Page 7 - CUAJ April 2019: Surveillance urodynamics for neurogenic lower urinary tract dysfunction: A systematic review

Surveillance urodynamics for neurogenic lower urinary tract dysfunction

these findings are even more unlikely. In these patients, it Current practice patterns
is probably not necessary to perform routine UDS without
symptoms or imaging prompting the study. Eight cross-sectional studies (all level 3, four SCI, two
NLUTD, two spina bifida) surveyed urologists regarding
MS current practice patterns of sUDS in the setting of NLUTD
(Table 4); 53% of 498 respondents and 39 specialty clinics
Six articles addressed sUDS in the adult MS population (Table in seven countries reported that they perform sUDS between
3). Studies included 163 adults with 528 patient-years of fol- 1–3 years using pooled estimate weighted average. The most
lowup. Five of six articles performed sUDS based on chang- common practice pattern was sUDS every 1–2 years.
ing patient symptoms (recurrent UTI, increased incontinence These results were in contrast to two retrospective cohort
between catheterization, or alarming features on ultrasound). series that demonstrated the actual use of sUDS among SCI
The changing clinical course of MS is a hallmark of the patients was substantially less frequent than reported prac-
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disease. Ciancio et al followed 22 adults with repeat UDS tice patterns suggest. Cameron et al observed a 6.7% use
performed because of new or persistent LUTS. Overall, 55% of sUDS in American SCI patients over a two-year period
of patients experienced a change in their urodynamic pat- despite over 35% urological consultation in the same period.
terns and/or compliance during a mean followup of 42 Similarly, Welk et al observed only 10% use of sUDS in
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months. In the largest retrospective series, Schoenberg and Canadian SCI patients over a two-year period.
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Gutrich performed repeated UDS evaluations on 33 symp-
tomatic patients during a 2.5-year period and found differ- Discussion
ences in 12, all of whom changed from having detrusor
hypocontractility to having detrusor hyperreflexia. Wheeler,
Goldstein, and Blaivas et al 34-36 also found temporal changes Change in patient management based on sUDS
in the urodynamic patterns in the majority of patients.
Several authors have demonstrated poor correlation Table 3 demonstrates heterogeneous data (level 2b–4) with
between UDS findings and patient symptoms in the MS variable underlying pathology, variable stimulus for adjust-
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population. Ciancio and colleagues found that 43% of ing treatment, and variable conditions for prompting sUDS.
MS patients with no new urological symptoms developed Although pooled-estimate meta-analysis is not possible
a change in the urodynamic pattern and/or compliance on given heterogeneity, sUDS has a tendency to adjust patient
followup UDS evaluation. Similarly, in a prospective study treatment often. A weighted average of results demonstrated
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by Bemelmans et al, 52% of patients demonstrated uro- that surveillance adjusted treatment in 48.4% of patients.
dynamic abnormalities without symptoms. However, the
incidence of positive urodynamic findings in patients with Determination of new findings in asymptomatic patients without
lower urinary tract complaints was 98%. The latter finding imaging changes
suggests that UDS evolution may be present without symp-
toms, but is highly likely if voiding symptoms exist. Similarly, clinical and methodologic heterogeneity of data
Fortunately, the rate of UUT deterioration in MS with limits the ability to perform pooled-estimate meta-analysis
NLUTD is low. In a meta-analysis of 1882 patients with MS, (Table 3) with respect to this question. Despite this, sUDS
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only 1% demonstrated UUT tract abnormality. Fletcher et al 39 has a tendency to provide new findings that are not sug -
investigated the prevalence of renal ultrasound abnormalities gested by patient symptoms or imaging changes. A weighted
over time in MS patients with LUTS. The authors defined UUT average of results demonstrated that surveillance determined
damage as the presence of hydronephrosis, caliectasis, corti- findings that prompted treatment in 48.9% of asymptomatic
cal scarring, or stone formation. Over a nine-year period, 173 patients without imaging changes. However, after establish-
patients had both UDS and renal ultrasound. Of these, 5.8% ing a ‘safe’ lower urinary tract, prompting sUDS with imag-
of subjects had abnormalities at initial ultrasound, whereas ing change or new symptoms did not appear to be associated
at followup, renal ultrasound (RUS) abnormalities were seen with adverse outcomes in the short-term. 23
in 12.4% of patients. Overall, there were seven patients who
developed new abnormalities. The authors concluded that Does sUDS demonstrate superior outcomes compared to long-term
the development of UUT abnormalities as determined by followup without UDS?
RUS overall is low, although older patients and those with
abnormal compliance may merit closer supervision. There are currently no high-quality studies available to sup-
port or refute this premise. Available evidence is primarily
level 4 without control groups. A single level 2b study is
available within the pediatric population.

CUAJ • April 2019 • Volume 13, Issue 4 139