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L’indagine urodinamica prima della chirurgia per IUS PRO
- 4. Nuovi parametri per fare diagnosi di deficit sfinterico e prevedere l’efficacia delle sling Salvatore S, Serati M. Int Urogynecol J 2007 Urodinamica: USI
- 8. Recent Cochrane review of clinical urodynamics ► Glazener and Lapitan: Urodynamic investigations for management of urinary incontinence in adults. Cochrane review, 2002-2003 ►Do urodynamic investigations improve clinical outcomes? ►Do urodynamic investigations alter clinical decision making? ►Only 2 small studies qualified ►No clear effect of urodynamics on outcome Derek Griffiths: 3rd ICI Committee 7, Dynamic testing, Monte Carlo 2004
- 9. While urodynamic tests did change clinical decision making, there was some high-quality evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment
- 11. only office evaluationurodynamic testing Urodinamica: USI
- 12. Conclusions: Women with uncomplicated stress urinary incontinence, a basic office evaluation as described in this report (i.e., a positive result on a provocative stress test, a normal post voiding residual volume, an assessment of urethral mobility, and confirmation of the absence of bladder infection) IS A SUFFICIENT PREOPERATIVE WORKUP. Urodinamica: USI
- 13. Urodinamica: USI
- 15. Conclusions: The omission of urodynamics is not inferior to the inclusion of urodynamics in the preoperative workup in women with (predominant) SUI.
- 16. Urodinamica: USI
- 18. (1) Conclusive analysis was performed only on 523 of the initially screened 4,083 female patients (<13%). (2) The two study arms were imbalanced on many relevant variables such as duration and severity of symptoms, previous treatment of incontinence, absence of estrogen therapy, and urethral hypermobility. (3) In the urodynamic group 12% of women presented with‘‘voiding dysfunction’’ but only 2.2% of them had the same diagnosis after the office evaluation. (4) women (possibly around 10%) in which intrinsic sphincter deficiency was suspected clinically, but not confirmed urodynamically. What were the results in this subgroup of patients?
- 20. (1) Conclusive analysis was performed only on 523 of the initially screened 4,083 female patients (<13%). (2) The two study arms were imbalanced on many relevant variables such as duration and severity of symptoms, previous treatment of incontinence, absence of estrogen therapy, and urethral hypermobility. (3) In the urodynamic group 12% of women presented with‘‘voiding dysfunction’’ but only 2.2% of them had the same diagnosis after the office evaluation. (4) women (possibly around 10%) in which intrinsic sphincter deficiency was suspected clinically, but not confirmed urodynamically. What were the results in this subgroup of patients?
- 21. NAGER CW RE TO: Voiding Dysfunction 29 vs 230 pts 62,1 vs. 78,3% success rate p=0,06…
- 22. (1) Conclusive analysis was performed only on 523 of the initially screened 4,083 female patients (<13%). (2) The two study arms were imbalanced on many relevant variables such as duration and severity of symptoms, previous treatment of incontinence, absence of estrogen therapy, and urethral hypermobility. (3) In the urodynamic group 12% of women presented with‘‘voiding dysfunction’’ but only 2.2% of them had the same diagnosis after the office evaluation. (4) women (possibly around 10%) in which intrinsic sphincter deficiency was suspected clinically, but not confirmed urodynamically. What were the results in this subgroup of patients?
- 24. While urodynamic tests did change clinical decision making, there was some high-quality evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment
- 29. Conclusion: Urodynamic evaluation is able to show that several patients with symptoms of pure SUI could present an underlying DO and do not require surgery, even 1 year after UDS. Conservative therapy, such as antimuscarinic treatment, appears to result in a good cure rate in these patients; thus, urodynamic evaluation could lead to the avoidance of a significant percentage of surgical procedures. 14% interventi evitati
- 30. COSTI PER 100 PAZIENTI (CALCOLO GROSSOLANO ESEGUITO IN TRENO…) • 1 UD: 204 € • 100 UD: 20.400 € • SE INTERVENTO: 2.000 € • -14% INTERVENTI: 28.000 € RISPARMIO 7.600 €! • SE INTERVENTO: 1.000 € (!!!) • -14% INTERVENTI: 14.000 € SPENDO 6.400 (64€/paziente) PER POTER ESEGUIRE UN COUSELING OTTIMALE E AVERE MAGGIORI INFORMAZIONI IN TUTTE LE PAZIENTI
- 32. Urodinamica: USI
- 33. CHOICE OF OPERATION/SURGICAL TECHNIQUE RPTS > TOTS IN PATIENT WITH ISD AT 6 MONTHS AND AT 3 YEARS. cut-off of: 20 cm H2O for maximum urethral closure pressure (MUCP) 60 cm H2O for valsalva leak point pressures (VLPP) Schierlitz L, et al.; Three year follow-up of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency. Obstet Gynecol 2012; Richter HE,et al. Retropubic versus transobturator Midurethral slings for stressincontinence. N Engl J Med 2010; TOTS > RPTS IN PATIENT WITH VD Houwert RM,et al. Risk factors for failure of retropubic and transobturator midurethral slings. Am J Obstet Gynecol 2009; Gamble TL, et al. Predictors of persistent detrusor overactivity after transvaginal sling procedures. Am J Obstet Gynecol 2008; TOTS > RPTS IN PATIENT WITH DO, URGE AND UI
- 34. PREDICTION OF FAILURE Nager CW,et al. Baseline urodynamic predictors of treatment failure 1 year after mid urethral sling surgery. J Urol 2011; Stav K, et al. Risk factors of treatment failure of midurethral sling Procedures for women with urinary stress incontinence. Int Urogecol J 2010; Urodinamica: USI
- 35. PREDICTION OF POSTOPERATIVE URGENCY,URGENCY INCONTINENCE AND VOIDING DYSFUNCTION Hong B, et al. Factors predictive of urinary retention after a tension-free vaginal tape procedure for female stress urinary incontinence. J Urol 2003; Jain P,et al. Effectiveness of midurethral slings in mixed urinary incontinence: systematic review and metaanalysis. Int Urogynecol J 2011; Lee JK, et al. Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG 2011; Lee JK, et al. Which women develop urgency or urgency urinary incontinence following midurethral slings? Int Urogynecol J 2012
- 36. PRO EVIDENCE BASED MEDICINE OR KNOWLEDGE BASED MEDICINE
- 37. 3rd ICI, Monte Carlo (France), July 2004 Committee 7 Dynamic testing Derek Griffiths (chair) Atsuo Kondo (co-chair) Stuart Bauer, Nick Diamant, Limin Liao, Gunnar Lose, Werner Schaefer, Naoki Yoshimura (members) Hans Palmtag (consultant)
- 38. Is urodynamics not clinically important? ► Urodynamics: the study of LUT function and dysfunction by any relevant method ► If urodynamics not very useful clinically, it is not important to understand how the LUT functions in order to treat it ► Surprising conclusion: Just treat blindfold!
- 39. Why do we do urodynamics? The broader view ►“Evidence-based” view is incomplete It is suitable only in simple, well-defined pathological situations ►Most situations are complicated Pathology is variable, uncertain and multifactorial ►The aim is to identify all contributing factors so as to formulate rational treatment “Knowledge-based medicine”
- 40. Urodynamics ►It is the study of function and dysfunction ►It is the only way of knowing objectively what that dysfunction is ►To work on a basis of knowledge requires urodynamics “Knowledge-based medicine”
- 41. Conclusioni ►Urodinamica: ancora "sostanzialmente" raccomandata nelle LG ►Non vantaggi rispetto a valutazione clinica: solo in pazienti molto selezionate (e con molti limiti…) ►Possibilità di individuare parametri (MUCP, VLPP, DO, Voiding Dysfunction) importanti per la decisione chirurgica e la scelta del tipo di intervento e per il counseling ►Costi: non rilevanti (possibili risparmi)
- 42. Paul Abrams Am J Obstet Gynecol 1994 Il migliore amico del chirurgo del pavimento pelvico? Urodinamica Il migliore amico del chirurgo del pavimento pelvico? Urodinamica