Glickman Urologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Neurourol Urodyn. 2018 Mar;37(3):1046-1052. doi: 10.1002/nau.23398. Epub 2017 Sep 6.
Many urologists use urodynamic testing (UDS) to assist clinical decision-making. The VALUE study, a multi-institutional, randomized controlled trial published in 2012, demonstrated that UDS prior to midurethral sling placement for uncomplicated stress urinary incontinence (SUI) did not change management. We sought to determine whether use of UDS for evaluation of SUI diminished thereafter.
Records of patients who underwent isolated mid-urethral sling surgery at our tertiary-care referral center from 2008 to 2009 (pre-VALUE) and 2014 to 2016 (post-VALUE) were reviewed. Comorbidities, presenting symptoms, surgeon specialty, use of UDS, UDS results and sling type were recorded. Patients with neurologic comorbidities or prior anti-incontinence procedures were excluded. Descriptive statistics were calculated and multivariable logistic regression analyses performed.
Three hundred and eighty-seven patients met inclusion criteria. Median age was 54 years. Patients most frequently presented with stress urinary incontinence (56% pre, 50% post), followed by stress predominant mixed urinary incontinence (40% pre, 48% post, P = 0.09). Before VALUE, UDS was performed in 70% of patients prior to primary sling; in the later cohort, this decreased to 41% (P < 0.0001). On multivariable analysis, provider specialty (P < 0.0001) and belonging to the pre-VALUE cohort (P = < 0.0001) predicted use of UDS prior to sling.
It is paramount that new data be incorporated into diagnostic and treatment algorithms. We found that the rate of preoperative urodynamic testing decreased after publication of a randomized-controlled trial demonstrating that these studies did not change procedural decision-making. Future studies that identify instances of over-testing may have the ability to positively impact patient care and contain costs.
许多泌尿科医生使用尿动力学检查（UDS）来协助临床决策。2012 年发表的一项多机构、随机对照试验——VALUE 研究表明，对于单纯压力性尿失禁（SUI）患者，在进行尿道中段吊带置入术之前进行 UDS 并不能改变治疗方法。我们试图确定此后 UDS 用于评估 SUI 的使用是否减少。
我们回顾了 2008 年至 2009 年（VALUE 之前）和 2014 年至 2016 年（VALUE 之后）在我们的三级转诊中心接受单纯尿道中段吊带手术的患者的病历。记录合并症、主要症状、外科医生专业、UDS 的使用、UDS 结果和吊带类型。排除有神经合并症或先前有抗失禁手术的患者。计算了描述性统计数据并进行了多变量逻辑回归分析。
符合纳入标准的 387 名患者。中位年龄为 54 岁。患者最常出现压力性尿失禁（56%在 VALUE 之前，50%在 VALUE 之后），其次是压力为主的混合性尿失禁（40%在 VALUE 之前，48%在 VALUE 之后，P=0.09）。在 VALUE 之前，70%的患者在进行原发性吊带之前进行了 UDS；在后来的队列中，这一比例下降到 41%（P<0.0001）。多变量分析显示，提供者专业（P<0.0001）和属于 VALUE 之前的队列（P=0.0001）预测了吊带前 UDS 的使用。
将新数据纳入诊断和治疗算法至关重要。我们发现，在一项随机对照试验表明这些研究不会改变手术决策后，术前尿动力学检查的比率下降。未来识别过度检查的实例的研究可能有能力对患者护理产生积极影响并控制成本。
