Do you use urodynamics when determining when to insert a sling following a prostatectomy?

“It depends on the situation. If it’s an obvious situation, where the urinalysis is normal, there’s no postvoid residual, and it seems like classic stress incontinence, I don’t necessarily do urodynamics.

We typically do urodynamics when something’s unclear and confusing. I don’t always do urodynamics before doing a sling.

In the majority of cases that need a sling, where they need fewer than 5 to 6 pads a day, if for some reason the history is not clear, I would do urodynamics. If the history seems clear and reasonable, and there aren’t other issues, I don’t do urodynamics because it doesn’t really help me decide. I don’t do urodynamics unless it’s going to influence my decision or help the decision process in some way.

The decision process could indicate a patient may not be a good candidate for a sling. If, for some reason, you’re concerned there’s some other issue—involuntary contractions or another type of neurogenic component in his bladder—urodynamics can help identify that a person is not a good candidate for a sling. But in a straightforward case, I don’t necessarily do it.

Obviously, if the patient had infection, high postvoid residual, or a history of neurological issues, whether it’s a previous stroke or some other neurological condition that could influence bladder function, it’s a good tool to have if used in the right place.”

Joshua Fine, MD

Dallas, Texas

“I use urodynamics in my patients for several reasons. I want an objective evaluation of the severity of their outlet incompetence, giving me an estimation of their leak-point pressure. It provides good objective proof that it’s stress incontinence. A lot of patients suffer mixed incontinence, and if there’s a significant overactive bladder component that hasn’t been adequately addressed, oftentimes I address that first, to see if we can get the patient to a point where they have satisfactory control.

It also really provides a baseline reference so if they develop recurrent incontinence after a sling or an AUS [artificial urinary sphincter], I can repeat the study and have a look before they have anything done to compare to data after.

I have no objection to the approach of not doing urodynamics if it’s demonstrated the patient has stress incontinence and empties well. It’s not a requirement, but it’s a reasonable adjunct. Moreover, for patients who are considering a male sling as opposed to an AUS, it’s important we delineate the severity of their incontinence because the literature is replete with examples that slings are for patients that fit some strict criteria regarding their degree of incompetence.

Urodynamics allows me to have more confidence that we have properly selected those patients.

Urodynamics itself is incredibly low risk. There’s a small risk of infection but it’s more objective support that we’ve made an accurate diagnosis and we’ve objectively evaluated the severity of that diagnosis to guide the decision-making of the sling versus artificial sphincter.”

Joel Funk, MD

Tucson, Arizona

“We usually do urodynamics prior to doing either a sling or a sphincter. It’s part of the work-up to assess the capacity and compliance.

My partner does the sphincters, but I’m sure there are some situations where they don’t have any preoperative lower urinary tract symptoms with a relatively normal-sized prostate [and] normal-sized bladder and everything looks fine, [and]where they had no symptoms pre-op. [In those cases,] maybe they may consider doing it without urodynamics. But if you can you do the urodynamics, there’s little downside to doing it. You might end up with someone who has a noncompliant bladder or similar issues that you could treat prior to a sling or sphincter that might improve their symptoms, and which might be a contraindication to doing a sphincter.

You don’t want to block up a bladder that has really poor compliance because then the pressure is just transmitted to the upper tract. Usually, that would be like a neurogenic bladder, somebody with a lot of symptoms pre-op, so that’s going to be unusual.

You can also give them an idea of whether they have an element that’s not going to be necessarily treated with the sphincter. Sphincters are going to treat all stress-related incontinence, but if there is an element of urge, the patients might need to be on medication after surgery, so you can counsel them about that as well.

You can use urodynamics no matter what procedure you’re considering, but the sphincter would provide more back pressure than the sling in general.”

Rebecca O’Malley, MD

Albany, New York

Fine is in group practice and is an assistant clinical professor at Texas A&M University in Dallas, Texas, Funk an associate professor of urology at the University of Arizona, Tucson, and O'Malley is assistant professor of urology at Albany Medical College and urology section lead at Albany Stratton VA.