The evidence-based role of urodynamics in men with lower urinary tract symptoms considering prostate surgery: an international expert consensus

Abstract

Background and objective: 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. Methods: 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. Key findings and limitations: 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. Conclusions and clinical implications: 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.