When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

INTRODUCTION AND HYPOTHESIS: Development of a model that can predict in which group of women pre-operative urodynamics can be safely omitted. METHODS: Three hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20 cm H2O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics. RESULTS: Women are likely to benefit from pre-operative urodynamics if they (1) are 53 years of age or older or (2) have a history of prior incontinence surgery and are at least 29 years of age or (3) have nocturia complaints and are at least 36 years of age. CONCLUSION: If urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29

Uterine Artery Embolization in Patients with a Large Fibroid Burden: Long-Term Clinical and MR Follow-up

Uterine artery embolization (UAE) in patients with a large fibroid burden is controversial. Anecdotal reports describe serious complications and limited clinical results. We report the long-term clinical and magnetic resonance (MR) results in a large series of women with a dominant fibroid of >10 cm and/or an uterine volume of >700 cm3. Seventy-one consecutive patients (mean age, 42.5 years; median, 40 years; range, 25–52 years) with a large fibroid burden were treated by UAE between August 2000 and April 2005. Volume reduction and infarction rate of dominant fibroid and uterus were assessed by comparing the baseline and latest follow-up MRIs. Patients were clinically followed at various time intervals after UAE with standardized questionnaires. There were no serious complications of UAE. During a mean follow-up of 48 months (median, 59 months; range, 6–106 months), 10 of 71 patients (14%) had a hysterectomy. Mean volume reduction of the fibroid and uterus was 44 and 43%. Mean infarction rate of the fibroid and overall fibroid infarction rate was 86 and 87%. In the vast majority of patients there was a substantial improvement of symptoms. Clinical results were similar in patients with a dominant fibroid >10 cm and in patients with large uterine volumes by diffuse fibroid disease. In conclusion, our results indicate that the risk of serious complications after UAE in patients with a large fibroid burden is not increased. Moreover, clinical long-term results are as good as in other patients who are treated with UAE. Therefore, a large fibroid burden should not be considered a contraindication for UAE

Perspectives by patients and physicians on outcomes of mid-urethral sling surgery

Introduction and hypothesis: The aim of this study is to determine patient expectations regarding wanted and unwanted sequels of mid-urethral sling (MUS) procedures and to identify mismatches during the physician-patient information exchange prior to MUS procedures. Methods: A patient preference study (40 patients) and a questionnaire study with 20 experts as control group were conducted. Seventeen different sequels, defined by an expert team, were evaluated. Results: Both patients and expert physicians ranked cure and improvement of stress urinary incontinence as the most important goals of treatment. De novo urge urinary incontinence, requiring post-operative intermittent self-catheterisation and dyspareunia were considered to be the most important complications by patients. Time to resume work after the operation and dyspareunia were among the highest rated sequels in the patient group compared to re-operation and intra-operative complications in the expert group. Conclusions: No differences were found in the five most important outcome parameters. In pre-operative counselling and future clinical trials, time to resume work and dyspareunia should be given more consideration by clinicians

Predictive Value of Urodynamics on Outcome After Midurethral Sling Surgery for Female Stress Urinary Incontinence EDITORIAL COMMENT

Urodynamic investigation (UDI) is routinely performed before midurethral sling surgery (MUS) for female stress urinary incontinence to detect factors that may adversely affect the surgical outcome or confirm the diagnosis. A recent review, however, concluded that there was insufficient evidence to demonstrate that the likelihood of incontinence was less among women who had preoperative UDI compared to those without the testing. This retrospective cohort study assessed the predictive value of UDI in the workup of 3 different midurethral sling procedures and determined risk factors associated with surgical failure. Data was obtained from the medical records of 437 patients with incontinence, who underwent UDI before surgical treatment with tension-free vaginal tape (TVT), Monarc, or TVT-obturator procedures. No other urogynecologic surgery was performed at the same time. The mean follow-up period was 14 months. The study cases had been included in prior prospective studies investigating the surgical outcome of the TVT and TVT-obturator procedures in women with female stress urinary incontinence. Women who had no loss of urine after physical exercise were considered to be cured. The report of any amount of leakage was considered a failure. The cure rate in the 437 patients who were treated with MUS was 79%, and there was no statistically significant difference in cure rate between the 3 procedures. Multivariate logistic regression analysis showed that risk factors associated with failure of MUS were mixed urinary incontinence (P = 0.042), previous incontinence surgery (P = 0.022), and detrusor overactivity (P = 0.024). None of the urodynamic parameters evaluated had any predictive value for failure in patients with mixed urinary incontinence or previous incontinence surgery. There was predictive value for patients with detrusor overactivity, which represents only 6% of the patient population. These findings indicate that UDI may have no overall clinically significant predictive value for failure of midurethral sling procedures. Only a small percentage of patients with detrusor overactivity appear to benefit from UDI. The investigators suggest that the current practice of routine UDI before the surgery should be reconsidered