Preoperative pressure-flow studies: useful variables to predict the outcome of continence surgery

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.

The role of urodynamics in the management of female stress urinary incontinence

AIM

The role of urodynamic study (UDS) in the management of female stress urinary incontinence (SUI) is one of the most controversial and debated topic in urogynecology. Here, we aimed to systematically assess the most relevant available evidence on urodynamics' value in the management of women with stress urinary incontinence.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in May 2018. Only randomized clinical trials, prospective studies, or retrospective studies articles evaluating the use of urodynamic studies in women with stress urinary incontinence were included.

RESULTS

After screening a total of 3055 records, 39 studies published from 1996 to 2018 were included.

CONCLUSIONS

In an uncomplicated population of women with SUI, it is not demonstrated that preoperative urodynamic evaluation can improve the outcome of continence surgery; however, UDS provides additional information regarding lower urinary tract function that could guide the physician to make the right therapeutic choice. UDS should be considered mandatory before surgery in complicated patients, but its use should also be evaluated in index patients when the results may help counseling and management of these women.

[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.

Are voiding parameters a marker for the severity of quality of life impairment in women with overactive bladder symptoms?

AIMS

There is evidence of an association between voiding parameters and the presence of overactive bladder symptoms. The aim of this study was to evaluate whether there is any association between pressure flow study parameters and the degree of health related quality of life impairment in women with OAB symptoms. The null hypothesis is that there is no significant correlation between quality of life domain scores and pressure flow study parameters.

METHODS

One hundred and sixty-seven consecutive women with overactive bladder symptoms underwent evaluation with a quality of life assessment plus filling and voiding cystometry. These data were used to evaluate for any correlation between pressure flow study parameters and quality of life domain scores.

RESULTS

Fifty-six out of 167 women had proven detrusor overactivity (DO). There were no differences in voiding parameters or quality of life scores between women with DO and women without DO. There was no consistent correlation identified between quality of life domain scores and pressure flow variables.

CONCLUSIONS

There is no evidence of an association between increasing quality of life impairment and voiding parameters in this cohort.

The association of changes in opening detrusor pressure with the resolution of overactive bladder symptoms after repair of pelvic organ prolapse

AIMS

To evaluate whether changes in opening detrusor pressure (ODP) are associated with resolution of overactive bladder symptoms in women undergoing surgical correction of pelvic organ prolapse.

METHODS

Forty women with DO and OAB together with anterior wall prolapse who underwent a repair between 2003 and 2007 were studied. Each woman was assessed pre- and post-operatively with a clinical assessment and cystometry. Opening pressures were recorded pre- and post-operatively for each patient by retrospective review of the pressure flow traces. Patients were divided into those who experienced resolution of OAB symptoms and those with persistent OAB symptoms. Wilcoxon matched pairs signed rank test was used to assess any change in opening pressures between these groups.

RESULTS

Resolution of urgency with an anterior repair was associated with a significant fall in ODP from a mean of 27.9 to 11.7 cmH(2)O (P = 0.01). There was no significant pre-operative difference in ODP between women in whom urgency resolved and those in whom it did not.

CONCLUSION

These results suggest that a fall in ODP is associated with resolution of urgency in women undergoing prolapse surgery. This may imply that decreased urethral resistance is of importance in symptom resolution.

Preoperative voiding detrusor pressures do not predict stress incontinence surgery outcomes

Introduction and hypothesis

The aim of this study was to determine whether preoperative voiding detrusor pressures were associated with postoperative outcomes after stress incontinence surgery.

Methods

Opening detrusor pressure, detrusor pressure at maximum flow (p_det Q_max), and closing detrusor pressure were assessed from 280 valid preoperative urodynamic studies in subjects without advanced prolapse from a multicenter randomized trial comparing Burch and autologous fascia sling procedures. These pressures were compared between subjects with and without overall success, stress-specific success, postoperative detrusor overactivity, and postoperative urge incontinence using independent sample t tests.

Results

There were no clinically or statistically significant differences in mean preoperative voiding detrusor pressures in any comparison of postoperative outcomes.

Conclusions

We found no evidence that preoperative voiding detrusor pressures predict outcomes in women with stress predominant urinary incontinence undergoing Burch or autologous fascial sling procedures.

Preoperative urethral parameters at rest and objective cure following laparoscopic colposuspension

INTRODUCTION AND HYPOTHESIS

The aim of this study is to investigate associations between preoperative resting urethral parameters and objective outcome of laparoscopic colposuspension.

METHODS

Data from 219 stress incontinent women who underwent laparoscopic colposuspension, with leakage at standardized pad test repeated after surgery, were collected. Associations between objective cure and preoperative maximum urethral closure pressure, functional urethral length, and continence area were analyzed using receiving operator characteristics curves. The level for 75% cure for each parameter was identified.

RESULTS

All parameters were positively associated with cure. Continence area showed the strongest association. No cut-off values for prediction of failure were found. Women having levels equal or higher than the "75% cure level" for all urethral parameters had a cure rate of 88% compared with 55% for women with all parameters lower than this level.

CONCLUSIONS

A combination of the urethral parameters may be useful for identifying patients with excellent chance for cure after colposuspension. Further studies are needed on continence area.

Do women with pure stress urinary incontinence need urodynamics?

OBJECTIVES

To evaluate the value of performing urodynamic investigations in the assessment of women with a history of pure stress urinary incontinence (SUI).

METHODS

Consecutive women with lower urinary tract symptoms were studied retrospectively. Urinary symptoms were determined from the frequency-volume chart and symptom section of the King's Health Questionnaire. Only women with pure SUI symptoms were included.

RESULTS

A total of 3428 women aged 24-81 years were studied. Only 308 women (8.9%) could be classified as having pure SUI from the questionnaire. Of these, 241 of women (78.2%) had urodynamic stress incontinence, 23 women (7.5%) had detrusor overactivity, 9 women (2.9%) had mixed urodynamic diagnosis, and 35 women (11.4%) had inconclusive urodynamics. Postvoid residual volumes greater than 100 mL were noted in 24 (7.8%) women.

CONCLUSIONS

Our results show that urodynamic investigations provide useful information in the assessment of women with a history of pure SUI, because as many as 20% of them might not need surgery as the first line of treatment.

Pre-operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence

AIMS

To determine if specific pre-operative urodynamic parameters could predict detrusor overactivity following TVT in patients with urodynamic mixed incontinence.

METHODS

Notes of women with detrusor overactivity (DO) and urodynamic stress incontinence (USI) before undergoing tension-free vaginal tape (TVT) surgery were retrospectively reviewed. Patients underwent clinical evaluation pre-operatively including history, examination, and conventional urodynamic studies and were treated with pelvic floor exercises and anti-cholinergic medication. Those with persistent stress urinary incontinence (SUI) underwent TVT. Patients were re-assessed after at least 6 months post-operatively. Pre- and post-operative opening and closing detrusor pressure, and detrusor pressure at maximum flow were recorded retrospectively from pre-operative urodynamics traces by two clinicians independently and compared to the patients' post-operative symptoms and urodynamic diagnosis.

RESULTS

Fifty-one women were reviewed. Forty-six of the 51 attended follow-up and 35/51 agreed to conventional urodynamic studies. Seventeen of the 35 reported OAB symptoms, and 18/35 were asymptomatic. Nineteen of the 35 women had DO and 16/35 had normal urodynamic studies (NUDS). The median pre-operative opening detrusor pressure was higher in women with overactive bladder symptoms post-operatively. The median pre-operative opening detrusor pressure in women with DO post-operatively was 33.0 cmH(2)O and the median pre-operative opening detrusor pressure in those with NUDS post-operatively was 16 cmH(2)O (15.0-23.0 cmH(2)O) (P < 0.05 Mann-Whitney U-test).

CONCLUSIONS

Higher numbers of patients are required to demonstrate the value of opening detrusor pressure in predicting post-operative overactive bladder symptoms. Opening detrusor pressure is predictive of post-operative DO after TVT.

The predictive value of preoperative pressure-flow studies in the resolution of detrusor overactivity and overactive bladder after tension-free vaginal tape insertion

OBJECTIVE

To determine whether preoperative pressure-flow studies (PFS) predict the resolution of detrusor overactivity (DO) and overactive bladder (OAB) symptoms after a tension-free vaginal tape procedure (TVT).

PATIENTS AND METHODS

Thirty-five consecutive women with mixed DO and urodynamic stress incontinence (USI) undergoing a TVT had PFS before and afterward reviewed, and the results compared.

RESULTS

There was resolution of OAB symptoms in 51%; the persistence of OAB symptoms was predicted by a significant decrease (20.0 to 14.0 mL/s) in the maximum flow rate after the TVT (P = 0.027) and a significant increase in the detrusor pressure at maximum flow after the TVT (P = 0.04). DO was absent on cystometry in 46% of women after the TVT. Women with persistent DO on cystometry had a significantly lower (P = 0.02) maximum flow rate before the TVT (mean 19.3 mL/s) than those with no persistent DO (mean 26.9 mL/s). This finding persisted when flow rates were corrected for voided volume (P = 0.04). Before and after TVT there were no significant differences between the groups in voiding time and acceleration of flow. USI was objectively cured in 92% of the women.

CONCLUSIONS

Women whose maximum flow rate decreases significantly after the TVT are more likely to have persistent OAB symptoms. The urinary flow rate before the TVT was significantly higher in women with an objective cure of DO after TVT than in women with persistent DO. These findings support an obstructive cause in women in whom DO does not resolve.