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L’indagine urodinamica prima della chirurgia per IUS - PRO
1.
2.
3.
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
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
15. Conclusions:
The omission of urodynamics is not inferior to the
inclusion of urodynamics in the preoperative workup
in women with (predominant) SUI.
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?
19.
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?
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?
23.
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
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
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
