Glup montecchio diagnosi urodinamica semplificata-torino_vignoli

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Glup Montecchio 24-9-10

Glup Montecchio 24-9-10

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  • 1. UDS ASSISTANT A Software for Urodynamic Semi-Automated Diagnosis
  • 2. Why a Software ?
    • In recent years the role of urodynamics in the assessment of lower urinary tract dysfunctions has become contentious
    • Often the literature is contradictory and lacks adequate evidence, rendering meaningful conclusions difficult
    • In an attempt to overcome these shortcomings the International Continence Society (ICS) has published a number of standardization reports to guide clinical and research activity .
  • 3. ECG Automated Diagnosis
    • “ Electrical” spikes & segments
    • “ Pressure” spikes & segments
  • 4. Algorithms Sources-I
    • An international urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction
    • Bernard T. Haylen 
    • Dirk de Ridder
    • Robert M. Freeman
    • Steven E. Swift
    • Bary Berghmans 
    • Joseph Lee 
    • Ash Monga 
    • Eckhard Petri 
    • Diaa E. Rizk
    • Peter K. Sand 
    • Gabriel N. Schaer
    • Neurourol Urodyn 2010
  • 5. Algorithms Sources -II
  • 6. Display
  • 7. Single vs multichannel UDS
  • 8. Quality control procedure before Pressure/Flow study
  • 9. Neurogenic patient
  • 10. Final report ( neurogenic patient )
  • 11. Algorithms Rationale
  • 12. Flowmetry Analysis Siroky - male < 50 yrs Bristol - male > 50 yrs Liverpool - female
  • 13. Male Free Flow Predictive Value
    • Unobstructed Qmax >15ml/s
    • ( Warning : 50% may be obstructed – High Pressure / High Flow )
    • Equivocal Qmax 10 to15 ml/s
    • ( Warning : 70% may be obstructed ; 30% may be unobstructed – DU
    • Obstructed Qmax<10ml/s
    • ( Warning : 10% may be unobstructed – DU
    • Source : Abrams P et a ,The ICS-BPH Study…, Br. J.Urol ,1998
  • 14. Pediatric Free Flowmetry Analysis
    • Warning :“staccato “ curve may indicate dysfunctional voiding.Check P/F & surface EMG
  • 15. Residual Urine
    • Warning : > 200ml check upper tract for dilation
  • 16. Filling Phase (Cystometry) Analysis
    • Normal tracing
    • Overactive Bladder
    • ( clinically < 15 cm H20 significant contractions)
    • Hypersensitive Bladder
    • ( early sensation < 100ml whithout contractions )
    • Low Compliance Bladder
    • ( > 10 cmH20 at cystometric capacity)
    • Yukio Homma ,2007
  • 17. PRESSURE/ FLOW ANALYSIS-Male ICS Nomograms
    • BOO Index: pdetMax-2Qmax
    • >40 obstructed
    • 20-40 equivocal
    • <20 unobstructed
    • BC Index: pdetMax+5Qmax
    • 150 strong
    • 100-150 normal activity
    • <100 weak
    • Abrams P, 1999
  • 18. Female voiding nomogram ( Groutz A & Blaivas J , Neurourol Urodyn 2000 ;19:553 )
    • Qmax < 12 ml /s ( non-intubated flow)
    • pdet max > 20 cmH20 ( not pdetQmax )
  • 19. Urethral function tests
  • 20.  
  • 21. Pressure Transmission Rate
  • 22. Intrinsic Urethral Function
    • Valsalva Leak Point Pressure
    • >90 cm H20 Hypermobility
    • between 60 and 90 cm H20 Equivocal
    • <60 cm H20 ISD
    • Maximal Urethral Closure Pressure
    • < 20 cm H20 ISD
    • Hypofunctional urethra ?
  • 23. “ The Hypofunctional Urethra”
    • “ While historically it has been helpful to categorize SUI, particularly when choosing an appropriate intervention, it must be remembered that these are simplistic/arbitrary concepts which belittle the complex nature of the underlying pathophysiology.
    • The majority of women will have varying amounts of urethral hypermobility and ISD combined with varying degrees of pelvic floor weakness and prolapse.
    • Unfortunately, there remains little consensus on how best to define ISD and urethral hypermobility and how to accurately assess them .”
    • Chapple C ,Patel A , Curr. Opin. Urology , 2008
  • 24. MUCP by age
    • decreases by 15 cm H20 per decade starting from 90 cm H20 at 25 yrs. ( Kapoor D & Abrams , P )
    • SIFUD formula : MUCP = 110 minus age
    • Example : a woman of 72 yrs should have a theoretical MUCP of : 110-72= 38 cmH20
    • The values between 20 and 38 cmH20 indicate a possible “hypofunctional” urethra
    • The values under 20 cm H20 indicate a possible ISD
  • 25. Dysfunctional voiding
    • ICS : Dysfunctional voiding is an intermittent and / or fluctuating flow rate due to involuntary intermittent contractions of peri-urethral striated muscle during voiding in neurologically normal patients
    • Male : 35% of bladder outlet obstruction especially in young adults
    • Khuo HC . Videourodynamic analysis of pathophysiology of men with both storage and voiding lower urinary tract symptoms.Urology 2007;70:272-6
    • Female : common in painful bladder and related pelvic floor syndromes
    • Kim SH,KimTB,Kim SW et a .Urodynamic findings of the painful bladder syndrome/interstitial cystitis : a comparison with idiopathic overactive bladder.J Urol 2009;181:2550-4
    • Gold Standard : Pressure / Flow & EMG
    • Office Urodynamics : Intermittent flow &
    • MUCP Female : excedent 10 cmH20 age - dependent value
    • MUCP Male : excedent 10 cm H20 a fixed value of 120 cm H20
  • 26. Incontinence after radical prostatectomy
    • Multifactorial etiology
    • Porena M ,Mearini E,Mearini L .Giannantoni A. Voiding disfunction after readical retropubic prostatectomy: more than external urethral sphincter mechanism.Eur Urol 2007; 52:38-45
    • Quantification of sphincteric damage important (balloons , sling surgery)
    • MUCP more reliable than VLPP
    • Comiter C ,Sullivan M,Yalla S .Correlation among maximal urethral closure pressure, retrograde leak point pressure and abdominal leak point pressure in men with postprostatectomy stress incontinence. Urology 2003 ;62:75-8
    • Kielb S , Clemens J Comprehensive urodynamics evaluation of 146 men after radical prostatectomy , Urology 2005;66:392-396
    • MUCP between 60 and 80 cm H20 mild sphincteric weakness,
    • MUCP between 40 and 60 cm H20 moderate sphincteric weakness
    • MUCP under 40 cm H20 severe sphincteric weakness.
  • 27. Neurogenic Bladder Algorithm
    • DETRUSOR :
    • Normal
    • Hyperactive
    • Hypoactive
    • Compliance normal
    • Compliance low
    • SPHINCTER:
    • Normal
    • Hyperactive
    • Hypoactive
    • Source : ICI – Madersbacher Classification,2002
  • 28. EMG Quantitative (kinesiological) Analysis
    • Synergic activity
    • Dyssinergic activity
    • Low amplitude activity*
    • * Warning : Possible peripheral denervation / check for electrophysiological EMG
  • 29. Agreement between software and examiner diagnosis on sample of 100 pts
    • Examiner skill : High( expert urodynamist ) ,average ( residents ),poor ( clinicians not involved in urodynamics )
    • Twelve examens rejected for inadequacy despite examiner diagnosis
    • Seventy-six examens: routine - Twenty-four examens : difficult cases
    • LUT dysfunction N° pts Diagnostic agreement %
    • Female incontinence 32 12/32 23.44
    • Male BOO 36 18/36 50
    • Neurogenic bladder 20 18/20 90
    • Overall 88 48/88 54.5
  • 30. Summary
    • Computer-based UDS diagnosis should minimize the total number of incorrect diagnoses
    • Studies to assess validation of the programme on larger scale and the effects on intra-and inter-observer variability of urodynamic diagnosis are under way
    • The computer may be an useful instrument to teach urodynamics
    • However , it must remain an adjunct to the physician not a substitute
  • 31.  
  • 32.  
  • 33.  
  • 34. UDS ASSISTANT Clinical Samples
  • 35.  
  • 36.  
  • 37.  
  • 38.  
  • 39.  
  • 40.  
  • 41. Summary
    • Computer-based UDS diagnosis should minimize the total number of incorrect diagnoses
    • Studies to evaluate sensitivity , specificity and predictive values of algorithms for single LUT diagnosis are under way
    • Since clinically important errors in automated diagnosis may exists,the computer remains an adjunct to the physician , not a substitute.
  • 42.  
  • 43.  
  • 44. Hypermobility vs ISD:from dychotomy to continuum
  • 45. Urethral Function Assessment
    • ISD definition
    • MUCP :
    • - Cut-off : 20 cm H20
    • VLPP :
    • - Cut-off : <60 cm H20 ; between 60 – 90 ; > 90 cmH20
    • HYPOFUNCTIONAL URETHRA definition
    • MUCP age – related :
    • - Minus 15 cm H20 per decade
    • - SIFUD formula : 110 minus age
  • 46. Compliance Analysis
  • 47. Laborie UDS Trainer Derek Griffiths ICS 2007
  • 48. UDS-ASSISTANT A Software for Urodynamic Automated Diagnosis
  • 49.  
  • 50.  
  • 51. Urodynamic Investigation Epitome
    • Standardization of Terminology ( ICS )
    • ( we have to speak the same language )
    • “ Good Urodynamic Practice”
    • ( we have to do a right examen )
    • Tracing Interpretation
    • ( that ‘s is a difficult isssue ! )
    • Translation into Clinical Practice
    • ( that’is a “tremendously” difficult issue ! )
  • 52. Tracing Interpretation
    • The experience of the Authors and anectodal evidence from others indicate that most of the time the personel carrying out urodynamics have little understanding of what the recordings mean.
    • Indeed ,there are instances of recordings being sent to the manufacturer for their interpretation!
  • 53. Software Sources
  • 54. Software Sources
  • 55. Software Sources
  • 56. Software Sources
    • Madersbacher H et a.
    • Conservative
    • Management
    • in Neuropathic
    • Urinary Incontinence
  • 57.
    • In case of controversial values , Author experience has been favoured.
    • However , the choosen values may be changed , according to personal preferences, without modifying the reliability of the algorithm
  • 58. Display Sample
  • 59. Display Sample
  • 60. Flowmetry Nomograms
    • Siroky nomogram
    • Bristol nomogram
    • Liverpool nomogram
  • 61. Siroky Nomogram Male < 50 yrs
  • 62. Bristol Nomogram Male > 50 yrs
  • 63. Liverpool Nomogram Female
  • 64. Male Free Flowmetry Predictive Value
    • Question :
    • “ Should all patients with LUTS have pressure-flow studies?”
  • 65. Display Sample
  • 66. Cistometry Display
  • 67. Diagnosis
  • 68. Urethral Function Analysis
  • 69. Male Pressure / Flow Display
  • 70. Female Pressure / Flow Display
  • 71. Display Sample
  • 72. Neurologic Patient Display
  • 73. Clinical Examples
  • 74.
    • Case 1 : 42 y.o. active tennis
    • player.Two vaginal deliveries.
    • She needs pads during matches.
  • 75. Case 2 : 72 y.o. women.Mixed incontinence. Previous hysterectomy & ant. and post. repair. TVT failed
  • 76. Case 4 :62 y.o. man with urgency,frequency,nocturia
  • 77. Conclusions
    • The purpose of the software is just to give some skill in interpreting the findings
    • The software does’nt substitute in any way the clinical experience
    • To get the best from a urodynamic investigation, it is necessary to understand the patient’s complaint and distinguish clinically significant findings from equipment malfunction.
    • The software may ensure consistency between all who carry out urodynamics
    • Once validated , it may be an instrument for the assessment of clinical reliabilty of current urodynamic tests
  • 78. Future Software Developments
    • Pediatric Urodynamics
    • Options for Treatment
  • 79. Urodynamics in Pediatric Age
    • Adjustments for :
    • Flowmetry ( Liverpool Nomogram )
    • Bladder Capacity ( Age x 30 + 30)
    • 6 years old boy : 6x30+30 = 210 ml
  • 80. Options for Treatment
    • Sources
    • EAU Guidelines
    • AUA Guidelines
    • ICI Guidelines
    • Cochrane Reviews
    • NICE Reviews
    • High IF articles , ecc…..
  • 81.  
  • 82.  
  • 83.  
  • 84.  
  • 85.  
  • 86.