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Re: Pre-Operative Urodynamics in Women with Stress Urinary Incontinence Increases Physician Confidence, but Does Not Improve Outcomes
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VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
It would seem that it is also true that to be labeled a biomarker, a quantifiable product must perform in one of the 3 scenarios and do it reproducibly. These authors, anchored by 2 stalwarts in the field, review several molecules in the urine and/or blood and other physiological parameters, touted by some as biomarkers for overactive bladder. My interpretation of their conclusion is that none of the biomarkers satisfies the criteria. With respect to overactive bladder, a biomarker should be able to guide a particular form of treatment and improve outcome. The value of the current group of proposed “biomarkers” is that they may suggest and help us to better understand some of the pathophysiological mechanisms underlying the signs and symptoms associated with this symptom syndrome. Alan J. Wein, MD, PhD (hon)
Re: Pre-Operative Urodynamics in Women with Stress Urinary Incontinence Increases Physician Confidence, but Does Not Improve Outcomes P. Zimmern, H. Litman, C. Nager, L. Sirls, S. R. Kraus, K. Kenton, T. Wilson, G. Sutkin, N. Siddiqui, S. Vasavada and P. Norton; Urinary Incontinence Treatment Network UT Southwestern Medical Center, Dallas, Texas Neurourol Urodyn 2014; 33: 302e306.
Abstract available at http://jurology.com/ Editorial Comment: This is an interesting secondary analysis of certain data in the ValUE (Value of Urodynamic Evaluation) trial,1 the conclusion of which is that in a group of women with demonstrable stress urinary incontinence (SUI) on office evaluation, predominant symptoms of SUI, no history of surgery for incontinence and a normal post-void residual the office evaluation alone was not inferior to evaluation with urodynamic studies and did not compromise surgery success. However, urodynamics did shift physician diagnosis from not confident to confident for the entities of intrinsic sphincter deficiency and overactive bladder wet. Lesser but statistically significant scores for indicating increased confidence were also associated with the diagnosis of stress urinary incontinence, overactive bladder dry and voiding phase dysfunction, although less strongly. Confidence scores of the clinical diagnosis were rated on a scale of 1 (not very confident) to 5 (extremely confident). What the small numerical changes in “confident” mean in terms of clinical significance is unknown. The implication of this seems to be that the concept of “degree of certainty,” which I first heard from Dr. Jerry Blaivas, is an important factor in determining whether an individual performs urodynamics preoperatively in patients with clear SUI and in more complicated patients with incontinence. Some individuals require more certainty than others, and there does not seem to be a valid ethical reason or, at this point, a financial reason not to proceed with urodynamics under these circumstances. Those surgeons who are supremely confident and who have never had a bad result, or think they have not, will need less confirmation, but the decision will be an individual one and will vary with the past and present history of the patient and her individual characteristics, the confusability of the signs and symptoms, and the local medicolegal climate regarding failure and postprocedural complications. In the future if and when 1 fee is paid yearly to care for a specific problem, it will be easy to tell those individuals who really feel that urodynamics are worthwhile and in which scenarios. Alan J. Wein, MD, PhD (hon) 1. Nager CW, Brubaker L, Litman HJ et al: A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366: 1987.
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
It would seem that it is also true that to be labeled a biomarker, a quantifiable product must perform in one of the 3 scenarios and do it reproducibly. These authors, anchored by 2 stalwarts in the field, review several molecules in the urine and/or blood and other physiological parameters, touted by some as biomarkers for overactive bladder. My interpretation of their conclusion is that none of the biomarkers satisfies the criteria. With respect to overactive bladder, a biomarker should be able to guide a particular form of treatment and improve outcome. The value of the current group of proposed “biomarkers” is that they may suggest and help us to better understand some of the pathophysiological mechanisms underlying the signs and symptoms associated with this symptom syndrome. Alan J. Wein, MD, PhD (hon)
Re: Pre-Operative Urodynamics in Women with Stress Urinary Incontinence Increases Physician Confidence, but Does Not Improve Outcomes P. Zimmern, H. Litman, C. Nager, L. Sirls, S. R. Kraus, K. Kenton, T. Wilson, G. Sutkin, N. Siddiqui, S. Vasavada and P. Norton; Urinary Incontinence Treatment Network UT Southwestern Medical Center, Dallas, Texas Neurourol Urodyn 2014; 33: 302e306.
Abstract available at http://jurology.com/ Editorial Comment: This is an interesting secondary analysis of certain data in the ValUE (Value of Urodynamic Evaluation) trial,1 the conclusion of which is that in a group of women with demonstrable stress urinary incontinence (SUI) on office evaluation, predominant symptoms of SUI, no history of surgery for incontinence and a normal post-void residual the office evaluation alone was not inferior to evaluation with urodynamic studies and did not compromise surgery success. However, urodynamics did shift physician diagnosis from not confident to confident for the entities of intrinsic sphincter deficiency and overactive bladder wet. Lesser but statistically significant scores for indicating increased confidence were also associated with the diagnosis of stress urinary incontinence, overactive bladder dry and voiding phase dysfunction, although less strongly. Confidence scores of the clinical diagnosis were rated on a scale of 1 (not very confident) to 5 (extremely confident). What the small numerical changes in “confident” mean in terms of clinical significance is unknown. The implication of this seems to be that the concept of “degree of certainty,” which I first heard from Dr. Jerry Blaivas, is an important factor in determining whether an individual performs urodynamics preoperatively in patients with clear SUI and in more complicated patients with incontinence. Some individuals require more certainty than others, and there does not seem to be a valid ethical reason or, at this point, a financial reason not to proceed with urodynamics under these circumstances. Those surgeons who are supremely confident and who have never had a bad result, or think they have not, will need less confirmation, but the decision will be an individual one and will vary with the past and present history of the patient and her individual characteristics, the confusability of the signs and symptoms, and the local medicolegal climate regarding failure and postprocedural complications. In the future if and when 1 fee is paid yearly to care for a specific problem, it will be easy to tell those individuals who really feel that urodynamics are worthwhile and in which scenarios. Alan J. Wein, MD, PhD (hon) 1. Nager CW, Brubaker L, Litman HJ et al: A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366: 1987.