Assessment of Renal Deterioration and Associated Risk Factors in Patients With Multiple Sclerosis.

OBJECTIVE: To evaluate predictors of renal deterioration (RD) in patients with multiple sclerosis (MS) at a tertiary referral center. METHODS: We reviewed adult patients with MS presenting for evaluation of lower urinary tract symptoms, with baseline urodynamic study (UDS) and either serum creatinine (SCr) or renal ultrasound, from a prospectively maintained database, and excluded patients with abnormal renal function. RD was defined as doubled SCr, new hydronephrosis, or renal atrophy on follow-up ultrasound. Demographic and UDS parameters were evaluated in multivariable models of RD. RESULTS: From 1999 to 2016, 660 patients were evaluated, and 355 met criteria with median follow-up of 79 months. SCr doubled in 8 patients, 4 had decline by renal ultrasound, and 1 by both (3%). Overall, 46 patients met less strict criteria of decrease in estimated glomerular filtration rate by ≥30%. Using the less rigid criterion, detrusor overactivity (DO) remained associated with RD on multivariable analysis. Eleven of 355 patients had RD by either imaging or doubled Cr, with which only history of diabetes mellitus and nephrolithiasis were associated. CONCLUSION: By strict criteria, the rate of RD in patients with neurogenic bladder due to MS was low (3%) at intermediate-term follow-up and was not associated with UDS parameters. Using more liberal criteria, DO was associated with deterioration, suggesting that study of the impact of more aggressive control of DO in this population may be warranted.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence.

CONTEXT: The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016. OBJECTIVE: We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination. EVIDENCE ACQUISITION: Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria. EVIDENCE SYNTHESIS: The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/. CONCLUSIONS: These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances. PATIENT SUMMARY: Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

The cost of preoperative urodynamics: A secondary analysis of the ValUE trial.

AIMS: Urodynamic studies (UDS) are generally recommended prior to surgical treatment for stress urinary incontinence (SUI), despite insufficient evidence that it impacts treatment plans or outcomes in patients with uncomplicated SUI. This analysis aimed to calculate the cost incurred when UDS was performed as a supplement to a basic office evaluation and to extrapolate the potential savings of not doing UDS in this patient population on a national basis. METHODS: This is a secondary analysis from the Value of Urodynamic Evaluation (ValUE) trial, a multicenter non-inferiority randomized trial to determine whether a basic office evaluation (OE) is non-inferior in terms of SUI surgery outcomes to office evaluation with addition of urodynamic studies (UDS). All participants underwent an OE; those patients who randomized to supplementary UDS underwent non-instrumented uroflowmetry, filling cystometry, and a pressure flow study. Costs associated with UDS were calculated using 2014 U.S. Medicare allowable fees. Models using various patient populations and payor mixes were created to obtain a range of potential costs of performing UDS in patients undergoing SUI surgery annually in the United States. RESULTS: Six hundred thirty women were randomized to OE or OE plus UDS. There was no difference in surgical outcomes between the two groups. The per patient cost of UDS varied from site to site, and included complex cystometrogram $314-$343 (CPT codes 51728-51729) plus complex uroflowmetry $16 (CPT code 51741). Extrapolating these costs for US women similar to our study population, 13-33 million US dollars could be saved annually by not performing preoperative urodynamics. CONCLUSION: For women with uncomplicated SUI and a confirmatory preoperative basic office evaluation, tens of millions of dollars US could be saved annually by not performing urodynamic testing. In the management of such women, eliminating this preoperative test has a major economic benefit.

A contemporary assessment of nocturia: definition, epidemiology, pathophysiology, and management--a systematic review and meta-analysis.

CONTEXT: Nocturia is a common urologic symptom that has been covered in a variety of reported studies in the literature but is not specifically covered in current guidelines. OBJECTIVE: To comprehensively review the literature pertaining to the definition, etiologies, and consequences of nocturia and assess the evidence supporting the use of conservative medical and interventional therapy. EVIDENCE ACQUISITION: A literature search was conducted using the keyword nocturia, restricted to articles in the English language, after 2000 and before April 2012, in PubMed/Medline, Embase, Scopus, Web of Science, and Cochrane Library databases. Regarding treatment modalities, studies were included only if nocturia was a primary end point and if the studies were designed as randomized controlled trials without limit of date. When suitable, a meta-analysis was conducted. Papers covering treatment options for nocturia specifically related to nonurologic conditions were excluded. EVIDENCE SYNTHESIS: Nocturia is still defined as the symptom of wakening from sleep once or more often to void. The prevalence is high in both genders and increases with age. Frequency-volume charts, which are the pivotal tool of clinical assessment, detect 24-h polyuria, nocturnal polyuria (NP), or reduced nocturnal bladder capacity and help to target specific nonurologic etiologies. Nocturia is a morbid condition that significantly affects quality of life and increases mortality. Besides behavioral measures, validated treatment options include oral desmopressin, which is superior to placebo in treating NP. While the level of evidence for desmopressin is high, limited data support the use of α1-blockers and antimuscarinics; however, only rarely has nocturia been a primary end point when studying these drug classes, and studies have not consistently controlled for the effect of NP. CONCLUSIONS: Our knowledge of nocturia, its etiology, and its management has substantially improved in recent years. The evidence available on the management of nocturia remains limited; contributory factors include (1) the complexity of associated conditions, (2) the underuse of objective evaluation tools, and (3) the lack of specific focus on nocturia in clinical trials.

Characteristics of persons with overactive bladder of presumed neurologic origin: results from the Boston Area Community Health (BACH) survey.

AIMS: To compare the descriptive epidemiology of overactive bladder (OAB) of presumed neurologic origin (NOAB) to OAB of non-neurologic origin (N-NOAB). METHODS: Five thousand five hundred three community-dwelling persons aged 30-79 were interviewed regarding urologic symptoms (2002-2005). NOAB was defined as symptoms of urgency and/or urgency incontinence among those with a self-reported history of healthcare provider diagnosed stroke (N = 98), multiple sclerosis (N = 21), or Parkinson's disease (N = 7). N-NOAB was defined identically but occurring among those not reporting neurologic disease (ND). Prevalence estimates were weighted to reflect sampling design; chi-square, Fisher's exact, or t-tests were used to test differences. Urologic symptom interference was assessed using the Epstein scale, while the impact of urinary incontinence (UI) on health-related quality-of-life (HRQOL) was measured using a modification of the Incontinence Impact Questionnaire-7. RESULTS: Forty-five (31.0%) of 125 persons with ND and 994 (16.7%) of 5378 persons without ND reported OAB symptoms. The overall prevalence of NOAB and N-NOAB was 0.6% and 16.4%, respectively. Persons with NOAB had higher (worse) mean American Urologic Association Symptom Index scores (13.0 vs. 10.0, P = 0.09) compared to those with N-NOAB, and were significantly more likely to have diabetes, high blood pressure, cardiac disease, and fair/poor self-reported health (all P < 0.05). Mean symptom interference and UI HRQOL scores were significantly higher (worse) in the NOAB group compared to persons with N-NOAB (all P < 0.05). CONCLUSIONS: Persons with NOAB appeared to have a greater burden of urologic illness with respect to symptom interference and HRQOL compared to persons with N-NOAB.

Mesh kits for anterior vaginal prolapse are not cost effective.

INTRODUCTION AND HYPOTHESIS: To analyze the cost-effectiveness of traditional anterior colporrhaphy (AC), hand-cut mesh, and mesh kit anterior vaginal prolapse (AVP) repair. METHODS: A decision analysis model was built using mean operating room (OR) times, mesh extrusion rates, and recurrence rates obtained from a meta-analysis along with Medicare reimbursement for surgeon fees and office visits, and hospital costs of supplies, OR time, and room and board. RESULTS: Non-kit mesh repair was $3,380, AC $3,461, and mesh kit $4,678. One-way sensitivity analyses demonstrated recurrence rate of AC would need to be 28% to be equally cost effective. Mesh kit repair did not reach cost equivalence even at 0 min OR time. Two-way sensitivity analysis comparing mesh extrusion and AC recurrence demonstrated AC is more cost effective if recurrence is <20% or extrusion >25%. CONCLUSIONS: Mesh kits for AVP repair are not cost effective, regardless of the OR time saved.

Urodynamic assessment of bladder-outlet obstruction in women.

Bladder-outlet obstruction (BOO) in women has become an increasingly recognized entity over the past several years. This is partly because of the greater number of anti-incontinence surgeries being performed, which can infrequently result in iatrogenic obstruction; and partly because of improvements in the ability to diagnose and recognize BOO. In this review, the symptoms associated with BOO in women, and whether these symptoms can reliably predict the presence of BOO, will be discussed. The incidence of BOO following surgical anti-incontinence procedures and the urodynamic diagnosis of BOO in women, detailing the various criteria that have been proposed, are also reviewed.

Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW: Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence. RECENT FINDINGS: There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group. SUMMARY: It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.

Distinguishing neurogenic from non-neurogenic detrusor overactivity: a urodynamic assessment of lower urinary tract symptoms in patients with and without Parkinson's disease.

OBJECTIVES: To examine the urodynamic (UDS) attributes of detrusor overactivity (DO) in patients with Parkinson's disease in comparison to DO in men without neurologic disease, in whom DO is presumably outlet obstruction induced. METHODS: The UDS database was reviewed for three groups of patients: group 1, men with lower urinary tract symptoms (LUTS) and no known neurologic condition with DO (n = 22); group 2, men with Parkinson's disease and LUTS (n = 39); and group 3, women with Parkinson's disease and LUTS (n = 18). Statistical analysis was used to compare the UDS parameters and diagnoses among the groups and to test for associations between Parkinson's disease duration, Hoehn and Yahr score, and UDS findings. RESULTS: Patients with Parkinson's disease had a significantly lower median volume at first detrusor contraction than those with non-neurogenic DO. The percentage of group 1 patients with urge incontinence was significantly lower than that found in the other two groups (9.1% versus 53.8% and 55.6%, P <0.001 and 0.002, respectively). No statistically significant correlation between the duration or severity of Parkinson's disease and UDS parameters was found. CONCLUSIONS: Men with non-neurogenic LUTS are less likely to have urge incontinence on UDS than either men or women with Parkinson's disease. DO owing to Parkinson's disease occurs earlier during filling compared with non-neurogenic DO, especially in women. The duration and severity of Parkinson's disease are not predictive of the nature or severity of UDS abnormalities.