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Re: Trends in Surgical Management and Pre-Operative Urodynamics in Female Medicare Beneficiaries with Mixed Incontinence
SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS
Editorial Comment: These 2 well written articles highlight the salient issues regarding the diagnosis and management of detrusor underactivity, with the 1 article referring specifically to men who have symptoms that could be a manifestation of benign prostatic obstruction, detrusor underactivity or both. The “underactive bladder” is a symptomatic diagnosis but the exact wording of a definition has yet to be agreed on. Detrusor underactivity implies a urodynamic diagnosis but, again, there is no consensus as to how to arrive at this diagnosis, given the accessible parameters on pressure flow urodynamic studies and the fact that “norms” will doubtless be different according to age and gender. The most clear-cut question, at least, seems to be how to assess detrusor activity in men in trying to arrive at a decision regarding outlet reduction or not. A few points and concepts seem quite relevant. We need an agreed on method to assess what the authors call the compensatory capacity of the detrusor contractility and the contractile reserve, and also the capacity of the outlet to relax. Proposed threshold values for the diagnosis of detrusor underactivity are currently maximum watts factor (Wmax) and bladder contractility index (BCI). These values apply only to men, and, in addition, these same 3 authors have published data indicating that Wmax and BCI continually rise with an increasing grade of obstruction. Rademakers et al cite as examples that a median BCI of 73 in Sch€ afer grade 0 transforms to a value of 188 in Sch€ afer grade 6, and a median Wmax increases from 9.6 in Sch€ afer grade 0 to 23 in Sch€ afer grade 6. Figure 2 in the article consists of a nomogram for simultaneous classification of bladder outlet resistance and bladder contractility in which Wmax plotted against the bladder outlet obstruction index with the 25th percentile line indicates the threshold for detrusor underactivity. Finally, the authors propose and cite prior evidence that in men detrusor wall thickness 1.23 mm or less as determined by suprapubic ultrasound in combination with bladder capacity greater than 445 ml can sufficiently predict detrusor underactivity in men. As we read more and understand less about the underactive bladder, a 2002 quote by Turner-Warwick seems especially apt: “The more one knows, the more one knows how little one knows. The less one understands, the less one understands how little one knows.” Alan J. Wein, MD, PhD (hon)
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Trends in Surgical Management and Pre-Operative Urodynamics in Female Medicare Beneficiaries with Mixed Incontinence B. Chughtai, N. Hauser, J. Anger, T. Asfaw, L. Laor, J. Mao, R. Lee, A. Te, S. Kaplan and A. Sedrakyan Departments of Urology, Obstetrics and Gynecology, and Healthcare Policy and Research, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, and Division of Urology, Urologic Reconstruction, Urodynamics and Female Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California Neurourol Urodyn 2015; Epub ahead of print. doi: 10.1002/nau.22946
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26678948 Editorial Comment: This analysis of the 5% Medicare sample evaluates patterns of care in women with presumed mixed urinary incontinence. I say “presumed” because it is difficult to be certain that patients truly have mixed incontinence based on the diagnosis codes in administrative data sets like the 5% Medicare sample. Acknowledging this point, the majority of women in the study cohort likely had mixed incontinence, so the results are probably still valid. The most interesting finding is not which surgical therapies are most commonly used to treat this condition (sling surgery in 63% of cases and injectable bulking agents in 28%) or the proportion of women requiring a second intervention (8.8%). Rather, what is most fascinating is the increasing use of preoperative urodynamic testing in patients undergoing a first procedure. Of the women 38.4% underwent a urodynamic study before their first intervention in 2000. This proportion increased to 74% in 2011. One wonders why there was this marked increase. To my knowledge, the evidence supporting the use of this testing did
1503
1504
BENIGN PROSTATIC HYPERPLASIA
not substantially improve or change during the study period, nor were new guidelines introduced that definitively recommended the use of urodynamics in this setting. One must wonder if the primary driving force in the increased use of urodynamics was financial. The other possibility is the practice of defensive medicine, and while this factor may have had a small role, I am still inclined to believe that reimbursement drove the increase. As the new MACRA (Medicare Access and CHIP Reauthorization Act) takes effect in the coming years and alternative payment models become more common, providers will be incentivized to do less testing in this setting. It will be interesting to see if use of urodynamics will be reduced. Either way, it is important for us as providers to ensure that our testing delivers value to the patient. Further research is needed to determine the role of urodynamic testing in the preoperative evaluation of women with mixed urinary incontinence. If the test does not add anything, we need to stop doing it. David F. Penson, MD, MPH
Re: Long Term Safety of Sacral Nerve Modulation in Medicare Beneficiaries B. Chughtai, A. Sedrakyan, A. Isaacs, R. Lee, A. Te and S. Kaplan Departments of Urology and Public Health, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, New York Neurourol Urodyn 2015; 34: 659e663. doi: 10.1002/nau.22618
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25066920 Editorial Comment: Sacral nerve modulation is a commonly used second-line therapy for refractory overactive bladder. While studies have shown that a considerable proportion of patients who undergo device implantation experience symptom relief, it is important to remember that the treatment is relatively costly and that, because the device is a foreign body, it sometimes requires explantation and/or replacement. This study uses the 5% Medicare sample from 2003 to 2011 to assess the long-term safety of the device. In the short term the majority of patients undergoing implantation experience few or no problems. However, by 3 years 17.3% of patients have had the device removed and 11.3% have had it replaced, with 26.1% of patients having undergone at least 1 of these additional interventions. Is a 1 in 4 removal/replacement rate acceptable? It is hard to say. Certainly refractory overactive bladder has a profound effect on quality of life, and sacral neuromodulation is effective in many patients. However, this approach does not work in all patients, and a 26% reoperation rate certainly adds significant cost to the treatment. As urologists, we need to consider the long-term cost-effectiveness of our interventions and have frank discussions with our patients, encouraging them to consider this factor in their decision making. If we do not do this with our patients, the payers will do it for us, and I do not believe we will like their choices. David F. Penson, MD, MPH
Suggested Reading Brazzelli M, Murray A and Fraser C: Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. J Urol 2006; 175: 835.
Benign Prostatic Hyperplasia Re: Prospective Evaluation of Ambulatory Laser Vaporization of the Prostate for Benign Prostatic Hyperplasia re, G. Verhoest, G. Berquet, L. Corbel, E. Della Negra, R. Huet, F. Trifard, Y. Codet, F. Boulie S. Vincendeau, K. Bensalah and R. Mathieu Departments of Urology, Rennes University Hospital, University of Rennes, Rennes and Saint Brieuc Private Hospital, St. Brieuc, France Lasers Surg Med 2015; 47: 396e402. doi: 10.1002/lsm.22363
Editorial Comment: These 2 well written articles highlight the salient issues regarding the diagnosis and management of detrusor underactivity, with the 1 article referring specifically to men who have symptoms that could be a manifestation of benign prostatic obstruction, detrusor underactivity or both. The “underactive bladder” is a symptomatic diagnosis but the exact wording of a definition has yet to be agreed on. Detrusor underactivity implies a urodynamic diagnosis but, again, there is no consensus as to how to arrive at this diagnosis, given the accessible parameters on pressure flow urodynamic studies and the fact that “norms” will doubtless be different according to age and gender. The most clear-cut question, at least, seems to be how to assess detrusor activity in men in trying to arrive at a decision regarding outlet reduction or not. A few points and concepts seem quite relevant. We need an agreed on method to assess what the authors call the compensatory capacity of the detrusor contractility and the contractile reserve, and also the capacity of the outlet to relax. Proposed threshold values for the diagnosis of detrusor underactivity are currently maximum watts factor (Wmax) and bladder contractility index (BCI). These values apply only to men, and, in addition, these same 3 authors have published data indicating that Wmax and BCI continually rise with an increasing grade of obstruction. Rademakers et al cite as examples that a median BCI of 73 in Sch€ afer grade 0 transforms to a value of 188 in Sch€ afer grade 6, and a median Wmax increases from 9.6 in Sch€ afer grade 0 to 23 in Sch€ afer grade 6. Figure 2 in the article consists of a nomogram for simultaneous classification of bladder outlet resistance and bladder contractility in which Wmax plotted against the bladder outlet obstruction index with the 25th percentile line indicates the threshold for detrusor underactivity. Finally, the authors propose and cite prior evidence that in men detrusor wall thickness 1.23 mm or less as determined by suprapubic ultrasound in combination with bladder capacity greater than 445 ml can sufficiently predict detrusor underactivity in men. As we read more and understand less about the underactive bladder, a 2002 quote by Turner-Warwick seems especially apt: “The more one knows, the more one knows how little one knows. The less one understands, the less one understands how little one knows.” Alan J. Wein, MD, PhD (hon)
Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Trends in Surgical Management and Pre-Operative Urodynamics in Female Medicare Beneficiaries with Mixed Incontinence B. Chughtai, N. Hauser, J. Anger, T. Asfaw, L. Laor, J. Mao, R. Lee, A. Te, S. Kaplan and A. Sedrakyan Departments of Urology, Obstetrics and Gynecology, and Healthcare Policy and Research, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, and Division of Urology, Urologic Reconstruction, Urodynamics and Female Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California Neurourol Urodyn 2015; Epub ahead of print. doi: 10.1002/nau.22946
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26678948 Editorial Comment: This analysis of the 5% Medicare sample evaluates patterns of care in women with presumed mixed urinary incontinence. I say “presumed” because it is difficult to be certain that patients truly have mixed incontinence based on the diagnosis codes in administrative data sets like the 5% Medicare sample. Acknowledging this point, the majority of women in the study cohort likely had mixed incontinence, so the results are probably still valid. The most interesting finding is not which surgical therapies are most commonly used to treat this condition (sling surgery in 63% of cases and injectable bulking agents in 28%) or the proportion of women requiring a second intervention (8.8%). Rather, what is most fascinating is the increasing use of preoperative urodynamic testing in patients undergoing a first procedure. Of the women 38.4% underwent a urodynamic study before their first intervention in 2000. This proportion increased to 74% in 2011. One wonders why there was this marked increase. To my knowledge, the evidence supporting the use of this testing did
1503
1504
BENIGN PROSTATIC HYPERPLASIA
not substantially improve or change during the study period, nor were new guidelines introduced that definitively recommended the use of urodynamics in this setting. One must wonder if the primary driving force in the increased use of urodynamics was financial. The other possibility is the practice of defensive medicine, and while this factor may have had a small role, I am still inclined to believe that reimbursement drove the increase. As the new MACRA (Medicare Access and CHIP Reauthorization Act) takes effect in the coming years and alternative payment models become more common, providers will be incentivized to do less testing in this setting. It will be interesting to see if use of urodynamics will be reduced. Either way, it is important for us as providers to ensure that our testing delivers value to the patient. Further research is needed to determine the role of urodynamic testing in the preoperative evaluation of women with mixed urinary incontinence. If the test does not add anything, we need to stop doing it. David F. Penson, MD, MPH
Re: Long Term Safety of Sacral Nerve Modulation in Medicare Beneficiaries B. Chughtai, A. Sedrakyan, A. Isaacs, R. Lee, A. Te and S. Kaplan Departments of Urology and Public Health, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, New York Neurourol Urodyn 2015; 34: 659e663. doi: 10.1002/nau.22618
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25066920 Editorial Comment: Sacral nerve modulation is a commonly used second-line therapy for refractory overactive bladder. While studies have shown that a considerable proportion of patients who undergo device implantation experience symptom relief, it is important to remember that the treatment is relatively costly and that, because the device is a foreign body, it sometimes requires explantation and/or replacement. This study uses the 5% Medicare sample from 2003 to 2011 to assess the long-term safety of the device. In the short term the majority of patients undergoing implantation experience few or no problems. However, by 3 years 17.3% of patients have had the device removed and 11.3% have had it replaced, with 26.1% of patients having undergone at least 1 of these additional interventions. Is a 1 in 4 removal/replacement rate acceptable? It is hard to say. Certainly refractory overactive bladder has a profound effect on quality of life, and sacral neuromodulation is effective in many patients. However, this approach does not work in all patients, and a 26% reoperation rate certainly adds significant cost to the treatment. As urologists, we need to consider the long-term cost-effectiveness of our interventions and have frank discussions with our patients, encouraging them to consider this factor in their decision making. If we do not do this with our patients, the payers will do it for us, and I do not believe we will like their choices. David F. Penson, MD, MPH
Suggested Reading Brazzelli M, Murray A and Fraser C: Efficacy and safety of sacral nerve stimulation for urinary urge incontinence: a systematic review. J Urol 2006; 175: 835.
Benign Prostatic Hyperplasia Re: Prospective Evaluation of Ambulatory Laser Vaporization of the Prostate for Benign Prostatic Hyperplasia re, G. Verhoest, G. Berquet, L. Corbel, E. Della Negra, R. Huet, F. Trifard, Y. Codet, F. Boulie S. Vincendeau, K. Bensalah and R. Mathieu Departments of Urology, Rennes University Hospital, University of Rennes, Rennes and Saint Brieuc Private Hospital, St. Brieuc, France Lasers Surg Med 2015; 47: 396e402. doi: 10.1002/lsm.22363