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Re: Invasive Urodynamic Studies for the Management of Lower Urinary Tract Symptoms (LUTS) in Men with Voiding Dysfunction
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
there is expert consensus on the additional value of video to urodynamics, and especially in patients with spinal dysraphism the importance of video urodynamics is acknowledged.” The elephant in the room, of course, is the additional cost and whether it can be justified. Alan J. Wein, MD, PhD (hon)
Re: Invasive Urodynamic Studies for the Management of Lower Urinary Tract Symptoms (LUTS) in Men with Voiding Dysfunction K. D. Clement, H. Burden, K. Warren, M. C. Lapitan, M. I. Omar and M. J. Drake Cochrane Incontinence Group, University of Aberdeen, Aberdeen, United Kingdom Cochrane Database Syst Rev 2015; 4: CD011179. doi: 10.1002/14651858.CD011179.pub2
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25918922 Editorial Comment: This Cochrane Review assessed the question of whether performing invasive urodynamic investigation, as opposed to other methods of diagnosis (noninvasive urodynamics, clinical history, examination) reduces the number of men with continuing symptoms of voiding dysfunction. The review was not intended to consider whether urodynamic tests are reliable for making clinical diagnoses nor whether a particular type of test is better than another for this purpose. The full text of 9 studies was reviewed but 7 were excluded because they did not randomly assign participants to at least 1 type of urodynamic investigation or 1 method of performing a urodynamic investigation. One ongoing trial that considered this question was also identified. Evidence from a single trial suggested that invasive urodynamic studies changed the management of lower urinary tract symptoms (LUTS) in men. Men receiving clinical assessment alone were more likely to undergo surgery. Men receiving clinical assessment alone were statistically significantly more likely to be obstructed at 6 months postoperatively than were those assessed using invasive urodynamic studies. No differences were observed between groups or percentage increase of urinary flow rates before and after intervention, nor in the decreases in International Prostate Symptom Scores. The “study” actually included only 1 of 2 eligible trials, the other being excluded because it did not provide usable data. The overall conclusion was that men with LUTS and voiding dysfunction who are assessed by invasive urodynamics are more likely to have their management changed and less likely to undergo surgery. The authors hypothesize that this may have been due to the fact that urodynamics identified no objectively measurable bladder outlet obstruction, but there was insufficient information to demonstrate this. Finally, there was no evidence available to show that differences in management resulted in measurable differences in health outcome compared to the management of those who did not undergo invasive urodynamic studies. The authors conclude that evidence regarding the value and risks of invasive urodynamics remains insufficient. There was no evidence found regarding the implications of storage, urinary symptoms and filling cystometry findings for decision making. The authors describe an adequate trial looking at this question as including men randomly assigned to treatment based on invasive urodynamic investigations rather than treatment based on clinical history and examination and other noninvasive clinical evaluations such as flow rate testing. Such a trial should include all men for whom urodynamics might be indicated to ensure that those considering surgery but who have decided not to proceed as the result of urodynamic findings are not missed and that those for whom surgery is not an option are also evaluated. The authors cite previous reviews identifying the lack of high quality primary research confirming the clinical utility of carrying out urodynamic investigations and close with the comment that “the value of urodynamic studies for the management of LUTS in men with voiding dysfunction requires further evaluation by randomized controlled trials, with reporting of relevant subjective, objective and economic outcomes.” They cite an apparently large ongoing trial, which began recruitment in 2014, led by Drake, which they hope, “may produce robust, reliable evidence in the future.” Alan J. Wein, MD, PhD (hon)
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there is expert consensus on the additional value of video to urodynamics, and especially in patients with spinal dysraphism the importance of video urodynamics is acknowledged.” The elephant in the room, of course, is the additional cost and whether it can be justified. Alan J. Wein, MD, PhD (hon)
Re: Invasive Urodynamic Studies for the Management of Lower Urinary Tract Symptoms (LUTS) in Men with Voiding Dysfunction K. D. Clement, H. Burden, K. Warren, M. C. Lapitan, M. I. Omar and M. J. Drake Cochrane Incontinence Group, University of Aberdeen, Aberdeen, United Kingdom Cochrane Database Syst Rev 2015; 4: CD011179. doi: 10.1002/14651858.CD011179.pub2
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25918922 Editorial Comment: This Cochrane Review assessed the question of whether performing invasive urodynamic investigation, as opposed to other methods of diagnosis (noninvasive urodynamics, clinical history, examination) reduces the number of men with continuing symptoms of voiding dysfunction. The review was not intended to consider whether urodynamic tests are reliable for making clinical diagnoses nor whether a particular type of test is better than another for this purpose. The full text of 9 studies was reviewed but 7 were excluded because they did not randomly assign participants to at least 1 type of urodynamic investigation or 1 method of performing a urodynamic investigation. One ongoing trial that considered this question was also identified. Evidence from a single trial suggested that invasive urodynamic studies changed the management of lower urinary tract symptoms (LUTS) in men. Men receiving clinical assessment alone were more likely to undergo surgery. Men receiving clinical assessment alone were statistically significantly more likely to be obstructed at 6 months postoperatively than were those assessed using invasive urodynamic studies. No differences were observed between groups or percentage increase of urinary flow rates before and after intervention, nor in the decreases in International Prostate Symptom Scores. The “study” actually included only 1 of 2 eligible trials, the other being excluded because it did not provide usable data. The overall conclusion was that men with LUTS and voiding dysfunction who are assessed by invasive urodynamics are more likely to have their management changed and less likely to undergo surgery. The authors hypothesize that this may have been due to the fact that urodynamics identified no objectively measurable bladder outlet obstruction, but there was insufficient information to demonstrate this. Finally, there was no evidence available to show that differences in management resulted in measurable differences in health outcome compared to the management of those who did not undergo invasive urodynamic studies. The authors conclude that evidence regarding the value and risks of invasive urodynamics remains insufficient. There was no evidence found regarding the implications of storage, urinary symptoms and filling cystometry findings for decision making. The authors describe an adequate trial looking at this question as including men randomly assigned to treatment based on invasive urodynamic investigations rather than treatment based on clinical history and examination and other noninvasive clinical evaluations such as flow rate testing. Such a trial should include all men for whom urodynamics might be indicated to ensure that those considering surgery but who have decided not to proceed as the result of urodynamic findings are not missed and that those for whom surgery is not an option are also evaluated. The authors cite previous reviews identifying the lack of high quality primary research confirming the clinical utility of carrying out urodynamic investigations and close with the comment that “the value of urodynamic studies for the management of LUTS in men with voiding dysfunction requires further evaluation by randomized controlled trials, with reporting of relevant subjective, objective and economic outcomes.” They cite an apparently large ongoing trial, which began recruitment in 2014, led by Drake, which they hope, “may produce robust, reliable evidence in the future.” Alan J. Wein, MD, PhD (hon)
845