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Glup montecchio dynamic testing in sui & pelvic prolapse_vignoli


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Glup Montecchio 24-9-10

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Glup montecchio dynamic testing in sui & pelvic prolapse_vignoli

  1. 1. Dynamic testing in SUI & Pelvic Prolapse
  2. 3. Urodynamics : which test and when? <ul><li>In recent years the role of urodynamics in the assessment of stress urinary incontinence (SUI) has become contentious. </li></ul><ul><li>Proponents and Opponents </li></ul><ul><li>Result : the literature is contradictory and lacks adequate evidence, rendering meaningful conclusions difficult. </li></ul>
  3. 4. Cons: The NICE document <ul><li>The Guideline states : </li></ul><ul><li>Pre-op UDS are NOT necessary for women with “ pure symptoms of SUI “ </li></ul><ul><li>The management of Urinary incontinence in women.NICE Clinical Guideline 40 ,2006 </li></ul>
  4. 5. Pro: Agur et a , 2009
  5. 6. Agur et a , 2009
  6. 7. Cons: Limited effect of UDS on decision-making and outcome <ul><li>Pro : Griffiths D , ICI Report on Dynamic Testing , 2005 </li></ul><ul><li>All patients in any symptom group ( i.e, SUI ) have similar underlying pathophysiology requiring similar treatment , and so UDS cannot classify them any better than symptoms alone </li></ul><ul><li>Current treatments are so non-specific that underlying dysfunction is unimportant : treatment works equally well or poorly in any case </li></ul>
  7. 8. Pro : Digesu et a.,2009
  8. 9. Risk factors in SUI & Prolapse surgery <ul><li>Detrusor dysfunction ( including de novo urgency) </li></ul><ul><li>ISD vs Hypofunctional urethra </li></ul><ul><li>Emptying problems </li></ul>
  9. 10. Detrusor dysfunction ( including de novo urgency )
  10. 11. Pro: Flisser A & Blaivas J , J.Urol , 2003 Urgency : the spectrum of urodynamics
  11. 12. Cons : G. Hosker - Committee 6 -Dynamic testing ICI ,2008
  12. 15. Urethral function studies VLPP - MUCP
  13. 16. Artibani W , Point - Counterpoint , AUA 2010
  14. 31. Emptying problems
  15. 32. <ul><li>Cons : </li></ul>
  16. 33. Emptying problems The Fact Sheet <ul><li>Pro: </li></ul><ul><li>Almost half of all women with advanced POP experienced incomplete bladder emptying </li></ul><ul><li>Dain L,Auslander R,Rosen T et a.Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms.Int J Gynaecol Obstet , 2010 </li></ul><ul><li>Recent evidence suggests that 35.5% of women with SUI have a PVR greater than 50 ml and 15.9% have a PVR greater than 100 ml . </li></ul><ul><li>Tseng LH, Liang CC, Chang YL,  et al . Postvoid residual urine in women with stress incontinence. Neurourol Urodyn 2008; 27:48–51 . </li></ul><ul><li>Approx. 25% of patients with SUI show detrusor underactivity or acontractile detrusor accounting for 36% failure rate after mid-urethral sling placement. </li></ul><ul><li>Kuo HC. Effect of detrusor function on the therapeutic outcome of sub-urethral sling procedure using a polypropilene sling for stress urinary incontinence in women.Scand J Urol Nephrol 2007;41:138-43 </li></ul><ul><li>Cons: </li></ul><ul><li>The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05). </li></ul>
  17. 34. Cons : Conclusions
  18. 35. Pro : Conclusions 1 <ul><li>SUI has a complex multifactorial mechanism which at present is poorly understood </li></ul><ul><li>Urodynamic evaluation may be rather primitive and questionable </li></ul><ul><li>BUT </li></ul><ul><li>Today we have nothing better </li></ul>
  19. 36. Pro: Conclusions 2 <ul><li>Any urodynamic parameter must be correctly interpreted </li></ul><ul><li>Any incongruence with the clinical picture should act as a red flag and imply a more detailed evaluation </li></ul><ul><li>Risk stratification is the basis of rational treatment recommendations in the context of scientific available evidence </li></ul>