Does pre-operative urodynamics lead to better outcomes in management of urinary incontinence in women? A linked systematic review and meta-analysis

Abstract

The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients' outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patientreported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I 2 statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Metaanalysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I 2 = 0% and P = 0.470, RR:0.87, 95% Cl 0.59-1.28, I 2 = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Metaanalysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88-1.16, I 2 = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95-1.08, I 2 = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB. In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and costeffectiveness of routine urodynamics prior to surgical management of SUI and OAB.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

“…In some publications, limited evidence shows that a routine urodynamic study before the surgical management of SUI is not associated with improved treatment outcomes compared to clinical evaluation alone (LOE 1, grade 1A) 26 …”

Postoperative Urinary Retention

“…There are numerous studies reporting on the use of preoperative urodynamics to predict postoperative voiding dysfunction and urinary retention 72–76,122,123 . Most studies report that no single urodynamic voiding parameter accurately predicts POUR.…”

“…[1][2][3][4][117][118][119] Several studies have shown the rate of POUR after isolated MUS is less than when the MUS is placed at the time of prolapse repair, The only preoperative urodynamic parameter that is predictive of a successful VT is a Q max > 30 mL/s and conversely a failed VT is associated with a preoperative maximal flow rate <15 mL/s. [72][73][74][75][76][77] 87.50…”

“…There are numerous studies reporting on the use of preoperative urodynamics to predict postoperative voiding dysfunction and urinary retention. [72][73][74][75][76]122,123 Most studies report that no single urodynamic voiding parameter accurately predicts POUR. However, a published abstract of a systematic review of MUS clinical trials from 1989 to 2010 identified 3 "good quality" studies that reported preoperative urodynamics and the status of the postoperative VT. 77 The authors found that a preoperative maximum flow rate of more than 30 mL/s was predictive of passing a VT, and a preoperative maximum flow rate of less than 15 mL/s was predictive of failure.…”

Is Urodynamic Study an Essential Step in Preoperative Evaluation of Women with Pelvic Organ Prolapse with Urinary Tract Dysfunction: Prospective Comparative Study

“…Urodynamic tests provide objective information regarding the normal and abnormal function so are essential in the assessment and diagnosis of patients presenting with lower urinary tract dysfunction [10] . Urodynamic investigation when added in the diagnostic work-up of women with lower urinary tract dysfunction with POP is debatable [11] . Most surgeons postulated that preoperative urodynamic studies helped to modify the surgical intervention planned and to add any additional surgical procedure needed to avoid the appearance of concealed stress urinary incontinence following the reduction of pelvic organ prolapse thereby nullifying the chance of postoperative voiding dysfunction [12] .…”