Utility of invasive urodynamics before surgery for 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.

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.

Do urodynamic findings influence the approach to mid-urethral sling surgery for stress urinary incontinence?

Recent press coverage on vaginal mesh surgery has resulted in a change in how patients are counselled, managed and treated in the UK. For stress urinary incontinence surgical procedures such as insertion of tension-free vaginal tape are commonplace and generally performed as a day-case procedure. Effective and successful management of female urinary incontinence is difficult, even when using diagnostic testing where all conservative managements have failed, and this indicates a need to investigate further. Specialist texts in the fields of urology and urogynaecology argue that urodynamics can help inform the success of surgical intervention for stress urinary incontinence. The aim of this review was to look for evidence of practice where urodynamic findings are used to determine the successful outcome of mid-urethral sling surgery in females. A literature search to identify research on this topic was performed with appraisal of qualifying literature. The qualifying research included attitudes towards urodynamic studies among urogynaecologists and urologists, demonstration that urodynamics has been proven to influence changes in diagnosis and surgical approaches, and the capacity for urodynamics to predict successful outcomes in mid-urethral sling surgery. Analysis of the literature found no evidence to suggest that urodynamic findings can be used to determine successful outcomes following mid-urethral sling surgery.

Comprehensive urodynamics: Being devoted to clinical urologic practice

As a combined electrophysiological system for evaluating the lower urinary tract (LUT), comprehensive urodynamics (UDS) aims at duplicating patient’s micturition process, either normal or abnormal, and further seeking for possible causative origin, either neurogenic or non-neurogenic, in order to guide treatment. Through thorough analysis, some so-called cut-off values, for example, bladder outlet obstruction (BOO) degree or dyssynergic degree between the detrusor and sphincter, could be gained; however, in most cases, their qualitative description, such as stress urinary incontinence, idiopathic detrusor underactivity (DUA), detrusor overactivity (IDO), low compliance, and idiopathic sphincter overactivity (ISO), is more preferable and important. In aged neurologically intact male patients with symptoms of the LUT (LUTS) including benign prostatic hyperplasia, a combined UDS system, which coupled BOO with compliance, was constructed. The patients may be categorized into one of the seven subgroups, including equivocal or mild BOO with sphincter synergia with or without IDO (pattern A), equivocal or mild BOO with ISO (B), classic BOO with sphincter synergia (C) or ISO (D), BOO with only low compliance (E), BOO with both DUA and low compliance (F), and potential BOO with DUA (G). This new system can be used to optimize diagnosis and treatment according to a derived guideline diagram.