Voiding Chain Cystourethography: Assessing A Historical Test's Role in Selection for Urethrolysis

Abstract

Objective: To analyze the benefit of voiding chain cystourethrography (VCC) [placing a radiographic opaque chain into the urethra and bladder and asking the patient to void under fluoroscopy] in the urodynamic evaluation of female bladder outlet obstruction (BOO). Materials and Methods: Females with post anti-incontinence operation voiding dysfunction who underwent urodynamic evaluation augmented with VCC and later had urethrolysis were identified. Six diagnostic criteria for obstruction were applied to each patient: (1) VCC ( obstructed: chain was angulated and could not be voiding out) (2) Video urodynamic study (VUDS) (detrusor contraction combined with radiographic obstruction) (3) maximum flow (Q max ) ≤ 15 cc/sec, detrusor pressure (pDet)@ Q max ≥ 20 cm H 2 0 (4) Q max ≤ 11 cc/sec, pDet@ Q max ≥ 25 cm H 2 0 (5) Q max ≤ 12 cc/sec, pDet@ Q max ≥ 25 cm H 2 0 (6) Blaivas-Groutz (B-G) nomogram. Urethrolysis results were reviewed. Agreement in assessment of BOO criteria was assessed by estimating the proportion of pair-wise agreements along with an exact binomial 95% confidence interval (CI) and by estimating kappa along with a 95% CI. Results: Twenty-one patients were identified. Twenty of the 22 urethrolyses (91%) were clinically successful. Diagnosis of BOO was most common for VCC (86%) and then B-G Nomogram (67%). Agreement with the VCC was relatively poor for each of the five other methods (14%-62%) with the video urodynamic study (VUDS) being the best. Three patients with successful urethrolysis were diagnosed only by the VCC. All of kappa values regarding agreement with the VCC were low; the highest value of 0.15 was observed for VUDS. Conclusion: VCC may augment selection criteria for urethrolysis. INTRODuCTIONSelection for urethrolysis in symptomatic females with a history of an anti-incontinence procedure may be challenging, especially in the absence of immediate temporal association and/ or with a history of previous failed urethrolysis. While recognizing the value of the various pressure flow criteria developed for female bladder outlet obstruction (BOO), our clinic relies principally on the video urodynamic appearance of the bladder and urethra with voiding as described by Nitti et al.(1) and the Blaivas Groutz (B-G) nomogram (2). In some patients with a high index of clinical suspicion, the pressure flow criteria for obstruction were not strictly met and/or it was difficult to identify the urethra during testing.

Are video-urodynamics superior to traditional urodynamic studies in changing treatment decision with urinary symptoms?

“…In our present study, the finding of VUR was also 10% (16 of 156 cases) and it significantly impacted the diagnosis, but not treatment management. In other studies utilising VUDS [5,6], the authors commented on the UDS findings with minimal to no comment on fluoroscopic findings, leaving one to ponder why VUDS was performed over UDS in the first place.…”