Value Of Urodynamic Evaluation Research Articles

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI. We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT. Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (β coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057). Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

De-implementation of urodynamics in The Netherlands after the VALUE/VUSIS-2 results: a nationwide survey

Introduction and hypothesisWe aimed to estimate the level of de-implementation of preoperative routine urodynamics (UDS) before stress urinary incontinence (SUI) surgery in The Netherlands and to analyze facilitators and barriers. Routine UDS was performed by 37% of the medical specialists in 2010. We hypothesized that the recommendations from the recent Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) and Value of Urodynamic Evaluation (ValUE) studies would have been followed by a reduction of routine UDS.MethodsA national survey was performed among all Dutch gynecologists and urologists dealing with SUI in daily practice. The questionnaire contained two parts: (1) respondents’ characteristics and their actual care concerning preoperative UDS, and (2) facilitators and barriers.ResultsThe response rate was 41% (127/308). Of the respondents, 93% (n = 118) did not perform routine UDS in the preoperative workup for women in this group. Professional characteristics associated with not following the recommendations were profession urologist, academic hospital, and a lower number of midurethral sling (MUS) placed yearly. Facilitators to follow the recommendation not to perform routine UDS were adequate design of the VUSIS-II study and outcome and recommendations from the studies. Barriers not to follow the recommendation were believe in the additional value of UDS, especially the pressure transmission ratio, and the presence of detrusor overactivity.ConclusionAccording to respondents to this questionnaire, VUSIS-II and ValUE study results are well implemented in The Netherlands. The vast majority of respondents replied as not performing routine preoperative UDS in women with primary, uncomplicated (predominant) SUI. Therefore, there is no need for a further de-implementation strategy.

MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Incontinence: Evaluation (Urodynamic Testing)1 Apr 2018MP27-03 PRE-OPERATIVE URODYNAMIC EVALUATION IN FEMALE MEDICARE PATIENTS UNDERGOING A STRESS URINARY INCONTINENCE PROCEDURE: RATES BEFORE AND AFTER THE VALUE TRIAL Annah Vollstedt, Rachel Moses, and E. Ann Gormley Annah VollstedtAnnah Vollstedt More articles by this author , Rachel MosesRachel Moses More articles by this author , and E. Ann GormleyE. Ann Gormley More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.882AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The American Urologic Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (AUA/SUFU) Guideline outlines the evaluation and treatment of stress urinary incontinence (SUI) and state that urodynamic (UDS) testing may be omitted in healthy females who have not undergone a prior SUI procedure. This recommendation is largely based on the data reported in the seminal Value of Urodynamic Evaluation (ValUE) trial. We sought to investigate the rates of UDS testing in those undergoing a SUI procedure before and after the ValUE trial publication. METHODS Using the Dartmouth Institute’s Atlas Rate Generator exploring a 100% Medicare claims data, we identified females with a diagnosis of SUI by ICD-9 codes and a CPT code for either urethral bulking or urethral sling procedure, within 306 hospital referral regions (HRR). We then identified the proportion of those who also had a CPT code for UDS within one year prior to their SUI procedure. RESULTS Complete 2011 and 2013 data was available for 151 of the 306 HHRs. The national percentage of pre-operative UDS evaluation was 53% (16020/30131) in 2011, compared to 55% (11,772/21579) in 2013, after the publication of the ValUE trial (p=0.157). In 2011, the highest percentage of UDS testing in was performed in Monroe, LA at 81% (48/59) and the lowest in Jonesboro, AR at 22% (14/64). In 2013, the highest percentage of UDS testing was performed in Longview, TX at 88% (43/49) and the lowest in Springfield, MO at 22% (22/99). Only 40% (61/151) of HHRs decreased their use of UDS, while 52% (79/151) increased UDS rates, and 8% (11/151) HHRs stayed the same. CONCLUSIONS There is significant regional variation in utilization of UDS in those undergoing a SUI procedure. Nationally, the overall rates of UDS, diagnostic testing did not change significantly after the publication of the ValUE trial. When evaluating at the HRR level, a larger proportion of HRRs demonstrated increased or unchanged rates between 2011 and 2013. Further research is needed to investigate the differences in UDS testing after the distribution of the SUI AUA/SUFU guidelines as well the rates of UDS testing in populations other than Medicare beneficiaries. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e347 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Annah Vollstedt More articles by this author Rachel Moses More articles by this author E. Ann Gormley More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urodynamics useless before surgery for female stress urinary incontinence: Are you sure? Results from a multicenter single nation database.

The role of urodynamics (UDS) before surgery for stress urinary incontinence (SUI) remains a debated issue in female urology as well as in urogynaecology and it has been recently questioned on the basis of data coming from selected population of patients defined as "uncomplicated." The aim of this study was to investigate the percentage of "uncomplicated" patients undergoing urodynamic evaluations in six referral Italian centers. The secondary aim was to assess the prevalence of women, for whom the urodynamic evaluation could add new information to the pre-urodynamic picture and in how many cases these findings had a significant impact on patient management. The data of women who underwent urodynamic evaluation prior to surgery for stress urinary incontinence between 2008 and 2013 were retrospectively analyzed. According to the definition of the Value of Urodynamic Evaluation (ValUE) trial criteria, patients presenting with SUI were classified as "uncomplicated" or "complicated." Urodynamic observations were then compared with pre-urodynamic data. Overall, 2,053 female patients were considered. Only 740/2,053 (36.0%) patients were defined "uncomplicated" according to the definition used in the ValUE trial. The urodynamic observations were not consistent with the pre-urodynamic diagnosis in 1,276 out of 2,053 patients (62.2%). Voiding dysfunctions were urodynamically diagnosed in 394 patients (19.2%). Planned surgery was cancelled or modified in 304 patients (19.2%), due to urodynamic findings. "Uncomplicated" patients represent a minority among female SUI patients evaluated before surgery. In "complicated" patients, the role of urodynamic has not been challenged yet and UDS seems still mandatory. Neurourol. Urodynam. 35:809-812, 2016. © 2015 Wiley Periodicals, Inc.

The cost of preoperative urodynamics: A secondary analysis of the ValUE trial.

Urodynamic studies (UDS) are generally recommended prior to surgical treatment for stress urinary incontinence (SUI), despite insufficient evidence that it impacts treatment plans or outcomes in patients with uncomplicated SUI. This analysis aimed to calculate the cost incurred when UDS was performed as a supplement to a basic office evaluation and to extrapolate the potential savings of not doing UDS in this patient population on a national basis. This is a secondary analysis from the Value of Urodynamic Evaluation (ValUE) trial, a multicenter non-inferiority randomized trial to determine whether a basic office evaluation (OE) is non-inferior in terms of SUI surgery outcomes to office evaluation with addition of urodynamic studies (UDS). All participants underwent an OE; those patients who randomized to supplementary UDS underwent non-instrumented uroflowmetry, filling cystometry, and a pressure flow study. Costs associated with UDS were calculated using 2014 U.S. Medicare allowable fees. Models using various patient populations and payor mixes were created to obtain a range of potential costs of performing UDS in patients undergoing SUI surgery annually in the United States. Six hundred thirty women were randomized to OE or OE plus UDS. There was no difference in surgical outcomes between the two groups. The per patient cost of UDS varied from site to site, and included complex cystometrogram $314-$343 (CPT codes 51728-51729) plus complex uroflowmetry $16 (CPT code 51741). Extrapolating these costs for US women similar to our study population, 13-33 million US dollars could be saved annually by not performing preoperative urodynamics. For women with uncomplicated SUI and a confirmatory preoperative basic office evaluation, tens of millions of dollars US could be saved annually by not performing urodynamic testing. In the management of such women, eliminating this preoperative test has a major economic benefit.

Pre‐operative urodynamics in women with stress urinary incontinence increases physician confidence, but does not improve outcomes

To determine if pre-operative urodynamic testing (UDS) affects physicians' diagnostic confidence and if physician confidence affects treatment outcomes at 1 year. The Value of Urodynamic Evaluation (ValUE) trial randomized 630 women with predominant stress urinary incontinence (SUI) to office evaluation (OE) or OE plus UDS prior to surgery. After OE, physicians completed a checklist of five clinical diagnoses: SUI, overactive bladder (OAB) wet and dry, voiding dysfunction (VD), and intrinsic sphincter deficiency (ISD), and reported their confidence in each. Responses ranged from 1 to 5 with; 1 = "not very confident (<50%)" to 5 = "extremely confident (95 + %)." After UDS, investigators again rated their confidence in these five clinical diagnoses. Logistic regression analysis correlated physician confidence in diagnosis with treatment success. Of 315 women who received OE plus UDS, 294 had complete data. Confidence improved after UDS in patients with baseline SUI (4.52-4.63, P < 0.005), OAB-wet (3.55-3.75, P < 0.001), OAB-dry (3.55-3.68 P < 0.005), VD (3.81-3.95, P < 0.005), and suspected ISD (3.63-3.92, P < 0.001). Increased confidence after UDS was not associated with higher odds of treatment success although mean changes in confidence were slightly higher for those who achieved treatment success. Physician diagnoses shifted more from not confident to confident for ISD and OAB-wet after UDS (McNemar's P-value <0.001 for both). In women undergoing UDS for predominant SUI, UDS increased physicians' confidence in their clinical diagnoses; however, this did not correlate with treatment success.

History and Future of Multi-Institutional Clinical Trials in Urinary Incontinence

History and Future of Multi-Institutional Clinical Trials in Urinary Incontinence

Design of the Value of Urodynamic Evaluation (ValUE) trial: A non-inferiority randomized trial of preoperative urodynamic investigations

Background and purpose Urodynamic studies (UDS) are routinely obtained prior to surgery for stress urinary incontinence (SUI) despite a lack of evidence that UDS information has an actual impact on outcome. The primary aim of this non-inferiority randomized clinical trial is to determine whether women with symptomatic, uncomplicated SUI who undergo only a basic office evaluation (BOE) prior to SUI surgery (No UDS arm) have non-inferior treatment outcomes compared to women who have BOE and UDS (UDS arm). Secondary aims are: 1) to determine how often physicians use preoperative UDS results to alter clinical and surgical decision-making, 2)to compare the amount of improvement in incontinence outcomes, and 3) to determine the incremental cost and utility of performing UDS compared with not performing UDS. Methods After an initial basic office evaluation, women planning surgery for uncomplicated SUI who consent to study participation will be randomized to receive preoperative UDS or No UDS. Treatment will be planned and performed by the surgeon utilizing all the data available to them. We will compare results from the basic office evaluation (No UDS) with results from the basic office evaluation and preoperative UDS. Results The primary outcome will be measured at 12 months using responses to the Urogenital Distress Inventory and the Patient Global Index-Improvement. Conclusions Randomized trials comparing the effects of different diagnostic alternatives on treatment outcomes pose study design challenges. A non-inferiority design is appropriate when comparing a less invasive and less expensive alternative with a standard of care approach.

Urodynamic Studies in Children who Wet

The value of urodynamic evaluation was assessed in children with diurnal and/or nocturnal enuresis without overt obstruction or neuropathy. The hypothesis that children with bladder instability and dysfunctional voiding represent 2 separate populations was also examined. A simplified urodynamic method was used to evaluate 191 children and they were divided into 3 groups: 64 had normal bladders which were stable during filling and voiding was co-ordinated and complete; 97 had unstable bladders but voiding was normal and co-ordinated; 30 had dyssynergic voiding and an increased volume of residual urine. The urodynamic evaluations were helpful in distinguishing the large number of children with normal findings in whom the problem was motivational. The children with unstable bladders had a physiological abnormality due to delayed maturation and in these cases anticholinergic and musculotrophic agents were usually helpful. The dysfunctional voiders had serious behavioural problems, were difficult to treat, and often required a multidisciplinary approach. These data indicate that there are indeed 2 distinct groups: 1 with instability alone and 1 with dysfunctional voiding with or without instability. Although infection and/or reflux are common in the former, the more devastating urinary tract changes, particularly heavy trabeculation and elongation of the bladder, occur in the latter group.

Urodynamic Features of Pelvic Plexus Injury

Benign and malignant neoplasms arising in and around the pelvic structures may cause urinary obstruction by mechanical compression of the bladder or proximal urethra. These neoplasms less commonly cause neurogenic voiding dysfunction. Herein we describe the urodynamic abnormalities in a young man with massive involvement of the true pelvis with choriocarcinoma. Destruction of the pelvic plexus produced deficits of parasympathetic, sympathetic and somatic innervation of the bladder and urethra. The value of urodynamic evaluation as a neurologic test of thoracolumbar and sacral cord function is demonstrated.