EUGA Linda Cardozo Lecture- The Value of Urodynamics

Dr. Kazibe Koyuncu Memorial Goztepe Hospital Gynecology and Obstetrics Speaker: Stefano Salvatore Moderator: Michele Meschia In an enlightening lecture by Stefano Salvatore, the following points were discussed in detail: Indications for urodynamic studies in women with complicated stress urinary incontinence (SUI) include the following: Presence of concomitant storage symptoms Uncertainty regarding the type of incontinence Suspicion of voiding dysfunction Post-void residual volume greater than 150 mL Coexisting pelvic organ prolapse History of pelvic radiation therapy Previous surgical treatment for SUI Urodynamics in Overactive Bladder In the management of overactive bladder (OAB), urodynamics has limited value in predicting treatment success. A randomized controlled trial comparing tolterodine extended-release with placebo demonstrated that urodynamic findings did not alter treatment outcomes. Accordingly, routine urodynamic testing prior to initiating anticholinergic therapy is not recommended. In refractory OAB, however, the role of invasive urodynamics has been further explored. Studies comparing cost-effectiveness and clinical effectiveness between patients assessed by clinical evaluation alone and those additionally undergoing urodynamic testing showed mixed results. In one study, no significant difference in treatment outcomes was observed. Conversely, another trial with a 20-month follow-up reported superior treatment outcomes in patients who underwent urodynamic evaluation. Furthermore, in idiopathic OAB, urodynamic assessment was shown to increase patient satisfaction with pharmacological therapy, although it did not consistently change management decisions. When OAB was phenotypically subdivided into provoked detrusor overactivity and filling-phase detrusor overactivity, response rates to tolterodine differed significantly: non-response occurred in 48% of patients with provoked detrusor overactivity versus only 14% with filling-phase detrusor overactivity. This suggests that different pathophysiological mechanisms underlie these phenotypes, influencing therapeutic response. Urodynamics may also identify coexisting impairments in bladder contractility, which has important management implications. Urodynamics in Pelvic Organ Prolapse The correlation between urinary symptoms and urodynamic findings in patients with pelvic organ prolapse (POP) has been investigated using advanced analytic methods such as artificial neural networks. Results indicate that neither symptoms alone nor urodynamic testing alone can reliably establish a diagnosis in these patients. The role of urodynamics prior to POP surgery remains uncertain. While it provides additional information and may enhance patient counseling, current evidence does not demonstrate an improvement in surgical success rates. However, preoperative detection of detrusor overactivity has been shown to predict persistent OAB symptoms after anterior compartment prolapse repair. Similarly, preoperative findings of poor detrusor contractility have been associated with postoperative voiding dysfunction. These findings support a role for individualized assessment and patient-specific counseling in selected cases. In occult SUI, both barrier tests and urodynamic studies appear to have comparable diagnostic accuracy. Nevertheless, a universal consensus on the necessity of preoperative urodynamics in POP surgery has not been established. Training and Standardization Urodynamic testing must adhere to standardized protocols to ensure reliability. Participation in urodynamic practice during residency has been shown to increase trainees’ confidence and familiarity with the procedure. Conclusion As highlighted in a recent review by Linda Cardozo and colleagues, urodynamics provides valuable insights across gynecology and urology, particularly in patients with complicated incontinence, failed prior surgery, or underlying neurological disorders. However, its role prior to primary SUI surgery remains uncertain. Urodynamic testing should therefore be considered selectively—especially in complicated cases—where it may refine diagnosis, improve counseling, and guide individualized management strategies, while avoiding unnecessary procedures in straightforward cases.