Viviane Dietz

Can preoperative urodynamic investigation be omitted in women with stress urinary incontinence? A non-inferiority randomized controlled trial†‡§

To assess in women with stress urinary incontinence (SUI) the value of urodynamics prior to treatment.

Protocol for the value of urodynamics prior to stress incontinence surgery (VUSIS) study: a multicenter randomized controlled trial to assess the cost effectiveness of urodynamics in women with symptoms of stress urinary incontinence in whom surgical treatment is considered.

BackgroundStress urinary incontinence (SUI) is a common problem. In the Netherlands, yearly 64.000 new patients, of whom 96% are women, consult their general practitioner because of urinary incontinence. Approximately 7500 urodynamic evaluations and approximately 5000 operations for SUI are performed every year. In all major national and international guidelines from both gynaecological and urological scientific societies, it is advised to perform urodynamics prior to invasive treatment for SUI, but neither its effectiveness nor its cost-effectiveness has been assessed in a randomized setting.The Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) study evaluates the positive and negative effects with regard to outcome, as well as the costs of urodynamics, in women with symptoms of SUI in whom surgical treatment is considered.Methods/designA multicentre diagnostic cohort study will be performed with an embedded randomized controlled trial among women presenting with symptoms of (predominant) SUI.Urinary incontinence has to be demonstrated on clinical examination and/or voiding diary. Physiotherapy must have failed and surgical treatment needs to be under consideration.Patients will be excluded in case of previous incontinence surgery, in case of pelvic organ prolapse more than 1 centimeter beyond the hymen and/or in case of residual bladder volume of more than 150 milliliter on ultrasound or catheterisation.Patients with discordant findings between the diagnosis based on urodynamic investigation and the diagnosis based on their history, clinical examination and/or micturition diary will be randomized to operative therapy or individually tailored therapy based on all available information.Patients will be followed for two years after treatment by their attending urologist or gynaecologist, in combination with the completion of questionnaires.Six hundred female patients will be recruited for registration from approximately twenty-seven hospitals in the Netherlands. We aspect that one hundred and two women with discordant findings will be randomized.The primary outcome of this study is clinical improvement of incontinence as measured with the validated Dutch version of the Urinary Distress Inventory (UDI). Secondary outcomes of this study include costs, cure of incontinence as measured by voiding diary parameters, complications related to the intervention, re-interventions, and generic quality of life changes.Trial registrationClinical Trials NCT00814749.

Vaginal surgery for uterine descent; which options do we have? A review of the literature

Several vaginal procedures are available for treating uterine descent. Vaginal hysterectomy is usually the surgeon’s first choice. In this literature review, complications, anatomical and symptomatic outcomes, and quality of life after vaginal hysterectomy, sacrospinous hysteropexy, the Manchester procedure, and posterior intravaginal slingplasty are described. All procedures had low complication rates, except posterior intravaginal slingplasty, with a tape erosion rate of 0–21%. Minimal anatomical success rates regarding apical support ranged from 85% and 93% in favor of the Manchester procedure. Data on symptomatic cure and quality of life are scarce. In studies comparing vaginal hysterectomy with sacrospinous hysteropexy or the Manchester procedure, vaginal hysterectomy had higher morbidity. Because no randomized, controlled trials have been performed comparing these surgical techniques, we can not conclude that one of the procedures prevails. However, one can conclude from the literature that vaginal hysterectomy is not the logical first choice.

Samenvatting van de nieuwe Nederlandse richtlijn urine-incontinentie

SamenvattingDit artikel vat de aanbevelingen uit de ‘Richtlijn Urine-incontinentie’ samen. Deze richtlijn is een voor de Nederlandse situatie aangepaste versie van de evidence-based ‘EAU Guideline on Urinary Incontinence’ uit 2013. Zowel diagnostiek, conservatieve (niet-medicamenteuze en medicamenteuze) behandeling als chirurgie komt uitvoerig aan bod. Al deze aanbevelingen hebben als doel de zorg voor patiënten met urine-incontinentie in de tweede en derde lijn richting te geven. Voor uitvoerige beschrijvingen van de literatuur en gebruikte methoden wordt verwezen naar de eigenlijke richtlijn. Deze is te vinden op de website van de NVU (www.nvu.nl).SummarySummary of the new Dutch guidelines on urinary-incontinenceThis paper summarizes the recommendations made in the new Dutch ‘Richtlijn Urine-incontinentie’ (Guidelines on Urinary Incontinence). These guidelines are based upon the 2013 EAU Guidelines on Urinary Incontinence. Diagnosis, conservative treatment, medical treatment and surgical treatment are thoroughly discussed. All these recommendations serve to guide the care for patients in second and third line centers. Thorough discussions on the literature are not included in this summary article; those interested in the literature upon which the recommendations are based should read the Guidelines (which can be found at www.nvu.nl).

Buttock pain after sacrospinous hysteropexy: reply to Wallner

We greatly appreciate the comment by Dr. Wallner [1] on the new insight into the positioning of the pudendal and levator ani nerves in relation to the complaint of buttock pain after sacrospinous hysteropexy [2].