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

[Urodynamic studies prior to urinary incontinence surgery : What is useful?]

Surgery is often necessary after failure of conservative therapy for urinary incontinence. Guidelines recommend urodynamic studies before surgery. A distinction is made between non-invasive (uroflowmetry) and invasive methods (cystometry and pressure-flow study, if necessary as combined videourodynamics, as well as urethral pressure profile). All examinations serve to objectify and quantify the symptoms, to correctly assign symptoms to the pathophysiology and anatomy as well as to identify risk factors, which often have a significant influence on the success of surgical therapy. Given appropriate experience, complications and often significant sequelae of bladder dysfunction affecting the patient's quality of life and life expectancy can be recognized. Urodynamic studies are performed to help narrow down potential diagnoses, to develop therapeutic strategies, and to obtain prognostic parameters. The following article is intended to provide some support.

[Indication for urodynamic testing]

BACKGROUND

The aim of urodynamic testing is to obtain objective information regarding urinary bladder storage and voiding function. Basic investigations provide information of the underlying incontinence form. Depending on the individual situation and findings, further urodynamic investigations are helpful or indicated. Prior to conservative therapy, a routine urodynamic investigation is not indicated.

OBJECTIVES

Due to limited evidence of preoperative urodynamic investigations on postoperative results, the urodynamic results may be helpful when considering various treatment options.

RESULTS

Urodynamic investigations should be performed preoperatively, especially in case of overactive bladder symptoms, prior incontinence surgery, or disordered bladder emptying. The assessment of urethral function should be considered in the urodynamic investigation of stress urinary incontinence. In patients with pelvic prolapse, urodynamic investigations should be performed during prolapse reposition.

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

BACKGROUND

Urodynamics is widely used in the investigation of urinary incontinence. The existing evidence questions its add-on value in improving the outcome of surgical treatment for stress urinary incontinence (SUI).

OBJECTIVES

To compare the surgical outcomes in women with SUI or stress-predominant mixed urinary incontinence (MUI) based on urodynamic diagnoses compared with diagnoses based on office evaluation without urodynamics.

SEARCH STRATEGY

We searched Cochrane, MedLine, Embase, CINAHL, LILACS, metaRegister of Controlled Trials (mRCT) and Google Scholar databases from inception until March 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only.

DATA COLLECTION AND ANALYSIS

Two independent reviewers (S.R. and P.L.) extracted the data and analysed it using review manager (revman) 5.2 software.

MAIN RESULTS

Of the 388 articles identified, only four RCTs met our criteria. The data from one study are as yet unpublished. In the other three RCTs, the women with SUI or stress-predominant MUI were randomised either to office evaluation and urodynamics (n = 388) or to office evaluation only (n = 387). There was no statistical difference in the risk ratio (RR) of subjective cure in the two groups (RR 1.02, 95%CI 0.90-1.15, P = 0.79, I(2) = 45%), objective cure (RR 1.01, 95%CI 0.93-1.11, P = 0.28, I(2) = 20%) or complications such as voiding dysfunction (RR 1.54, 95%CI 0.61-3.89, P = 0.27, I(2) = 18%) or urinary urgency (RR 0.80, 95%CI 0.28-2.3, P = 0.19, I(2) = 40%).

AUTHORS' CONCLUSIONS

In women undergoing primary surgery for SUI or stress-predominant MUI without voiding difficulties, urodynamics does not improve outcomes - as long as the women undergo careful office evaluation.

Ketamine-associated urinary tract dysfunction: an underrecognized clinical entity

INTRODUCTION

The use of ketamine as a recreational drug is on the increase among young adults attending clubs and parties. Recreational ketamine users have anecdotally reported increased lower urinary tract symptoms while using the substance.

METHODS

We describe the severe lower urinary tract symptoms experienced in 6 patients with chronic recreational ketamine use. We obtained a detailed history and physical examination along with further investigation to identify a relationship between recreational ketamine use and these symptoms.

RESULTS

The urine cultures were sterile in all cases. Intravenous urography was performed in 3 patients and demonstrated bilateral upper ureteric narrow, mild bilateral hydronephrosis and contracted bladder urodynamic studies showed detrusor instability with urinary leakage when the bladder was filled to a capacity of 30- 50 ml. Cystoscopy revealed a small capacity bladder with erythematous lesions throughout the bladder. Bladder biopsies were performed in 3 patients and showed up as chronic cystitis. Ketamine cessation along with intravesical sodium hyaluronate solution appeared to provide some symptomatic relief.

CONCLUSION

Ketamine-associated urinary tract dysfunction appears to be a relatively new clinical phenomenon. The pathological mechanism of ketamine-associated urinary tract dysfunction is unknown and current management strategies are ketamine cessation along with intravesical sodium hyaluronate solution.

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

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