Expert Commentary

Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence?

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No, provided the patient undergoes careful office evaluation instead, according to this systematic review and meta-analysis

Rachaneni S, Latthe P. Does preoperative urodynamics improve outcomes for women undergoing surgery for stress urinary incontinence? A systematic review and meta-­analysis. BJOG. 2015;122(1):8–16.



In their review, Rachaneni and Latthe included randomized controlled trials (RCTs) comparing surgical outcomes in women investigated by urodynamics and women who had office evaluation only. Three RCTs met their a priori criteria of women with pure stress incontinence or stress-predominant mixed urinary incontinence, with outcomes describing cure or improvement of stress urinary incontinence (SUI). There were no statistical differences in the risk ratios of subjective cure, objective cure, voiding dysfunction, or urinary urgency between the 2 groups. Rachaneni and Latthe appropriately concluded that: “In women undergoing primary surgery for SUI or stress-predominant mixed urinary incontinence without voiding difficulties, urodynamics does not improve outcomes—as long as the women undergo careful office evaluation.”

Thorough evaluation is critical
It cannot be emphasized strongly enough that the mere presence of symptoms of SUI is insufficient justification for surgery. Providers should demonstrate SUI during office evaluation before operating on someone without urodynamics. The addition of a full-bladder standing stress test usually is sufficient to demonstrate incontinence in women with bothersome SUI.

National professional societies agree on what is involved in office evaluation. In June 2014, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society published a joint committee opinion on evaluation of uncomplicated SUI in women before surgical treatment.1 The committee opinion states1:

The minimum evaluation before primary midurethral sling surgery in women with symptoms of SUI includes the following 6 steps: 1) history, 2) urinalysis, 3) physical examination, 4) demonstration of stress incontinence, 5) assessment of urethral mobility, and 6) measurement of postvoid residual urine volume.

Although the most recent Cochrane review found no evidence about urodynamic use in men, children, and people with neurologic disease and noted that large definitive trials are needed in which people are randomly allocated to urodynamics or not,2 most experts believe, and this review confirms, that the issue has been settled for preoperative urodynamics in women with uncomplicated SUI before surgery.

What this evidence means for practic
It is safe to proceed to surgery for SUI without urodynamic testing in women who meet all the following criteria: no previous surgery, no prolapse beyond the introitus, presence of predominant SUI complaints, demonstration of stress incontinence on cough stress testing, normal postvoid residual, mobile urethra, and normal urinalysis.
— Charles W. Nager, MD

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