Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis

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.

Pelvic floor ultrasound versus urodynamics in evaluating insensible urinary incontinence: A retrospective study

OBJECTIVE

Insensible Urinary Incontinence (IUI) is a situation when you complain of urinary incontinence but are unaware of how it occurred. Therefore, it is necessary to apply highly specific diagnostic methods to promote accuracy in the diagnosis of IUI, including pelvic floor ultrasound (PFU) and urodynamic studies (UDS).

METHODS

A total of 41 women with IUI were retrospectively included. Patients were categorized into two groups: the urodynamic urinary incontinence group (UUI group, n=20) and the non-urodynamic urinary incontinence group (NUUI group, n=21), according to the urine leakage during UDS. The baseline clinical characteristics, UDS results, and PFU parameters were collected.

RESULTS

Compared with the NUUI group, the UUI group had a smaller maximum cystometric capacity (P=0.008), lower maximum urethral closure pressure (P=0.005), shorter functional urethral length (FUL) (P=0.01), more bladder neck funneling (BNF) (P=0.02), greater BNF depth (P=0.04), and larger BNF area (P=0.01). The area and depth of BNF were negatively correlated with maximum urethral closure pressure (r=-0.42, P=0.01), FUL (r=-0.36, P=0.02 versus r=-0.39, P=0.01), and maximum cystometric capacity (r=-0.35, P=0.03), but positively correlated with maximum urinary flow rate (r=0.33, P=0.04 versus r=0.36, P=0.02). The canonical correlation analysis of the ultrasound parameters and UDS parameters shows that the first pair of canonical variables was statistically significant (r1=0.9, P<0.001).

CONCLUSIONS

The PFU is associated with UDS in evaluating IUI. It has the advantages of low cost and high comfort, thus should be used as an auxiliary examination for IUI.

International Survey on Urodynamic Investigations in Women Undergoing Stress Urinary Incontinence Surgery

OBJECTIVE

To evaluate the role of invasive urodynamics (UD) in women candidates for stress urinary incontinence (SUI) surgery.

MATERIALS AND METHODS

This was a worldwide survey on current trends in use of preoperative invasive UD in women undergoing SUI surgery. Demographic respondents' data, whether routine invasive UD is performed before surgery and its diagnostic role were investigated.

RESULTS

The survey was completed by 504 respondents: urologists 83.1%, gynecologists 16.8%. UD findings were reported influencing the surgical decision in 84.3% of the cases and may change planned surgery in 72.4%, may discourage it in 43.6%, may change surgical expectations in 55.5%, and are useful for preoperative counselling in 96.6%. We found a very low rate of routine performance of UD for uncomplicated SUI. The most impactful UD findings were related to the conditions of detrusor contractility, overactivity and underactivity. Among voiding disorders, dyssynergia was considered the most relevant dysfunction. Valsalva Leak Point Pressure was the most reported tool to investigate urethral function. The surgical management was influenced by UD findings in the vast majority of the cases, although about 60% reported that a relevant impact of the UD occurred in less than 40% of the investigations. The crucial effect of UD on surgical management was high. This finding showed that for many respondents UD still has a pivotal role before SUI surgery.

CONCLUSION

This survey showed a worldwide picture on preoperative UD in SUI surgery highlighting the crucial role of UD. UD investigation influences surgical management, but whether it influences outcomes is unclear.

European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed Urinary Incontinence

CONTEXT

Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guideline expands the remit to include these symptoms and conditions.

OBJECTIVE

To summarise the diagnostic section of the non-neurogenic female LUTS guideline and the management of female overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI).

EVIDENCE ACQUISITION

New literature searches were carried out in September 2021 and evidence synthesis was conducted using the modified GRADE criteria as outlined for all EAU guidelines. A new systematic review (SR) on OAB was carried out by the panel for the purposes of this guideline.

EVIDENCE SYNTHESIS

The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

CONCLUSIONS

Non-neurogenic female LUTS are an important cause of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion based on the best available evidence. This guideline serves to present this evidence to health care providers in an easily accessible and digestible format.

PATIENT SUMMARY

This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to diagnosis of these conditions, as well as the treatment of overactive bladder, stress urinary incontinence, and mixed urinary incontinence.

In women with incontinence, the need for pressure-flow study before surgery and abnormalities in the voiding phase. An up-to-date comment on the available problem accompanied by literature

OBJECTIVE

To investigate the differences between urodynamic findings and history in women with urinary incontinence before surgery and clarify the need for preoperative pressure-flow studies.

MATERIALS AND METHODS

The medical records of 1018 women who underwent urodynamic examination for urinary incontinence between 2010 and 2015 were evaluated retrospectively. Stress (n = 442), urge (n = 334) and mixed (n = 242) were classified as type urinary incontinence according to urodynamics. The voiding phase findings of the patients were examined.

RESULTS

The mean age of the patients was 47.85 ± 0.27 years. 18.4% of patients (n = 187) had voiding phase problems. Furthermore, this condition was seen in the most urge incontinence type urinary incontinence (35%). There was a statistically significant difference between the groups' voiding phase findings (p < 0.0001). The relationship between the patient's history and international consultation on incontinence questionnaire form scoring (ICIQ) and the urodynamics results showed no excellent correlation.

CONCLUSIONS

Voiding phase abnormalities are not uncommon in patients with urinary incontinence. They should be considered in the evaluation of patients. Voiding phase findings may show significant differences between urodynamic data and history. Besides, the data obtained with the questionnaire forms were significantly different from the findings obtained by urodynamics. Consequently, urodynamics may change pre-operative clinical decision.

Transvaginal repair of anterior vaginal wall prolapse with polyvinylidene fluoride (PVDF) mesh: an alternative for previously restricted materials?

INTRODUCTION AND HYPOTHESIS

To study the mid-term safety and functional outcomes of transvaginal anterior vaginal wall prolapse repair using polyvinylidene fluoride (PVDF) mesh (DynaMesh®-PR4) by the double trans-obturator technique (TOT).

METHODS

Between 2015 and 2020, we prospectively included women with symptomatic high-stage anterior vaginal wall prolapse with or without uterine prolapse or stress urinary incontinence (SUI) in the study. The patients underwent transvaginal repair of the prolapse using PVDF mesh in two medical centers. We followed all patients for at least 12 months. We recorded the characteristics of vaginal and sexual symptoms, urinary incontinence, and prolapse stage pre- and postoperatively using International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF), and Pelvic Organ Prolapse Quantification (POP-Q) system, respectively.

RESULTS

One hundred eight women were included in the final analysis with a mean follow-up time of 34.5 ± 18.6 months. The anatomical success was achieved in 103 (95.4%) patients. There was a significant improvement in patients' vaginal symptoms, urinary incontinence, and quality of life scores postoperatively (p < 0.0001). Only six patients (5.5%) had mesh extrusion, five of whom were managed successfully. The total rates of complications and de novo urinary symptoms were 21.3% and 7.4%, respectively. Significant pain was reported in 17 cases (15.7%).

CONCLUSION

Our findings show that using PVDF mesh in the double TOT technique for anterior vaginal wall prolapse repair is a safe procedure with high anatomic and functional success rates and acceptable complication rates in mid-term follow-up.

Clinical and urodynamic predictors of Q-tip test urethral hypermobility

BACKGROUND

Urodinamics and Q-tip test represent diagnostic tools for the assessment of stress urinary incontinence. The aim of the present study is to investigate the possibility to predict the Q-tip test urethral hypermobility on the basis of clinical and urodynamic parameters.

METHODS

We analyzed all women performed urodynamics between 2008 and 2016 presenting urodynamic stress urinary incontinence. Symptoms were collected by the Incontinence Questionnaire-Short Form questionnaire.

RESULTS

A total of 501 women presented urodynamic stress incontinence, of which 270 had urethral hypermobility, according to the Q-tip test. Patients with urethral hypermobility were younger (p<0.0001) and presented a more advanced anterior compartment descensus according to the POP-Q system (Aa point p=0.0155; Ba point p=0.0374), a higher detrusor pressure at maximum flow (p=0.0075) and maximum flow rate compared to controls.

CONCLUSIONS

Age, Aa POP-Q point and detrusor pressure at maximum flow were found to be independent predictors of Q-tip test urethral hypermobility. However, the final model can not be used as an effective predictor of the Q-tip test result.

Effect of Preoperative Urodynamic Study on Urinary Outcomes after Transobturator Sling

OBJECTIVE

 To evaluate whether performing preoperative urodynamic study influences postoperative urinary symptoms of women with stress urinary incontinence that underwent transobturator sling.

METHODS

 Retrospective analysis of patients treated for stress urinary incontinence by transobturator sling from August 2011 to October 2018. Predictor variables included preoperative urodynamic study, age, incontinence severity, body mass index, preoperative storage symptoms and previous anti-urinary incontinence procedure. Outcome variables were postoperative subjective continence status, storage symptoms and complications. Logistic regression after propensity score was employed to compare outcomes between patients who underwent or not pre-operative urodynamic study.

RESULTS

 The present study included 88 patients with an average follow-up of 269 days. Most patients (n = 52; 59.1%) described storage symptoms other than stress urinary incontinence, and 38 patients (43.2%) underwent preoperative urodynamic studies. Logistic regression after propensity score did not reveal an association between urinary continence outcomes and performance of preoperative urodynamic study (odds ratio 0.57; confidence interval [CI]: 0.11-2.49). Among women that did not undergo urodynamic study, there was a subjective improvement in urinary incontinence in 92% of the cases versus 87% in those that underwent urodynamic study (p = 0.461). Furthermore, postoperative storage symptoms were similar between women who did not undergo urodynamic study and those who underwent urodynamic study, 13.2% versus 18.4%, respectively (p = 0.753).

CONCLUSION

 Preoperative urodynamic study had no impact on urinary incontinence cure outcomes as well as on urinary storage symptoms after the transobturator sling in women with stress urinary incontinence.

Prevalence of "uncomplicated" and "complicated" stress urinary incontinence in Argentinian women: Assessing the role of the urodynamic study

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.

Recent advances in urodynamics in women

Urodynamics is the study of the storage and evacuation of urine from the urinary tract. The aim is to reproduce the patient’s symptoms and provide a pathophysiological explanation for them by identifying all factors that contribute to the lower urinary tract dysfunction, including those that are asymptomatic. Urodynamics consists of various tests, each of which is designed to assess a different aspect of lower urinary tract function. There is a lack of evidence regarding when urodynamics should be used in the non-neurogenic bladder. Some small randomised controlled trials suggest that urodynamics does not alter the outcome of surgery for stress urinary incontinence when compared with office evaluation alone. However, this is widely felt to be inaccurate and many health-care professionals still advocate the use of urodynamics prior to any invasive treatment, especially surgery on the lower urinary tract. There have been few technological advances in urodynamics in recent years. Air-charged rather than fluid-filled catheters were thought to help reduce artefact, but the evidence is unclear, and there is doubt over their accuracy. Ambulatory urodynamics is carried out over a longer period of time, enabling physiological bladder filling, but it remains invasive and artificial. To attempt to replicate symptoms more accurately, there have been efforts to develop wireless devices to measure detrusor pressure directly. These may be promising but are far from suitable in humans at present. Urodynamics continues to provide useful information for assessing lower urinary tract function, but further large studies are required to assess its value and develop innovations to improve the accuracy of the tests and acceptability to patients.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS

To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI.

METHODS

We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT.

RESULTS

Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (β coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057).

CONCLUSIONS

Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

No. 397 - Conservative Care of Urinary Incontinence in Women

OBJECTIVE

To outline the evidence for conservative care, including both assessment and management options, for urinary incontinence in women.

INTENDED USERS

Relevant primary care providers and medical specialists including but not limited to physicians, nurses, midwives, and pelvic health physiotherapists.

TARGET POPULATION

Women (>18 years of age) with urinary incontinence.

OPTIONS

Assessment options include gathering of a detailed history, physical examination, laboratory analysis, urodynamic evaluation, and cystoscopy. Conservative management options include lifestyle management, pelvic floor muscle training, behavioural management, and mechanical devices.

OUTCOMES

To provide an evaluation-based summary of current available evidence concerning efficacy of conservative care (assessment and management) strategies for urinary incontinence in women.

EVIDENCE

The Cochrane Library and Medline (2013-2018) were searched to find articles related to conservative care of urinary incontinence in women (>18 years). Articles were appraised, and the collective evidence was graded.

VALIDATION METHODS

The evidence obtained was reviewed and evaluated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) Urogynecology Committee under the leadership of the principal authors. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, AND COSTS

Evidence for the efficacy of conservative care (assessment and management) options for women with urinary incontinence is strong. Furthermore, these options carry minimal or no harm and confer an established cost benefit.

GUIDELINE UPDATE

This SOGC Clinical Practice Guideline will be automatically reviewed 5 years after publication.

SUMMARY STATEMENTS

RECOMMENDATIONS.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 1 - Female population

Although, until a few years ago, the diagnostic power of urodynamic testing had never been questioned, recent studies in the literature have raised some doubts on the routine use of this tool. The benefits of the urodynamic studies (UDS) should be weighted against costs, time-consumption and patient discomfort. These recommendations are intended to guide clinicians in the right selection of the female patients to submit to a urodynamic evaluation. We reviewed the literature, regarding the use of UDS in female adults with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction. Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and uro-gynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in female population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with lower urinary tract symptoms and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Does pre-operative urodynamics lead to better outcomes in management of urinary incontinence in women? A linked systematic review and meta-analysis

The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients' outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patient-reported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I² statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Meta-analysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I² = 0% and P = 0.470, RR:0.87, 95% Cl 0.59-1.28, I² = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Meta-analysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88-1.16, I² = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95-1.08, I² = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB. In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and cost-effectiveness of routine urodynamics prior to surgical management of SUI and OAB.

Comparison of translabial ultrasonographic and urodynamic data of female patients with urinary incontinence: Importance of translabial ultrasonography in the diagnosis of incontinence

OBJECTIVE

To explore the diagnostic importance of translabial ultrasonographic data in incontinence, for comparison with urodynamic data.

MATERIAL AND METHODS

The study was performed between January and May 2017 on 64 patients aged between 40 and 65 years with complaints of mixed type incontinence. The patients were separated into two groups according to their urodynamic data. Translabial ultrasonography was performed in both groups.

RESULTS

Mean age of the patients was 51.19±7.01 years, and mean body mass index was 26.69±2.02 kg/m². The patients were separated into two groups as those with (n=33) or without (n=31) stress urinary incontinence based on urodynamic findings (despite the presence of mixed urinary incontinence complaints, stress urinary incontinence and detrusor overactivity associated with incontinence could not be detected in the urodynamic study). Average x descend, y descend and bladder neck mobilization values detected with translabial ultrasonography were found to be statistically significantly higher in the urodynamic stress incontinence group. There was an opposite-directional, 37.6% and statistically significant relation between maximum cystometric capacity and x descend parameters. Y descend values and bladder neck mobilization of females with negative Q-tip test were found to be statistically significantly lower than females with positive Q-tip test.

CONCLUSION

As a complementary examination tool in the evaluation of urinary incontinence translabial ultrasonography may become one of the main diagnostic evaluation tools in the future.

Impact of preoperative urodynamics on women undergoing pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

Preoperative urodynamic studies (UDS) are frequently performed before pelvic organ prolapse (POP) surgery to assess urethral and bladder function. The primary goal of this study is to examine how preoperative UDS are utilized and what value these studies have in patient treatment and/or counseling.

METHODS

We retrospectively reviewed patients who underwent prolapse surgery and had preoperative UDS between June 2010 and February 2015. Indications for UDS were classified into four categories: (1) occult stress urinary incontinence only, (2) overactive bladder symptoms, (3) mixed or insensible urinary incontinence, and (4) voiding symptoms and/or elevated post-void residual. We identified changes in management or counseling that were directly attributable to UDS results prior to surgery.

RESULTS

Three hundred ninety-two patients underwent urodynamic testing for indications 2-4 above, and 316 met the inclusion criteria. Fifty-seven percent (180/316) had OAB symptoms (34.4% wet, 65.6% dry), 40.2% (127/316) had mixed incontinence, and 17.1% (54/316) had voiding symptoms and/or elevated PVR. A total of 3.5% (11/316) patients had alteration in their management or counseling based on the results of the UDS; 29.4% (50/170) of the women evaluated for occult SUI alone or with other symptoms demonstrated it and 41 underwent sling placement.

CONCLUSIONS

UDS did not have a significant impact on preoperative management or counseling in POP surgery if demonstration of occult SUI was not the indication for preoperative study in women committed to POP surgery. Major alterations in treatment were rare and occurred mostly in women with stress incontinence that also had concomitant voiding symptoms and/or elevated PVR.

The role of urodynamics in females with lower urinary tract symptoms

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; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

Urodynamics Useless in Female Stress Urinary Incontinence? Time for Some Sense-A European Expert Consensus

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.

National Trend of Uroflowmetry, Urodynamic Study and Cystoscopy Considering the Change in the Population Structure in Korea from 2010 to 2015

BACKGROUND

Although lower urinary tract symptoms (LUTS) show a higher prevalence with age, few studies have reported the trend of these examination tools including uroflowmetry, urodynamic study and cystoscopy.

METHODS

We evaluated the trend of performance of uroflowmetry, urodynamic study and cystoscopy by using National Health Insurance Data from 2010 to 2015. Primary outcome findings included cumulative number of patients per year, cumulative age-standardized patient rate per year and per age group, and correlation between the number of patients per year and the percentage of population per year in each age group.

RESULTS

The overall trend for frequency of uroflowmetry and cystoscopy showed an increasing pattern (P < 0.001, respectively) while the trend for frequency of urodynamic study showed a decreasing pattern (P < 0.001). After age standardization, the overall trend showed similar results. Correlation between the number of patients per year and the percentage of population per year showed a positive correlation in the 50s age group and the above 70s age group (P = 0.003 and < 0.01, respectively) on uroflowmetry and in the above 70s age group (P < 0.01) on cystoscopy. Urodynamic study showed negative correlations in the 50s age group and the above 60s age group (P = 0.001 and 0.01, respectively).

CONCLUSION

National trend for frequency of uroflowmetry, urodynamic study and cystoscopy showed a different trend. The increasing trend of uroflowmetry and cystoscopy was related with growth of the aged population. However, urodynamic study showed a decreasing trend regardless of the age group.

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

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.

The effects of a heating pad on anxiety, pain, and distress during urodynamic study in the female patients with stress urinary incontinence

AIMS

Although generally well tolerated, a urodynamic study is an unpleasant and stressful procedure for some patients. This study evaluated the effects of a heating pad on anxiety, pain, and distress during urodynamic studies in female patients with stress urinary incontinence.

METHODS

A total of 74 female patients with stress urinary incontinence who underwent a urodynamic study between May 2015 and October 2015 were randomized to either the experimental group using a heating pad (n = 37) or control group (n = 37). In the experimental group, a heating pad was applied on the patient's sacrum during the urodynamic study. All patients completed the State-Trait Anxiety Inventory (20-80) before and after the procedure and assessed their degree of pain and distress after the procedure by the visual analog scale (0-10). Systolic and diastolic blood pressure and pulse rate were also checked before and after the procedure.

RESULTS

Demographic characteristics, mean age, procedure duration, pre and post-procedural systolic, and diastolic blood pressures, and pulse rate were statistically similar between the experimental and control groups. The mean State-Trait Anxiety Inventory was significantly lower in the experimental group than in the control group (30.9 ± 7.5 vs 42.5 ± 10.1, P < 0.001). The experimental group showed significantly lower pain and distress scores (Visual Analog Scale, 2.7 ± 1.5, 3.0 ± 1.5) compared with the control group (4.0 ± 1.6, 4.7 ± 2.0, both P < 0.001).

CONCLUSIONS

Using a heating pad for female patients with stress urinary incontinence during a urodynamic study is a simple, economical, and effective therapy that enhances patient comfort and decreases anxiety, pain, and distress.

Trends in urodynamic testing prior to midurethral sling placement-What was the value of the VALUE trial?

BACKGROUND

Many urologists use urodynamic testing (UDS) to assist clinical decision-making. The VALUE study, a multi-institutional, randomized controlled trial published in 2012, demonstrated that UDS prior to midurethral sling placement for uncomplicated stress urinary incontinence (SUI) did not change management. We sought to determine whether use of UDS for evaluation of SUI diminished thereafter.

METHODS

Records of patients who underwent isolated mid-urethral sling surgery at our tertiary-care referral center from 2008 to 2009 (pre-VALUE) and 2014 to 2016 (post-VALUE) were reviewed. Comorbidities, presenting symptoms, surgeon specialty, use of UDS, UDS results and sling type were recorded. Patients with neurologic comorbidities or prior anti-incontinence procedures were excluded. Descriptive statistics were calculated and multivariable logistic regression analyses performed.

RESULTS

Three hundred and eighty-seven patients met inclusion criteria. Median age was 54 years. Patients most frequently presented with stress urinary incontinence (56% pre, 50% post), followed by stress predominant mixed urinary incontinence (40% pre, 48% post, P = 0.09). Before VALUE, UDS was performed in 70% of patients prior to primary sling; in the later cohort, this decreased to 41% (P < 0.0001). On multivariable analysis, provider specialty (P < 0.0001) and belonging to the pre-VALUE cohort (P = < 0.0001) predicted use of UDS prior to sling.

CONCLUSION

It is paramount that new data be incorporated into diagnostic and treatment algorithms. We found that the rate of preoperative urodynamic testing decreased after publication of a randomized-controlled trial demonstrating that these studies did not change procedural decision-making. Future studies that identify instances of over-testing may have the ability to positively impact patient care and contain costs.

The impact of urodynamics on treatment and outcomes in women with an overactive bladder: a longitudinal prospective follow-up study

INTRODUCTION AND HYPOTHESIS

The aim of this study was to establish if the management of women with overactive bladder (OAB) and patient-reported outcomes differed based on the findings of urodynamics (UDS).

METHODS

A prospective, longitudinal observational study conducted in urogynaecology clinics in 22 UK hospitals participating in the Diagnostic Accuracy of Bladder Ultrasound Study (BUS). A total of 687 women with OAB symptoms or urgency-predominant mixed urinary incontinence were recruited into a diagnostic study that used UDS as the reference standard. Detailed clinical history and International Consultation on Incontinence OAB Short Form (ICIQ-OAB sf) questionnaire responses were obtained before the UDS test was carried out. These questionnaires were subsequently collected at a mean of 7 and 20 months, along with patient global impression of improvement and details on medical and surgical treatments. The relationship between UDS diagnosis and treatment was examined using a multinomial regression model; logistic and repeated measures regressions were used to examine other outcomes.

RESULTS

We recruited 687 women and the response rate was 69% at 20 months. Treatment subsequent to UDS was highly associated with diagnosis (p < 0.0001). Women who received treatment concordant with their UDS findings were more likely to report an improvement in bladder symptoms (57% vs 45%; p = 0.02) and ICIQ-OAB sf scores (0.5 points, 95%CI: 0.1 to 0.9; p = 0.02).

CONCLUSIONS

Urodynamics influenced treatment decisions made by clinicians in determining treatment pathways in women presenting with OAB. Women treated based on UDS diagnoses appear to have greater reductions in symptoms than those who do not.

The role of preoperative urodynamics in stress urinary incontinence surgery

The routine use of urodynamics prior to incontinence surgery continues to be debated. The evidence available from randomized, control trials suggests that preoperative urodynamics do not improve surgical outcomes and are not cost-effective.

Medium-term results of Mini-arc for urinary stress incontinence in ambulatory patients under local anesthesia

OBJECTIVE

To evaluate the medium-term outcome and patient's satisfaction after Single-incision mini-sling (SIMS) procedure done under local anesthesia in ambulatory set up for patients with stress urinary incontinence (SUI).

MATERIALS AND METHODS

This is a retrospective cohort study, including all patients submitted to SIMS procedure for SUI with MiniArc (AMS, U.S.A) without concomitant surgery between January 2011 and March 2013. Patients were followed up during 12 months after surgery and once a year subsequently. Telephone interviews were conducted to evaluate patient satisfaction. Outcome masseurs included: SUI cure rate, urinary urge incontinence (UUI) cure rate in patients with mixed urinary incontinence (MUI), intra and post-operative complications and patient satisfaction.

RESULTS

Ninety-three patients were included with mean follow-up of 23 months. Fifty percent had MUI with predominant SUI. The cure rates of SUI (objective and subjective) were 89%. UUI was cured in 40% of patients. No major complications occur, neither voiding obstruction or groin pain. Telephone interviews conducted after 26 months on average revealed high satisfaction rate from the procedure (8.8 out of 10) and from the local anesthesia. Visual analog scale (VAS) rating was low during and after the procedure (2.38 and 2.69 respectively).

CONCLUSIONS

The SIMS procedure is safe and highly effective for SUI and it can be performed successfully under local anesthesia in an ambulatory setup.

Bladder ultrasonography for diagnosing detrusor overactivity: test accuracy study and economic evaluation

BACKGROUND

Urodynamics (UDS) has been considered the gold standard test for detrusor overactivity (DO) in women with an overactive bladder (OAB). Bladder ultrasonography to measure bladder wall thickness (BWT) is less invasive and has been proposed as an alternative test.

OBJECTIVES

To estimate the reliability, reproducibility, accuracy and acceptability of BWT in women with OAB, measured by ultrasonography, in the diagnosis of DO; to explore the role of UDS and its impact on treatment outcomes; and to conduct an economic evaluation of alternative care pathways.

DESIGN

A cross-sectional test accuracy study.

SETTING

22 UK hospitals.

PARTICIPANTS

687 women with OAB.

METHODS

BWT was measured using transvaginal ultrasonography, and DO was assessed using UDS, which was performed blind to ultrasonographic findings. Intraobserver and interobserver reproducibility were assessed by repeated measurements from scans in 37 and 57 women, respectively, and by repeated scans in 27 women. Sensitivity and specificity were computed at pre-specified thresholds. The smallest real differences detectable of BWT were estimated using one-way analysis of variance. The pain and acceptability of both tests were evaluated by a questionnaire. Patient symptoms were measured before testing and after 6 and 12 months using the International Consultation on Incontinence modular Questionnaire Overactive Bladder (short form) (ICIQ-OAB) questionnaire and a global impression of improvement elicited at 12 months. Interventions and patient outcomes were analysed according to urodynamic diagnoses and BWT measurements. A decision-analytic model compared the cost-effectiveness of care strategies using UDS, ultrasonography or clinical history, estimating the cost per woman successfully treated and the cost per quality-adjusted life-year (QALY).

RESULTS

BWT showed very low sensitivity and specificity at all pre-specified cut-off points, and there was no evidence of discrimination at any threshold (p = 0.25). Extensive sensitivity and subgroup analyses did not alter the interpretation of these findings. The smallest detectable difference in BWT was estimated to be 2 mm. Pain levels following both tests appeared relatively low. The proportion of women who found the test 'totally acceptable' was significantly higher with ultrasonography than UDS (81% vs. 56%; p < 0.001). Overall, subsequent treatment was highly associated with urodynamic diagnosis (p < 0.0001). There was no evidence that BWT had any relationship with the global impression of improvement responses at 20 months (p = 0.4). Bladder ultrasonography was more costly and less effective than the other strategies. The incremental cost-effectiveness ratio (ICER) of basing treatment on the primary clinical presentation compared with UDS was £491,500 per woman successfully treated and £60,200 per QALY. Performing a UDS in those women with a clinical history of mixed urinary incontinence had an ICER of £19,500 per woman successfully treated and £12,700 per QALY compared with the provision of urodynamic to all women. For DO cases detected, UDS was the most cost-effective strategy.

CONCLUSION

There was no evidence that BWT had any relationship with DO, regardless of the cut-off point, nor any relationship to symptoms as measured by the ICIQ-OAB. Bladder ultrasonography has no diagnostic or prognostic value as a test in this condition. Furthermore, despite its greater acceptability, BWT measurement was not sufficiently reliable or reproducible.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46820623.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 7. See the NIHR Journals Library website for further project information.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Objective

To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence.

Design

Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources.

Methods

Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken.

Results

Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties.

Conclusions

Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Post-void residual urine under 150 ml does not exclude voiding dysfunction in women

INTRODUCTION AND HYPOTHESIS

It has been claimed that post-void residual urine (PVR) below 150 ml rules out voiding dysfunction in women with stress urinary incontinence (SUI) and provides license to perform sling surgery. The cut-off of 150 ml seems arbitrary, not evidence-based, and so we sought to investigate the ability of PVR < 150 ml to exclude voiding dysfunction.

METHODS

We retrospectively reviewed the charts of all patients who underwent invasive urodynamics from 1 January 2013 to 31 December 2013. Voiding dysfunction was diagnosed if both the invasive urodynamic and the free flow showed abnormal results. We registered the PVR in patients with voiding dysfunction and divided them into groups with PVR < 150 ml and PVR ≥ 150 ml. Patients were then analyzed for bladder outlet obstruction and detrusor underactivity.

RESULTS

Of the 205 patients undergoing invasive urodynamics in 2013, a total of 20 had voiding dysfunction, 2 with PVR ≥ 150 ml. Eighteen patients had PVR < 150 ml (range 0-50 ml); 9 had bladder outlet obstruction while 7 had detrusor underactivity. Two patients were uncategorized. Out of the 20 patients, 7 had no symptoms or complaints indicating voiding dysfunction.

CONCLUSIONS

Patients with voiding dysfunction often have normal PVR and so PVR < 150 ml cannot exclude voiding dysfunction. All patients should be evaluated using free flow measurements along with PVR to obtain a reliable, objective measurement of their voiding pattern, before anti-incontinence surgery.

Urodynamic test and female urinary stress incontinence: An open debate

In this editorial we discussed the pros and cons of urodynamics in the assessment of female stress urinary incontinence.