The Utility of Urodynamic Studies in Neuro-Urological Patients

Round 1

Reviewer 1 Report

Thank you for this important paper.

I have a few suggestion:

78. Some studies report a sensitivity ranging between 45%-72% when UDS were compared to clinical symptoms of urge urinary incontinence on overactive bladder in non-neurogenic patients(16). CON – please give a range of volumes and pressures for diagnosis.

94. diagnosed during the voiding phase of the UDS using electromyography (Figure 1)(21).  CON please give a range of values for this diagnosis.

96.   Kurzrock and Polse demonstrated that the presence of a DSD was  correlated to UUT impairment. CON define UUT.

99. The UDS follow-up showed a resolution of the UUT damage by clean intermittent 99 self-catheterization in approximately one third of the patients presenting a DSD(23). CON, please state what was used prior to CIC.

FIG 1. Figure 1. UDS with electromyography. CON, the abd pr goes below zero; thus, there was a problem with this recording. Please provide an artifact free recording.

112. The UDS follow up showed a resolution of the UUT damage by clean intermittent self-catheterization in approximately 36% of these patients(23).  CON, what were they converting from.

128. and to optimize the urinary quality of life (continence, catheter, stoma, social acceptability of bladder management).  CON. This parenthesis is not clear. Please state examples such as volitional voiding, ect.

131. first use of NB, please spell out.

136. Anticholinergic medications are the first line of treatment for NDO and may be associated with beta-3-receptor agonist(31). CON not an association, please clarify.

136. paragraph. CON, please give more details about dose of medication and the decrease in detrusor pressures.

174. The clinical presentation of LUT dysfunction are unreliable, particularly in the context of NB(39). CON, please clarify. Is this in the absence of UDS?

182. Please include UTI.

213. UDS is costly, including purchase of the equipment and disposables, and the 213 requirement for specialized staff. In the context of ongoing rise in healthcare expenditures, 214 early and appropriate intervention based on urodynamic findings rather than initiating 215 treatment only once complications of NLUTD are present could spare resources and re- 216 duce overall costs(41,47). CON, please clarify contradiction of both UDS and NLUTD as both costly.

TABLE 1, not clear, cant read. Consider shortening some of the text.

243. . Some studies showed that a large proportion of patients present- 243 ing a NB never underwent any UDS investigation in the course of their manage- 244 ment(50,51).  CON, please describe the empirical methods use for patient management without UDS.

Author Response

RESPONSE TO REVIEWER

 

Reviewer 1

Comments and Suggestions for Authors :

Thank you for this important paper. I have a few suggestion:

78. Some studies report a sensitivity ranging between 45%-72% when UDS were compared to clinical symptoms of urge urinary incontinence on overactive bladder in non-neurogenic patients(16). CON – please give a range of volumes and pressures for diagnosis.

We added to the text:

“In one study, UDS diagnosis of detrusor overactivity (instability) was made if the filling cystometry demonstrated a rise in true detrusor pressure of  >15 cmH20. This diagnosis was also made if a true detrusor rise of more than 5 cmH20 was associated with urethral relaxation and incontinence. All terminology, methods and diagnostic criteria were used according to recommendations published by the International Continence Society(1). Volumes were not mentioned in the studies reviewed.”

94. diagnosed during the voiding phase of the UDS using electromyography (Figure 1)(21). CON please give a range of values for this diagnosis.

We added to the text:

“The diagnosis of DSD during electromyography (EMG) is poorly standardized. EMG findings in DSD have been classified into three types by Blaivas(2):

1. Type 1 DSD presents a progressive increase in the external urinary sphincter (EUS) activity, with a peak at maximal detrusor contraction followed by a quick relaxation of the EUS as the detrusor pressure declines allowing urination.
2. Type 2 DSD shows clonic contractions of the EUS intermittently during the detrusor contraction, provoking intermittency of the urinary stream.
3. Type 3 DSD is characterized by a continuous EUS contraction during the entire detrusor contraction resulting in urinary obstruction or inability to urinate.

A simplified classification has been suggested by Weld et al. by dividing DSD in two groups, continuous versus intermittent(3).

Both classifications are currently used.

VUDS is valuable to diagnose of DSD(4).”

96. Kurzrock and Polse demonstrated that the presence of a DSD was correlated to UUT impairment. CON define UUT.

We added to the text:

“These UUT impairment included anatomical changes such as the development of hydronephrosis, vesico-ureteral reflux and cortical loss.”

99. The UDS follow-up showed a resolution of the UUT damage by clean intermittent 99 self-catheterization in approximately one third of the patients presenting a DSD(23). CON, please state what was used prior to CIC.

The authors didn’t specify the voiding technique used prior CIC. We assume this to mean spontaneous voiding.

FIG 1. Figure 1. UDS with electromyography. CON, the abd pr goes below zero; thus, there was a problem with this recording. Please provide an artifact free recording.

We couldn’t find a proper recording of DSD in our recent records, therefore we removed the figure.

112. The UDS follow up showed a resolution of the UUT damage by clean intermittent self-catheterization in approximately 36% of these patients (23). CON, what were they converting from.

-> See answer 99

128. and to optimize the urinary quality of life (continence, catheter, stoma, social acceptability of bladder management). CON. This parenthesis is not clear. Please state examples such as volitional voiding, ect.

We changed the paragraph as follows:

“There are 3 management goals in patient with NLUTD:  preserve the UUT function by maintaining a low storage pressure with proper bladder capacity and compliance and a low spontaneous voiding pressure; minimize the occurrence of urinary tract infection (UTI) and optimize continence.”

131. first use of NB, please spell out.

Thank you for the comment, it will be corrected -> neurogenic bladder

136. Anticholinergic medications are the first line of treatment for NDO and may be associated with beta-3-receptor agonist (31). CON not an association, please clarify.

“associated” has been replaced by to “combined” to match conclusion of Abrams P et al.

136. paragraph. CON, please give more details about dose of medication and the decrease in detrusor pressures.

We added to the text:

“Amarenco et al. showed that in a population of MS and SCI patients, after 4 weeks of treatment, solifenacin 5 mg PO DIE improved the maximum detrusor pressure (MDP) (- 16.6 cmH20) compared to placebo (+ 7.5 cmH20). There wasn’t a dose-response relationship as the MDP decrease was -10.5 cmH20 with solifenacin 10 mg PO DIE. It remained a significant improvement compared to placebo. In the same study, oxybutynin 15mg PO DIE showed an even better improvement (-24.3 cmH20)(5).”

174. The clinical presentation of LUT dysfunction are unreliable, particularly in the context of NB(39). CON, please clarify. Is this in the absence of UDS?

Yes. The clinical presentation of LUT dysfunction is not reliable as etiologies may vary significantly for the same clinical pattern compared to a non-neurological patient.

182. Please include UTI.

Thank you for your comment, UTI will be added.

213. UDS is costly, including purchase of the equipment and disposables, and the 213 requirement for specialized staff. In the context of ongoing rise in healthcare expenditures, 214 early and appropriate intervention based on urodynamic findings rather than initiating 215 treatment only once complications of NLUTD are present could spare resources and re- 216 duce overall costs(41,47). CON, please clarify contradiction of both UDS and NLUTD as both costly.

The paragraph has been modified as follows:

“UDS is costly, including purchase of the equipment and disposables, and the requirement for specialized staff. Early intervention based on urodynamic findings rather than initiating treatment only once complications of NLUTD are present could spare resources and reduce overall costs(41,47).”

TABLE 1, not clear, cant read. Consider shortening some of the text.

We fully agree with your comment. The table has been shortened as follows:

Document or Guidelines	Organization, Version	Recommendations	Level of Evidence / Grade of Recommendations	References
The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation	American Urological Association, 2021	UDS is recommended at initial evaluation of patients with unknown risk NLUTD and in the follow‑up of those thought to be at moderate and high risk if change in signs and symptoms, new complications (autonomic dysreflexia, UTI, stones), UUT or renal function deterioration.	Moderate Recommendation; Evidence Level: Grade C	(2)
EAU Guidelines on Neuro-Urology	European Association of Urology, 2022	UDS investigation is the only method that can objectively assess the (dys-)function of the LUT.	2a	EAU Guidelines, 2022.
		Video-urodynamics is the optimum procedure for urodynamic investigation in neuro-urological disorders.	4
		Perform urodynamic investigation as a mandatory baseline diagnostic intervention in high-risk patients at regular intervals.	Strong recommendation
Urinary incontinence in neurological disease: assessment and management	National Institute for Health and Care Excellence, 2012	Do not offer UDS routinely to people at low risk of renal complications (most MS patients).		(57)
		Offer VUDS to people at high risk of renal complications (spina bifida, SCI or anorectal abnormalities).
		Offer UDS before performing surgical treatments for NLUTD.
Neurogenic Lower Urinary Tract Dysfunction: Clinical Management Recommendations	Fifth International Consultation on Incontinence 2013 (Published 2016)	UDS should selectively be employed to supplement clinical assessment in determining management in NLUTD		(58)
		UDS should be used to gauge potential impact on a renal function as a consequence of NLUTD.
		Patients on CIC and bladder storage treatment often require long-term UDS and upper tract monitoring	A
		Patients with stress incontinence in association with NLUTD require VUDS to evaluate both bladder and sphincter function	C

 

243. Some studies showed that a large proportion of patients present- 243 ing a NB never underwent any UDS investigation in the course of their manage- 244 ment(50,51). CON, please describe the empirical methods use for patient management without UDS.

We added to the text:

“When referred, their initial management consisted of a focused history and clinical evaluation, combined with a urinalysis and PVR measurement. Additional tests such as voiding diaries, pad-test, uroflowmetry, kidney imaging, cystoscopy and UDS were performed if clinically indicated at initial assessment and follow-up.”

Revision’s references

1. De Muylder X, Claes H, Neven P, De Jaegher K. Usefulness of urodynamic investigations in female incontinence. Eur J Obstet Gynecol Reprod Biol. 13 mai 1992;44(3):205‑8.
2. Blaivas JG, Sinha HP, Zayed AA, Labib KB. Detrusor-external sphincter dyssynergia: a detailed electromyographic study. J Urol. avr 1981;125(4):545‑8.
3. Weld KJ, Graney MJ, Dmochowski RR. Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury. Urology. 1 oct 2000;56(4):565‑8.
4. D’Ancona C, Haylen B, Oelke M, Abranches-Monteiro L, Arnold E, Goldman H, et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn. févr 2019;38(2):433‑77.
5. Amarenco G, Sutory M, Zachoval R, Agarwal M, Del Popolo G, Tretter R, et al. Solifenacin is effective and well tolerated in patients with neurogenic detrusor overactivity: Results from the double-blind, randomized, active- and placebo-controlled SONIC urodynamic study. Neurourol Urodyn. févr 2017;36(2):414‑21.
6. Ginsberg DA, Boone TB, Cameron AP, Gousse A, Kaufman MR, Keays E, et al. The AUA/SUFU Guideline on Adult Neurogenic Lower Urinary Tract Dysfunction: Diagnosis and Evaluation. J Urol. nov 2021;206(5):1097‑105.
7. Urinary incontinence in neurological disease asse.pdf [Internet]. [cité 16 janv 2023]. Disponible sur: https://www.nice.org.uk/guidance/cg148/resources/urinary-incontinence-in-neurological-disease-assessment-and-management-pdf-35109577553605
8. Drake MJ, Apostolidis A, Cocci A, Emmanuel A, Gajewski JB, Harrison SCW, et al. Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013. Neurourol Urodyn. août 2016;35(6):657‑65.
9. Bodmer NS, Wirth C, Birkhäuser V, Sartori AM, Leitner L, Averbeck MA, et al. Randomised Controlled Trials Assessing the Clinical Value of Urodynamic Studies: A Systematic Review and Meta-analysis. Eur Urol Open Sci. oct 2022;44:131‑41.

 

 

 

Author Response File: Author Response.pdf

Reviewer 2 Report

General comment

The manuscript entitled “The utility of Urodynamic studies in neurogenic bladder” aims to summarize the role of urodynamic in several conditions related to neurogenic bladder. Despite the paucity of available data, the paper is quite well written, and few corrections are required before considering the manuscript suitable for publication. Lastly, typos and few grammar errors have to be corrected within the main body of the paper.

In detail:

METHODS

if this work is a systematic review, a prisma flow chart is required, as well as inclusion and exclusion criteria. If this work is, instead, a narrative review, this paragraph would not be required, as the criteria of papers included in the study would not be rigorous and predetermined.

62-64: move this consideration to the discussion.

ANALYSIS

67-70: it has to be reported that this is one of the limitations of UDS, which, albeit an undeniable usefulness in the clinical practice, is still not properly codified.

153-154: check sentence construction as it seems redundant.

199-200: Be clearer.

FIGURES

Figure 1: add a description which could aid also non expert readers.

Author Response

RESPONSE TO REVIEWER

Reviewer 2

General comment

The manuscript entitled “The utility of Urodynamic studies in neurogenic bladder” aims to summarize the role of urodynamic in several conditions related to neurogenic bladder. Despite the paucity of available data, the paper is quite well written, and few corrections are required before considering the manuscript suitable for publication. Lastly, typos and few grammar errors have to be corrected within the main body of the paper.

In detail:

METHODS

if this work is a systematic review, a prisma flow chart is required, as well as inclusion and exclusion criteria. If this work is, instead, a narrative review, this paragraph would not be required, as the criteria of papers included in the study would not be rigorous and predetermined.

Our work is indeed a narrative review.

It will be added in the Methods

62-64: move this consideration to the discussion.

“It is important to note that none of these articles dealt directly with the utility of UDS in the management of NLUTD. Therefore, the strength of conclusions is limited by the fact that they have been drawn from studies with different objectives.”

 

-> Will be moved to Discussion

ANALYSIS

67-70: it has to be reported that this is one of the limitations of UDS, which, albeit an undeniable usefulness in the clinical practice, is still not properly codified.

We agree with this comments. Thank you.

153-154: check sentence construction as it seems redundant.

The sentence has been shortened as follows:

“When CIC is not possible, patients can consider indwelling urethral or suprapubic catheter.”

199-200: Be clearer.

The sentence has been changed as follows:

“Recent studies in the UK showed an improving adherence to the guidelines in recent years. A French survey observed that routine follow-up including UDS were performed by 56% of urologists and 83% of physiatrists, most often annually.”

FIGURES

Figure 1: add a description which could aid also non expert readers.

The figure 1 has been removed.

Author Response File: Author Response.pdf