Preoperative Urodynamic Assessment Research Articles

Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention

BackgroundPost-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk. MethodsAll male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR. ResultsTwo hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m2. The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69. ConclusionUrodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.

Combined vaginal-laparoscopic approach vs. laparoscopy alone for prevention of bladder voiding dysfunction after removal of large rectovaginal endometriosis.

To assess whether the combined vaginal-laparoscopic route may reduce the risk of postoperative bladder atony, when compared to an exclusively laparoscopic approach, in patients presenting with deeply infiltrating rectovaginal endometriosis with extensive vaginal infiltration. Retrospective comparative cohort study using data prospectively recorded in the CIRENDO database. Academic Tertiary Care Centre. One hundred and thirty-two consecutive patients who underwent surgery of rectovaginal endometriosis with vaginal infiltration measuring greater than 3cm diameter. Combined vaginal-laparoscopic versus laparoscopic approach. Sixty-two patients underwent excision of endometriosis via a combined vaginal-laparoscopic approach (study group, or cases), while 71 patients underwent surgery via an exclusively laparoscopic route (controls). Rates of preoperative cyclical voiding difficulty and sensation of incomplete bladder emptying were comparable between the two groups. Preoperative urodynamic assessment was carried out in 18% of cases and 38% of controls, with abnormal results in 27.3% and 11.1% of cases and controls respectively. Early postoperative voiding difficulty (post-void residual>100mL) occurred in 14.7% and 24.3% of cases and controls respectively. There was a significant reduction in risk of intermittent self-catheterisation of 13% at time of discharge in the study cases. Three months postoperatively, one case and 6 controls had persistent voiding dysfunction requiring prolonged self-catheterisation. The combined vaginal-laparoscopic approach for large rectovaginal endometriotic nodules could reduce the risk of postoperative bladder dysfunction, when compared to an exclusively laparoscopic approach, most likely due to a reduced risk of damage to the pelvic splanchnic nerves at the paravaginal level.

Magnetic resonance imaging as an assessment tool following intervention with an AdVance XP suburethral sling for postprostatectomy urinary incontinence.

The aim of this study was to compare magnetic resonance imaging (MRI) parameters in patients with mild incontinence after radical prostatectomy, who had undergone treatment with a suburethral sling. The objective was to compare patients who had been successfully treated with unsuccessful patients. This observational cohort study at a single institution evaluated consecutive patients treated with an AdVance XP sling. MRI was performed using a 1.5 Tesla system. Preoperative urodynamic assessment and flexible cystoscopy were performed. The qualitative analysis was based on sling indentation (complete vs incomplete). The quantitative analysis comprised the following three parameters: the sling-pubis distance, the thickness of the proximal urethral bulb, and the sling backward distance (SBD), defined as the distance between the prolongation of a line through the major axis of the pubis (the line-segment joining the vertices of the pubis) and the sling indentation. The primary outcome was pad count at 3 months; cure as zero pads. A logistic univariate regression model was employed to assess the potential predictors of successful outcomes. An adjusted multivariate logistic regression model using the significant univariate factors was developed. Of the 83 patients enrolled, the univariate analysis revealed a relationship between failure and adverse urodynamics and between success and sling indentation, thickness of the proximal bulb and SBD. Only the association with SBD persisted in the multivariate analysis. MRI revealed a strong relationship between proper positioning of the sling (small SBD) and continence outcome. These data have important implications for a second surgery following initial sling failure.

Prospective Evaluation of Sacral Neuromodulation in Children: Outcomes and Urodynamic Predictors of Success

Sacral neuromodulation has been demonstrated to improve refractory bowel bladder dysfunction in children. The purpose of the current study was to determine whether results are durable in children after longer followup, whether children with a lower body mass index are at risk for device failure and whether pretreatment urodynamic evaluation can predict posttreatment outcome. Pediatric patients with refractory bowel bladder dysfunction were enrolled following informed consent and followed prospectively. All patients underwent preoperative videourodynamic evaluation and a 2-stage implantation procedure. Validated questionnaires were used to assess symptom severity and quality of life. Complications were analyzed with regard to treatment required and patient body mass index. During 45 months 30 patients were enrolled. Median age was 8.3 years at enrollment. Median followup was 14.8 months. Patients had significant improvement in quality of life and symptom scores, which persisted at the most recent followup. Patients who had uninhibited detrusor contractions on preoperative urodynamic assessment had significantly greater improvement in symptoms. Of the patients 23% had a complication requiring reoperation, most commonly neurostimulator lead breakage in those with a significantly lower body mass index. Sacral neuromodulation significantly improves quality of life and symptom severity in children with refractory bowel bladder dysfunction. Children gain greater benefit if they show uninhibited bladder contractions on preoperative urodynamic evaluation. Children have a high rate of lead breakage requiring operative revision, which was seen after minor trauma in those with a lower body mass index.

Résultats d’une deuxième bandelette sous-urétrale dans le traitement de l’incontinence urinaire d’effort féminine persistante ou récidivante

To evaluate the results of a second midurethral sling (MUS) implantation after immediate or late recurrence of stress urinary incontinence (SUI) in women following a first MUS implantation. We performed a retrospective study of 36 patients who have had a second MUS between 2000 and 2011. All patients had preoperative urodynamic assessment using French validated scales (measurement of urinary handicap [MUH] and Ditrovie's scale) a correction of SUI by Ulmsten's test. The second tape was placed in the usual way without removal of the first one. The therapeutic results were evaluated by the presence or the absence of leaks as measured by MUH and Ditrovie's scale, and classified as "success" in the absence of leaks or the presence of small leaks without needing protection, "improvement" if significant decrease in urine leakage at subjective patient interview and "failed" in other cases. The mean age of 36 patients was 64 ± 9.6 years. Thirty patients had a tension-free vaginal tape (TVT) as second tape and six patients had a transobturator tape. At 3 months, success rate was 74.3% (n=26). Six patients had partial improvement (17.1%) and three patients had no improvement (8.6%). One was lost sight. After a follow-up of 5 years, these results remained unmodified for the ten patients reviewed. The implantation of a second MUS was a good option for women with persistence or recurrence of SUI after a first MUS implantation.

AdVance/AdVance XP Transobturator Male Slings: Preoperative Degree of Incontinence as Predictor of Surgical Outcome

To evaluate the efficacy of the AdVance transobturator male sling in the treatment of male stress urinary incontinence and to identify the preoperative predictors of a successful outcome. All patients were considered for sling placement 1 year after radical prostatectomy or transurethral resection of the prostate. The degree of incontinence was assessed using the 24-hour pad weight test. A preoperative urodynamic assessment and cystoscopy were performed in all cases. Patients without sphincter contractions during the "repositioning test" were excluded. Since September 2010, we have implanted the AdVance XP transobturator sling. Cure was defined as no pad use. From February 2008 to June 2011, 61 patients underwent transobturator sling (34 AdVance and 27 AdVance XP) insertion. In 26 cases, the sling was anchored with bioabsorbable sutures, and in 35 cases, it was not fixed. Of the 61 patients, 7 had a history of anastomotic stricture and 3 of radiotherapy. Preoperatively, median 24-hour pad weight was 200 g (range 25-1848). Finally, 26 patients had detrusor overactivity or low bladder compliance. The median follow-up was 26 months (range 12-53). The overall cure rate was 80% (49 of 61). Deterioration of continence was observed during follow-up in 2 patients. The preoperative variables (age, body mass index, 24-hour pad weight, International Consultation on Incontinence Questionnaire-Short Form, adverse urodynamics, sling fixation, AdVance XP) and their association with the surgical outcome were analyzed. The preoperative 24-hour pad weight correlated inversely with the outcome (odds ratio 0.996), with a 0.4% decrease in cure rate for each 1-g increase in the preoperative 24-hour pad weight. The complications included perineal hematoma in 2, acute urinary retention in 9, perineal numbness in 5, and de novo storage symptoms (urgency) in 5 patients. The results of our study have shown that the AdVance and AdVance XP male slings are safe and efficient in patients with mild postprostatectomy stress incontinence. The severity of incontinence was the only predictor of a successful outcome.

Preoperative Assessment of Neurovesical Function in Children with Anorectal Malformation: Association with Vertebral and Spinal Malformations

We preoperatively assessed neurovesical function and spinal cord function in children with anorectal malformations. In cases of neurovesical dysfunction we looked for an association with vertebral malformation or myelodysplasia. We prospectively evaluated 80 children with anorectal malformations via preoperative urodynamics and magnetic resonance imaging of the spine. Bladder compliance and volume, detrusor activity and vesicosphincteric synergy during voiding allowed urodynamic evaluation. Results were reported according to Wingspread and Krickenbeck classifications of anorectal malformations. Urodynamic findings were pathological in 14 children (18%). Pathological evaluations did not seem related to type of fistula or level of anorectal malformation. Vertebral anomalies were seen in 34 patients (43%) and myelodysplasia in 16 (20%). Neither vertebral anomaly nor myelodysplasia seemed associated with type of fistula or severity of anorectal malformation. Of 14 children with pathological urodynamics no vertebral anomaly or myelodysplasia was found in 7. Of 66 children with normal urodynamics 40 presented with vertebral or spinal malformation. Lower urinary tract dysfunction is common in patients with anorectal malformations. Normal spine or spinal cord does not exclude neurovesical dysfunction. Myelodysplasia or vertebral anomaly does not determine lower urinary tract dysfunction. Thus, we recommend preoperative urodynamic assessment of the bladder and magnetic resonance imaging of the spine in children with anorectal malformations.

Preoperative Urodynamic Assessment in Patients with Spinal Cord Lesions Undergoing Sphincterotomy: Is Success Predictable?

Objective: Sphincterotomy is a well-established therapeutic option in male patients with neurogenic bladder dysfunction and detrusor-sphincter-dyssynergia due to spinal cord lesions. Indication and prediction of treatment outcome, however, are mainly based on clinical parameters. We analyzed the clinical usefulness of preoperative urodynamic evaluation for the prediction of success in patients undergoing external sphincterotomy. Materials and Methods: In a retrospective study, residual urine, retrograde perfusion pressure (RESP) and detrusor leak point pressure (DLPP) in 62 male patients with spinal cord injury were assessed before sphincterotomy. Data were compared to surgical success evaluated by postoperative DLPP and residual urine. Results: Sphincterotomy was successful in 85.4% of our patients. In multivariate analysis, both preoperative DLPP and RESP were superior to measurement of residual urine concerning prediction of surgical success. However, these differences were not statistically significant. Conclusion: To our knowledge, this is the first study to evaluate preoperative predictors for surgical success in patients undergoing sphincterotomy. Although urodynamic evaluation is strongly advised prior to surgery in patients with spinal cord lesions, it improves prediction of success only marginally.

The Techniques of Trocar Insertion and Intraoperative Urethrocystoscopy in Tension-Free Vaginal Taping: An Experience of 600 Cases

The author presents his experience with trocar insertion and urethrocystoscopy associated with the tension-free vaginal tape procedure (TVT). Over a 5-year period from November 1995 to March 2001, he performed TVT in 600 women with stress urinary incontinence with or without pelvic prolapse. All patients underwent preoperative urodynamic assessment. In addition, all patients had an intraoperative urethrocystoscopy to ascertain the integrity of the bladder and urethra. A concomitant procedure was performed in 169 (28%) cases. Of 188 women who had undergone previous pelvic surgery, 34 had procedures that posed a significant risk of ureteral injury. These patients were injected with 1% methylene blue solution before cystoscopy to confirm ureteral patency. The study population had a mean age of 53 years (range, 32-76 years) and a mean parity of 2.54 (range, 0-6). Of 270 (45%) women who were menopausal, 140 (51.9%) were taking hormone replacement therapy. Endoscopy findings included identification of 5 patients (0.8%) who had bladder perforation or near perforation that required reinsertion of the trocar. One woman had a biopsy of a benign granuloma. Sutures from a previous retropubic urethropexy were discovered in 1 patient and removed. Another subject required excision of an adhesion band in the urethra, which was placed during a previous excision of urethral diverticulum. A ureteral obstruction resulting from a previous laparoscopic Burch colposuspension was suggested by delayed dye emission in 1 of the 34 women who was injected with intravenous methylene blue dye. Ureteroscopy was performed and a stricture of the right distal ureter was identified and incised with electrocautery. A double-J catheter was inserted and left in place until a patent ureter was established.

The natural history of lower urinary tract dysfunction in men: the influence of detrusor underactivity on the outcome after transurethral resection of the prostate with a minimum 10‐year urodynamic follow‐up

To assess the long-term outcome of the efficacy of transurethral resection of the prostate (TURP) in men with detrusor underactivity (DUA), a cause of lower urinary tract symptoms (LUTS) in a significant minority of men. Neurologically intact men with LUTS, who were investigated in our department between 1972 and 1986, diagnosed with DUA and who underwent surgical intervention, were invited for a repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of the results. In all, 224 men were initially diagnosed with DUA; 87 (39%) of these died in the interim and 22 followed had a TURP, with a mean follow-up since surgery of 11.3 years. There were no significantly sustained reductions in any symptoms. There was a small but significant reduction of questionable clinical significance in the bladder outlet obstruction index, but this did not translate into an improved flow rate. Comparison with 58 age-matched patients with DUA who remained untreated showed no significant advantage of surgical intervention in the long-term; on the contrary, there was more chronic retention in those who had had surgery. There are no long-term symptomatic or urodynamic gains from TURP in men shown to have DUA. The results of TURP in men with DUA are important, as urologists who surgically treat patients based on the symptoms and uroflowmetry alone will do so in a significant minority of men with DUA. These results strengthen the argument for a routine preoperative urodynamic assessment.

Preliminary Results of Muscle Cuff Cervicoplasty in the Ewe for the Treatment of Urinary Incontinence

Muscle cuff cervicoplasty consists of dissecting a strip of the superior slip of the levator ani muscle, by sectioning it flush with the symphysis pubis, and applying it like a cuff around the urethra below the bladder neck. We conducted a preliminary study in 12 ewes, including preoperative urodynamic assessment, intravenous urography with retrograde cystography on day 15, and another urodynamic assessment 1 and 3 months after the operation. Two animals died, but the other 10 animals were able to be evaluated. An increase in the urethral functional length with an infracervical plateau was revealed on all postoperative urethral profiles. Only transrectal electrostimulation, performed on the last 5 ewes, demonstrated an elevation of the closure pressure by 5-10 cm H2O. At sacrifice of the animals at 4 months, in situ stimulation of the muscle strip induced muscle contraction in 7 of 10 cases. Histological examination demonstrated persistence of muscle fibers in the cuff, despite the presence of marked fibrosis. The preliminary results are encouraging: urinary continence was improved with a minimal risk of retention, and cervicoplasty appears to retain its contractile activity, suggesting the possibility of a long-term sphincteric and proprioceptive action. This technique could be proposed in women suffering from urinary stress incontinence with sphincter hypoactivity.

Is day-case prostatectomy feasible?

To assess the possibility of discharging patients, catheter-free, on the same day that they undergo contact-laser prostatectomy. Ten patients underwent contact vaporization of the prostate using the SLT (Surgical Laser Technologies, Oaks, PA, USA) Nd:YAG laser with an MTRL10 6 mm tip. Patients were selected in the out-patient clinic for day-case surgery on the basis of their good general health and clinically small glands. All patients had pre-operative urodynamic assessment and were proven obstructed and stable. Contact vaporization was carried out under general anaesthesia. Both intra-operative blood loss and irrigant absorption were assessed. The follow-up at 3 and 6 months included American Urological Association (AUA-7) symptom scores and the measurement of urinary flow rates. The mean operating time was 25.2 min, with a mean application of 43.05 kJ of laser energy. The mean absorption of irrigant fluid was 30 mL and the mean intra-operative blood loss was 31 mL. Nine patients were discharged on the day of treatment. Two patients went into clot retention following discharge and had a suprapubic catheter sited, and two failed to void once discharged, necessitating catheterization for 2 weeks. At 3 and 6 months, there was a substantial decrease in the AUA symptom score and an improvement in urinary flow rate. Day-case laser prostatectomy is possible, but the patients must be selected carefully and, perhaps more importantly, a specialist day-case anaesthetist must be available.

Effect of transurethral resection of the prostate on detrusor instability and urge incontinence in elderly males

Detrusor instability is common in men with evidence of outflow obstruction due to benign prostatic hypertrophy and typically reverses in about two thirds of patients after transurethral resection of the prostate (TURP). It is also common among the elderly without outflow obstruction and may lead to urge incontinence. To determine whether TURP has an effect on detrusor instability and urge incontinence in elderly men, or whether these abnormalities are due to other age-associated changes, 12 males (mean age 80 years) with urge incontinence or frequency and urgency of micturition, and symptomatic benign prostatic hypertrophy, were studied by 24-hour monitoring of incontinence and videourodynamic examination, before and after TURP; 7/12 patients were significantly cognitively impaired. Preoperatively, all patients showed detrusor instability, which reversed postoperatively in only one patient, a significantly smaller proportion than that consistently reported in younger patients. Preoperatively, 11/12 patients were incontinent. After TURP, 8/11 patients had an improvement in the amount of incontinence, by up to 458 g in 24 hours. Those who improved had been urodynamically more severely obstructed preoperatively. Those with the most improvement were also cognitively impaired. We conclude that, in the geriatric population, detrusor instability and urge incontinence may be the result of age-associated changes and not secondary to obstruction. Detrusor instability is likely to persist following TURP. Preoperative urodynamic assessment of obstruction in the incontinent male with benign prostatic hypertrophy may be useful since the severity of incontinence responds well to TURP if there is marked obstruction. Cognitive impairment should not be a deterrent to operation.

A review of the gauze-hammock sling operation for patients with recurrent stress incontinence following surgery

SummarySummaryThirty-seven patients with recurrent stress incontinence despite previous surgery, underwent the gauze-hammock sling operation. Seven patients had pre-operative urodynamic assessment. Three yean after surgery 28 patients (76 per cent) were cured. In nine cases the operation failed. Three of the nine needed removal of the sling, and two others had detrusor instability on postoperative urodynamic studies. Age, weight, and parity were not related to surgical outcome. The gauze-hammock operation is an effective treatment for recurrent stress incontinence. The success rate could possibly be improved further by pre-operative urodynamic assessment.