Glup montecchio diagnosi urodinamica semplificata-torino_vignoli

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Glup Montecchio 24-9-10

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Glup montecchio diagnosi urodinamica semplificata-torino_vignoli

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

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