Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations

Trial Design for Mixed Urinary Incontinence: Midurethral Sling Versus Botulinum Toxin A

IMPORTANCE

Mixed urinary incontinence (MUI) is common and can be challenging to manage.

OBJECTIVES

We present the protocol design and rationale of a trial comparing the efficacy of 2 procedures for the treatment of women with MUI refractory to oral treatment. The Midurethral sling versus Botulinum toxin A ( MUSA) trial compares the efficacy of intradetrusor injection of 100 U of onabotulinimtoxinA (an office-based procedure directed at the urgency component) versus midurethral sling (MUS) placement (a surgical procedure directed at the stress component).

STUDY DESIGN

The MUSA is a multicenter, randomized trial of women with MUI electing to undergo procedural treatment for MUI at 7 clinical centers in the NICHD Pelvic Floor Disorders Network. Participants are randomized to either onabotulinumtoxinA 100 U or MUS. OnabotulinimtoxinA recipients may receive an additional injection between 3 and 6 months. Participants may receive additional treatment (including crossover to the alternative study intervention) between 6 and 12 months. The primary outcome is change from baseline in Urogenital Distress Inventory (UDI) at 6 months. Secondary outcomes include change in UDI at 3 and 12 months, irritative and stress subscores of the UDI, urinary incontinence episodes, predictors of poor treatment response, quality of life and global impression outcomes, adverse events, use of additional treatments, and cost effectiveness.

RESULTS

Recruitment and randomization of 150 participants is complete and participants are currently in the follow-up phase.

CONCLUSIONS

This trial will provide information to guide care for women with MUI refractory to oral treatment who seek surgical treatment with either onabotulinumtoxinA or MUS.

Factors associated with polyacrylamide hydrogel outcomes in women with stress urinary incontinence

Knowledge of factors associated with superior outcomes in women treated with urethral bulking agents for stress urinary incontinence (SUI) remains limited. The aim of this study was to examine associations between post-treatment outcomes in women who had undergone polyacrylamide hydrogel injections for SUI, and physiological and self-reported variables captured during pre-treatment clinical evaluation. A cross-sectional study was undertaken in female patients treated for SUI with polyacrylamide hydrogel injections by a single urologist between January 2012 and December 2019. Post-treatment outcome data were gathered in July 2020 using the Patient Global Impression of Improvement (PGI-I), Urinary Distress Inventory-short form (UDI-6), Incontinence Impact Questionnaire (IIQ7), and International Consultation on Incontinence Questionnaire Short Form (ICIQ SF). All other data were gathered from women's medical records including pre-treatment patient-reported outcomes. Associations between post-treatment outcomes and pre-treatment physiological and self-reported variables were investigated using regression models. One hundred seven of the 123 eligible patients completed post-treatment patient-reported outcome measures. Mean age was 63.1 years (range 25-93 years), and median time between first injection and follow-up was 51 months (inter-quartile range 23.5-70 months). Fifty-five (51%) women had a successful outcome based on PGI-I scores. Women with type 3 urethral hypermobility pre-treatment were more likely to report treatment success (PGI-I). Poor bladder compliance pre-treatment was associated with greater urinary distress, frequency and severity (UDI-6 and ICIQ) post-treatment. Older age was associated with worse urinary frequency and severity (ICIQ) post-treatment. Associations between patient-reported outcomes and time between first injection and follow-up were trivial and not statistically significant. Severity of pre-treatment incontinence impact (IIQ-7) was associated with worse incontinence impact post-treatment. Type 3 urethral hypermobility was associated with a successful outcome, whereas pre-treatment incontinence impact, poor bladder compliance and older age were associated with poorer self-reported outcomes. Long-term efficacy appears to hold in those who responded to initial treatment.

Variations in maximum urethral closure pressure in stress urinary incontinence

Introduction:

Urethral Pressure Profilometry (UPP) assesses the urethral closing function. The literature is scarce regarding the change in the Maximum Urethral Closure Pressure (MUCP) values during Pelvic Floor Muscle Contraction (PFMC). The objective was to evaluate the change in the urethral closure pressure (UCP) at rest and during a PFMC in patients with Stress Urinary Incontinence.

Materials and methods:

This was a descriptive, comparative, and observational study. The study comprised female patients with either Pure Stress Urinary Incontinence (PSUI) or Complicated Stress Urinary Incontinence (CSUI). The urethral closure pressure was measured at rest and during PFMC using urethral profilometry. The effect of the pelvic musculature contraction was evaluated by comparing the changes in the indicated values.

Results:

Patients with pure stress urinary incontinence had a mean age of 57.18 ± 10.74 years ( p = 0.12), while those with complicated stress urinary incontinence had a mean age of 58.26 ± 14.39 years ( p = 0.12). UCP in PSUI was 58.58 ± 26.96 cmH2O at rest compared to 61.26 ± 34.17 cmH2O in CSUI ( p = 0.59), with MUCP increasing to 73.93 ± 31.51 and 79.71 ± 36.26 cmH2O during PFMC ( p = 0.001). Between the two measurements, there was an average rise of 26.2% (range 26.2%−32.59%) ( p = 0.001). MUCP during PFM contractions was found to be inversely associated to age ( r = −0.28, p = 0.007).

Conclusion:

The urethral pressure profile is the same for all types of urinary stress incontinence, whether simple or complicated. When comparing UCP at rest to MUCP during PFMC, there is at least a functional 25% increase.

Preoperative abdominal straining in uncomplicated stress urinary incontinence: is there a correlation with voiding dysfunction and de novo overactive bladder after mid-urethral sling procedures?

Objectives:

To evaluate the role of preoperative abdominal straining in predicting de novo overactive bladder (OAB) and voiding dysfunction in female patients undergoing suburethral taping by trans-obturator approach (TVT-O) for uncomplicated stress urinary incontinence (SUI).

Methods:

Data from patients who underwent TVT-O surgery for SUI were retrospectively analyzed. Inclusion criteria included: history of pure SUI. Exclusion criteria included previous surgery for urinary incontinence, pelvic radiation, pelvic surgery within the last 3 months, and anterior or apical pelvic organ prolapse (POP) ⩾ +1 cm. Voiding dysfunction has been defined through symptoms and or urodynamics (UDS) signs. Accordingly, patients were divided into group A and group B according to the presence of abdominal straining during UDS. Patients were observed clinically and with UDS at a 3-year follow-up.

Results:

A total of 192 patients underwent TVT-O surgery for uncomplicated SUI. Preoperative abdominal straining was identified in 60/192 patients (Group A: 31.2% vs Group B: 68.8%). Qmax was not different in the two groups (Group A: 19.5 vs Group B: 20.5 mL/s, p = 0.76). Demographics was similar for the two groups regarding age, parity. At 3-year follow-up, voiding dysfunction was reported in Group A: 9 and Group B: 8 patients (p = 0.056), de novo OAB was significantly reported in Group A: 23 and Group B: 26 patients (p = 0.007).

Conclusion:

Preoperative abdominal straining was found to be related to a significant incidence of de novo OAB. A significant correlation was not assessed for postoperative voiding dysfunction. Further studies may better define the impact of preoperative abdominal straining.

Prospective Evaluation of Urodynamic Utility in a Subspecialty Tertiary Practice

OBJECTIVE

To prospectively evaluated the utility of urodynamic evaluations (UDS) ordered in a tertiary referral center as part of a quality improvement project.

METHODS

Patients with UDS ordered by 3 subspecialty physicians were included. Physicians were surveyed when ordering UDS and at the post-UDS clinic visit to assess indications for UDS, pre- and post-UDS diagnosis, treatment plan, confidence level, and perceived helpfulness of UDS. UDS trained nurses conducting studies were surveyed on patient reported reproducibility of their symptoms and perceived difficulty of UDS.

RESULTS

From April 2017 to October 2017, 127 UDS were included of which 102 met study criteria. UDS were done for neurogenic (23%) and non-neurogenic lower urinary tract symptoms (76%). The majority were conducted for incontinence evaluation (79%), or after prior lower urinary tract surgery (33%). UDS nurses reported 90% of UDS fully or partially reproduced patient symptoms. Nurses found 18% of UDS difficult due to catheter malfunctions, physical limitations, and communication abilities. Post-UDS, providers found 97% of UDS interpretable. UDS resulted in a change in treatment plan in 78% of patients. On a Likert scale, mean pre-UDS confidence level was 2.9 ± 0.8 (range 0-5). This increased to 4.1 ± 0.6 post-UDS with 76% of evaluations having a change of at least 1 point.

CONCLUSION

UDS in a tertiary referral center result in change in patient treatment plans over three-fourths of the time with high rates of interpretability.

Evaluation of the urinary microbiota of women with uncomplicated stress urinary incontinence

BACKGROUND

Female urinary microbiota are associated with urgency urinary incontinence and response to medication. The urinary microbiota of women with stress urinary incontinence has not been described.

OBJECTIVE

We sought to study the cross-sectional relationships between urinary microbiota features and demographic and clinical characteristics of women undergoing stress urinary incontinence surgery.

STUDY DESIGN

Preoperative urine specimens were collected from women without urinary tract infection and were available from 197 women (174 voided, 23 catheterized) enrolled in a multicenter prospective randomized trial, the Value of Urodynamic Evaluation study. Demographic and clinical variables were obtained including stress and urgency urinary incontinence symptoms, menopausal status, and hormone use. The bacterial composition of the urine was qualitatively assessed by sequencing the bacterial 16S ribosomal RNA gene. Phylogenetic relatedness and microbial alpha diversity were compared to demographics and symptoms using generalized estimating equation models.

RESULTS

The majority of 197 urine samples (86%) had detectable bacterial DNA. Bacterial diversity was significantly associated with higher body mass index (P = .02); increased Medical, Epidemiologic, and Social Aspects of Aging urge index score (P = .04); and hormonal status (P < .001). No associations were detected with stress urinary incontinence symptoms. Increased diversity was also associated with a concomitant lower frequency of Lactobacillus in hormone-negative women.

CONCLUSION

Women undergoing stress urinary incontinence surgery have detectable urinary microbiota. This cross-sectional analysis revealed that increased diversity of the microbiota was associated with urgency urinary incontinence symptoms, hormonal status, and body mass index. In contrast, the female urinary microbiota were not associated with stress urinary incontinence symptoms.

Predicting urinary incontinence after surgery for pelvic organ prolapse

PURPOSE OF REVIEW

Many women choosing to have surgery for pelvic organ prolapse also choose to undergo continence surgery. This review focuses on available evidence that clinicians may use to counsel patients when choosing whether to perform continence surgery and how predictive analytic tools improve this decision-making process.

RECENT FINDINGS

Midurethral sling, Burch cystourethropexy and bladder neck sling are highly effective for the surgical treatment of stress urinary incontinence. Trials demonstrate that continence surgery may be routinely performed to reduce the risk of postoperative incontinence in women undergoing surgery for pelvic organ prolapse with or without preoperative stress urinary incontinence. Although these procedures are effective and well tolerated on average, media concerns, regulatory warnings and litigation reinforce the need for a balanced discussion regarding efficacy and potential adverse events directed at the individual patient during the preoperative visit. Advances in predictive analytics allow surgeons to quantitate individual risk using algorithms that tailor estimates for the individual patient and facilitate shared understanding of risks and benefits. These models are less prone to cognitive biases and frequently outperform experienced clinicians.

SUMMARY

This review discusses how predictive analytic tools can be used to improve decisions about continence surgery in the woman planning to undergo prolapse surgery.

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.

Methods for a multicenter randomized trial for mixed urinary incontinence: rationale and patient-centeredness of the ESTEEM trial

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) can be a challenging condition to manage. We describe the protocol design and rationale for the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) trial, designed to compare a combined conservative and surgical treatment approach versus surgery alone for improving patient-centered MUI outcomes at 12 months.

METHODS

ESTEEM is a multisite, prospective, randomized trial of female participants with MUI randomized to a standardized perioperative behavioral/pelvic floor exercise intervention plus midurethral sling versus midurethral sling alone. We describe our methods and four challenges encountered during the design phase: defining the study population, selecting relevant patient-centered outcomes, determining sample size estimates using a patient-reported outcome measure, and designing an analysis plan that accommodates MUI failure rates. A central theme in the design was patient centeredness, which guided many key decisions. Our primary outcome is patient-reported MUI symptoms measured using the Urogenital Distress Inventory (UDI) score at 12 months. Secondary outcomes include quality of life, sexual function, cost-effectiveness, time to failure, and need for additional treatment.

RESULTS

The final study design was implemented in November 2013 across eight clinical sites in the Pelvic Floor Disorders Network. As of 27 February 2016, 433 total/472 targeted participants had been randomized.

CONCLUSIONS

We describe the ESTEEM protocol and our methods for reaching consensus for methodological challenges in designing a trial for MUI by maintaining the patient perspective at the core of key decisions. This trial will provide information that can directly impact patient care and clinical decision making.

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

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.

Trends in urodynamics study utilization in a Southern California managed care population

OBJECTIVE

We examined trends in overall and preoperative urodynamics utilization among women with stress urinary incontinence (SUI) to determine if practice patterns changed following publication of a 2012 randomized trial questioning the value of preoperative urodynamics in patients with uncomplicated SUI.

STUDY DESIGN

We collected electronic medical record data on the number of female patient visits to Kaiser Permanente Southern California urology and urogynecology clinics with stress or mixed incontinence, urodynamic studies (UDS) performed, surgeries performed for stress incontinence, and the demographic and clinical characteristics of these patients during 2 discrete time periods before and after a potentially practice-changing publication. We used χ(2) tests and t tests as appropriate. A multivariate logistic regression model was used to estimate the odds of urodynamics performed during January 2013 through June 2014 (study period 2) compared to urodynamics performed during July 2010 through December 2011 (study period 1) after adjustment for demographic and clinical characteristics.

RESULTS

In all, 33,775 women were diagnosed as having SUI or mixed urinary incontinence during study period 1 and 37,238 women were diagnosed with these conditions during study period 2. Among these women 12.8% underwent UDS in study period 1 compared to 8.4% in study period 2 (P < .01). The rate of UDS per patient visit decreased 27.0% between the 2 time periods (P < .01). In women undergoing surgery for stress incontinence, urodynamics were performed 56.5% of the time in study period 1 and 46.5% of the time in study period 2. After controlling for demographic, pelvic organ prolapse, and other bladder diagnoses, the odds of urodynamics performed in study period 2 was 0.54 times the odds of urodynamics performed in study period 1 (95% confidence interval, 0.52-0.57). Among women with only the diagnosis of stress incontinence, 1.78% underwent urodynamics in study period 1 compared with 0.84% in study period 2 (P < .01). Preoperative urodynamics decreased from 39% in study period 1 to 20% in study period 2 (P < .01).

CONCLUSION

Significantly fewer UDS are being performed overall and prior to stress incontinence surgery in this population. This change may be due to recent studies suggesting low utility of urodynamics in patients with uncomplicated, stress-dominant incontinence.

Diagnosis and surgical treatment of stress urinary incontinence

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation's female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort.

Urodynamic studies for management of urinary incontinence in children and adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive, objective diagnosis. The aim is to help select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of people with urinary incontinence and better clinical outcomes.The intention was to test the following hypotheses in predefined subgroups of people with incontinence:(i) urodynamic investigations improve the clinical outcomes;(ii) urodynamic investigations alter clinical decision making;(iii) one type of urodynamic test is better than another in improving the outcomes of management of incontinence or influencing clinical decisions, or both.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process, handsearching of journals and conference proceedings (searched 19 February 2013), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another were included. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Eight trials involving around 1100 people were included but data were only available for 1036 women in seven trials, of whom 526 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was significant evidence that the tests did change clinical decision making. Women in the urodynamic arms of three trials were more likely to have their management changed (proportion with change in management compared with the control arm 17% versus 3%, risk ratio (RR) 5.07, 95% CI 1.87 to 13.74), although there was statistical heterogeneity. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31). On the other hand, in five trials women undergoing treatment following urodynamic investigation were not more likely to undergo surgery (RR 0.99, 95% CI 0.88 to 1.12).There was no statistically significant difference however in the number of women with urinary incontinence if they received treatment guided by urodynamics (37%) compared with those whose treatment was based on history and clinical findings alone (36%) (for example, RR for the number with incontinence after the first year 1.02, 95% CI 0.86 to 1.21). It was calculated that the number of women needed to treat was 100 women (95% CI 86 to 114 women) undergoing urodynamics to prevent one extra individual being incontinent at one year.One trial reported adverse effects and no significant difference was found (RR 1.10, 95% CI 0.81 to 1.50).

AUTHORS' CONCLUSIONS

While urodynamic tests did change clinical decision making, there was some evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment. There was no evidence about their use in men, children, or people with neurological diseases. Larger definitive trials are needed in which people are randomly allocated to management according to urodynamic findings or to management based on history and clinical examination to determine if performance of urodynamics results in higher continence rates after treatment.

Surgical preparation: are patients "ready" for stress urinary incontinence surgery?

INTRODUCTION AND HYPOTHESIS

Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life.

METHODS

The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ).

RESULTS

Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008).

CONCLUSIONS

Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

Pre-operative urodynamics in women with stress urinary incontinence increases physician confidence, but does not improve outcomes

AIMS

To determine if pre-operative urodynamic testing (UDS) affects physicians' diagnostic confidence and if physician confidence affects treatment outcomes at 1 year.

METHODS

The Value of Urodynamic Evaluation (ValUE) trial randomized 630 women with predominant stress urinary incontinence (SUI) to office evaluation (OE) or OE plus UDS prior to surgery. After OE, physicians completed a checklist of five clinical diagnoses: SUI, overactive bladder (OAB) wet and dry, voiding dysfunction (VD), and intrinsic sphincter deficiency (ISD), and reported their confidence in each. Responses ranged from 1 to 5 with; 1 = "not very confident (<50%)" to 5 = "extremely confident (95 + %)." After UDS, investigators again rated their confidence in these five clinical diagnoses. Logistic regression analysis correlated physician confidence in diagnosis with treatment success.

RESULTS

Of 315 women who received OE plus UDS, 294 had complete data. Confidence improved after UDS in patients with baseline SUI (4.52-4.63, P < 0.005), OAB-wet (3.55-3.75, P < 0.001), OAB-dry (3.55-3.68 P < 0.005), VD (3.81-3.95, P < 0.005), and suspected ISD (3.63-3.92, P < 0.001). Increased confidence after UDS was not associated with higher odds of treatment success although mean changes in confidence were slightly higher for those who achieved treatment success. Physician diagnoses shifted more from not confident to confident for ISD and OAB-wet after UDS (McNemar's P-value <0.001 for both).

CONCLUSIONS

In women undergoing UDS for predominant SUI, UDS increased physicians' confidence in their clinical diagnoses; however, this did not correlate with treatment success.

The effect of urodynamic testing on clinical diagnosis, treatment plan and outcomes in women undergoing stress urinary incontinence surgery

PURPOSE

We evaluated the influence of preoperative urodynamic studies on diagnoses, global treatment plans and outcomes in women treated with surgery for uncomplicated stress predominant urinary incontinence.

MATERIALS AND METHODS

We performed a secondary analysis from a multicenter, randomized trial of the value of preoperative urodynamic studies. Physicians provided diagnoses before and after urodynamic studies and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification and nonoperative therapy. Treatment plan changes and surgical outcomes between office evaluation and office evaluation plus urodynamic studies were compared by the McNemar test.

RESULTS

Of 315 subjects randomized to urodynamic studies after office evaluation 294 had evaluable data. Urodynamic studies changed the office evaluation diagnoses in 167 women (56.8%), decreasing the diagnoses of overactive bladder-wet (41.6% to 25.2%, p <0.001), overactive bladder-dry (31.4% to 20.8%, p = 0.002) and intrinsic sphincter deficiency (19.4% to 12.6%, p = 0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p <0.001). After urodynamic studies physicians canceled surgery in 4 of 294 women (1.4%), changed the incontinence procedure in 13 (4.4%) and planned to modify mid urethral sling tension (more or less obstructive) in 20 women (6.8%). Nonoperative treatment plans changed in 40 of 294 women (14%). Urodynamic study driven treatment plan changes were not associated with treatment success (OR 0.96, 95% CI 0.41, 2.25, p = 0.92) but they were associated with increased postoperative treatment for urge urinary incontinence (OR 3.23, 95% CI 1.46, 7.14, p = 0.004).

CONCLUSIONS

Urodynamic studies significantly changed clinical diagnoses but infrequently changed the global treatment plan or influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for postoperative urgency urinary incontinence.

What is an evidence-based appropriate workup?

At the present time, there is no evidence-based guidance available for workup of stress urinary incontinence (SUI). In the absence of such evidence, we must rely on expert consensus, which dictates that a workup should typically include documentation of SUI, assessment of impact on the patient, and information on voiding function. Typical assessment may need to be adjusted for more complicated populations (e.g., those with mixed incontinence, those who have failed previous treatment).

When are urodynamics indicated in patients with stress urinary incontinence?

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.

Making sense of urodynamic studies for women with urinary incontinence and pelvic organ prolapse: a urogynecology perspective

The support for routine urodynamic testing in the management of women with urinary incontinence or pelvic organ prolapse is eroding. The reasons for this change largely reflect the growing evidence that urodynamic testing in this context renders little additional information over basic office assessment. The clinical features of urodynamic testing and its diagnostic and prognostic precision and accuracy are all problematic. As our understanding of female lower urinary tract dysfunction improves, the inadequacy of urodynamic testing to meaningfully improve patient and clinician decision making has become more apparent.

Preoperative clinical, demographic, and urodynamic measures associated with failure to demonstrate urodynamic stress incontinence in women enrolled in two randomized clinical trials of surgery for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The unexpected absence of urodynamic stress incontinence (USI) in women planning surgery for stress urinary incontinence (SUI) is a challenge to surgeons. We examined the prevalence and clinical and demographic factors associated at baseline (preoperatively) with the unexpected absence of USI among study participants of two multicenter randomized clinical trials of surgery for treating SUI.

METHODS

Women with SUI symptoms and positive stress tests on physical examination enrolled in two separate clinical trials-one comparing the autologous fascial sling with the Burch colposuspension [Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr), and the other comparing the retropubic mid-urethral sling with the transobturator midurethral sling [Trial of Mid-Urethral Slings (TOMUS)]-were evaluated for USI preoperatively. The association of clinical, demographic, and urodynamic parameters was examined in women without USI in univariate and multivariate analyses.

RESULTS

Overall, 144 of 1,233 women (11.7 %) enrolled in the two studies showed no USI. These women had a significantly lower mean volume at maximum cystometric capacity than those with USI (347.5 vs. 395.8 in SISTEr, p = 0.012), (315.2 vs. 358.2 in TOMUS, p = 0.003) and a lower mean number of daily accidents reported on a 3-day diary (2.2 vs 2.7 in SISTEr, p = 0.030) (1.7 vs 2.7 in TOMUS, p < 0.001). Additionally, those without demonstrable USI were more likely to have Pelvic Organ Prolapse Quantification (POP-Q) stage III/IV (31.7 % vs 14.4 % in SISTEr, p = 0.002), (15.5 % vs 6.9 % in TOMUS, p = 0.025). SUI severity as recorded on the Urogenital Distress Inventory (UDI) correlated strongly with the presence of USI in both studies.

CONCLUSIONS

We observed that about one of eight women planning surgery for SUI does not show USI. Stage 3/4 POP was strongly associated with the unexpected absence of USI. A diminished urodynamic bladder capacity among women who did not display USI may reflect an inability to reach the limits of capacity during urodynamics, at which these women normally leak.

A randomized trial of urodynamic testing before stress-incontinence surgery

BACKGROUND

Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes.

METHODS

We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of "much better" or "very much better" on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points.

RESULTS

A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, -0.3 percentage points; 95% confidence interval, -7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes.

CONCLUSIONS

For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.).

Urodynamic studies for management of urinary incontinence in children and adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive objective diagnosis. The aim is to help to select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to discover if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of urinary incontinence and better clinical outcomes.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings (searched 24 May 2011), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamics against another. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Seven small trials involving around 400 people were included but data were only available for 385 women in five trials, of whom 197 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was some evidence that the tests did change clinical decision making. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31) but not, in three trials, surgery (RR 1.75, 95% CI 0.39 to 7.75). Women in the urodynamic arms of two trials were more likely to have their management changed but this did not quite reach statistical significance (proportion with no change in management 76% versus 99%, RR 0.79, 95% CI 0.57 to 1.10).However, there was not enough evidence to demonstrate whether or not this resulted in a clinical benefit. For example there was no statistically significant difference in the number of women with urinary incontinence if they received treatment guided by urodynamics (70%) versus those whose treatment was based on history and clinical findings alone (62%) (e.g. RR for number with incontinence after first year 1.23, 95% CI 0.60 to 2.55).No trials reported whether or not there were any adverse effects.

AUTHORS' CONCLUSIONS

While urodynamic tests may change clinical decision making, there was not enough evidence to suggest whether this would result in better clinical outcomes. There was no evidence abut their use in men, children or people with neurological diseases. Larger definitive trials are needed, in which people are randomly allocated to management according to urodynamic findings or to standard management based on history and clinical examination.

INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?): study protocol for a mixed methods study to assess the feasibility of a future randomised controlled trial of the clinical utility of invasive urodynamic testing

BACKGROUND

Urinary incontinence is an important health problem to the individual sufferer and to health services. Stress and stress predominant mixed urinary incontinence are increasingly managed by surgery due to advances in surgical techniques. Despite the lack of evidence for its clinical utility, most clinicians undertake invasive urodynamic testing (IUT) to confirm a functional diagnosis of urodynamic stress incontinence before offering surgery for this condition. IUT is expensive, embarrassing and uncomfortable for women and carries a small risk. Recent systematic reviews have confirmed the lack of high quality evidence of effectiveness.The aim of this pilot study is to test the feasibility of a future definitive randomised control trial that would address whether IUT alters treatment decisions and treatment outcome in these women and would test its clinical and cost effectiveness.

METHODS/DESIGN

This is a mixed methods pragmatic multicentre feasibility pilot study with four components:-(a) A multicentre, external pilot randomised trial comparing basic clinical assessment with non-invasive tests and IUT. The outcome measures are rates of recruitment, randomisation and data completion. Data will be used to estimate sample size necessary for the definitive trial.(b) Qualitative interviews of a purposively sampled sub-set of women eligible for the pilot trial will explore willingness to participate, be randomised and their overall trial experience.(c) A national survey of clinicians to determine their views of IUT in this context, the main outcome being their willingness to randomise patients into the definitive trial.(d) Qualitative interviews of a purposively sampled group of these clinicians will explore whether and how they use IUT to inform their decisions.

DISCUSSION

The pilot trial will provide evidence of feasibility and acceptability and therefore inform the decision whether to proceed to the definitive trial. Results will inform the design and conduct of the definitive trial and ensure its effectiveness in achieving its research aim.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN71327395 assigned 7th June 2010.

Novel biomarkers for overactive bladder

Biomarkers constitute any objectively measurable indicator of a biological process. The classic biomarker used in the diagnosis of overactive bladder (OAB) has been detrusor overactivity, which is assessed urodynamically. In the search for a reliable, noninvasive alternative to urodynamics, interest has focused on genetic, imaging, and urinary factors. Along with other cytokines detectable in urine, prostaglandin E2 and nerve growth factor are indicators of low-grade inflammation. Although they correlate with OAB symptom severity, they have not been shown to have independent prognostic benefit. Imaging biomarkers have been investigated since the earliest days of video urodynamics. Despite extensive research on the ultrasonographic estimation of bladder wall thickness, further standardization of the technique is required before conclusions can be reached regarding diagnostic accuracy. Genetic factors contribute approximately half of the total risk for urgency incontinence. Functional polymorphisms of the cytochrome P450 IID6 gene significantly alter the metabolism of some commonly used anticholinergic drugs, but no genetic loci that influence risk of OAB have been definitively identified. The first genome-wide association studies for OAB are in progress, and should identify new susceptibility genes. Although current putative biomarkers correlate with OAB severity, much future work is required to assess their prognostic value, and establish their role in clinical practice.

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.