- Email: [email protected]
Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence
EUF-80; No. of Pages 2 EUROPEAN UROLOGY FOCUS XXX (2015) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Point of Focus Debate: For
Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence Maurizio Serati a,*, Enrico Finazzi Agro` b a
Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy; b Department of Experimental Medicine and Surgery, University Tor Vergata,
Rome, Italy
The reliability and clinical impact of urodynamics (UDS) remains one of the most debated issues in urogynecology. Several recent studies have found that the routine use of UDS before midurethral sling placement for the treatment of stress urinary incontinence (SUI) is not clearly useful. The latest recommendations of the International Consultation on Incontinence and findings reported by some recent large studies [1,2] confirmed the relevance of preoperative urodynamic testing in women with SUI with or without concomitant genital prolapse. Conversely, available data on the use of UDS in cases of uncomplicated and pure SUI are conflicting and heterogeneous [3,4]. In 2008, Patel and Chapple stated that in cases of female SUI, the evidence (although not overwhelming) pointed to the utility of UDS in diagnosis, preoperative planning, severity assessment, and prognosis of surgery [5]. In this scenario, the scientific landmark seems to be the randomized trial published in 2012 by Nager et al [6]. This study evaluated whether UDS can somehow improve objective and subjective surgical outcomes in the treatment of SUI. The authors concluded that a basic preoperative outpatient evaluation is a sufficient workup for women with SUI, since their incontinence surgery outcomes were not inferior to those of women who underwent urodynamic testing [6]. In subsequent years, a plethora of small studies, similarly designed, confirmed the same finding. However, in the available recently published systematic reviews and meta-analyses [7,8] on this topic, the majority of the analyzed patients came from the Value of Urodynamic
Evaluation (ValUE) study. Consequently, the conclusion that ‘‘UDS do not improve outcomes in women undergoing primary surgery for SUI or stress-predominant MUI [mixed urinary incontinence] without voiding difficulties’’ is strongly influenced by the results of the ValUE trial. Unfortunately, this famous study presents several methodological biases; in particular, it is remarkable that the authors included only uncomplicated cases of SUI. The real question is, in clinical practice, are the uncomplicated cases of SUI a relevant percentage of the general population of women with SUI? The answer is, clearly, not at all. The authors of ValUE study admitted that ‘‘conclusive analysis was performed only on 523 of the initially screened 4,083 female patients (<13%).’’ In particular, 2708 patients (66.3%) were excluded because they did not meet the inclusion criteria, thus the vast majority of patients are complicated. Are they not relevant? Was a negligible percentage of women excluded from the analysis? For these women, the findings of the study are not at all applicable. On the contrary, it is mandatory to emphasize that several papers have identified different urodynamic parameters that are able to predict sling outcomes in terms of efficacy [9,10] and risk of postsurgical voiding dysfunction [11]. Giarenis and Cardozo collected all these papers and concluded that UDS tests provide additional information regarding lower urinary tract symptoms. Although UDS would not be expected to improve the outcome of continence surgery, it offers valuable information to the
* Corresponding author. Department of Obstetrics and Gynecology, Urogynecolgy Unit, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy. Tel.: +39 0332 299 309; fax: +39 0332 299 307. E-mail address: [email protected] (M. Serati). http://dx.doi.org/10.1016/j.euf.2015.10.006 2405-4569/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Serati M, Agro` EF, Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence. Eur Urol Focus (2015), http://dx.doi.org/10.1016/j.euf.2015.10.006
EUF-80; No. of Pages 2 2
EUROPEAN UROLOGY FOCUS XXX (2015) XXX–XXX
surgeon and to the patient. The authors noted that UDS includes not only cystometry but a variety of tests that, when appropriately used, improve patient management overall and not just the outcome of surgery [12]. Two large studies showed that urodynamic investigations provide useful information for women with apparently pure SUI because 15–20% present detrusor overactivity that can be cured with anticholinergic therapy and that does not require any surgical procedure [13,14]. For these women, conservative therapies, such as antimuscarinic treatment, appear to have good cure rates and avoid unnecessary surgical procedures. With the purpose of answering the fundamental question, cited above, a large multicenter Italian database, including 2053 women with SUI, was analyzed [15]. The included patients were classified as uncomplicated and complicated, according to the ValUE criteria. It is very interesting to note that only 740 of 2053 patients (36.0%) were considered uncomplicated. It is evident that in clinical practice, the uncomplicated forms affect a small minority of women with SUI, and it is equally evident that the results of the ValUE study and of other similar studies may be applied to only this small percentage—as Shakespeare said >400 yr ago, ‘‘much ado about nothing.’’ Moreover, this multicenter study demonstrated that in the large majority of complicated patients, UDS could provide new information, in comparison to simple clinical examination, that changes subsequent management in a relevant percentage of cases [15]. Some believe that a minimally invasive examination can be avoided; in my opinion, the goal is to avoid unnecessary operations and to improve the counseling of patients. UDS is able to achieve both of these objectives.
[2] Serati M, Salvatore S, Siesto G, et al. Urinary symptoms and urodynamic findings in women with pelvic organ prolapse: is there a correlation? Results of an artificial neural network analysis. Eur Urol 2011;60:253–60. [3] Weber AM, Taylor RJ, Wei JT, Lemack G, Piedmonte MR, Walters MD. The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women. BJU Int 2002;89:356–63. [4] Laurikainen E, Kiilholma P. The tension-free vaginal tape procedure for female urinary incontinence without preoperative urodynamic evaluation. J Am Coll Surg 2003;196:579–83. [5] Patel AK, Chapple CR. Urodynamics in the management of female stress incontinence–which test and when? Curr Opin Urol 2008;18: 359–64. [6] Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012;366:1987–97. [7] Clement KD, Lapitan MC, Omar MI, Glazener CM. Urodynamic studies for management of urinary incontinence in children and adults: a short version Cochrane systematic review and metaanalysis. Neurourol Urodyn 2015;34:407–12. [8] Rachaneni S, Latthe P. Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis. BJOG 2015;122: 8–16. [9] Salvatore S, Serati M, Khullar V, et al. Opening vesical pressure: a new test to discriminate urethral sphincter deficiency? Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1435–8. [10] Guerette NL, Bena JF, Davila W. Transobturator slings for stress incontinence: using urodynamic parameters to predict outcomes. Int Uorgynecol J 2008;19:97–102. [11] Salin A, Conquy S, Elie C, et al. Identification of risk factors for voiding dysfunction following TVT placement. Eur Urol 2007;51: 782–7. [12] Giarenis I, Cardozo L. What is the value of urodynamic studies before stress incontinence surgery? BJOG 2013;120:130–2.
Conflicts of interest: The authors have nothing to disclose.
[13] Digesu GA, Hendricken C, Fernando R, Khullar V. Do women with pure stress urinary incontinence need urodynamics? Urology
References
2009;74:278–81. [14] Serati M, Cattoni E, Siesto G, et al. Urodynamic evaluation: Can it
[1] Abrams P, Andersson KE, Artibani W, et al. Recommendation of the
prevent the need for surgical intervention in women with apparent
International Scientific Committee: evaluation and treatment of
pure stress urinary incontinence? BJU Int 2013;112:E344–50.
urinary incontinence, pelvic organ prolapse and faecal incontinence.
[15] Serati M, Topazio L, Bogani G, et al. Urodynamics useless before
III. Urinary incontinence in women. B. Specialised management. In:
surgery for female stress urinary incontinence: are you sure?
Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. ed 5.
Results from a multicenter single nation database. Neurourol Uro-
Paris, France: Health Publication Ltd; 2013. p. 1914–5.
dyn. In press. http://dx.doi.org/10.1002/nau.22804
Please cite this article in press as: Serati M, Agro` EF, Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence. Eur Urol Focus (2015), http://dx.doi.org/10.1016/j.euf.2015.10.006
available at www.sciencedirect.com journal homepage: www.europeanurology.com/eufocus
Point of Focus Debate: For
Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence Maurizio Serati a,*, Enrico Finazzi Agro` b a
Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy; b Department of Experimental Medicine and Surgery, University Tor Vergata,
Rome, Italy
The reliability and clinical impact of urodynamics (UDS) remains one of the most debated issues in urogynecology. Several recent studies have found that the routine use of UDS before midurethral sling placement for the treatment of stress urinary incontinence (SUI) is not clearly useful. The latest recommendations of the International Consultation on Incontinence and findings reported by some recent large studies [1,2] confirmed the relevance of preoperative urodynamic testing in women with SUI with or without concomitant genital prolapse. Conversely, available data on the use of UDS in cases of uncomplicated and pure SUI are conflicting and heterogeneous [3,4]. In 2008, Patel and Chapple stated that in cases of female SUI, the evidence (although not overwhelming) pointed to the utility of UDS in diagnosis, preoperative planning, severity assessment, and prognosis of surgery [5]. In this scenario, the scientific landmark seems to be the randomized trial published in 2012 by Nager et al [6]. This study evaluated whether UDS can somehow improve objective and subjective surgical outcomes in the treatment of SUI. The authors concluded that a basic preoperative outpatient evaluation is a sufficient workup for women with SUI, since their incontinence surgery outcomes were not inferior to those of women who underwent urodynamic testing [6]. In subsequent years, a plethora of small studies, similarly designed, confirmed the same finding. However, in the available recently published systematic reviews and meta-analyses [7,8] on this topic, the majority of the analyzed patients came from the Value of Urodynamic
Evaluation (ValUE) study. Consequently, the conclusion that ‘‘UDS do not improve outcomes in women undergoing primary surgery for SUI or stress-predominant MUI [mixed urinary incontinence] without voiding difficulties’’ is strongly influenced by the results of the ValUE trial. Unfortunately, this famous study presents several methodological biases; in particular, it is remarkable that the authors included only uncomplicated cases of SUI. The real question is, in clinical practice, are the uncomplicated cases of SUI a relevant percentage of the general population of women with SUI? The answer is, clearly, not at all. The authors of ValUE study admitted that ‘‘conclusive analysis was performed only on 523 of the initially screened 4,083 female patients (<13%).’’ In particular, 2708 patients (66.3%) were excluded because they did not meet the inclusion criteria, thus the vast majority of patients are complicated. Are they not relevant? Was a negligible percentage of women excluded from the analysis? For these women, the findings of the study are not at all applicable. On the contrary, it is mandatory to emphasize that several papers have identified different urodynamic parameters that are able to predict sling outcomes in terms of efficacy [9,10] and risk of postsurgical voiding dysfunction [11]. Giarenis and Cardozo collected all these papers and concluded that UDS tests provide additional information regarding lower urinary tract symptoms. Although UDS would not be expected to improve the outcome of continence surgery, it offers valuable information to the
* Corresponding author. Department of Obstetrics and Gynecology, Urogynecolgy Unit, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy. Tel.: +39 0332 299 309; fax: +39 0332 299 307. E-mail address: [email protected] (M. Serati). http://dx.doi.org/10.1016/j.euf.2015.10.006 2405-4569/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Serati M, Agro` EF, Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence. Eur Urol Focus (2015), http://dx.doi.org/10.1016/j.euf.2015.10.006
EUF-80; No. of Pages 2 2
EUROPEAN UROLOGY FOCUS XXX (2015) XXX–XXX
surgeon and to the patient. The authors noted that UDS includes not only cystometry but a variety of tests that, when appropriately used, improve patient management overall and not just the outcome of surgery [12]. Two large studies showed that urodynamic investigations provide useful information for women with apparently pure SUI because 15–20% present detrusor overactivity that can be cured with anticholinergic therapy and that does not require any surgical procedure [13,14]. For these women, conservative therapies, such as antimuscarinic treatment, appear to have good cure rates and avoid unnecessary surgical procedures. With the purpose of answering the fundamental question, cited above, a large multicenter Italian database, including 2053 women with SUI, was analyzed [15]. The included patients were classified as uncomplicated and complicated, according to the ValUE criteria. It is very interesting to note that only 740 of 2053 patients (36.0%) were considered uncomplicated. It is evident that in clinical practice, the uncomplicated forms affect a small minority of women with SUI, and it is equally evident that the results of the ValUE study and of other similar studies may be applied to only this small percentage—as Shakespeare said >400 yr ago, ‘‘much ado about nothing.’’ Moreover, this multicenter study demonstrated that in the large majority of complicated patients, UDS could provide new information, in comparison to simple clinical examination, that changes subsequent management in a relevant percentage of cases [15]. Some believe that a minimally invasive examination can be avoided; in my opinion, the goal is to avoid unnecessary operations and to improve the counseling of patients. UDS is able to achieve both of these objectives.
[2] Serati M, Salvatore S, Siesto G, et al. Urinary symptoms and urodynamic findings in women with pelvic organ prolapse: is there a correlation? Results of an artificial neural network analysis. Eur Urol 2011;60:253–60. [3] Weber AM, Taylor RJ, Wei JT, Lemack G, Piedmonte MR, Walters MD. The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women. BJU Int 2002;89:356–63. [4] Laurikainen E, Kiilholma P. The tension-free vaginal tape procedure for female urinary incontinence without preoperative urodynamic evaluation. J Am Coll Surg 2003;196:579–83. [5] Patel AK, Chapple CR. Urodynamics in the management of female stress incontinence–which test and when? Curr Opin Urol 2008;18: 359–64. [6] Nager CW, Brubaker L, Litman HJ, et al. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012;366:1987–97. [7] Clement KD, Lapitan MC, Omar MI, Glazener CM. Urodynamic studies for management of urinary incontinence in children and adults: a short version Cochrane systematic review and metaanalysis. Neurourol Urodyn 2015;34:407–12. [8] Rachaneni S, Latthe P. Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis. BJOG 2015;122: 8–16. [9] Salvatore S, Serati M, Khullar V, et al. Opening vesical pressure: a new test to discriminate urethral sphincter deficiency? Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1435–8. [10] Guerette NL, Bena JF, Davila W. Transobturator slings for stress incontinence: using urodynamic parameters to predict outcomes. Int Uorgynecol J 2008;19:97–102. [11] Salin A, Conquy S, Elie C, et al. Identification of risk factors for voiding dysfunction following TVT placement. Eur Urol 2007;51: 782–7. [12] Giarenis I, Cardozo L. What is the value of urodynamic studies before stress incontinence surgery? BJOG 2013;120:130–2.
Conflicts of interest: The authors have nothing to disclose.
[13] Digesu GA, Hendricken C, Fernando R, Khullar V. Do women with pure stress urinary incontinence need urodynamics? Urology
References
2009;74:278–81. [14] Serati M, Cattoni E, Siesto G, et al. Urodynamic evaluation: Can it
[1] Abrams P, Andersson KE, Artibani W, et al. Recommendation of the
prevent the need for surgical intervention in women with apparent
International Scientific Committee: evaluation and treatment of
pure stress urinary incontinence? BJU Int 2013;112:E344–50.
urinary incontinence, pelvic organ prolapse and faecal incontinence.
[15] Serati M, Topazio L, Bogani G, et al. Urodynamics useless before
III. Urinary incontinence in women. B. Specialised management. In:
surgery for female stress urinary incontinence: are you sure?
Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence. ed 5.
Results from a multicenter single nation database. Neurourol Uro-
Paris, France: Health Publication Ltd; 2013. p. 1914–5.
dyn. In press. http://dx.doi.org/10.1002/nau.22804
Please cite this article in press as: Serati M, Agro` EF, Urodynamics Before Surgery for Stress Urinary Incontinence: The Urodynamic Examination Is Still One of the Best Friends of the Surgeon and of Patients with Stress Urinary Incontinence. Eur Urol Focus (2015), http://dx.doi.org/10.1016/j.euf.2015.10.006