Do preoperative urodynamics still have a role in female stress urinary incontinence?

How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence?

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.

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.

The bladder is an unreliable witness: The case for urodynamic investigations in female stress urinary incontinence

For some years, the role of urodynamics (UDS) in female stress urinary incontinence (SUI) has been a topic of intense debate. The findings of the VaLUE and VUSIS-II randomised clinical trials (RCTs) published in 2012 appeared to suggest that UDS is not useful in women with uncomplicated SUI, with the result that several authoritative guidelines were amended and the routine use of UDS in this setting fell sharply. However, many experts have raised concerns about the design of these two RCTs and their subsequent interpretation - including the inappropriate generalisation of the findings beyond uncomplicated cases, which represent only a small minority of the overall patient population. In this paper, we consider a range of issues and confounding factors which raise doubts about how influential these RCTs should have been and reflect on the potential value of UDS both for objective diagnosis and patient counselling in female SUI.

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.