Is detrusor underactivity associated with voiding dysfunction after single incision sling surgery?

BACKGROUND: Some women experience voiding dysfunction after stress urinary incontinence (SUI) surgery. We explore if detrusor underactivity (DU) found in urodynamic study (UDS) prior to SUI surgery using an adjustable single incision sling (SIS) may be related to voiding dysfunction after surgery. METHODS: This is a prospective, diagnostic, transversal, single center study comparing voiding dysfunction after SUI surgery with a SIS (Altis®; Coloplast, Humlebæk, Denmark) between women with DU (cases) or normal detrusor (controls). Inclusion criterium was women ≥18 years with SUI/mixed UI (stress predominant) operated between June 2013 and December 2020. Exclusion criteria were: women without UDS prior to surgery or without voiding phase in the P/Q, previous incontinence surgery, POP stage ≥2, neurogenic conditions, other pelvic floor surgery. Urinary symptoms were assessed using structured questions evaluating storage/voiding symptoms. Patients were divided into two groups according to projected Isovolumetric Pressure Index (PIP1) with 30-75 cmH2O indicating normal contractility. RESULTS: A total of 139 women were included, 29 (20.9%) in DU group and 110 (79.1%) in control group. Control and DU groups have shown similar objective (75.5% vs. 71.4% P=0.66) and subjective (85.4% vs. 96.1% P=0.22) success rates, respectively, without statistical differences. Voiding symptoms increased after surgery in both groups (+20.7% DU group vs. +8.1% normal group, P=0.29). More voiding symptoms (persistent/de novo) were found in DU group vs. normal group, but without statistically significant differences. CONCLUSIONS: According to our results, the presence of DU previous to SUI surgery with a SIS (Altis®, Coloplast) has no impact on objective and subjective success rates. On the other hand, patients with preoperative DU showed higher proportion of voiding dysfunction but no statistical difference.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa).

Introduction: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement. Results: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or ß 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance. Conclusions: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

[Cystoscopy in the assessment of patients with bladder pain syndrome: Results of a national multicenter observational study.] / La cistoscopia en la evaluación del síndrome de dolor vesical: resultados de un estudio observacional multicéntrico nacional.

OBJECTIVES: To study the use and results of cystoscopy and bladder hydrodistension in the objective assessment of patients with Bladder Pain Syndrome (BPS), in routine clinical practice. MATERIAL AND METHODS: Observational, non-interventional, national, multicenter study carried out in Functional Urology and Urodynamic Units of Spain belonging to the IFU Group. 273 women with BPS who underwent cystoscopy at baseline as a diagnostic tool according to clinical criteria and following the routine clinical practice of each center, were studied. The pre and post hydrodistension findings and the scores of the symptom and Health-Related Quality of Life (HRQoL) questionnaires were described: BPIC-SS, PPBC, PGI-S and EQ-5D-5L. RESULTS: The mean age (SD) was 59 (14) years with a high presence of bladder symptoms: increased voiding frequency (81.7%), nocturia (74%) and urgency (60.4%). 40.7% of cystoscopies were performed under anesthesia and 73.7% uses a standard rigid cystoscope. Hunner lesions were observed in 9.9% of the patients, hypervascularizations (46.2%), glomerulations (23.4%), mild bleeding (6.6%) and scars (2.2%). After hydrodistension, a greater number of grade 1 and 2 lesions were observed. In 51.6% of the patients there were no changes, but in 27.5% slight changes were observed and in 11.4% moderate or severe changes. Symptom and HRQoL questionnaire scores showed no association with cystoscopy findings before and after hydrodistension. CONCLUSIONS: The value of the cystoscopic findings in the SDV has yet to be defined, although it plays a fundamental role in the differential diagnosis. In this observational study, we did not find a correlation of the cystoscopic findings with the symptoms of the patients, measured by validated questionnaires, nor with the HRQoL.

OBJETIVO: Analizar el uso y resultados de la cistoscopia y la hidrodistensión vesical para la evaluación objetiva de pacientes con Síndrome de Dolor Vesical (SDV), en el contexto de práctica clínica habitual.MATERIAL Y MÉTODOS: Estudio observacional, no intervencionista, multicéntrico de ámbito nacional, realizado en Unidades de Urología Funcional y Urodinámica de España pertenecientes al Grupo IFU en el que se analizaron 273 mujeres con SDV a las que se les realizó una cistoscopia a nivel basal como herramienta diagnóstica según criterio clínico y siguiendo la práctica clínica habitual de cada centro. Se describieron los hallazgos pre y post hidrodistensión y las puntuaciones de los cuestionarios de síntomas y de Calidad de Vida Relacionada con la Salud (CVRS): BPIC-SS, PPBC, PGI-S y EQ-5D-5L. RESULTADOS: La edad media (DE) fue de 59 (14) años con gran presencia de síntomas vesicales: frecuencia miccional aumentada (81,7%), nocturia (74,0%) y urgencia (60,4%). El 40,7% de las cistoscopias se realizaron bajo anestesia y en el 73,7% se empleó un cistoscopio rígido estándar. Se observaron lesiones de Hunner en un 9,9% de las pacientes, hipervascularizaciones (46,2%), glomerulaciones (23,4%), sangrado leve (6,6%) y cicatrices (2,2%). Tras la hidrodistensión se observó un mayor número de lesiones grado 1 y 2. En el 51,6% de las pacientes no hubo cambios, pero en el 27,5% se observaron cambios leves y en el 11,4% cambios moderados o graves. Las puntuaciones de los cuestionarios de síntomas y CVRS no mostraron asociación con los hallazgos de la cistoscopia antes y después de la hidrodistensión. CONCLUSIONES: El valor de los hallazgos cistoscópicos en el SDV está aún por definir, aunque juega un papel fundamental en el diagnóstico diferencial. En este estudio observacional no encontramos correlación de los hallazgos cistoscópicos con los síntomas de las pacientes, medidos por cuestionarios validados, ni con la CVRS.

Can radiation-induced lower urinary tract disease be ameliorated in patients treated for pelvic organ cancer: ICI-RS 2019?

AIMS: This article reviews the clinical outcomes and basic science related to negative effects of radiotherapy (RT) on the lower urinary tract (LUT) when used to treat pelvic malignancies. METHODS: The topic was discussed at the 2019 meeting of the International Consultation on Incontinence-Research Society during a "think tank" session and is summarized in the present article. RESULTS: RT is associated with adverse effects on the LUT, which may occur during treatment or which can develop over decades posttreatment. Here, we summarize the incidence and extent of clinical symptoms associated with several modes of delivery of RT. RT impact on normal tissues including urethra, bladder, and ureters is discussed, and the underlying biology is examined. We discuss innovative in vivo methodologies to mimic RT in the laboratory and their potential use in the elucidation of mechanisms underlying radiation-associated pathophysiology. Finally, emerging questions that need to be addressed through further research are proposed. CONCLUSIONS: We conclude that RT-induced negative effects on the LUT represent a significant clinical problem. Although this has been reduced with improved methods of delivery to spare normal tissue, we need to (a) discover better approaches to protect normal tissue and (b) develop effective treatments to reverse radiation damage.

[Functional urology during COVID-19: Recommendations during de-escalation.] / La urología funcional en la era COVID-19. Consejos para la desescalada.

OBJECTIVES: Due to the COVID-19 Pandemic, all surgical activity that was not life threatening was cancelled , as well as most face-to-face consultations. Currently the beginning of the de-escalation phases that will led us to a new normal, forces us to establish some degree of priority in the interventions as well as in the medical consultations. Our objective is to establish some recommendation on Functional Urology office visits and surgical interventions that serve as a tool to facilitate decision-making. MATERIAL AND METHODS: Experts in Functional Urology from different autonomous communities of Spain were contacted to design a strategy to reorganize the activity of both, diagnosis and treatment. A modified nominal group technique has been used due to the extraordinary restrictions of assembly and mobility during the COVID pandemic. The first signer (EMC) made the first draft with the measures adopted and the strategy to be followed during the evolution of the COVID-19 pandemic. The proposal was sent to the rest of the authors, in order to unify criteria and experiences to reach a quick consensus on the relative priority of the different activities, problems and solutions. A final version was approved by all authors May 27, 2020. RESULTS: Tables of recommendation have been prepared for outpatient consultation, surgical and technical interventions, according to de-escalation phases proposed by the Spanish Associations of Surgeons. CONCLUSIONS: The change that COVID-19 Pandemich as involved in our clinical practice force us to seek alternative methods to treat our patients, some of which may already be established. Mean while, a consensusin decision making is necessary. Documents such as the current one, are intended to guide the management of patients with urological functional pathology in exceptional situations. Logically, it should be adapted to material and human availability, and to the idiosyncrasy of each Urology service.

OBJETIVOS: Debido a la Pandemia COVID-19 se suspendió toda actividad quirúrgica que no fuera una urgencia vital, así como la mayoría de consultas presenciales. Actualmente el inicio de las fases dedesescalada que nos llevarán a una nueva normalidad nos obliga a establecer unos grados de prioridad en las intervenciones así como en las consultas médicas. Nuestro objetivo es establecer una serie de recomendaciones sobre las consultas de Urología Funcional y las intervenciones quirúrgicas que sirva como herramientade ayuda en la toma de decisiones.MATERIAL Y MÉTODOS: Expertos en Urología Funcionalde distintas comunidades autónomas de España fueron contactados para diseñar una estrategia parareorganizar la actividad tanto de diagnóstico como de tratamiento. Se ha utilizado una técnica de grupo nominal modificada debido a las restricciones extraordinarias de reunión y movilidad durante la pandemia COVID. El primer firmante (EMC) realizó el primer borrado rcon las medidas adoptadas y la estrategia a seguir durante la evolución de la pandemia COVID19. Se remitió la propuesta al resto de autores, con el fin de unificar criterios y experiencias para llegar a un rápido consenso sobre la importancia relativa de las distintas actividades, problemas y soluciones. Se realizó una versión definitiva, aprobada por todos los autores, el día 27 de mayo de 2020. RESULTADOS: Se han elaborado tablas de recomendaciones tanto para consultas externas, como para intervenciones quirúrgicas y técnicas, de acuerdo con las fases de desescalada propuestas por la Asociación Española de Cirujanos (AEC). CONCLUSIONES: El cambio que ha supuesto la Pandemia COVID-19 en nuestra práctica clínica nos obliga a buscar métodos alternativos para seguir y tratar a nuestros pacientes, algunos de los cuales pueden ya quedar instaurados. Mientras, es necesario un consenso en la toma de decisiones. Documentos como el actual, pretenden orientar en el manejo de los pacientes con patología funcional urológica en situaciones excepcionales. Lógicamente, deberá adaptarse alas disponibilidades materiales y humanas, y a la idiosincrasia de cada servicio de Urología.

Management of Female and Functional Urology Patients During the COVID Pandemic.

CONTEXT: Coronavirus disease 19 (COVID-19) has changed standard urology practice around the world. The situation is affecting not only uro-oncological patients but also patients with benign and disabling conditions who are suffering delays in medical attention that impact their quality of life. OBJECTIVE: To propose, based on expert advice and current evidence where available, a strategy to reorganize female and functional urological (FFU) activity (diagnosis and treatment). EVIDENCE ACQUISITION: The present document is based on a narrative review of the limited data available in the urological literature on SARS-Cov-2 and the experience of FFU experts from several countries around the world. EVIDENCE SYNTHESIS: In all the treatment schemes proposed in the literature on the COVID-19 pandemic, FFU surgery is not adequately covered and usually grouped into the category that is not urgent or can be delayed, but in a sustained pandemic scenario there are cases that cannot be delayed that should be considered for surgery as a priority. The aim of this document is to provide a detailed management plan for noninvasive and invasive FFU consultations, investigations, and operations. A classification of FFU surgical activity by indication and urgency is proposed, as well as recommendations adopted from the literature for good surgical practice and by surgical approach in FFU in the COVID-19 era. CONCLUSIONS: Functional, benign, and pelvic floor conditions have often been considered suitable for delay in challenging times. The long-term implications of this reduction in functional urology clinical activity are currently unknown. This document will help functional urology departments to reorganize their activity to best serve their patients. PATIENT SUMMARY: Many patients will suffer delays in urology treatment because of COVID-19, with consequent impairment of their physical and psychological health and deterioration of their quality of life. Efforts should be made to minimize the burden for this patient group, without endangering patients and health care workers.

Female neurogenic stress urinary incontinence.

PURPOSE OF REVIEW: The aim of this article is to look into recent updates on the management of neurogenic stress urinary incontinence (NSUI) in adult females. RECENT FINDINGS: Recently, a small number of studies have investigated different surgical modalities in treatment of NSUI in adult females including artificial urinary sphincter (AUS), suburethral tapes (SUT) and adjustable slings and urethral bulking agents. Up to 70% of neurogenic patients who received AUS implants are continent and have not required surgical revision over a 20-year follow-up period. However, the risk for explantation of AUS may be twice as high in neurogenic patients compared with nonneurogenic patients. SUT have success and improvement in quality of life rates of up to 52 and 68%, respectively. However, complications may be as high as 24%. Early data on adjustable slings may suggest up to 80% continence with low complication rates. SUMMARY: AUS can provide satisfactory continence levels with acceptable rates of revision and explantation. SUT are effective but more than half of patients may require additional procedures. Adjustable slings could be a promising option. Further high-quality studies with careful attention to methodology and standardization of both definitions used and outcome reporting are required to help us reach safe conclusions.

What developments are needed to achieve less-invasive urodynamics? ICI-RS 2019.

AIMS: To assess the state of technologies for urodynamics that are less invasive than standard cystometry and pressure-flow studies and to suggest areas needing research to improve this. METHODS: A summary of a Think Tank debate held at the 2019 meeting of the International Consultation on Incontinence Research Society is provided, with subsequent analysis by the authors. Less-invasive techniques were summarized, classified by method, and possible developments considered. Discussions and recommendations were summarized by the co-chairs and edited into the form of this paper by all authors. RESULTS: There is a full spectrum of technologies available for less-invasive assessment, ranging from simple uroflowmetry through imaging techniques to emerging complex technologies. Less-invasive diagnostics will not necessarily need to replace diagnosis by, or even provide the same level of diagnostic accuracy as, invasive urodynamics. Rather than aiming for a technique that is merely less invasive, the priority is to develop methods that are either as accurate as current invasive methods, or spare patients from the necessity of invasive methods by improving early triaging. CONCLUSIONS: Technologies offering less-invasive urodynamic measurement of specific elements of function can be potentially beneficial. Less-invasive techniques may sometimes be useful as an adjunct to invasive urodynamics. The potential for current less-invasive tests to completely replace invasive urodynamic testing is considered, however, to be low. Less-invasive techniques must, therefore, be tested as screening/triaging tools, with the aim to spare some patients from invasive urodynamics early in the treatment pathway.

Consensus document on the multidisciplinary management of neurogenic lower urinary tract dysfunction in patients with multiple sclerosis.

AIM: Neurogenic lower urinary tract dysfunction (NLUTD) is very common in multiple sclerosis (MS) patients. Early diagnosis and treatment are crucial to avoid irreversible damage and improve quality of life. Our aim was to develop recommendations to improve NLUTD identification in MS patients, along with their referral and management. METHODS: A multidisciplinary group of 14 experts in the management of patients with MS and NLUTD (nine urologists, three neurologists, and two rehabilitators) was selected. A comprehensive review of the literature was undertaken and a set of recommendations was generated and submitted to a Delphi panel of 114 experts. Recommendations were presented according to the grade of agreement (GA). RESULTS: Early diagnosis in asymptomatic patients with risk factors for complications is recommended (GA 94%). Postvoid residual volume should be measured if changes in urinary symptoms (GA 87%), preferably ultrasound-guided (GA 86%). Early referral to urologist is recommended if urinary incontinence (GA 91%), significant post-void residual volume (94%), quality of life impairment (GA 98%) and recurrent urinary infections (GA 97%). The initial evaluation should include physical examination (GA 99%) and urodynamics including cystometry (GA 89%), pressure-flow study (90%) and electromyography (GA 70%). The panel recommends multidisciplinary collaboration (GA 100%) with a rehabilitation specialist and trained nurses in the management of NLUTD (GA 99%). CONCLUSIONS: Multidisciplinary management for patients with NLUTD due to MS is advised, including urologists, neurologists, rehabilitation, and nurses. Panel recommends early diagnosis with post-void residual volume in symptomatic patients before referring to urologist and urodynamics when referred.

Mid-term safety and efficacy of the ALTIS® single-incision sling for female stress urinary incontinence: less mesh, same results.

OBJECTIVE: To analyse the mid-term safety and efficacy of the ALTIS® single-incision sling (Coloplast Corp., Minneapolis, MN, USA) for female stress urinary incontinence (SUI). PATIENTS AND METHODS: We conducted a prospective, single-arm, unsponsored, observational single-centre trial in a cohort of patients undergoing SUI surgery with the ALTIS procedure. All patients were diagnosed according to clinical reports, physical exploration and urodynamics. Body mass index (BMI) was categorised according to World Health Organization classification. Valsalva leak-point pressure (VLPP) was categorised in three groups: <60, 60-90 and >90 cmH2 O. Patients were evaluated postoperatively at 1, 6, 12 and 24 months with physical examination, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), and satisfaction visual scale (SVS; score 0-10). Adverse events were assessed at each visit. Multivariate analysis for risk factors of surgery failure was performed. RESULTS: We recruited 110 women, with a mean (SD) follow-up of 22.34 (10.34) months. Regarding efficacy, 91 patients (82.7%) were objectively cured and 97 (88.2%) were subjectively cured. Regarding VLPP and BMI, no differences were seen between groups (P > 0.05). There was a ~20% decrease in urge UI (P = 0.04). No variable showed to be an independent risk factor for ALTIS failure (P > 0.05). Overall, nearly 96% of the women reported 9 or 10 points on the SVS. A total of 24 patients (21.8%) had some kind of complication. No mesh erosion was reported in any patient. CONCLUSIONS: The ALTIS sling demonstrated to be an effective and safe procedure for SUI in the mid-term setting. Objective and subjective cure rates are at least comparable to 'gold standard' procedures with a minimal rate of self-limiting non-surgical complications.

Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence.

CONTEXT: Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP). OBJECTIVE: A consensus review of existing data based on published meta-analyses and reviews. EVIDENCE ACQUISITION: This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations. EVIDENCE SYNTHESIS: Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae. CONCLUSIONS: When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres. PATIENT SUMMARY: Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres.

Predicting self-perceived antimuscarinic therapy effectiveness on overactive bladder symptoms using the Overactive Bladder 8-Question Awareness Tool.

INTRODUCTION AND HYPOTHESIS: This work was designed to explore the ability of the self-administered Overactive Bladder 8-Question Awareness Tool (OAB-V8) to predict patient self-assessed effectiveness of antimuscarinic therapy on OAB symptoms in daily practice. Also, the ability of the tool to predict clinician evaluation of improvement was explored. METHODS: Patients of both genders, >18 years, with symptomatic OAB (score >8 on OAB-V8), and able to understand patient-reported outcome instruments were enrolled in this 3-month study. Patients were prescribed treatment with an antimuscarinic drug according to usual practice. Treatment effectiveness was assessed by the clinician and patient using the Clinical Global Impression of Improvement and Treatment Benefit Scale and by improved self-perceived quality of life using the Overactive Bladder Questionnaire Short Form (OAB-q SF) 3 months after initiating or changing an antimuscarinic therapy. Multivariate linear and logistic regression models were applied to explore the predictive validity of OAB-V8 scores at the baseline visit. RESULTS: A total of 246 patients (57.7 years, 67 % women) were analyzed. Based on baseline OAB-V8 scores, logistic regression models were capable of predicting clinical improvement and patient self-perceived treatment benefit in 70 % of cases. OAB-V8 scores significantly correlated with OAB-q SF domains at baseline: 0.790 and - 0.659 for symptom bother and health-related quality of life domains, respectively (p < 0.001 in both cases). Baseline OAB-V8 score was able to predict changes in both domains of the OAB-q SF: R (2) = 0.212 and 0.162 for symptom bother and health-related quality of life, respectively. CONCLUSIONS: The OAB-V8 scale showed evidence of predictive validity for antimuscarinic effectiveness in daily practice based on physician assessment and patient self-assessment of improved quality of life and treatment benefit.

Usefulness of bladder-prostate ultrasound in the diagnosis of obstruction/hyperactivity in males with BPH.

OBJECTIVE: To determine the utility of prostate ultrasound in the diagnosis of infravesical obstruction (IVO) and detrusor hyperactivity(DH). METHODS: Prospective study with 39 patients consulting for LUTS. Clinical history was compiled, IPSS was determined, a digital rectal exam was performed, abdominal ultrasound was used to calculate detrusor thickness/weight, prostate volume, and middle lobe length (MLL). Urodynamic study (UD) was performed with determination of the Abrams-Griffiths number and ICS nomogram. Mean values were compared with Mann-Whitney U-test, and ROC curves were plotted determining the cutoff points for optimum sensitivity/specificity. RESULTS: Mean age was 63.1 years (SD: 7.8), with a mean IPSS score of 14 (SD: 6). 53.8% of the patients presented IVO at UD evaluation, and 43.6% DH. The differences between free flowmetry Qmax(p=0.015) and MLL (p=0.003) between patients with and without IVO proved significant. The ROC curves yielded an AUC for middle lobe length of 0.772, with a maximum sensitivity and specificity cutoff point at 10.5 mm (sensitivity 90%, specificity 73%, PPV 76%, NPV 85%). There were no significant differences in any parameter between patients with and without DH. CONCLUSION: Ultrasound MLL measurement in patients with LUTS offers high sensitivity/specificity in diagnosing IVO, with a cutoff point of 10.5 mm. In our study it wasn't effective in the noninvasive diagnosis of DH.