Peggy Norton

University of Utah, Salt Lake City, Utah, United States

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Publications (68)410.12 Total impact

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    ABSTRACT: Understanding the clustering of pelvic floor disorders (PFDs) within families is important because it may suggest underlying risk factors that may be environmental, genetic or both. The objective of this study was to describe clinical characteristics observed in familial cases with PFDs and compare them with strictly defined controls.
    International Urogynecology Journal 10/2014; · 2.17 Impact Factor
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    ABSTRACT: Urological chronic pelvic pain syndrome includes interstitial cystitis/painful bladder syndrome (IC/PBS), a chronic bladder pain condition of unknown etiology. Interstitial cystitis/painful bladder syndrome can co-occur with a number of associated conditions such as irritable bowel syndrome and fibromyalgia. The purpose of this study was to estimate the heritability of approximately 20 associated conditions in first-degree relatives (and if appropriate, second- and third-degree relatives) of patients with IC/PBS to identify shared genetic contributions for the disease combinations.
    Female pelvic medicine & reconstructive surgery. 10/2014;
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    ABSTRACT: AimsUrodynamic studies (UDS) are generally recommended prior to surgical treatment for stress urinary incontinence (SUI), despite insufficient evidence that it impacts treatment plans or outcomes in patients with uncomplicated SUI. This analysis aimed to calculate the cost incurred when UDS was performed as a supplement to a basic office evaluation and to extrapolate the potential savings of not doing UDS in this patient population on a national basis.Methods This is a secondary analysis from the Value of Urodynamic Evaluation (ValUE) trial, a multicenter non-inferiority randomized trial to determine whether a basic office evaluation (OE) is non-inferior in terms of SUI surgery outcomes to office evaluation with addition of urodynamic studies (UDS). All participants underwent an OE; those patients who randomized to supplementary UDS underwent non-instrumented uroflowmetry, filling cystometry, and a pressure flow study. Costs associated with UDS were calculated using 2014 U.S. Medicare allowable fees. Models using various patient populations and payor mixes were created to obtain a range of potential costs of performing UDS in patients undergoing SUI surgery annually in the United States.ResultsSix hundred thirty women were randomized to OE or OE plus UDS. There was no difference in surgical outcomes between the two groups. The per patient cost of UDS varied from site to site, and included complex cystometrogram $314–$343 (CPT codes 51728–51729) plus complex uroflowmetry $16 (CPT code 51741). Extrapolating these costs for US women similar to our study population, 13–33 million US dollars could be saved annually by not performing preoperative urodynamics.Conclusion For women with uncomplicated SUI and a confirmatory preoperative basic office evaluation, tens of millions of dollars US could be saved annually by not performing urodynamic testing. In the management of such women, eliminating this preoperative test has a major economic benefit. Neurourol. Urodynam. 9999:1–4, 2014. © 2014 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 10/2014; · 2.67 Impact Factor
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    ABSTRACT: Few studies have characterized longer-term outcomes after retropubic and transobturator midurethral slings.
    The Journal of urology. 08/2014;
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    ABSTRACT: AimsThe Blaivas–Groutz nomogram defines voiding obstruction in women using Qmax from the NIF and the maximum detrusor pressure (Pdetmax) from the PFS. The aim of this study was to understand the relationship between NIF and PFS maximum flow rates in women with stress incontinence.Methods We analyzed the UDS of 597 women with stress-dominant urinary incontinence. Each subject underwent a NIF and then a PFS. Mixed model was used to test the hypothesis that the relationship between flow rates and voided volume (VV) were similar for NIF and PFS.ResultsThere were 452 subjects with both NIF and PFS studies that met the inclusion criteria and had max flow rate (Qmax) for both NIF and PFS. The mean age was 53. Overall, higher VV were observed during PFS compared to NIF and subjects had higher Qmax with NIF compared to PFS. The relationship between Qmax and VV was significantly different between NIF and PFS (P < 0.004). At 200 ml, NIF Qmax was 14% higher than PFS Qmax and this difference increased to 30% at 700 ml.Conclusion The difference between PFS Qmax and NIF Qmax increases as VV increase. As a result, values from PFS and NIF cannot be used interchangeably as has been suggested in the Blaivas–Groutz nomogram for obstruction in women. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 04/2014; · 2.67 Impact Factor
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    ABSTRACT: More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery. To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence. Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%. The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188). The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success. At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months. Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years. clinicaltrials.gov Identifier: NCT00597935.
    JAMA The Journal of the American Medical Association 03/2014; 311(10):1023-34. · 29.98 Impact Factor
  • Journal of Minimally Invasive Gynecology 03/2014; 21(2):S3. · 1.61 Impact Factor
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    ABSTRACT: The aim of our study was to observe pelvic organ prolapse (POP) over time, treated and untreated, in a group of highly characterized women being followed subjectively and objectively over 5-7 years following continence surgery.
    Journal of Minimally Invasive Gynecology 03/2014; 21(2):S1. · 1.61 Impact Factor
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    ABSTRACT: To construct and validate a prediction model for estimating the risk of de novo stress urinary incontinence (SUI) after vaginal pelvic organ prolapse (POP) surgery and compare it with predictions using preoperative urinary stress testing and expert surgeons' predictions. Using the data set (n=457) from the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial, a model using 12 clinical preoperative predictors of de novo SUI was constructed. De novo SUI was determined by Pelvic Floor Distress Inventory responses through 12 months postoperatively. After fitting the multivariable logistic regression model using the best predictors, the model was internally validated with 1,000 bootstrap samples to obtain bias-corrected accuracy using a concordance index. The model's predictions were also externally validated by comparing findings against actual outcomes using Colpopexy and Urinary Reduction Efforts trial patients (n=316). The final model's performance was compared with experts using a test data set of 32 randomly chosen Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial patients through comparison of the model's area under the curve against: 1) 22 experts' predictions; and 2) preoperative prolapse reduction stress testing. A model containing seven predictors discriminated between de novo SUI status (concordance index 0.73, 95% confidence interval [CI] 0.65-0.80) in Outcomes Following Vaginal Prolapse Repair and Midurethral Sling participants and outperformed expert clinicians (area under the curve 0.72 compared with 0.62, P<.001) and preoperative urinary stress testing (area under the curve 0.72 compared with 0.54, P<.001). The concordance index for Colpopexy and Urinary Reduction Efforts trial participants was 0.62 (95% CI 0.56-0.69). This individualized prediction model for de novo SUI after vaginal POP surgery is valid and outperforms preoperative stress testing, prediction by experts, and preoperative reduction cough stress testing. An online calculator is provided for clinical use. : III.
    Obstetrics and Gynecology 02/2014; 123(2 Pt 1):279-87. · 4.80 Impact Factor
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    ABSTRACT: Objective To estimate the effect of Burch and fascial sling surgery on out-of-pocket urinary incontinence (UI) management costs at 24 months post-operatively and identify predictors of change in cost among women enrolled in a randomized trial comparing these procedures. Methods Resources used for UI management (supplies, laundry, dry cleaning) were self-reported by 491 women at baseline and 24 months post-surgery and total out-of-pocket costs for UI management (in 2012 US dollars) were estimated. Data from the two surgical groups were combined to examine change in cost for UI management over 24 months. Univariate and bivariate changes in cost were analyzed using Wilcoxon signed rank test. Predictors of change in cost were examined using multivariate mixed models. Results At baseline mean (±SD) age of participants was 53±10 years, and frequency of weekly UI episodes was 23±21. Weekly UI episodes decreased by 86% at 24 months (P<0.001). Mean weekly cost was $16.60±$27 (median $9.39) at baseline and $4.57±$15 (median $0.10) at 24 months (P<0.001), a decrease of 72%. In multivariate analyses, cost decreased by $3.38±$0.77 per week for each decrease of 1 UI episode per day (P<0.001) and was strongly associated with greater improvement in UDI and IIQ scores (P<0.001) and decreased 24-hour pad weight (P<0.02). Conclusion Following Burch or fascial sling surgery, UI management cost at 24 months decreased by 72% ($625 per woman per year) and was strongly associated with decreasing UI frequency. Reduced out-of-pocket expenses may be a benefit of these established urinary incontinence procedures.
    American journal of obstetrics and gynecology 01/2014; · 3.28 Impact Factor
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    ABSTRACT: To report the frequency of abnormal cystoscopy at incontinence surgery and identify risk factors and sequelae of injury. Findings of cystoscopy were prospectively collected in 3 multicenter surgical trials. Clinical, demographic, procedure characteristics and surgeon experience were analyzed for association with iatrogenic injury and non-injury abnormalities. Impact of abnormalities on continence outcomes and adverse events during 12 months post-procedure were assessed. Abnormal findings in the bladder or urethra were identified in 95 of 1,830 (5.2%) women. Most injuries were iatrogenic (75.8%). Lower urinary tract (LUT) injury was most common at retropubic urethropexy and retropubic midurethral slings (MUS) (6.4% each), followed by autologous pubovaginal slings (PVS) (1.7%) and transobturator MUS (0.4%). Increasing age (56.9 v. 51.9 years; p=0.04), vaginal deliveries (3.2 vs. 2.6, p=0.04), and blood loss (393 vs. 218 ml, p=0.01) were associated with LUT injury during retropubic urethropexy, but only age (62.9 vs 51.4 yrs, p=0.02) and smoking history (p=0.04) were associated for PVS. No factors correlated with increased risk of injury at retropubic and transobturator MUS. Notably, prior incontinence surgery, concomitant procedures, anesthesia type and trainee participation did not increase LUT injury frequency. Though discharge with an indwelling catheter was more common after trocar perforation compared to the non-injury group (55.6% vs. 18.5%, p < 0.001), they did not differ in overall success, voiding dysfunction, recurrent UTIs or urge urinary incontinence. Universal cystoscopy at incontinence surgery detects abnormalities in 1 in 20 women. Urinary trocar perforations addressed intraoperatively have no long-term adverse sequelae.
    American journal of obstetrics and gynecology 12/2013; · 3.28 Impact Factor
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    ABSTRACT: To describe the prevalence and risk factors for incomplete bladder emptying after midurethral slings (MUS) in a large multicenter trial. Five hundred ninety-seven women were randomized to retropubic (RMUS) or transobturator midurethral slings as part of the Trial of MidUrethral Slings study. Demographic data and voiding symptoms were obtained preoperatively along with urodynamics. Patients underwent a standardized voiding trial at discharge after continence surgery. Incomplete bladder emptying was defined as a postvoid residual of >150 mL. Three-quarters of patients (454 of 597) were self-voiding at discharge, whereas 114 of 597 (19%) were managed with an indwelling urethral catheter and 29 of 597 (5%) with intermittent catheterization. At 2 weeks, only 38 of 586 (6%) reported any catheter use, and by 6 weeks, only 9 of 587 (2%) reported any catheter use. Women with incomplete bladder emptying at discharge were more likely to have had a RMUS (odds ratio 1.79; 95% confidence interval 1.22-2.62) and to report preoperative voiding accommodations such as straining to void (odds ratio 1.75; 95% confidence interval 1.04-2.96). Urodynamic and clinicodemographic parameters were not predictive of incomplete bladder emptying. Incomplete bladder emptying at discharge after MUS is common, especially after RMUS, but of short duration. Risk factors include preoperative voiding accommodations such as straining or bending over to void, but other variables including urodynamics did not predict incomplete bladder emptying after MUS.
    Urology 11/2013; 82(5):1038-41. · 2.42 Impact Factor
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    ABSTRACT: AIMS: This study examined the association between the need for a repeat voiding trial after midurethral sling (MUS) surgery and 1-year success rates. METHODS: We conducted this secondary analysis of the participants in the Urinary Incontinence Treatment Network trial of midurethral sling (TOMUS) study which compared retropubic versus transobturator MUS. A standard voiding trial was attempted on all subjects. The "repeat voiding trial" group included subjects discharged with catheterization. All others were considered "self voiding." Success rates between the groups at 1-year were compared, followed by multivariate analyses controlling for previously reported clinical predictors of success. RESULTS: Most women (76%) were self-voiding, while 24% required a repeat voiding trial. The objective success rate at 1-year was 85.8% in the repeat voiding trial group and 75.3% in the self-voiding group (P = 0.01). Subjective success rate at 1-year was 61.0% in the repeat voiding trial group and 55.1% in the self-voiding group (P = 0.23). Women in the repeat voiding trial group continued to demonstrate greater objective success than the self-voiding group in multivariate analysis that controlled for previous incontinence surgery, pad weight, urethral mobility, urge score, and type of MUS (P = 0.04, OR 1.82, 95% CI 1.03-3.22). CONCLUSIONS: Women who require a repeat voiding trial following MUS surgery have greater objective success at 1-year postoperatively when compared to those who are self-voiding at the time of discharge. These results may help reassure women who require catheterization after MUS surgery that their outcome is not compromised by this immediate transient post-operative result. Neurourol. Urodynam.
    Neurourology and Urodynamics 08/2013; · 2.67 Impact Factor
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    ABSTRACT: Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life. The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ). Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008). Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.
    International Urogynecology Journal 08/2013; · 2.17 Impact Factor
  • Obstetrics and Gynecology 05/2013; · 4.80 Impact Factor
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    ABSTRACT: AIMS: To determine if pre-operative urodynamic testing (UDS) affects physicians' diagnostic confidence and if physician confidence affects treatment outcomes at 1 year. METHODS: The Value of Urodynamic Evaluation (ValUE) trial randomized 630 women with predominant stress urinary incontinence (SUI) to office evaluation (OE) or OE plus UDS prior to surgery. After OE, physicians completed a checklist of five clinical diagnoses: SUI, overactive bladder (OAB) wet and dry, voiding dysfunction (VD), and intrinsic sphincter deficiency (ISD), and reported their confidence in each. Responses ranged from 1 to 5 with; 1 = "not very confident (<50%)" to 5 = "extremely confident (95 + %)." After UDS, investigators again rated their confidence in these five clinical diagnoses. Logistic regression analysis correlated physician confidence in diagnosis with treatment success. RESULTS: Of 315 women who received OE plus UDS, 294 had complete data. Confidence improved after UDS in patients with baseline SUI (4.52-4.63, P < 0.005), OAB-wet (3.55-3.75, P < 0.001), OAB-dry (3.55-3.68 P < 0.005), VD (3.81-3.95, P < 0.005), and suspected ISD (3.63-3.92, P < 0.001). Increased confidence after UDS was not associated with higher odds of treatment success although mean changes in confidence were slightly higher for those who achieved treatment success. Physician diagnoses shifted more from not confident to confident for ISD and OAB-wet after UDS (McNemar's P-value <0.001 for both). CONCLUSIONS: In women undergoing UDS for predominant SUI, UDS increased physicians' confidence in their clinical diagnoses; however, this did not correlate with treatment success. Neurourol. Urodynam. 9999:XX-XX, 2013. © 2013 Wiley Periodicals, Inc.
    Neurourology and Urodynamics 04/2013; · 2.67 Impact Factor
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    ABSTRACT: Genetic epidemiology, the study of genetic contributions to risk for disease, is an innovative area in medicine. While research in this arena has advanced in other disciplines, few genetic epidemiologic studies have been conducted in obstetrics and gynecology. It is crucial that we study the genetic susceptibility for issues in women's health, as this information will shape the new frontier of "personalized medicine." To date, preterm birth may be one of the best examples of genetic susceptibility in obstetrics and gynecology, but many areas are being evaluated including endometriosis, fibroids, polycystic ovarian syndrome and pelvic floor disorders. An essential component to genetic epidemiologic studies is to characterize, or "phenotype," the disorder in order to identify genetic effects. Given the growing importance of genomics and genetic epidemiology, we discuss the importance of accurate phenotyping of clinical disorders and highlight critical considerations and opportunities in phenotyping, using pelvic organ prolapse as a clinical example.
    American journal of obstetrics and gynecology 11/2012; · 3.28 Impact Factor
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    ABSTRACT: Genetic epidemiology, the study of genetic contributions to risk for disease, is an innovative area in medicine. Although research in this arena has advanced in other disciplines, few genetic epidemiological studies have been conducted in obstetrics and gynecology. It is crucial that we study the genetic susceptibility for issues in women's health because this information will shape the new frontier of personalized medicine. To date, preterm birth may be one of the best examples of genetic susceptibility in obstetrics and gynecology, but many areas are being evaluated including endometriosis, fibroids, polycystic ovarian syndrome, and pelvic floor disorders. An essential component to genetic epidemiological studies is to characterize, or phenotype, the disorder to identify genetic effects. Given the growing importance of genomics and genetic epidemiology, we discuss the importance of accurate phenotyping of clinical disorders and highlight critical considerations and opportunities in phenotyping, using pelvic organ prolapse as a clinical example.
    American Journal of Obstetrics and Gynecology 11/2012; · 3.88 Impact Factor
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    ABSTRACT: PURPOSE: Longer term comparative efficacy information regarding transobturator and retropubic mid urethral slings is needed. We report 24-month continence rates, complications and symptom outcomes from a randomized equivalence trial. MATERIALS AND METHODS: Primary outcomes were objective (negative stress test, negative pad test and no re-treatment for stress urinary incontinence) and subjective (no self-report of stress urinary incontinence symptoms, no leakage episodes on 3-day bladder diary and no re-treatment for stress urinary incontinence) success at 24 months. The predetermined equivalence margin was ±12%. RESULTS: Of 597 randomized participants 516 (86.4%) were assessed. Objective success rates for retropubic and transobturator mid urethral slings were 77.3% and 72.3%, respectively (95% CI for difference of 5.1% was -2.0, 12.1), and subjective success rates were 55.7% and 48.3%, respectively (CI for difference of 7.4% was -0.7, 15.5). Neither objective nor subjective success rates met the prespecified criteria for equivalence. Patient satisfaction (retropubic 86.3% vs transobturator 88.1%, p = 0.58), frequency of de novo urgency incontinence (retropubic 0% vs transobturator 0.3%, p = 0.99) and occurrence of mesh exposure (retropubic 4.4% vs transobturator 2.7%, p = 0.26) were not significantly different. The retropubic mid urethral sling group had higher rates of voiding dysfunction requiring surgery (3.0% vs 0%, p = 0.002) and urinary tract infections (17.1% vs 10.7%, p = 0.025), whereas the transobturator group had more neurological symptoms (9.7% vs 5.4%, p = 0.045). CONCLUSIONS: Objective success rates met the criteria for equivalence at 12 months but no longer met these criteria at 24 months. Subjective success rates remained inconclusive for equivalence. Patient satisfaction remained high and symptom severity remained markedly improved. Continued surveillance is important in women undergoing mid urethral sling surgery.
    The Journal of urology 10/2012; · 3.75 Impact Factor
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    ABSTRACT: PURPOSE: To evaluate the influence of pre-operative urodynamic studies (UDS) on diagnoses, global treatment plan and outcomes in women having surgery for uncomplicated stress predominant urinary incontinence (SUI). MATERIALS & METHODS: Secondary analysis from a multicenter, randomized trial of the value of preoperative UDS. Physicians provided pre- and post-UDS diagnoses and global treatment plans, defined as proceeding with surgery, surgery type, surgical modification, non-surgical therapy. Treatment plan changes and surgical outcomes between office evaluation (OE) and OE plus UDS were compared by McNemar's test. RESULTS: 294 of 315 subjects randomized to UDS after OE had evaluable data. UDS changed the OE diagnoses in 167 women (56.8%), decreasing the diagnoses of OAB-wet (41.6% to 25.2%, p<0.001), OAB-dry (31.4% to 20.8%, p=0.002) and intrinsic sphincter deficiency (ISD) (19.4% to 12.6%, p=0.003) but increasing the diagnosis of voiding dysfunction (2.2% to 11.9%, p<0.001). After UDS, physicians cancelled surgery in 4/294 (1.4%), changed the incontinence procedure in 13/294 (4.4%), and planned to modifiy the midurethral sling tension ("more or less obstructive") in 20/294 women (6.8%). Non-surgical treatment plans changed in 40/294 (14%). UDS driven treatment plan changes were not associated with treatment success (OR, 0.96 (0.41, 2.25), p = 0.92), but were associated with increased postoperative treatment for urge UI (OR 3.23, 95% CI 1.46, 7.14), p = 0.004). CONCLUSIONS: UDS significantly changed clinical diagnoses and global treatment plan but infrequently influenced surgeon decision to cancel, change or modify surgical plans. Global treatment plan changes were associated with increased treatment for post operative urgency UI.
    The Journal of urology 09/2012; · 3.75 Impact Factor

Publication Stats

867 Citations
410.12 Total Impact Points

Institutions

  • 2006–2014
    • University of Utah
      • • Department of Obstetrics and Gynecology
      • • School of Medicine
      Salt Lake City, Utah, United States
  • 2012–2013
    • University of Texas Southwestern Medical Center
      • Department of Urology
      Dallas, Texas, United States
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
  • 2011
    • University of Texas Health Science Center at San Antonio
      • Department of Urology
      San Antonio, TX, United States
  • 2010–2011
    • University of Alabama at Birmingham
      • Department of Obstetrics and Gynecology
      Birmingham, AL, United States
    • Loyola University Chicago
      • Department of Obstetrics and Gynecology
      Chicago, Illinois, United States
  • 2007–2011
    • University of California, San Diego
      • • Department of Reproductive Medicine
      • • Division of Urology
      San Diego, CA, United States
  • 2008
    • University of British Columbia - Vancouver
      • Department of Obstetrics and Gynaecology
      Vancouver, British Columbia, Canada