Preoperative urodynamics ‘has no added value’ in SUI patients

Preoperative urodynamic studies may be unnecessary in many women undergoing primary surgery for stress urinary incontinence (SUI), say the authors of a systematic review and meta-analysis.

Suneetha Rachaneni (University of Birmingham, UK) and colleagues evaluated data from relevant randomised controlled trials and found that cure and complication rates were similar between women with a urodynamic diagnosis and those who underwent careful office evaluation.

The omission of preoperative urodynamics “might lead to massive savings for healthcare systems and could also save women valuable time and embarrassment and from potential urinary tract infections”, say the researchers writing in BJOG: An International Journal of Obstetrics & Gynaecology.

The team searched literature databases and identified three published randomised clinical trials that compared outcomes of SUI surgery in 775 women. Of these, 387 women underwent noninvasive office evaluation only (history, bladder scan, bladder diaries and clinical examination) and 388 underwent additional preoperative urodynamic studies.

Women in the trials had either SUI or stress-predominant mixed urinary incontinence (MUI) without voiding difficulties; women with a postvoid residual (PVR) volume greater than 150 mL or prolapse above grade 2 were excluded. Two of the studies were of good methodological quality and all used an unblinded noninferiority design.

Meta-analysis indicated that cure rates did not differ between the two treatment strategies, with a risk ratio of 1.02 for subjective cure (based on scores on the Urogenital Distress Inventory Scale or the Patient Global Impression of Improvement Scale) and 1.01 for objective cure (based on negative cough stress test at 12–49 months’ follow-up).

Postoperative complications were reported in two studies. Again, rates of specific complications – voiding dysfunction at 1 year and either new or continued treatment for urgency – were not significantly different in the two groups, with risk ratios of 1.54 and 0.80, respectively.

Rachaneni and co-authors note that the diagnostic accuracy of urodynamics in lower urinary tract conditions has never been studied due to the absence of an acceptable reference standard. “Urodynamics may not differentiate the various pathologies of stress incontinence,” they remark; by contrast, uroflowmetry is known to have a high correlation with voiding cystometry.

They conclude that “urodynamics does not have any add-on value as long as detailed office evaluation is carried out prior to primary SUI surgery in women with isolated SUI or stress-predominant MUI who have a normal bladder capacity and PVR.”

They add that clinical models need to be constructed to “universally standardise” office evaluation.

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