Urological Survey Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology Re: Detrusor Underactivity in Men following Radical Retropubic ProstatectomydPrevalence, Importance and Evaluation C. S. Elliott and C. V. Comiter Division of Urology, Santa Clara Valley Medical Center, San Jose and Department of Urology, Stanford University School of Medicine, Stanford, California Curr Bladder Dysfunct Rep 2013; 8: 223e228.
Permission to Publish Abstract Not Granted
Re: The Many Faces of Impaired Bladder Emptying K.-E. Andersson Institute for Regenerative Medicine, Wake Forest University School of Medicine and Department of Urology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, and Aarhus Institute for Advanced Sciences, Aarhus University, Aarhus, Denmark Curr Opin Urol 2014; 24: 363e369.
Abstract available at http://jurology.com/ Editorial Comment: These 2 articles bring up a number of intriguing factors related to the concept of detrusor underactivity (DUA), also known as impaired detrusor contractility. The first is that there is no consensus on how to measure this. Elliott and Comiter list several different criteria from 7 studies, 6 of which rely on detrusor pressure at peak flow. They rightly point out that measuring detrusor contractility in someone with decreased outlet resistance is quite different from measuring it in a man with a normal or enlarged prostate (the population in which the norms were established). They advocate isovolumetric detrusor pressure (Piso) as a direct measure of detrusor contractility and one which correlates well with the Watts factor. Piso is the detrusor pressure measured during occlusion of the penile urethra or bladder outlet. Although the authors consider measurements less than 50 cm H2O diagnostic of detrusor underactivity, there is no documentation of this, just opinion. The clinical significance of detrusor activity, utilizing this diagnosis, is uncertain, as men with incontinence after prostatectomy with “detrusor underactivity” generally empty well. However, the authors regard a Piso of less than 50 cm H2O as a contraindication for placing a sling rather than an artificial sphincter for treatment. Utilizing these various parameters for the definition of DUA, between 9.1% and 43% of patients following radical prostatectomy qualified for this diagnosis. The de novo rate is unknown, as such individuals do not undergo urodynamic studies before prostatectomy. The mechanism of de novo development of DUA after radical prostatectomy is unknown. The most logical hypothesis is that there is injury to the pelvic nerve affecting detrusor contraction and this may be more common during removal of the seminal vesicles. The Andersson article discusses the various underlying causes of DUA, points out the difficulties in establishing the diagnosis according to the currently accepted definition and offers the opinion that there is no universally successful pharmacological treatment. Theoretically agents with a well
0022-5347/15/1931-0217/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.10.077 Vol. 193, 217-224, January 2015 Printed in U.S.A.
www.jurology.com
j
217
218
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
established contractile effect on human bladder smooth muscle could be a useful treatment for underactive bladder but the problem is that an increase in detrusor pressure is not the same as stimulation of a coordinated bladder contraction. All drugs that improve decreased sensation and increase afferent activity “should” be useful but have not proved to be so as yet. Agents that decrease outlet resistance do not directly treat detrusor underactivity but may overcome the consequence of decreased emptying. Experimental and hopeful treatments include gene therapy and cell therapy. Alan J. Wein, MD, PhD (hon)
Re: The Pharmacological Rationale for Combining Muscarinic Receptor Antagonists and b-Adrenoceptor Agonists in the Treatment of Airway and Bladder Disease P. R. Dale, H. Cernecka, M. Schmidt, M. R. Dowling, S. J. Charlton, M. P. Pieper and M. C. Michel Department of Pharmacology, Cambridge University, Cambridge and Department of Molecular Pharmacology, Respiratory Diseases, Novartis Institutes for Biomedical Research, Horsham, United Kingdom, Department of Molecular Pharmacology, University of Groningen, and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, GRIAC, Groningen, The Netherlands, and Respiratory Diseases Research, and Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH, Ingelheim and Department of Pharmacology, Johannes Gutenberg University, Mainz, Germany Curr Opin Pharmacol 2014; 16: 31e42.
Abstract available at http://jurology.com/
Re: Combination Treatment with Mirabegron and Solifenacin in Patients with Overactive Bladder: Efficacy and Safety Results from a Randomised, Double-Blind, Dose-Ranging, Phase 2 Study (Symphony) P. Abrams, C. Kelleher, D. Staskin, T. Rechberger, R. Kay, R. Martina, D. Newgreen, A. Paireddy, R. van Maanen and A. Ridder Bristol Urological Institute, Southmead Hospital, Bristol, Guys and St. Thomas’ Hospitals, London and RK Statistics, Ltd., Bakewell, United Kingdom, Tufts University School of Medicine, Boston, Massachusetts, Department of Gynaecology, Medical University, Lublin, Poland, and Astellas Pharma BV, Leiden, The Netherlands Eur Urol 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: The Dale et al article gives an excellent summary of assumed signal transduction pathways involved in the regulation of smooth muscle contraction by muscarinic and b-adrenergic pathways. The hypothesis is that the muscarinic and b-adrenergic systems in the bladder and airways oppose each other at multiple levels, and both organs have pathologies characterized by too much muscarinic and too little b-adrenergic input. Therefore, the concept of combining muscarinic antagonists and b-adrenergic receptor agonists in the treatment of overactive bladder (OAB) and airway disease is attractive. The phase 2 study of the combination of mirabegron and solifenacin in patients with OAB showed that, compared to 5 mg solifenacin, monotherapy and various combinations of mirabegron with 5 or 10 mg solifenacin improved mean voided volume, with adjusted differences ranging from 18 to 26.3 ml, decreased micturition frequency (by 0.80 to 0.98 voids daily) and decreased urgency episodes (by 0.98 to 1.37 episodes daily). The differences in mean voided volume seemed to be about the same whether 5 mg or 10 mg solifenacin was utilized and whether 25 mg or 50 mg mirabegron was utilized. A careful read of the article is necessary to decipher some of the results and decide for oneself whether the differences in efficacy are clinically meaningful. Obviously further studies utilizing the most favorable dose combinations will be carried out and should answer some questions related to this. Importantly, however, the addition of 25 mg or 50 mg mirabegron did not appear to significantly increase the incidence of dry mouth over solifenacin alone, and the numbers recorded for the
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
combinations of mirabegron with 10 mg solifenacin are actually lower than the dry mouth rate reported with solifenacin alone. Hypertension rates varied, with 11.7% and 14.1% of patients taking 25 mg and 50 mg mirabegron alone, respectively, being recorded as having hypertension as opposed to 8.6% of those taking placebo. Interestingly the rates with 5 or 10 mg solifenacin were less than those recorded in the 50 mg mirabegron alone group. Studies of larger numbers of patients and fewer groups will obviously be necessary to confirm some of the suggestions made in this article. However, it certainly appears that the 2 agents can be combined with a minimum, if any, increase in adverse event profile and with an improvement in at least some efficacy parameters. It would seem that the goal would be to achieve the efficacy of high dose antimuscarinic therapy alone by combining a b-agonist with low dose antimuscarinic therapy, resulting in a lower incidence of adverse events than would be seen with higher dose antimuscarinic therapydan obvious advantage for patients, which might improve compliance with oral therapy for OAB. Alan J. Wein, MD, PhD (hon)
Re: Urodynamic Studies for Management of Urinary Incontinence in Children and Adults C. M. Glazener and M. C. Lapitan Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, Scotland Cochrane Database Syst Rev 2012; 1: CD003195.
Abstract available at http://jurology.com/ Editorial Comment: Here we go again. This is a noble effort by the Cochrane Collaboration to discover if treatment according to a urodynamic based diagnosis, compared to treatment based on history and examination, leads to more effective clinical care and better clinical outcomes. The authors concluded, “When women with incontinence are assessed using urodynamics in addition to clinical methods, they may be more likely to receive treatment, or to have their management plan changed. However, there was not enough evidence to show whether these differences in management resulted in differences in health outcomes, such as incontinence, quality of life or economic outcomes, compared to women who did not have urodynamic tests.” It was noted that insufficient data were available to evaluate the use of urodynamics in men, children or those with neurological diseases. Further randomized trials were recommended, and the comment was made that such trials would need about 400 people in each arm to have 80% power to detect a 10% difference in incontinence rates at a significance level of 5%. Such studies should include subjective and objective assessment of cure and improvement, adverse events, effect on clinical decision making, patient opinion and satisfaction, quality of life and economic outcome measures. Alan J. Wein, MD, PhD (hon)
Re: Biomarkers in Lower Urinary Tract Symptoms/Overactive Bladder: A Critical Overview T. Antunes-Lopes, C. D. Cruz, F. Cruz and K. D. Sievert Translational NeuroUrology, Institute for Molecular and Cell Biology, and Department of Experimental Biology, Faculty of Medicine of Porto, University of Porto and Department of Urology, Hospital de S. Joa˜o, Porto, Portugal, and Department of Urology, Eberhard-Karls University, Tubingen, Germany Curr Opin Urol 2014; 24: 352e357.
Abstract available at http://jurology.com/ Editorial Comment: To quote the authors, “Biomarkers are objectively measurable characteristics that may be used to define the presence of a condition (diagnostic biomarker), its severity and progression (prognostic biomarker) or the response to a particular treatment (predictive biomarker)”!
219
220
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
It would seem that it is also true that to be labeled a biomarker, a quantifiable product must perform in one of the 3 scenarios and do it reproducibly. These authors, anchored by 2 stalwarts in the field, review several molecules in the urine and/or blood and other physiological parameters, touted by some as biomarkers for overactive bladder. My interpretation of their conclusion is that none of the biomarkers satisfies the criteria. With respect to overactive bladder, a biomarker should be able to guide a particular form of treatment and improve outcome. The value of the current group of proposed “biomarkers” is that they may suggest and help us to better understand some of the pathophysiological mechanisms underlying the signs and symptoms associated with this symptom syndrome. Alan J. Wein, MD, PhD (hon)
Re: Pre-Operative Urodynamics in Women with Stress Urinary Incontinence Increases Physician Confidence, but Does Not Improve Outcomes P. Zimmern, H. Litman, C. Nager, L. Sirls, S. R. Kraus, K. Kenton, T. Wilson, G. Sutkin, N. Siddiqui, S. Vasavada and P. Norton; Urinary Incontinence Treatment Network UT Southwestern Medical Center, Dallas, Texas Neurourol Urodyn 2014; 33: 302e306.
Abstract available at http://jurology.com/ Editorial Comment: This is an interesting secondary analysis of certain data in the ValUE (Value of Urodynamic Evaluation) trial,1 the conclusion of which is that in a group of women with demonstrable stress urinary incontinence (SUI) on office evaluation, predominant symptoms of SUI, no history of surgery for incontinence and a normal post-void residual the office evaluation alone was not inferior to evaluation with urodynamic studies and did not compromise surgery success. However, urodynamics did shift physician diagnosis from not confident to confident for the entities of intrinsic sphincter deficiency and overactive bladder wet. Lesser but statistically significant scores for indicating increased confidence were also associated with the diagnosis of stress urinary incontinence, overactive bladder dry and voiding phase dysfunction, although less strongly. Confidence scores of the clinical diagnosis were rated on a scale of 1 (not very confident) to 5 (extremely confident). What the small numerical changes in “confident” mean in terms of clinical significance is unknown. The implication of this seems to be that the concept of “degree of certainty,” which I first heard from Dr. Jerry Blaivas, is an important factor in determining whether an individual performs urodynamics preoperatively in patients with clear SUI and in more complicated patients with incontinence. Some individuals require more certainty than others, and there does not seem to be a valid ethical reason or, at this point, a financial reason not to proceed with urodynamics under these circumstances. Those surgeons who are supremely confident and who have never had a bad result, or think they have not, will need less confirmation, but the decision will be an individual one and will vary with the past and present history of the patient and her individual characteristics, the confusability of the signs and symptoms, and the local medicolegal climate regarding failure and postprocedural complications. In the future if and when 1 fee is paid yearly to care for a specific problem, it will be easy to tell those individuals who really feel that urodynamics are worthwhile and in which scenarios. Alan J. Wein, MD, PhD (hon) 1. Nager CW, Brubaker L, Litman HJ et al: A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366: 1987.
Permission to Publish Abstract Not Granted
Re: The Many Faces of Impaired Bladder Emptying K.-E. Andersson Institute for Regenerative Medicine, Wake Forest University School of Medicine and Department of Urology, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, and Aarhus Institute for Advanced Sciences, Aarhus University, Aarhus, Denmark Curr Opin Urol 2014; 24: 363e369.
Abstract available at http://jurology.com/ Editorial Comment: These 2 articles bring up a number of intriguing factors related to the concept of detrusor underactivity (DUA), also known as impaired detrusor contractility. The first is that there is no consensus on how to measure this. Elliott and Comiter list several different criteria from 7 studies, 6 of which rely on detrusor pressure at peak flow. They rightly point out that measuring detrusor contractility in someone with decreased outlet resistance is quite different from measuring it in a man with a normal or enlarged prostate (the population in which the norms were established). They advocate isovolumetric detrusor pressure (Piso) as a direct measure of detrusor contractility and one which correlates well with the Watts factor. Piso is the detrusor pressure measured during occlusion of the penile urethra or bladder outlet. Although the authors consider measurements less than 50 cm H2O diagnostic of detrusor underactivity, there is no documentation of this, just opinion. The clinical significance of detrusor activity, utilizing this diagnosis, is uncertain, as men with incontinence after prostatectomy with “detrusor underactivity” generally empty well. However, the authors regard a Piso of less than 50 cm H2O as a contraindication for placing a sling rather than an artificial sphincter for treatment. Utilizing these various parameters for the definition of DUA, between 9.1% and 43% of patients following radical prostatectomy qualified for this diagnosis. The de novo rate is unknown, as such individuals do not undergo urodynamic studies before prostatectomy. The mechanism of de novo development of DUA after radical prostatectomy is unknown. The most logical hypothesis is that there is injury to the pelvic nerve affecting detrusor contraction and this may be more common during removal of the seminal vesicles. The Andersson article discusses the various underlying causes of DUA, points out the difficulties in establishing the diagnosis according to the currently accepted definition and offers the opinion that there is no universally successful pharmacological treatment. Theoretically agents with a well
0022-5347/15/1931-0217/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.10.077 Vol. 193, 217-224, January 2015 Printed in U.S.A.
www.jurology.com
j
217
218
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
established contractile effect on human bladder smooth muscle could be a useful treatment for underactive bladder but the problem is that an increase in detrusor pressure is not the same as stimulation of a coordinated bladder contraction. All drugs that improve decreased sensation and increase afferent activity “should” be useful but have not proved to be so as yet. Agents that decrease outlet resistance do not directly treat detrusor underactivity but may overcome the consequence of decreased emptying. Experimental and hopeful treatments include gene therapy and cell therapy. Alan J. Wein, MD, PhD (hon)
Re: The Pharmacological Rationale for Combining Muscarinic Receptor Antagonists and b-Adrenoceptor Agonists in the Treatment of Airway and Bladder Disease P. R. Dale, H. Cernecka, M. Schmidt, M. R. Dowling, S. J. Charlton, M. P. Pieper and M. C. Michel Department of Pharmacology, Cambridge University, Cambridge and Department of Molecular Pharmacology, Respiratory Diseases, Novartis Institutes for Biomedical Research, Horsham, United Kingdom, Department of Molecular Pharmacology, University of Groningen, and Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, GRIAC, Groningen, The Netherlands, and Respiratory Diseases Research, and Department of Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH, Ingelheim and Department of Pharmacology, Johannes Gutenberg University, Mainz, Germany Curr Opin Pharmacol 2014; 16: 31e42.
Abstract available at http://jurology.com/
Re: Combination Treatment with Mirabegron and Solifenacin in Patients with Overactive Bladder: Efficacy and Safety Results from a Randomised, Double-Blind, Dose-Ranging, Phase 2 Study (Symphony) P. Abrams, C. Kelleher, D. Staskin, T. Rechberger, R. Kay, R. Martina, D. Newgreen, A. Paireddy, R. van Maanen and A. Ridder Bristol Urological Institute, Southmead Hospital, Bristol, Guys and St. Thomas’ Hospitals, London and RK Statistics, Ltd., Bakewell, United Kingdom, Tufts University School of Medicine, Boston, Massachusetts, Department of Gynaecology, Medical University, Lublin, Poland, and Astellas Pharma BV, Leiden, The Netherlands Eur Urol 2014; Epub ahead of print.
Abstract available at http://jurology.com/ Editorial Comment: The Dale et al article gives an excellent summary of assumed signal transduction pathways involved in the regulation of smooth muscle contraction by muscarinic and b-adrenergic pathways. The hypothesis is that the muscarinic and b-adrenergic systems in the bladder and airways oppose each other at multiple levels, and both organs have pathologies characterized by too much muscarinic and too little b-adrenergic input. Therefore, the concept of combining muscarinic antagonists and b-adrenergic receptor agonists in the treatment of overactive bladder (OAB) and airway disease is attractive. The phase 2 study of the combination of mirabegron and solifenacin in patients with OAB showed that, compared to 5 mg solifenacin, monotherapy and various combinations of mirabegron with 5 or 10 mg solifenacin improved mean voided volume, with adjusted differences ranging from 18 to 26.3 ml, decreased micturition frequency (by 0.80 to 0.98 voids daily) and decreased urgency episodes (by 0.98 to 1.37 episodes daily). The differences in mean voided volume seemed to be about the same whether 5 mg or 10 mg solifenacin was utilized and whether 25 mg or 50 mg mirabegron was utilized. A careful read of the article is necessary to decipher some of the results and decide for oneself whether the differences in efficacy are clinically meaningful. Obviously further studies utilizing the most favorable dose combinations will be carried out and should answer some questions related to this. Importantly, however, the addition of 25 mg or 50 mg mirabegron did not appear to significantly increase the incidence of dry mouth over solifenacin alone, and the numbers recorded for the
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
combinations of mirabegron with 10 mg solifenacin are actually lower than the dry mouth rate reported with solifenacin alone. Hypertension rates varied, with 11.7% and 14.1% of patients taking 25 mg and 50 mg mirabegron alone, respectively, being recorded as having hypertension as opposed to 8.6% of those taking placebo. Interestingly the rates with 5 or 10 mg solifenacin were less than those recorded in the 50 mg mirabegron alone group. Studies of larger numbers of patients and fewer groups will obviously be necessary to confirm some of the suggestions made in this article. However, it certainly appears that the 2 agents can be combined with a minimum, if any, increase in adverse event profile and with an improvement in at least some efficacy parameters. It would seem that the goal would be to achieve the efficacy of high dose antimuscarinic therapy alone by combining a b-agonist with low dose antimuscarinic therapy, resulting in a lower incidence of adverse events than would be seen with higher dose antimuscarinic therapydan obvious advantage for patients, which might improve compliance with oral therapy for OAB. Alan J. Wein, MD, PhD (hon)
Re: Urodynamic Studies for Management of Urinary Incontinence in Children and Adults C. M. Glazener and M. C. Lapitan Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, Scotland Cochrane Database Syst Rev 2012; 1: CD003195.
Abstract available at http://jurology.com/ Editorial Comment: Here we go again. This is a noble effort by the Cochrane Collaboration to discover if treatment according to a urodynamic based diagnosis, compared to treatment based on history and examination, leads to more effective clinical care and better clinical outcomes. The authors concluded, “When women with incontinence are assessed using urodynamics in addition to clinical methods, they may be more likely to receive treatment, or to have their management plan changed. However, there was not enough evidence to show whether these differences in management resulted in differences in health outcomes, such as incontinence, quality of life or economic outcomes, compared to women who did not have urodynamic tests.” It was noted that insufficient data were available to evaluate the use of urodynamics in men, children or those with neurological diseases. Further randomized trials were recommended, and the comment was made that such trials would need about 400 people in each arm to have 80% power to detect a 10% difference in incontinence rates at a significance level of 5%. Such studies should include subjective and objective assessment of cure and improvement, adverse events, effect on clinical decision making, patient opinion and satisfaction, quality of life and economic outcome measures. Alan J. Wein, MD, PhD (hon)
Re: Biomarkers in Lower Urinary Tract Symptoms/Overactive Bladder: A Critical Overview T. Antunes-Lopes, C. D. Cruz, F. Cruz and K. D. Sievert Translational NeuroUrology, Institute for Molecular and Cell Biology, and Department of Experimental Biology, Faculty of Medicine of Porto, University of Porto and Department of Urology, Hospital de S. Joa˜o, Porto, Portugal, and Department of Urology, Eberhard-Karls University, Tubingen, Germany Curr Opin Urol 2014; 24: 352e357.
Abstract available at http://jurology.com/ Editorial Comment: To quote the authors, “Biomarkers are objectively measurable characteristics that may be used to define the presence of a condition (diagnostic biomarker), its severity and progression (prognostic biomarker) or the response to a particular treatment (predictive biomarker)”!
219
220
VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
It would seem that it is also true that to be labeled a biomarker, a quantifiable product must perform in one of the 3 scenarios and do it reproducibly. These authors, anchored by 2 stalwarts in the field, review several molecules in the urine and/or blood and other physiological parameters, touted by some as biomarkers for overactive bladder. My interpretation of their conclusion is that none of the biomarkers satisfies the criteria. With respect to overactive bladder, a biomarker should be able to guide a particular form of treatment and improve outcome. The value of the current group of proposed “biomarkers” is that they may suggest and help us to better understand some of the pathophysiological mechanisms underlying the signs and symptoms associated with this symptom syndrome. Alan J. Wein, MD, PhD (hon)
Re: Pre-Operative Urodynamics in Women with Stress Urinary Incontinence Increases Physician Confidence, but Does Not Improve Outcomes P. Zimmern, H. Litman, C. Nager, L. Sirls, S. R. Kraus, K. Kenton, T. Wilson, G. Sutkin, N. Siddiqui, S. Vasavada and P. Norton; Urinary Incontinence Treatment Network UT Southwestern Medical Center, Dallas, Texas Neurourol Urodyn 2014; 33: 302e306.
Abstract available at http://jurology.com/ Editorial Comment: This is an interesting secondary analysis of certain data in the ValUE (Value of Urodynamic Evaluation) trial,1 the conclusion of which is that in a group of women with demonstrable stress urinary incontinence (SUI) on office evaluation, predominant symptoms of SUI, no history of surgery for incontinence and a normal post-void residual the office evaluation alone was not inferior to evaluation with urodynamic studies and did not compromise surgery success. However, urodynamics did shift physician diagnosis from not confident to confident for the entities of intrinsic sphincter deficiency and overactive bladder wet. Lesser but statistically significant scores for indicating increased confidence were also associated with the diagnosis of stress urinary incontinence, overactive bladder dry and voiding phase dysfunction, although less strongly. Confidence scores of the clinical diagnosis were rated on a scale of 1 (not very confident) to 5 (extremely confident). What the small numerical changes in “confident” mean in terms of clinical significance is unknown. The implication of this seems to be that the concept of “degree of certainty,” which I first heard from Dr. Jerry Blaivas, is an important factor in determining whether an individual performs urodynamics preoperatively in patients with clear SUI and in more complicated patients with incontinence. Some individuals require more certainty than others, and there does not seem to be a valid ethical reason or, at this point, a financial reason not to proceed with urodynamics under these circumstances. Those surgeons who are supremely confident and who have never had a bad result, or think they have not, will need less confirmation, but the decision will be an individual one and will vary with the past and present history of the patient and her individual characteristics, the confusability of the signs and symptoms, and the local medicolegal climate regarding failure and postprocedural complications. In the future if and when 1 fee is paid yearly to care for a specific problem, it will be easy to tell those individuals who really feel that urodynamics are worthwhile and in which scenarios. Alan J. Wein, MD, PhD (hon) 1. Nager CW, Brubaker L, Litman HJ et al: A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med 2012; 366: 1987.
