The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients' outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patientreported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I 2 statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Metaanalysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I 2 = 0% and P = 0.470, RR:0.87, 95% Cl 0.59-1.28, I 2 = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Metaanalysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88-1.16, I 2 = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95-1.08, I 2 = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB. In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and costeffectiveness of routine urodynamics prior to surgical management of SUI and OAB.

Background Studies from countries such as Australia and South Africa have demonstrated a difference in the types of injury managed in rural hospitals compared to larger, urban hospitals and so conclude staff require a different skill-set to work in these environments. There is some evidence this attitude may be prevalent amongst UK surgical trainees, resulting in difficulty recruiting to rural settings. In addition, studies have compared mortality in paediatric trauma patients in rural and urban hospitals, but none have described types of injury or orthopaedic operations required. We hypothesise the distribution of operative, orthopaedic paediatric trauma in a rural district general and an urban major trauma centre will not differ significantly in terms of patterns and mechanism of injury, orthopaedic intervention or time to theatre. Materials/methods All operative paediatric patients (0–15yrs) seen during an acute orthopaedic take at a rural district general and an urban major trauma centre were included. Non-operative admissions were excluded. Patients were identified using daily trauma work lists from each site. Outcomes were age, injury type, operation, time to theatre, seasonality and mechanism. Results 183 patients from the urban hospital and 103 from the rural were identified. There were no significant differences found in age of patient, seasonality or time to theatre between cohorts (p > 0.05). There were also broadly similar patterns of injury and operations performed in both groups, although k-wiring was more often employed in the rural cohort than the urban (27% vs 17% of total operations). There were more bicycle and shinty related injuries in the rural cohort, and equine related in the urban. Conclusions Paediatric trauma admissions do not vary significantly between rural and urban trauma centres, although the types of procedure performed may be less conservative in a rural hospital. This may be due to geography or differences in ED practice.

The usefulness of urodynamics in the evaluation of women with urinary incontinence is a recurring theme in the literature. Current is considered optional in index patients with typical stress incontinence (1) particularly if the first option is for physical therapy treatment. In the initial approach of patients with overactive bladder, whether wet or dry, is still considered to be expendable. On the other hand, its indication in patients with relapsed stress incontinence and mixed urinary incontinence is consensual (2). It is also found that few studies have included cost-effectiveness analysis among their outcomes. In this context, the authors presented three correlated systematic reviews and meta-analyzes of randomized controlled trials (RCTs) to compare the exclusive clinical versus the urodynamic use in three clinical scenarios: clinical pre-treatment of urinary incontinence, before surgical treatment of stress urinary incontinence and before invasive treatment of overactive bladder. Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded from the analysis. Patient-reported and objective success post-treatment were the primary outcomes assessed and the secondary outcomes were adverse events, quality of life, sexual function and health economic measures (3). Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of. Meta-analysis of 150 women showed no evidence of significant difference in the patient-reported (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I2 = 0%) and objective success rates (P = 0.470, RR: 0.87 , 95% Cl 0.59-1.28, I2 = n / a) between pelvic floor muscle training alone compared to pelvic floor muscle training with pharmacological therapy. Seven RCTs evaluated surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Meta-analysis of 1149 women showed significant difference in patient-reported (P = 0.850, RR: