Value of urodynamics: Important caveats

Dr. Jellison is a fellow in female pelvic medicine and reconstructive surgery at the UCLA School of Medicine, where Dr. Raz, a member of the Urology Times Editorial Council, is professor of surgery/urology.

Publication of the Value of Urodynamic Evaluation (ValUE) study has drawn attention to whether urodynamics improves patient outcomes when added to an office evaluation of stress urinary incontinence (SUI) before surgical intervention. The well-designed study included patients with mixed UI, with SUI being predominant. Two articles in this issue of Urology Times discuss recent analyses of the ValUE data (see pages 1 and 9).

The primary finding was that the addition of urodynamics did not change surgical outcomes and patient satisfaction at 12 months in patients demonstrating SUI on exam and an uncomplicated history.

It should be emphasized that this finding only applies to uncomplicated, stress-predominant UI. Urodynamics is indicated when there is a history of SUI that is not demonstrable on exam, prior history of SUI surgery, obstructive symptoms, pelvic radiation, grade >2 prolapse of anterior vaginal compartment, neurologic disease, elevated postvoid residual, or recent pelvic surgery.

Urodynamic testing is useful in confirming the diagnosis of SUI but is not correlated to the degree of incontinence. The additional information gained from urodynamic studies (UDS) has to be considered in the context of the clinical scenario and the test’s limitations. In cases of a clinically uncomplicated history and physical demonstration of SUI, there was 97% agreement with urodynamics in the ValUE study. The additional information of urodynamics did result in a different diagnosis in 57% of women, while the treatment plan changed in only 14%. A subgroup analysis in these 14% found no change in outcomes and satisfaction.

In other instances, the information gained from urodynamics may be of more value. This includes the presence of complicating factors with SUI or a history of SUI that is not demonstrable on exam. Urodynamics may aid in diagnosis in these instances, although videourodynamics may be the only modality able to diagnose a small amount of leakage or outlet obstruction.

In summary, the ValUE study confirms that an office evaluation is adequate for women with uncomplicated history of SUI on exam. Consideration may be given to updating the AUA guidelines on urodynamics to indicate that multichannel UDS can be performed selectively before surgical intervention. Omitting unnecessary testing can result in health care savings and spare the patient potential morbidity.UT