-saving compared to 'no IUT' because of the reduction in surgery following invasive investigation. However, uncertainty remains over the probability of 'IUT' being considered cost-effective, especially in the longer term. The VoI analysis indicated that further research would be of value. TRIAL REGISTRATION ISRCTN. ISRCTN71327395. Registered 7 June 2010.
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Affiliation(s)
- Tara Homer
- Health Economics Group, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Jing Shen
- Health Economics Group, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Luke Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Elaine McColl
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Paul Hilton
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence. Eur Urol Focus 2016; 2:272-273. [DOI: 10.1016/j.euf.2015.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Yande SD, Joglekar OV, Joshi M. Role of urodynamics in stress urinary incontinence: A critical appraisal. J Midlife Health 2016; 7:119-125. [PMID: 27721639 PMCID: PMC5051231 DOI: 10.4103/0976-7800.191016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Role of urodynamics prior to surgery of stress urinary incontinence (SUI) is under constant debate. Demonstration of the presence of detrusor overactivity is the only aspect that has been emphasized in the literature so far. We believe that there are number of other factors which may influence the evaluation and in turn the choice of surgical management and prediction of outcome of treatment. They are as follows: (1) Presence of voiding inefficiency, (2) asymptomatic detrusor overactivity, (3) and severity of SUI. These features may complicate the precise evaluation of patients of SUI. The main objective of this study is to analyze the dynamics of leakage and voiding using urodynamics. This study also aims at correlating these findings with clinical information. Materials and Methods: One hundred consecutive cases referred to our center for preoperative evaluation of SUI were recruited in the study prospectively. All patients were interrogated using International Consultation on Incontinence Questionnaire. All patients underwent complete urodynamic evaluation including uroflowmetry, filling cystometry, leak point pressure measurement, and pressure flow studies, according to Good Urodynamic Practice guidelines. Patients’ symptoms were correlated with urodynamic findings, with special emphasis on the presence of detrusor overactivity, severity of SUI, voiding efficiency, and presence of bladder outlet obstruction. Clinical information and urodynamic findings were correlated using Chi-square test. Results: There is a statistically significant correlation between the presence of symptoms of urge urinary incontinence and urodynamic findings of detrusor overactivity at P < 0.05. There is a statistically significant correlation between the symptoms of urge incontinence (in addition to SUI) and urodynamic findings of intrinsic sphincter deficiency at P < 0.05. Fifteen of 51 patients who did not have associated storage symptoms were found to have some degree of detrusor overactivity on urodynamic evaluation. There was no statistically significant correlation between asymptomatic cases of urge incontinence and incidental finding of detrusor overactivity at P < 0.05. There is no statistically significant correlation between the urodynamic findings of symptoms of voiding dysfunction and urodynamic findings, suggestive of the same value at P < 0.05. Conclusions: Urodynamic study in SUI has a potential of giving much more information than demonstration of Detrusor Overactivity alone. The predominant symptom of urge urinary incontinence can predictably diagnose detrusor overactivity in these cases. However, the incidence of asymptomatic detrusor overactivity remains as high as 15% and may have implication in postoperative results. This study clearly shows that there is a definite incidence of significant voiding dysfunction, which cannot be reliably evaluated without properly conducted pressure flow study. This factor may govern the choice of correct treatment which also predicts the outcome more reliably. Preoperative urodynamic study thus adds a dimension of precision to evaluation of the patients of SUI and may also influence technique and outcome measures in this group of patients.
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Affiliation(s)
- Shirish Dattatraya Yande
- Department of Urology, Ruby Hall Clinic, Pune, Maharashtra, India; Crystal Centre for Urinary Incontinence and Neurourology, Ratna Memorial Hospital, Pune, Maharashtra, India
| | | | - Maya Joshi
- Crystal Centre for Urinary Incontinence and Neurourology, Ratna Memorial Hospital, Pune, Maharashtra, India
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Hilton P, Armstrong N, Brennand C, Howel D, Shen J, Bryant A, Tincello DG, Lucas MG, Buckley BS, Chapple CR, Homer T, Vale L, McColl E. INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?): a mixed-methods study to assess the feasibility of a future randomised controlled trial of invasive urodynamic testing prior to surgery for stress urinary incontinence in women. Health Technol Assess 2015; 19:1-273, vii-viii. [PMID: 25714493 DOI: 10.3310/hta19150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The position of invasive urodynamic testing in the diagnostic pathway for urinary incontinence (UI) is unclear. Systematic reviews have called for further trials evaluating clinical utility, although a preliminary feasibility study was considered appropriate. OBJECTIVES To inform the decision whether or not to proceed to a definitive randomised trial of invasive urodynamic testing compared with clinical assessment with non-invasive tests, prior to surgery in women with stress UI (SUI) or stress predominant mixed UI (MUI). DESIGN A mixed-methods study comprising a pragmatic multicentre randomised pilot trial; economic evaluation; survey of clinicians' views about invasive urodynamic testing; qualitative interviews with clinicians and trial participants. SETTING Urogynaecology, female urology and general gynaecology units in Newcastle, Leicester, Swansea, Sheffield, Northumberland, Gateshead and South Tees. PARTICIPANTS Trial recruits were women with SUI or stress predominant MUI who were considering surgery after unsuccessful conservative treatment. Relevant clinicians completed two online surveys. Subsets of survey respondents and trial participants took part in separate qualitative interview studies. INTERVENTIONS Pilot trial participants were randomised to undergo clinical assessment with non-invasive tests (control arm); or assessment as controls, plus invasive urodynamic testing (intervention arm). MAIN OUTCOME MEASURES Confirmation that units can identify and recruit eligible women; acceptability of investigation strategies and data collection tools; acquisition of outcome data to determine the sample size for a definitive trial. The proposed primary outcome for the definitive trial was International Consultation on Incontinence Modular Questionnaire (ICIQ) Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) (total score) 6 months after surgery or the start of non-surgical treatment; secondary outcomes included: ICIQ-FLUTS (subscales); ICIQ Urinary Incontinence Short Form; ICIQ Lower Urinary Tract Symptoms Quality of Life; Urogenital Distress Inventory; EuroQol-5D; costs, quality-adjusted life-years (QALYs) and incremental cost per QALY, Short Form 12; 3-day bladder diary. RESULTS Of 284 eligible women, 222 (78%) were recruited; 165/219 (75%) returned questionnaires at baseline and 125/200 (63%) who were sent questionnaires at follow-up. There were few missing data items in returned questionnaires, with individual outcome scales calculable for 81%-94%. Most women underwent surgery; management plans were changed in 19 (19%) participants following invasive urodynamic testing. Participant Costs Questionnaires were returned by 53% 6 months after treatment; complete data to undertake cost-utility analysis were available in 27% (intervention) and 47% (control). While insufficient to recommend changes in practice, the results suggest further research would be valuable. All clinicians responding to the survey had access to invasive urodynamic testing, and most saw it as essential prior to surgery in women with SUI with or without other symptoms; nevertheless, 70% considered the research question underlying INVESTIGATE important and most were willing to randomise patients in a definitive trial. Participants interviewed were positive about the trial and associated documentation; the desire of some women to avoid invasive urodynamic testing contrasted with opinions expressed by clinicians through both survey and interview responses. CONCLUSIONS All elements of a definitive trial and economic evaluation were rehearsed; several areas for protocol modification were identified. Such a trial would require to 400-900 participants, depending on the difference in primary outcome sought. FUTURE WORK A definitive trial of invasive urodynamic testing versus clinical assessment prior to surgery for SUI or stress predominant MUI should be undertaken. TRIAL REGISTRATION Current Controlled Trials ISRCTN71327395. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Paul Hilton
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Catherine Brennand
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Douglas G Tincello
- Reproductive Sciences Section, Department of Cancer Studies & Molecular Medicine, University of Leicester, Leicester, UK
| | | | - Brian S Buckley
- School of Medicine, National University of Ireland, Galway, Ireland
| | | | - Tara Homer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
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12
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Hilton P, Armstrong N, Brennand C, Howel D, Shen J, Bryant A, Tincello DG, Lucas MG, Buckley BS, Chapple CR, Homer T, Vale L, McColl E. A mixed methods study to assess the feasibility of a randomised controlled trial of invasive urodynamic testing versus clinical assessment and non-invasive tests prior to surgery for stress urinary incontinence in women: the INVESTIGATE-I study. Trials 2015; 16:400. [PMID: 26350343 PMCID: PMC4563900 DOI: 10.1186/s13063-015-0928-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 08/27/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The position of invasive urodynamic testing (IUT) in diagnostic pathways for urinary incontinence is unclear, and systematic reviews have called for further trials evaluating clinical utility. The objective of this study was to inform the decision whether to proceed to a definitive randomised trial of IUT compared to clinical assessment with non-invasive tests, prior to surgery in women with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI). METHODS A mixed methods study comprising a pragmatic multicentre randomised pilot trial, a qualitative face-to face interview study with patients eligible for the trial, an exploratory economic evaluation including value of information study, a survey of clinicians' views about IUT, and qualitative telephone interviews with purposively sampled survey respondents. Only the first and second of these elements are reported here. Trial participants were randomised to either clinical assessment with non-invasive tests (control arm) or clinical assessment with non-invasive tests plus IUT (intervention arm). The main outcome measures of these feasibility studies were confirmation that units can identify and recruit eligible women, acceptability of investigation strategies and data collection tools, and acquisition of outcome data to determine the sample size for a definitive trial. The primary outcome proposed for a definitive trial was ICIQ-FLUTS (total score) 6 months after surgery or the start of nonsurgical treatment. RESULTS Of 284 eligible women, 222 (78%) were recruited, 165/219 (75%) returned questionnaires at baseline, and 125/200 returned them (63%) at follow-up. Most women underwent surgery; management plans were changed in 19 (19%) participants following IUT. Participants interviewed were positive about the trial and the associated documentation. CONCLUSIONS All elements of a definitive trial were rehearsed. Such a trial would require between 232 and 922 participants, depending on the target difference in the primary outcome. We identified possible modifications to our protocol for application in a definitive trial including clarity over inclusion/exclusions, screening processes, reduction in secondary outcomes, and modification to patient questionnaire booklets and bladder diaries. A definitive trial of IUT versus clinical assessment prior to surgery for SUI or stress predominant MUI is feasible and remains relevant. TRIAL REGISTRATION Current Controlled Trials: ISRCTN 71327395, registered 7 June 2010.
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Affiliation(s)
- Paul Hilton
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
- Royal Victoria Infirmary, Level 5, Leazes Wing, Newcastle upon Tyne, NE1 4LP, UK.
| | - Natalie Armstrong
- Department of Health Sciences, University of Leicester, Leicester, UK.
| | - Catherine Brennand
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK.
| | - Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
| | | | | | - Brian S Buckley
- School of Medicine, National University of Ireland, Galway, Ireland.
| | | | - Tara Homer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK.
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
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Agrò EF, Iacovelli V, Costantini E. Urodynamic test and female urinary stress incontinence: An open debate. World J Clin Urol 2015; 4:75-77. [DOI: 10.5410/wjcu.v4.i2.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 06/13/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
In this editorial we discussed the pros and cons of urodynamics in the assessment of female stress urinary incontinence.
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14
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Serati M, Topazio L, Bogani G, Costantini E, Pietropaolo A, Palleschi G, Carbone A, Soligo M, Del Popolo G, Li Marzi V, Salvatore S, Finazzi Agrò E. Urodynamics useless before surgery for female stress urinary incontinence: Are you sure? Results from a multicenter single nation database. Neurourol Urodyn 2015; 35:809-12. [PMID: 26061435 DOI: 10.1002/nau.22804] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/18/2015] [Indexed: 01/28/2023]
Abstract
AIMS The role of urodynamics (UDS) before surgery for stress urinary incontinence (SUI) remains a debated issue in female urology as well as in urogynaecology and it has been recently questioned on the basis of data coming from selected population of patients defined as "uncomplicated." The aim of this study was to investigate the percentage of "uncomplicated" patients undergoing urodynamic evaluations in six referral Italian centers. The secondary aim was to assess the prevalence of women, for whom the urodynamic evaluation could add new information to the pre-urodynamic picture and in how many cases these findings had a significant impact on patient management. METHODS The data of women who underwent urodynamic evaluation prior to surgery for stress urinary incontinence between 2008 and 2013 were retrospectively analyzed. According to the definition of the Value of Urodynamic Evaluation (ValUE) trial criteria, patients presenting with SUI were classified as "uncomplicated" or "complicated." Urodynamic observations were then compared with pre-urodynamic data. RESULTS Overall, 2,053 female patients were considered. Only 740/2,053 (36.0%) patients were defined "uncomplicated" according to the definition used in the ValUE trial. The urodynamic observations were not consistent with the pre-urodynamic diagnosis in 1,276 out of 2,053 patients (62.2%). Voiding dysfunctions were urodynamically diagnosed in 394 patients (19.2%). Planned surgery was cancelled or modified in 304 patients (19.2%), due to urodynamic findings. CONCLUSIONS "Uncomplicated" patients represent a minority among female SUI patients evaluated before surgery. In "complicated" patients, the role of urodynamic has not been challenged yet and UDS seems still mandatory. Neurourol. Urodynam. 35:809-812, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Maurizio Serati
- Department of Obstetrics and Gynaecology, University Insubria, Varese, Italia
| | - Luca Topazio
- School of Specialization in Urology, University Tor Vergata, Roma, Italia
| | - Giorgio Bogani
- Department of Obstetrics and Gynaecology, University Insubria, Varese, Italia
| | | | - Amelia Pietropaolo
- School of Specialization in Urology, University of Perugia, Perugia, Italia
| | | | - Antonio Carbone
- Department of Urology, University La Sapienza, Latina, Italia
| | - Marco Soligo
- Department of Obstetrics and Gynaecology, Buzzi Hospital, Milano, Italia
| | | | | | - Stefano Salvatore
- Department of Obstetrics and Gynaecology, University Vita e Salute, Milano, Italia
| | - Enrico Finazzi Agrò
- Department of Experimental Medicine and Surgery, University Tor Vergata, Roma, Italia
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Giarenis I, Thiagamoorthy G, Zacchè M, Robinson D, Cardozo L. Management of recurrent stress urinary incontinence after failed midurethral sling: a survey of members of the International Urogynecological Association (IUGA). Int Urogynecol J 2015; 26:1285-91. [DOI: 10.1007/s00192-015-2696-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 03/16/2015] [Indexed: 11/27/2022]
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Ignjatovic I, Potic M, Basic D, Dinic L, Medojevic N, Laketic D, Skakic A, Mihajlovic M. Self-created transobturator tape treatment of stress urinary incontinence without prior urodynamic investigation. Eur J Obstet Gynecol Reprod Biol 2014; 182:76-80. [PMID: 25262290 DOI: 10.1016/j.ejogrb.2014.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 07/31/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate and compare the results of tension free self-created transobturator tape (SCTOT) with the standard industrially created transobturator tape (ICTOT) in the treatment of stress urinary incontinence (SUI). STUDY DESIGN A prospective study of the treatment of SUI with SCTOT (67 patients) and ICTOT (47 patients) was performed. SCTOT was created from polypropylene mesh and monofilament sutures. The symptoms were evaluated before and after the surgery with the following: the Incontinence Impact questionnaire (IIC-7), the urogenital distress inventory (UDI-6), and the International Continence impact questionnaire short form (ICIQ5-SF). The overactive bladder symptom score (OABSS) was used to classify patients in the SUI or the mixed urinary incontinence (MUI) group. The follow up period was 18 months. Cure was defined as a negative stress test and no need for additional surgery. RESULTS Objective cure was achieved in 56/67 (83.5%) participants in the SCTOT group and in 40/47 (85.1%) participants in the ICTOT group (p>0.05). There was a significant improvement in IIC-7, UDI-6, ICIQ5-SF and OABSS in both groups. Improvement was better in the group with pure SUI than in patients with MUI, but this difference was not significant. Postoperative infection occurred in 5/67 (7.4%) participants and in 5/47 (10.6%) patients in the SCTOT and the ICTOT group, respectively. De novo overactive bladder symptoms occurred in 4/67 (5.9%) of the participants in the SCTOT group and in 3/47 (6.3%) of the patients in the ICTOT group. Operating time was longer in patients with SCTOT compared to those with ICTOT. CONCLUSION The results of the treatment with SCTOT are not inferior to the results of the treatment with ICTOT and other results reported in the literature.
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Affiliation(s)
- Ivan Ignjatovic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia.
| | - Milan Potic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
| | - Dragoslav Basic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
| | - Ljubomir Dinic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
| | - Nina Medojevic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
| | | | - Aleksandar Skakic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
| | - Marija Mihajlovic
- Clinic of Urology, Clinical Center Nis and Faculty of Medicine Nis, Serbia
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Abstract
Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. All women complaining of incontinence require a basic assessment and those with complex or refractory symptoms may benefit from urodynamic studies. Initial treatment includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. For those women with persistent stress urinary incontinence following conservative therapy, surgical management might be considered. The development of the minimally invasive, retropubic, synthetic, mid-urethral sling procedures has revolutionized stress incontinence surgery and reduced the popularity of 'traditional' procedures, such as colposuspension and autologous fascial sling. In an attempt to reduce further the morbidity, transobturator and single-incision slings have been introduced. While antimuscarinic agents are the mainstay of the current medical management of urgency urinary incontinence, a recently developed selective β3-adrenergic receptor agonist (mirabegron) offers an alternative pharmacological option. Modalities such as intravesical botulinum toxin and neuromodulation (peripheral or sacral) are available to women with refractory urgency incontinence. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion might be considered as a last resort. The aim of this paper is to review conservative, medical and surgical management for urinary incontinence by using the best available evidence in the literature.
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Affiliation(s)
- I Giarenis
- Department of Urogynaecology, King's College Hospital NHS Foundation Trust , London , UK
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