Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
Lower urinary tract symptoms (LUTS) are highly prevalent among men aged >50 yr and are a daily challenge for urologists and general practitioners [1]. Indeed, the latter are confronted with the most important aspects of initial LUTS management: characterization, assessment, and diagnosis, for which the following steps should be mandatory [2]:
Once this task has been completed, a suitable treatment plan can be initiated or the patient can be referred to a urologist. In the case of voiding symptoms (eventually identified as being associated with storage symptoms and/or nocturia), benign prostatic obstruction (BPO) is the most frequent etiology, which can be medically or surgically treated. In complex cases, obstruction has to be confirmed before any surgical treatment can be considered. A urodynamic study (UDS) including a pressure flow study (PFS) is viewed as the gold standard for defining bladder outlet obstruction (BOO) using recognized and validated nomograms [2]. However, UDS is often seen as expensive, invasive, not available everywhere, and requiring specific expertise. Thus, UDS has to be useful, justified, and reliable for clinical decision-making. It would be better replaced by a competitive, noninvasive and completely safe new tool that would ideally be cheaper than UDS.
In this issue of European Urology, Malde et al [3] review all the noninvasive alternatives to PFS for BOO ascertainment. After a rigorous systematic review, they were able to gather a few studies about each non-invasive tool. Although some tests have impressive accuracy, the review will have very limited impact in clinical practice for several reasons.
The authors included very different tools for BOO assessment, but not all of them are relevant as alternatives to PFS. First, uroflowmetry is included in UDS, which makes the comparison difficult to consider. In addition, the role of uroflowmetry is not comparable to the role of UDS. The former is a filter, used very early in LUTS assessment to ascertain a voiding problem, while the latter is a second-line specialized investigation to ascertain BOO or postulate an alternative etiology for such a voiding problem. Given its specificity, uroflowmetry should be seen merely as a potential way to identify patients with possible obstruction who require second-stage investigation. It is not relevant for making definitive conclusions in complex cases. Second, anatomic factors such as prostate weight and intravesical prostatic protrusion index (IPPI) are positively correlated with BOO. However, on an individual basis, no firm prediction based on prostate weight or IPPI is possible because these ignore dynamic movements of the prostatic lobes and alternative diagnoses such as stenosis. Other parameters such as bladder wall thickness and bladder weight have intrinsic variations and are mainly a consequence of BOO, and thus cannot be used to detect all cases (especially in the early stages).
The most relevant alternative is the penile cuff test, but heterogeneity and many inconclusive results limit interest in the device, for which a head-to-head comparison with UDS is required before any recommendations are possible.
Thus, all these parameters would be only relevant in a context of a score (that could also include age, for example) that could be strengthened by use of endoscopy, especially in a preoperative context. However, no composite index predictive of BPO has been proposed to date.
Another issue that lowers the impact of the review is the fact that UDS comprises not just PFS but also cystometry and evaluation of compliance and detrusor function during storage and voiding. In specific cases, cystometry is of utmost importance for decision-making, and all the alternatives suggested by Malde et al can only replace PFS, and not UDS. Furthermore, curves are constantly available during UDS, including during PFS. Thus, valuable interpretation of UDS leads to many more data than when obtaining the binary results (BOO vs no BOO) that other tests yield. Finally, even rigorous application of the International Continence Society or Abrams-Griffith nomogram can lead to equivocal situations. No method has been directly compared to UDS in a randomized clinical trial to date, so it remains unclear whether any alternative method can correctly classify these patients.
The ultimate goal of BPO assessment is to identify the best therapeutic option. In this context, the role of UDS is not clear, and data from the UPSTREAM trial are urgently awaited [4]. UPSTREAM is actively recruiting to study the role of UDS for patient selection among men who are candidates for surgical relief of BPO. With few exclusion criteria and an ambitious noninferiority design, this first study to provide level 1 evidence will hopefully clarify the role of UDS. If basic evaluation is not inferior to UDS, the role of the latter will obviously be reduced to complex cases with previous prostate surgery or neurologic symptoms. The new standard for preoperative assessment would thus be uroflowmetry. If the results favor a significant role for UDS, the potential indications for UDS will surely dramatically increase, and the review by Malde et al will be an excellent basis for planning future studies on valuable, cheaper, and safer alternatives.
The author has received research funding from Assistance Publique Hôpitaux de Paris, Oak Ridge Associated Universities, Association Française d’Urologie and GSK. He is a consultant/researcher for Allergan, Astellas, Bard, Boston Scientific, Bouchara-Recordati, Coloplast, Ipsen, Pfizer, Takeda, and Majorelle.
