So take it away.
Benjamin Brucker: Great. Thanks, Alan, and thanks to UroToday. It is great to have a paper and a discussion about urodynamics. And as you had mentioned, I think rather than looking at all the things where we can say it's not going to help with... I still use urodynamics as a clinician, and one of the areas with which I use urodynamics for are some of these complicated patients. So this is sort of highlighting a paper, the role of urodynamics, and assessing lots in a post-prostatectomy patient, and it was a review in neurourology.
My co-authors and I sort of set forth to evaluate how urodynamics are still used following radical prostatectomy. Want to start by giving you little insights in the typical urodynamic findings post-prostatectomy, and then maybe go a little bit beyond that into some of the ways in which we think about urodynamics, and then ultimately use them.
So it's just a narrative review, and then hopefully we'll have a little bit of time for discussion to ask some questions and get some of your insights. And I know that this is a population that you've looked at as well, but the conclusion, maybe I shouldn't tell you the conclusion before I tell you the paper, but essentially urodynamics are a useful adjunct in the appropriate selected patient, without sort of going too far into it. I'm not here to tell you that urodynamics is needed in every patient after radical prostatectomy, but a lot of what we know about patients' post-prostatectomy, and what filled my knowledge bank was having done lots of urodynamics on patients both before and after urodynamics, and sort of the understanding of the condition, I think was what I wanted to share a little bit.
I think looking at patient reported outcomes after a prostatectomy in terms of findings, and about 64% of patients in this study, this was about 19 months out, about 30% of these patients had salvage radiation ended up having stress incontinence only. But what you realize is that means a lot of patients have other conditions, mixed incontinence, detrusor underactivity. There were a couple of papers that we found looking at Valsalva voiding in about half of the patients, detrusor underactivity, and even bladder outlet obstruction. Important to realize that men that have prostate cancer often come into the clinic, or come into the urology world with preexisting lower urinary tract symptoms. So about 50 to 60% of men that are newly diagnosed with prostate cancer, if you do sort of an assessment of them, they have moderate to severe LUTS.
Now we know some LUTs get better when you do a prostatectomy, which is great, we're relieving the obstruction, but a lot of these patients may have an overactive bladder, about 50% of them. And whether that improves or not, I think is something to consider. Post-prostatectomy incontinence, again, if we looked at urodynamic stress incontinence, you can find it in about 95% of patients at four years if you look for it. We know the numbers that actually seek treatment or surgical intervention for stress incontinence is way lower. But because of that, I would say if the only thing you're looking to define is whether someone has stress incontinence or not, I don't know that you need urodynamics.
This figure that is from the paper in neurourology and urodynamics explains, I think, a couple of things. The orange little box in the middle is sort of coming after a little bit of a detrusor overactivity, a little bit of DO happens, and then the patient is trying to hold it, try and hold it. The pressure comes down a little bit, but then you see in the flow on the bottom there, that little pink bell-shaped curve, the patient voids with a tremendously large flow rate. When we sort of fill the patient again, we stress the patient, that's sort of the little hash marks, the black hash marks, and the patient does have stress incontinence, not really a very surprising finding. But then just to remind you all that men post-prostatectomy sometimes do void very similarly to a woman in terms of the fact that they can just relax their pelvic floor and generate a very good uroflow. So again, just tracing and sort of looking at the background of what these men have.
I think this slide, probably inspired by the time I spent with Alan, and really, a concept that he popularized and sort of had us all think about, and sort of a tremendous contribution to the field of urology and urodynamics is, we can think about lower urinary tract symptoms as storage symptoms, or voiding symptoms. And I think post-prostatectomy, a good sort of hypothesis or theorem sort of holds true in whatever situation you use, and this is the same for a post-prostatectomy. So storage symptoms, we might end up having stress incontinence. Sometimes there may be urgency associated with that. The other storage things we look at, things like detrusor overactivity, and then impaired compliance. I think clinically, we see stress incontinence, the overactive bladder, and stress incontinence together, that would be sort of the mixed incontinence patients. And then we look at the voiding, and there are patients that can have detrusor underactivity, but remember, that obstruction can occur. And certainly, if you have a post-prostatectomy man complaining of symptoms, and has some of these clinical presentations, we should think that there may be other etiology at play, ultimately, that we're going to need to fix.
I would also mention, I think the application of urodynamics like in post-prostatectomy, and for any men or women, you should do a urodynamics if there's a clinical question that you're sort of looking to help answer. Is it going to alter management? Which is often what we look at in many of the trials in urodynamics used as the measure, or the litmus test to say, "Hey, is this sort of useful or not?" But I think it's also important to think about if it gives and provides information for shared decision-making. Can we counsel patients differently? And can expectations be there? And again, this table just goes over a couple of the different concepts in terms of what we may want to figure out.
Patients that have had, for example, remote history of salvage therapy or radiation therapy. Is there evidence of impaired compliance? Patients that have had, let's say for example, a prior anti-incontinence surgery and are still having incontinence, well, is that contributing negatively or not? So for example, a man that has a sling that's still having incontinence, and maybe some urgency, urgency's gotten worse. Is he obstructed now? Is the stress incontinence there or not? Pretty easy to find on just, again, a standing cough stress test, but we may want to better understand what their voiding mechanics are.
And then there are certainly lots of complex situations with radiation for example, or prior surgeries, and realizing that... Again, this is another image of a gentleman who had seen us for lower urinary tract symptoms and urgency incontinence, and his bladder is just sort of firing off IDC after IDC, and he's having a little bit of leak with that. But realizing that radiation in this population does have a very high likelihood of having overactive bladder. And I might not need to know if they have overactive bladder or not to select for a therapy like an oral agent, but certainly if I want to know a little bit, like for example, impaired compliance, which is fairly common between 20 and 60% of radiation patients can have that, urodynamic is really the tests that are needed.
And I think we also use videourodynamics a lot, and I do a lot of videourodynamics in this population, because this guy who was having the overactivity of the bladder, as it turns out, he does have a narrowing, and when he's voiding, we then subsequently look in with a cystoscopy, and he has a radiation-induced stricture. So how I treat him, and what I decide to treat first will come into play based on this data that I got. Again, the urodynamics having a role.
So summarizing here, the paper introduces the role basically of urodynamics, and talks about lower urinary tract symptoms in this population. And as we were taught by you, Alan, looking at the storage symptoms, and then the voiding symptoms, I think these are the basic concepts of looking at the literature and the data. And it's okay to realize that most of these post-prostatectomy, lower urinary tract symptoms may arise from sphincteric issue, but it also can come from detrusor dysfunction, or a combination of both. Symptoms can be present preoperatively, or arrive de novo postoperatively because of things like denervation, surgical intervention, post-surgical changes, and basically then the subsequent therapies.
I think history and physical exam, and non-invasive testing should absolutely be done first, but urodynamics do serve as a valuable diagnostic tool in selective cases, particularly helpful mixed incontinence, prior radiation, impaired compliance, underactivity and SUI treatments. And the literature, I think we're relying really on some smaller cohort studies, and so expert opinion ends up informing a lot of this, and it's really maybe a call to the medical community to continue to look at this population, and come up with some high quality research so that we can continue to improve the quality of life of our patients. And just a thanks to my co-authors and to you, Alan, for this conversation, and this opportunity, and UroToday for the platform to talk to all of you. So, thanks.
Alan Wein: Great summary. So it sounds like there's a real difference in selection of urodynamics for patients that have had salvage radiation and patients who haven't. In other words, it sounds like it's almost mandatory in somebody that's had radiation after a prostatectomy, and complains of whatever to really do urodynamics now. Do you routinely do those with video or not?
Benjamin Brucker: Yeah. So I think video, I routinely do. I think it's going to be helpful, especially in the radiated patient, the patient that might have voiding issues. And I guess the one piece of this that maybe I would say, "Look, if I have a guy that's complaining of frequency and urgency, his residual's low, his creatinine's normal, one or the other, endourologist, had gotten an ultrasound, his kidneys look normal. Just because he's seeing me for an overactive bladder, I'm not getting urodynamics on him." But if this is a guy that's been radiated, maybe we don't have a ton of data, and I'm considering something like an anti-incontinence surgery, or advanced therapy for his overactive bladder, I definitely think that the radiated patient, I'm more likely to find something that might change my thought process or counseling. So I think that in those cases, the more invasive that I'm going to get with the patient, the more likely I am to get urodynamics.
And video, I think, again, just gives you the ability to assess that voiding phase in a way that, again, can help me understand anatomically, is this a urethral vesicle junction narrowing a stricture? Is this a stricture, again, in the urethra itself? Or is there something else that's going on?
Alan Wein: So going back to that tracing of the radiated patient where you see a bunch of involuntary bladder contractions, what do you tell the patient, "This is what you have." Is that going to get better or worse after you put in a sphincter or sling?"
Benjamin Brucker: Yeah. So-
Alan Wein: I mean, what do you tell the patient when you see that?
Benjamin Brucker: Right. And so this is where you're getting to the point which is, look, I might still choose an anti-incontinence surgery because this guy is leaking anyway. And so if that's my endpoint in a study, the urodynamic didn't inform anything. But what's great is, I can have the discussion to tell the guy that, "Hey, you do have overactivity." I will often treat them with a therapy before rushing to treat the stress incontinence. That patient that was on that slide was actually a guy that, I think in him, you may need to also have a discussion about what to do with the urethral stricture-
Alan Wein: Right.
Benjamin Brucker: ... because certainly treating that urethral stricture may help the overactivity-
Alan Wein: Right. Yeah.
Benjamin Brucker: ... but the incontinence gets worse. So these are complicated patients, and when you're dealing with something that's not so straightforward, it's just about data. It's that shared decision-making, it's sort of informing him. So he's a guy that I would say, "Look, if we're going to move forward with something, I absolutely would favor a sphincter versus something like a sling." Because of the radiation, and because of the overactivity, frankly. I may tell him, "Look, we need to get that stricture open, see what happens with the urgency, see what happens with the incontinence, and then ultimately get a sphincter implanted."
So it's sometimes multiple steps, and patients need to understand that. And what you or I may really very clearly understand in terms of, "Hey, this is a bladder issue, and this is an outlet issue." I think sometimes having this tool, and sort of visual aid to show him can actually go... Rather than waving my hands, and saying, "Well, you might have some overactivity." I can point to it, and say, "That's the overactivity you have." And what's useful is, post-op, again, if a guy, let's say, has a sphincter placed, and now is still having incontinence, gives me a little bit more confidence that I didn't do something that's causing this, and now I'm going to be a little more inclined to treat him, for example, with Botox if oral therapies haven't worked.
Alan Wein: So for the patient that comes in with, of course, we've never seen this, we've just heard about it, pretty significant incontinence-
Benjamin Brucker: Sure.
Alan Wein: ... they leak, when you do the urodynamic study to really classify the filling and storage phase, do you have to occlude the outlet or not?
Benjamin Brucker: Yeah. I mean, if they're leaking considerably enough where you can't actually fill them to watch the voiding, and see if they have overactivity, yeah, absolutely. It can be a hand clamp, it can be a Cunningham clamp, but I think you do need something in order to fill if your question has to do with the storage phase. And if I'm just looking to see if the guy leaks, who cares? He can pull-
Alan Wein: Yeah. Exactly.
Benjamin Brucker: ... his pants down, and I'll see him leak. So most of these guys, you do need to occlude it. Now, there are guys that dribble a little bit, and this is, again, the advantage with a fluoroscopic image, I can see the bladder getting larger-
Alan Wein: Now filling. Yeah.
Benjamin Brucker: ... and larger, and say-
Alan Wein: Right.
Benjamin Brucker: ... "Hey, he looks pretty full." So I do bring a biased lens to this, because I do have videourodynamics, but I think if you don't, even more important to really understand, hey, how much is in there? Because is this pressure really an elevated pressure based on the volume, or is the pressure low just because I didn't fill him adequately?
Alan Wein: I mean, that may be a good reason why the videos are going to be much more informative than just the pressure-flow studies. So if you do occlude the outlet in somebody that has a pretty significant incontinence, and you're basically doing it to see... And they've had radiation, let's say. And so you say, "Hey, probably something else is going on here." And you fill it up, and you see really significantly decreased compliance. In other words, the pressure rises inappropriately, almost... Maybe not 40 degrees, but 30 degrees and 45 degrees. I mean, what do you tell those people? Do you go ahead and put a sphincter in those people, and hope for the best, or...
Benjamin Brucker: Yeah. I mean, the one thing you said that makes me less nervous about this is the fact that he's floridly incontinent. So some of this may be more of just the functional... His bladder's not cycling, his bladder's not filling.
Alan Wein: Right.
Benjamin Brucker: And so if I put the sphincter in-
Alan Wein: Less issues.
Benjamin Brucker: ... it may be better.
Alan Wein: Right.
Benjamin Brucker: But I do think that that's a role. And again, maybe I'm unpopular saying it, but I do need to see this guy and sort of follow, and maybe I get a repeat urodynamic three months, six months down the road. Maybe I get an ultrasound in this guy.
Alan Wein: Right.
Benjamin Brucker: So there are cases where, yeah, it can be quite dangerous. Or even putting, let's say, the non-radiated patient that you put a sling in, where the compliance that's impaired can actually start to have an impact because now we've increased that detrusor leak point pressure. And so I think those are patients where maybe I don't need the information before, but it's nice to have my baseline to compare, and say, "Hey, you know what? Your detrusor pressure rose really quickly, now it's not as quickly, or the volume's larger." So we talk about it. And these might be patients that ultimately need treatment with ACs, beta-3s, or even Botox, or in some cases augmentation cystoplasty if there's something really more severe going on from really devastating radiation complications. But that's a great reason why we get the urodynamics in this population.
Alan Wein: Yeah. So I guess the bottom line is, if you're going to do something, and you're really not positive about what's going on, then the safest thing to do for yourself and the patient is do a urodynamic study with fluoroscopy, do a video study?
Benjamin Brucker: Yeah. And I think someone once told me, "If you don't know what to do, get a little bit more data, get another test." It might have been you, but that's I think words that I live by. But you're right, and this is something that, it's informing you as I'm not sure. Again, straightforward non-radiated patient, we can have a value trial in men and say it doesn't work, but you and I can have a nice conversation about all the reasons where, hey, it's coming to actual practice for me to say this is helpful for me, the patient, or that conversation.
Alan Wein: Yes, if you're going to do something, I mean...
Benjamin Brucker: Yeah.
Alan Wein: Well, that was great. I think people will be better informed the next time they look at a post-radical prostatectomy patient, or any kind of post-prostatectomy for benign disease. I mean, the incontinence rate with whole EPID a year is not zero, to take a look and see what else is going on. So as usual, thanks very much. Valuable information. See you soon at one of the meetings, I hope.
Benjamin Brucker: All right. Take care. Thanks again, everyone.