This aim of this international expert consensus project was to clarify the appropriate use of urodynamics (UDS) in men with bothersome lower urinary tract symptoms (LUTS) who are considering prostate surgery in light of high-quality published evidence, particularly high-certainty data from the UPSTREAM study, and expert clinical experience.
A modified version of the Delphi method was used. Postsurgical patients, catheterised patients, and patients with neurological disease were not included. Eight questions covered UDS in specific contexts; four addressed quality assurance.
Consensus was reached on the need for UDS in any of the following circumstances: if the corrected maximum flow rate is ≥13 ml/s; if bothersome urinary urgency is present; if scores are below stated thresholds for overall symptoms or voiding symptoms; if the postvoid residual volume is considered meaningfully elevated; if there is extensive comorbidity; and if incontinence (any type) is identified. Consensus was not reached on the need for UDS in men with scores below the stated threshold for the impact on quality of life. Consensus was achieved for quality assurance in terms of cross-checking UDS pressure traces and derived indices; ensuring the trustworthiness of traces by experienced health care professionals; and review within the individual clinical context. UDS was considered important when benign prostatic obstruction (BPO) is less likely and in cases in which detrusor underactivity or overactivity is more likely. In cases with severe voiding symptoms, UDS was not considered necessary to increase confidence in recommending surgery to treat LUTS.
UDS retains an important role in men with bothersome LUTS considering surgery for presumed BPO. Our consensus recommends specific criteria to guide selective UDS use.
The role of urodynamics has remained controversial for many years in the assessment and management of male lower urinary tract symptoms (LUTS).
The UPSTREAM trial (1) was a multicentre UK randomised controlled trial, published in 2020, which compared a diagnostic pathway including urodynamics with one based on routine care without urodynamics in men with LUTS being considered for prostate surgery. It showed that including urodynamics was non-inferior in symptom outcomes (IPSS at 18 months), suggesting that patients did just as well irrespective of undergoing urodynamic evaluation. This study was the largest of its kind and, although it concluded that routine urodynamics prior to prostate surgery was not necessary, it highlighted the importance of a selective, individualised approach.
Following this, an international expert consensus statement (2) aimed to help identify which patients are most likely to benefit from urodynamics. Using a rigorous Delphi process, a group of international male LUTS experts concluded that urodynamic studies have important utility in a subset of male patients, particularly when diagnosis is uncertain. Rather than defining urodynamic parameters themselves, the panel focused on clinical features including flow rate, post-void residual volume and symptom scores, to help appropriately select patients for testing.
This approach facilitates improved patient counselling by identifying those with concomitant detrusor overactivity and/or detrusor underactivity, who may be less likely to benefit from bladder outflow surgery. In addition, comorbidity is another important consideration, as certain conditions (e.g. neurological disease) may influence lower urinary tract dysfunction and increase surgical risk, making further diagnostic clarification valuable in guiding risk-benefit decisions.
Out of 12 statements, 11 achieved consensus. Six clinical scenarios were identified where urodynamics is most likely to influence management:
1) Bothersome urgency – observed on the symptom score or bladder diary
2) Urinary incontinence – observed on the symptom score or bladder diary
3) Low symptom scores – low to moderate scores for overall symptoms or voiding symptoms
· Specifically utilising IPSS and ICIQ M-LUTS as the preferred validated symptom score
o IPSS <17, ICIQ-MLUTS <19
o ICIQ-MLUTS voiding sub score 8
4) Comorbidity – presence of extensive comorbidity
5) Elevated PVR – post-void residual volume meaningfully elevated (definitions remain variable*)
6) Flow rate ≥13ml/s – corrected maximum flow rate ≥13 ml/s on uroflowmetry
* It is acknowledged that there is no universally accepted definition of an ‘elevated PVR’. Furthermore, the significance of an elevated PVR alone is unclear; bladder voiding efficiency may provide a more meaningful assessment by relating voided volume to total bladder capacity.
A statement regarding the impact of quality of life (i.e. low QoL score) and the need for urodynamics did not achieve consensus. Although the UPSTREAM study identified a QoL threshold predicting poorer postoperative outcomes, the expert panel concluded that QoL scoring is highly subjective, with wide interindividual variability and so applying the population threshold to an individual case risks overweighting a single item response within the complex and multifaceted area of QoL.
Additionally, this consensus document highlighted a few statements about quality assurance when conducting urodynamic studies:
Overall, the consensus provides practical guidance on when urodynamics is most useful, while emphasising that decisions should remain individualised. There remains a paucity of level 1 evidence in this field, with the USPTREAM trial representing the only major randomised controlled trial to date. Notably, UPSTREAM focused predominantly on TURP, and therefore may not fully reflect current practice given the increasing use of minimally invasive surgical therapies (MIST), which may require a more tailored diagnostic approach. This highlights the need for further high-quality research in this evolving area.
It is therefore reasonable to conclude that urodynamics should not be routinely performed prior to all prostate surgery but plays an important role in selected patients where diagnostic uncertainty exists or where outcomes are difficult to predict.
References:
1) Drake MJ, Lewis AL, Young GJ, et al. Diagnostic Assessment of Lower Urinary Tract Symptoms in Men Considering Prostate Surgery: A Noninferiority Randomised Controlled Trial of Urodynamics in 26 Hospitals. Eur Urol. 2020;78(5):701-710
2) Drake MJ, Iacovelli V, Cruz F, et al. The evidence-based role of urodynamics in men with lower urinary tract symptoms considering prostate surgery: An international expert consensus. European Urology Focus 2025