Utility of invasive urodynamics before surgery for stress urinary incontinence

Abstract

The utility of invasive urodynamic testing in the preoperative evaluation of women with stress urinary incontinence (SUI) has been challenged by two recent randomized controlled trials (RCTs) [1,2] that could not document any gain on outcome of surgery. However, both studies have common methodological issues that make it difficult to draw a general conclusion.Urodynamics (UDS) is defined by the International Continence Society (ICS) as the study of the function and dysfunction of the urinary tract by any appropriate method [3]. Accordingly, UDS is the only way to understand why people are continent or incontinent. Treatment that is not carried out blindfolded but based on knowledge requires (noninvasive and/or invasive) UDS [4].It is well documented that invasive urodynamic testing (in terms of cystometry and pressure-flow study) in women with predominant symptomatic SUI may show either detrusor overactivity (DO) solely or genuine SUI in combination with other urodynamic findings, such as DO and/or voiding difficulties (in terms of obstruction or hypoactive detrusor function). In addition, urethral profilometry or leak-point pressure allows identification of individuals with low urethral pressure [i.e., intrinsic sphincter deficiency (ISD)]. The surgeon who wishes to acquire this knowledge needs to use invasive UDS.Invasive UDS has principally two goals: to confirm clinical and noninvasive UDS impression; to identify parameters that may alter diagnosis or treatment. However, prerequisites for taking advantage of invasive UDS imply:1. Performing the most appropriate UDS, and secure highquality performance and expertise in interpretation. 2. Clear definition of urodynamic entities (i.e., clear cutoff values for urodynamic parameters), which make subcategorizing possible; e.g., obstruction or hyperactive detrusor function.3. Evidence/knowledge-based stratified therapeutic strategy based on urodynamic findings.The authors of the two papers deserve much credit for trying to answer the research question regarding the utility of invasive UDS before surgery for female SUI. However, both studies have common conceptual flaws: Choice of UDS, quality, and expertiseThe choice of UDS was different in the two studies. None of the study centers seem to be UDS-certified by the ICS (or another organization), although there are references to the ICS and the principles of good urodynamic practice [5]. The Dutch study [2] includes one academic and nine nonacademic hospitals. Altogether, 31 patients had invasive UDS (about three per center). It is remarkable that only 52 % of patients (16/31) had urodynamically demonstrable SUI. Furthermore, some values given in Table 2 of that study are obviously outliers (i.e., artefacts): e.g., maximal urethral closing pressure 212 mmHg.In the Value of Urodynamic Evaluation study (ValUE) [1], 11 centers participated. Urodynamic SUI was demonstrated in 97 % of patients.In both studies, UDS quality and the level of urodynamic expertise are unclear. No clear definition of urodynamic entitiesThere was...

Urodynamics Useless in Female Stress Urinary Incontinence? Time for Some Sense—A European Expert Consensus

“…Robustly designed RCTs must always be welcomed, and if their findings challenge accepted clinical practice, they must be taken very seriously. However, no fewer than six major criticisms of the VALUE and VUSIS studies have been highlighted [14,15,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35], including the fact that the narrow participant cohort was unrepresentative of the SUI population. These criticisms are explained in full in Table 1.…”

“…Questions have been raised about the quality of UDS practice undertaken in both the VALUE and VUSIS studies and the possibility of subjective interpretation of findings at contributing study sites. [30] point out that none of the study centres seemed to be UDS certified by the ICS (or another organisation) and that, in both studies, UDS quality and the level of urodynamic expertise are unclear. 2.…”

Utility of invasive urodynamics before surgery for stress urinary incontinence: response to correspondence

“…We thank Sanne van Leijsen et al [1] for their comments on our editorial [2]. They point out that we did not include the Value of Urodynamics before Stress Urinary Incontinence Surgery (VUSIS) II study in our editorial; unfortunately, however, the VUSIS II study also used a design that is unfit for evaluating the value of invasive urodynamics (IUD).…”

Utility of urodynamics before surgery for stress urinary incontinence: response to editorial by Lose and Klarskov

“…Dear Editor, We thank the authors for their interest in our study [1]; however, their criticism of the design cannot be shared by us.…”