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Authors' response re: Do preoperative urodynamics still have a role in female stress urinary incontinence? Neurourol Urodyn 2013;32:1144–5

We highly appreciate the comments of Del Popolo et al. with regard to our study and would like to address their comments. Guidelines of professional organizations and authorities are not uniform on the advice when to perform urodynamics prior to invasive treatment for stress urinary incontinence (SUI). The statements are largely based on expert opinion rather than solid evidence. Moreover, the conclusion from a recently updated Cochrane review on the value of urodynamics was that randomized trials are needed to conclude the debate. The inclusion of the present study (VUSIS 1) has been interrupted before the accomplishment of the necessary number of patients, which indeed limits the strength of our findings. The findings of the VUSIS 1 study, the VUSIS 2 study and the VALUE-trial are to a large extent concordant and may be combined in meta-analysis and result in strong conclusions. Whether the large number of including clinics has changed anything to the strength of our findings is unknown, but does not seem very likely. The strength of our study was that there was a homogenous group of women with pre-dominant SUI. It was not our intention to provide information on the value of preoperative urodynamics in women with ‘‘complicated stress urinary incontinence.’’ The trial excluded women with an advanced pelvic organ prolapse, previous incontinence surgery, and large postvoid residuals. Inclusion of these women would make the study group too diverse. In our opinion it was inappropriate to analyze various group, and the value of urodynamics in more complex cases should be investigated separately. The number of included women with a low maximum urethral closure pressure was limited, and therefore no comments could be made on the value of urodynamics in these women. For women with poor intrinsic urethral sphincteric function, theoretically a retropubic approach may result in better continence rates than the transobturator sling, and therefore the use of the urethral pressure profile could attribute to the determination of the most effective type of sling in individuals. However, recent evidence-based recommendations for the treatment of stress incontinence did not utilize intrinsic sphincter deficiency and bladder neck hypermobility as primary determinants in the selection of the type of sling. Furthermore, in a survey among gynecologists and urologist, treating SUI in daily practice, we found that only 9% of the specialists differentiate in the choice of sling on measurement of the closure mechanism. The majority of specialists apply only one type of sling procedure, which is possibly due to surgeon’s experience and familiarity with that specific type. Whether this is an appropriate clinical approach is an appropriate question for further research. The study of Digesu et al. which was cited by Del Popolo et al., has shown that in women with complaints of pure SUI, 20% might not need surgery as primary treatment. However, the study did not describe treatment and follow-up among these women, which limits the value of the statement. Ward et al. reported the probability to change management after urodynamics, however the study did not evaluated the effect on outcome of treatment. In summary, the limitations as suggested by Del Popo et al. had already been mentioned in the discussion section of our publication. Larger trials will be needed to answer all our questions and conclude the debate. The results of the present trial are in line with the VALUE trial and the VUSIS 2 trial and could be combined in a meta-analysis.