Suneetha Rachaneni

Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-analysis.

Urodynamics is widely used in the investigation of urinary incontinence. The existing evidence questions its add‐on value in improving the outcome of surgical treatment for stress urinary incontinence (SUI).

Urinary nerve growth factor: a biomarker of detrusor overactivity? A systematic review

Nerve growth factor (NGF) is a signalling protein that interacts with specific receptors in autocrine, paracrine and endocrine modes. It is produced by bladder smooth muscle and urothelium. Patients with overactive bladder and detrusor overactivity (DO) have been found to have increased urinary NGF levels in several small studies. The objective of the review was to assess the accuracy of NGF as a biomarker in the diagnosis of DO by a systematic review of the literature. A systematic search of MEDLINE, Embase, CINAHL, MEDION and LILACS databases was conducted (inception till December 2012). Selection criteria included studies where NGF (as a biomarker for DO) and urodynamics were performed in humans with symptoms of overactive bladder. Two reviewers independently selected articles and extracted data on study characteristics, quality and results. All the eight included studies were of case-control design. A meta-analysis was not performed as there were variations in the quality, methods of performing the NGF assay, different NGF cut-offs used and the format of reporting findings. Two studies used a cut-off of 0.05 for NGF levels. Six studies observed a trend towards higher NGF levels in patients with DO. There was a trend towards higher NGF in patients with DO. However, the data are imprecise and hence cannot be recommended for use in current clinical practice.

Ultrasound bladder wall thickness and detrusor overactivity: a multicentre test accuracy study

Women with overactive bladder (OAB) often undergo urodynamics before invasive treatments are considered. Ultrasound measurement of bladder wall thickness (BWT) is a less invasive, less expensive and widely available test. It has the potential to diagnose the presence of detrusor overactivity (DO). We aimed to evaluate the accuracy of BWT in the diagnosis of DO.

Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study.

Objective To compare the cost-effectiveness of bladder ultrasonography, clinical history, and urodynamic testing in guiding treatment decisions in a secondary care setting for women failing first line conservative treatment for overactive bladder or urgency-predominant mixed urinary incontinence. Design Model-based economic evaluation from a UK National Health Service (NHS) perspective using data from the Bladder Ultrasound Study (BUS) and secondary sources. Methods Cost-effectiveness analysis using a decision tree and a 5-year time horizon based on the outcomes of cost per woman successfully treated and cost per Quality-Adjusted Life-Year (QALY). Deterministic and probabilistic sensitivity analyses, and a value of information analysis are also undertaken. Results Bladder ultrasonography is more costly and less effective test-treat strategy than clinical history and urodynamics. Treatment on the basis of clinical history alone has an incremental cost-effectiveness ratio (ICER) of £491,100 per woman successfully treated and an ICER of £60,200 per QALY compared with the treatment of all women on the basis of urodynamics. Restricting the use of urodynamics to women with a clinical history of mixed urinary incontinence only is the optimal test-treat strategy on cost-effectiveness grounds with ICERs of £19,500 per woman successfully treated and £12,700 per QALY compared with the treatment of all women based upon urodynamics. Conclusions remained robust to sensitivity analyses, but subject to large uncertainties. Conclusions Treatment based upon urodynamics can be seen as a cost-effective strategy, and particularly when targeted at women with clinical history of mixed urinary incontinence only. Further research is needed to resolve current decision uncertainty.

Authors' reply re re: Does preoperative urodynamics improve outcome for women undergoing surgery for stress urinary incontinence? A systematic review and meta - analysis.

Sir, We thank both Niels Klarskov and Gunnar Lose for their continued interest in our published systematic review and meta-analyses on the role of preoperative urodynamics in stress urinary incontinence (SUI) surgery. We agree that uroflowmetry is a non-invasive part of urodynamics. Many clinicians use only uroflowmetry in isolation rather than complete urodynamics procedure on several occasions to assess voiding. Hence we did not use the two terms ‘uroflowmetry’ and ‘urodynamics’ synonymously. We hope that we have clarified the use of uroflowmetry as an office test to assess voiding function without the insertion of urethral catheter and filling of the bladder to assess lower urinary tract function. Niels Klarskov and Gunnar Lose seem to use noninvasive urodynamics as an alternative term for uroflowmetry. However, other authors have stated a range of techniques such as drop spectrometry, condom catheter, penile cuff inflation/ deflation, penile compression and release and bladder wall thickness as well as uroflowmetry for non-invasive urodynamics. So the use of a nonspecific term such as non-invasive urodynamics may be completely misleading. With regard to their second comment —‘two of which (689 patients together) investigate the value of uroflowmetry and found no value of uroflowmetry in patients with uncomplicated SUI or predominant SUI’—we would like to point out that we have not stated the above in our manuscript. We share Niels Klarskov and Gunnar Lose’s concern about placing midurethral tapes in patients with voiding dysfunction. One of the RCTs in our systematic review had 11.9% of women with voiding dysfunction in the urodynamics group and all of them had a postvoid residual (PVR) <150 ml, which was their inclusion criteria. However, our systematic review included three RCTs. Based on their findings we have recommended performance of uroflowmetry and PVR scan as a part of office evaluation to exclude voiding dysfunction before contemplating surgery for SUI. So all of this argument about why to perform uroflowmetry and exclude voiding dysfunction if voiding dysfunction does not matter is irrelevant to our systematic review and metaanalysis. The sub-group analyses which the authorsmention in their letter is not a part of our systematic review and hence we cannot comment on its statistical significance.&