Welcome to the AUGS Urogynecology webinar series. I'm Sarah Ashmore, AUGS Education Committee member and the moderator for today's webinar. Today's webinar is titled Complex Video Urodynamic Cases in Urogynecology. Our speaker today is Dr. Victor Nitti. Dr. Nitti is Professor of Urology and Obstetrics and Gynecology and the Shlomo Ross Chair in Urology, as well as the Administrative Chief of the Division of Urogynecology and Pelvic Reconstructive Surgery and the Fellowship Director for the ACGME Accredited Program at the David Geffen School of Medicine at UCLA. Prior to coming to UCLA, Dr. Nitti was Professor of Urology and Obstetrics and Gynecology and Vice Chair of Urology at New York University Langan Medical Center, where he was also the FPRMRS Fellowship Director. Dr. Nitti is a graduate of the University of Rochester and Rutgers New Jersey Medical School. He completed urology residency at SUNY Downstate in Brooklyn, New York, and then completed a fellowship in female urology, neuro urology, and reconstructive urology at UCLA. Dr. Nitti served on the faculty at SUNY Brooklyn before joining the faculty at NYU from 1995 to 2018. He's an authority in urodynamic techniques, medical and surgical therapies for urinary incontinence, pelvic organ prolapse, female pelvic reconstructive surgery, and voiding dysfunction. He has authored over 195 peer-reviewed articles, as well as 80 book chapters on these subjects. He's the editor of two textbooks, Practical Urodynamics and Vaginal Surgery for the Urologist. He's presented his research at national and international meetings, as well as been invited as a visiting professor and participated in postgraduate courses throughout the world. In 2015, he was the recipient of the AUA Victor Pulitano Award for expertise and contributions in urodynamics, medical and surgical therapies for urinary incontinence, female pelvic reconstruction, and voiding dysfunction. In 2020, he received the Sufu Lifetime Achievement Award. Dr. Nitti, we're so excited to have you here today. Before we begin, I'd like to review some housekeeping items. The presentation will last around 60 minutes. The first 45 minutes will consist of lecture, and the last 15 minutes will be dedicated to Q&A. AUGS designates this live activity for a maximum of one AMA PRA Category 1 credit. To claim your CME credit, you must log into the AUGS Online Learning Portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live-streamed. A recording of the webinar will be made available in the AUGS Online Learning Portal. Please use the Q&A feature of the Zoom webinar to ask questions and use the chat feature if you have any technical issues. AUGS staff will be monitoring the chat and can assist you. Thanks, Dr. Nitti, again for being here, and you may begin. Well, thank you, Sarah, and welcome to everyone. These are my disclosures. I don't think any of them are relevant to this talk, per se. These are our objectives, and what I really hope to accomplish is have everybody get a good understanding of the indications and value of video urodynamics in specific urogynecologic conditions, appreciate the timing of fluoroscopic imaging to minimize exposure, and to develop some treatment algorithms based on our video urodynamic findings and interpretation. So, I always like to start any urodynamics talk with this very simple concept of what the lower urinary tract does. It stores urine at low pressures to protect the kidneys and assure continence, and that allows for voluntary evacuation of urine. So, that's what our lower urinary tract should do, and urodynamics is just a dynamic study of that function. Now, urodynamics has clinical applicability in two general scenarios. One is to obtain information needed to make an accurate diagnosis for whatever condition they're causing symptoms, and then the second is to determine the impact of a certain disease that has the potential to cause serious and maybe even irreversible damage to the upper and lower urinary tracts. So, sometimes we just want to sort out symptoms. Sometimes we want to see if there's sequelae that may be associated with a particular patient's history. Now, this is a really simple way of looking at urodynamics before you even start, and that is to say all of lower urinary tract dysfunction can be divided into either problems with emptying, problems with storage, or a combination of both, and either can be due to bladder dysfunction or bladder outlet dysfunction. So, for example, failure to store based on outlet dysfunction would be stress incontinence. Failure to empty due to bladder dysfunction would be due to detrusor underactivity, etc., and you can have multiple combinations of things. I think that sets the scene for taking your urodynamic findings and making a therapeutic strategy. So, video urodynamics is simply the simultaneous measurement of urodynamic parameters and imaging that allows us to visualize the lower urinary tract. Now, video urodynamics is certainly not necessary in all cases of lower urinary tract dysfunction, and urodynamics isn't necessary in probably the vast majority of lower urinary tract dysfunction, but when is video urodynamics most helpful? Well, when an anatomic picture is needed or desired, particularly when you have a known anatomic abnormality, and we'll show examples of that. Failure to demonstrate incontinence by conventional methods, not the most common reason for it, but sometimes can be helpful. Neurologic disease or other potentially dangerous causes of lower urinary tract dysfunction. Radiation cystitis, where we're concerned there may be reflux, and we want to see when it occurs, at what pressure it occurs, and at what volume it occurs, and for me, probably the most common reason is to localize outlet obstruction in women, and we'll talk a little bit more in detail about that in a second, and I'm going to use a lot of different case scenarios or case presentations to demonstrate my points. One thing I want to just say up front is that we don't need to expose patients to massive amounts of radiation when we're doing video urodynamics. This is a paper we wrote a few years ago that showed that by being judicious with x-ray imaging, you can really limit the exposure of radiation, so you take pictures or images at critical times in a study. If we're looking for reflux to document how severe it is, at what pressure, and what volume it occurs, we want to view the outlet during leakage, and we want to view the outlet during voiding. Those are the most important images to capture. We don't need to take 30 images during most video urodynamic studies. Now, occasionally, something incredibly unusual or interesting may be going on where we want to take more images, but that's not the norm. So, the first concept I want to present is the importance of outlet resistance. So, I'm going to show you two patients with the same condition, the same presentation, but a different problem and a different intervention. Now, these two happen to be pediatric patients because it shows this problem so nicely, but after I show you the two, I'm going to spin it into something that we would more commonly see in urogynecology. So, this is a patient with spina bifida, myelomeningocele, and they're on intermittent catheterization, and they're incontinent between catheterizations. And if we look here at this tracing, we can see that this patient has a low abdominal leak point pressure, meaning there's stress incontinence at low pressure, and they also have a low detrusor leak point pressure, meaning when the pressure gets to about 11 centimeters of water, which is a very mildly impaired compliance, that patient will start to leak. So, we can look at a picture here, and we can see if we look at the bladder, if we look at the outlet, we see an open outlet with straining. We see an open outlet on the bottom without straining, just with a pressure of 11 centimeters of water. The bladder looks pretty normal. It doesn't look—it's not a terrible looking bladder. So, these are the kinds of things we may appreciate on video urodynamics. Now, let's look at this young girl who has—her presentation is the same. She has spina bifida. She's on self-catheterization, and she's incontinent between catheterizations. Now, the first patient was incontinent because of low outlet resistance, but this patient is incontinent because of high storage pressures. We see on the P detrusor curve, we see pressure going up. There's some overactivity, superimposed unimpaired compliance, and then leakage occurs at a very high pressure, 53 centimeters of water. And we can look at that bladder and say, my goodness, what a difference. It's a Christmas tree-like bladder, severely trabeculated with saccules and diverticuli. This is a dangerous situation, where the other situation was not dangerous. So, let's say—let's assume that both of these were 25-year-old women, okay? So, the first patient is going to need her outlet resistance increased. So, this could be a 25-year-old woman with spina bifida who has a large capacity, compliant, stable bladder with a poor outlet, and she needs to have her outlet resistance increased, and that would best be done probably with an autologous fascial sling. Whenever we add outlet resistance, we want to remember that could affect compliance, and we should repeat our study probably six months down the line, where the second patient, even though the presentation is similar, needs aggressive treatment to lower bladder pressures. Medication, botulinum toxin, even bladder augmentation, because that second patient is in trouble. The upper tracts are in trouble. So, I think in this case, the video helps you determine, first of all, was there reflux or not? There wasn't reflux in either case. There was high storage pressures. What does the bladder look like, and how can we best treat the patient? So, and this is just—I started with this because it's just getting you to think about outlet resistance, and when there's high outlet resistance, like in the second patient, it can lead to all kinds of problems, and we're going to show some more of that as we go along. Now, bladder emptying problems are one of the most common places where I like to use video urodynamics in women, because bladder emptying problems, when they're not obvious, can be tricky to isolate just by standard urodynamics. So, the etiology of poor bladder emptying is either the bladder's underactive, there's obstruction, or there's combinations of both, and typically we don't think of non-obvious obstruction in women, but it certainly can happen, and it probably happens more commonly than we think. So, bladder underactivity, lots of reasons. We don't really need video urodynamics to diagnose bladder underactivity, but the problem is when we're evaluating these patients, we don't know they have bladder underactivity until we do our study. So, these are the various causes, and this isn't a lecture on bladder underactivity, so you can just take a look at those, but what about bladder outlet obstruction in women? Well, there's two types. There's anatomical, and there's functional. Anatomical obstruction is usually pretty obvious in the clinical presentation, and usually doesn't need any type of urodynamics to diagnose it. Somebody has a high-grade prolapse. If they have a urethral diverticulum, if they have a pelvic mass, usually that's pretty obvious in your standard evaluation, and you don't need urodynamics to tell you that a prolapse is causing an obstruction. You can put a pessary in and see how the patient empties, or you can even make a presumptive diagnosis that the stage 3 or 4 prolapse is causing obstruction if the bladder is not emptying properly, but functional obstruction is different, and there's a few different types. There's obstruction at the level of the bladder neck, which is a primary bladder neck obstruction, or there's obstruction at the external sphincter, which could be dysfunctional voiding or sphincter dysenergia if there's neurological or occult neurological disease, and Fowler's syndrome is sort of, I never know if I put that as a bladder problem or as a sphincter problem, because what's happening there is the sphincter, the bladder doesn't contract because the sphincter doesn't relax. It's a little bit different than the other two, but as I said, anatomical obstruction is straightforward. You're going to treat the cause. We generally don't need to do any advanced testing to figure that out. However, functional obstruction can be difficult, and when we have a woman who doesn't empty her bladder well, and there's no obvious anatomic obstruction, then the cause is either the bladder being underactive or there's some bit of obstruction. Now, women are tricky because we don't have a highly prevalent disease or condition like we do in men, which is benign prostatic obstruction. So, we don't, we can't take hundreds of women with a condition, look at aerodynamic parameters, and make nomograms so easily because there's all those different anatomic conditions, and then there's the functional conditions that are not all that common. So, it makes nomograms, while they do exist, it makes nomograms a little bit difficult to develop, and thus it's always been my practice to use an individualized approach, look at each patient differently, look at their studies individually, and then come up with a plan. So, of all of the criteria for female bladder outlet obstruction, the one that works best for me is the video urodynamic criteria. This is something that we came up with many years ago by doing a retrospective study of a little over 250 video urodynamics, and we defined obstruction as radiographic evidence of obstruction between the bladder neck and the distal urethra in the presence of a sustained detrusor contraction of any magnitude. And I will show you where this idea came from with a case presentation in a moment. Now, it does mean that we have to have simultaneous fluoroscopy. It also means that we can also have an underactive bladder, but with a component of obstruction. So, when we use this criteria, what you can see on this slide is just, there was a huge difference in flow rate, in pressure, in post-void residual, in patients who had obstruction and who didn't. But the overlap was incredible. The standard error was huge. And these were the different conditions that we found in this particular study as we were developing this criteria. So, it's that large overlap that really made an individual approach and adding the video so important. If we just used pressure flow criteria, it would be really hard to be accurate. So, that's where the video helped. So, this is the patient many, many years ago that gave the idea of the video urodynamic criteria for obstruction. So, what I'm going to tell you is this is a patient who is in urinary retention doing self-catheterization. And what this isolated picture shows is it shows that this patient is having a sustained detrusor contraction of 15 centimeters of water. Now, 15 centimeters of water is not really high pressure. It's not really high pressure. And you would be very tempted to say this patient has an underactive detrusor. It's weak. And that's why she can't empty her bladder, especially at 85 years of age. It would be easy to say that if you didn't have the picture. Now, what we see here is we see this little balloon under the bladder. That little balloon that's under the bladder was not present, this right here, was not present before the bladder started to contract. Now, if we look a little bit further into the patient's history, she developed retention after excision of a distal urethral lesion, presumed to be a car uncle, and she's been on CIC ever since. Well, what this actually was, that little balloon that you see is actually the patient's urethra that has been completely closed, and she was catheterizing through a false passage above where the urethra was, and that's how she was emptying her bladder. So, you know, that's kind of interesting and all that, but what fascinated me about this case was, if I did not have the picture, I would not have made the diagnosis of an obstruction, I just would have thought this patient had a weak bladder. Once this patient's urethra was actually opened, she was able to void normally and didn't have to catheterize anymore. So that's where the concept of the video urodynamic criteria for obstruction came from, and I'm gonna show you another paper in a few minutes that will support its use. So let's start talking about some individual cases. So the first one is a 23-year-old woman, frequency, urgency, urgency incontinence, progressive over time. She had incomplete bladder emptying diagnosed with a UTI. She had three 350 cc's of residual, and she was placed on self-catheterization, and she's been on that for the past year. And this is a young woman without any known neurologic disease and without any known neurologic symptoms. So here's her video urodynamics. And what you see here is you see she definitely has a good detrusor contraction, even though her abdominal pressure drops a little bit. She has some increased EMG activity. She has a poor flow, even with the high pressure, and she has what we call a spinning top urethra. She has no neurologic disease. So this is dysfunctional voiding. Dysfunctional voiding is failure to relax the external sphincter appropriately during voiding. This opposed to detrusor sphincter dyssynergia if there was a neurologic problem, and I'll show you an example of that in just a moment. So what I will tell you is you might say, well, couldn't I have made that diagnosis without the picture? And I will tell you that in my opinion and in my hands, making a diagnosis based slowly on surface EMGs is difficult. And most of us don't use needle EMGs as they're very uncomfortable. And I'll show you a case in a moment where you could get fooled by the EMG. So I rely heavily on what the bladder outlet looks like. Now, here's a little bit different case, but also a case of a young, healthy woman in retention. So this 37-year-old, one year prior to me seeing her, had a distended bladder, basically asymptomatic retention. I think she went to the emergency room with an abdominal mass and it was her bladder. So eventually, after it was determined that she had a full bladder, she was started on self-catheterization. She stopped voiding spontaneously. No neurologic history or symptoms, no medical problems, had never had a child, an unremarkable physical exam. Renal ultrasound was normal after her bladder was decompressed. Her renal function was normal and someone even did a cystoscopy and that was normal. So no obvious reason for this young, healthy woman to be in urinary retention. So here's the non-video portion of her urodynamics. So the thing that got me excited about this was we see a couple of episodes here and then here of detrusor overactivity. So that tells me, okay, the bladder is working to some degree. Then have her void. There's not any flow, but there is a fairly good sustained contraction. This is a compressed study over here and then a little less sustained here. So you might look at that and say, well, there's increased EMG activity. This must be another case of dysfunctional voiding. However, when we look at the picture, which is taken during voiding, and we look at the bladder neck, we don't see a spinning top urethra. We see a bladder neck that's completely closed. Also, if we take a more careful look at the study, we see that the increase in EMG activity starts to occur after the contraction starts. And I believe, now, with detrusor overactivity, that could simply be a guarding reflex, right? When you have an involuntary contraction, you're gonna start to guard. But with the actual voiding, as this patient starts to voluntarily void and nothing is coming out, she's gonna start to move a little bit. And I believe that's what caused that change in EMG activity. This, to me, is a primary bladder neck obstruction because her bladder neck never opens. Now, this is not a common thing, but it's something that I see quite frequently. And it's going to be treated a lot different than dysfunctional voiding. Dysfunctional voiding is treated with biofeedback. Primary bladder neck obstruction, you can do all the biofeedback in the world. There is no way you're gonna get a bladder neck to contract in any way, shape, or form, or bladder neck to relax in any way, shape, or form with any sort of, in any voluntary way. So she was given a trial of an alpha blocker, which didn't help, not surprising, but worth a try. And then she underwent a unilateral bladder neck incision to disrupt the fibers that are causing this problem. And three and a half years later, she was voiding spontaneously, no self-catheterization, no lower urinary tract symptoms. Upon questioning, she had a rare bout of stress incontinence only with sneezing. And here's her non-invasive uroflow. So this is a problem that without video urodynamics, I would have never been able to diagnose. And it made a huge difference in this woman's life. Along the same lines, this is an 18-year-old whose chief complaint was bedwetting. But she also had frequency, urgency, and daytime urgency incontinence. She is otherwise apparently healthy. No significant residual. She's medical and gynecologic, urogynecologic history, neurologic history, unremarkable. So here again, we have a situation where there's an involuntary contraction. There's an increase in sphincter activity, could be a guarding reflex, and if you have demonstrable leakage on a flow meter, that's a lot of leakage. And then the second time we filled her a little bit slower and I said, okay, when you get the urge, don't try to hold it this time, just let go. And again, it looks like the same situation. The EMG is active. Is this real or not? She voids, but her void is not much better than her urge incontinence episode. And her picture shows a spinning top urethra. So this again, well, she must have dysfunctional voiding, right? She's 18. She has no neurologic symptoms. But when you see this in a patient that has not had a neurological workup, this patient needs a neurological workup. So what we found in this patient, rather than start her on biofeedback, what we found was she had a lipoma of her cord. So this is a neurogenic problem. This is a spinal dysraphism, an occult spinal dysraphism. So she got started on self-catheterization with first started on an anticholinergic at that time. This is many years ago. She developed, as expected, a large post-void residual, was started on self-catheterization, had an untethering of her cord, but not to correct her urinary problems. Once this was diagnosed, it was felt that she was at risk for developing some lower extremity problems. Now, does this patient need follow-up? Does she need urodynamic follow-up? You could make an argument that with her normal compliance, if you followed her with renal ultrasounds, that would be adequate. Back in those days, I did a follow-up. So I like to show this follow-up because it's not perfect. Also, it's something where we don't need video because we just wanna look at her storage pressures. Now, what's interesting is during this, she was completely asymptomatic on her anticholinergic, but during this study, she had some urgency that was associated with all those little involuntary contractions. Now, the good news about this study is her pressures, even though she has some detrusor overactivity, the pressures remain relatively low. They are not dangerous. She's not emptying anymore except by using a catheter. So this is actually a good study. And the reason for her overactivity, the reason I like to show this particular study is that she forgot to take her anticholinergic that day. So she felt different than she normally does. But nevertheless, we're in a safe situation here. So this is an important urodynamic concept, but also an important video urodynamic concept. And that is a study should always duplicate the patient's symptoms. And if it doesn't, consider altering, repeating, or at least interpreting with caution. And I'm going to show you two examples, one of a study that duplicated symptoms and one of a study that didn't. And how we could have been very much misled. So this first one's an 85 year old woman with incontinence and a very large residual after hospitalization for a fall injury. I have no idea what her residual was before she fell. But anyway, if we look at this study, what we see is we see a lot of little low pressure, involuntary contractions, and they were associated with leakage. And then she attempted to void. And this is her during voiding. And she really didn't generate any significant contraction. And she urinated a little. Her bladder neck actually does open and funnel a little bit, but she doesn't void much. So in this case, the patient told me, yes, this is what happens to me. I'm leaking all the time. And then I want to urinate and I can't. Only a little bit comes out. So to me, I recreated the symptoms. So this is one of these detrusor overactivity plus detrusor underactivity situations. What we used to call DHIC, detrusor hyperactivity with impaired contractility. Not an easy problem to treat in an elderly patient. Probably gonna need, if she wants to, she's not in any danger, but if she wants to stop leaking, probably gonna need some self-catheterization and then lowering of bladder pressures instituted. But this is a good study. Now, let's contrast that to this patient. So this is another one of these young, healthy women. And when I see these young, healthy women who are in retention, it's always striking to me. Why, you know, there's gotta be something we can do to help this young, healthy woman. So she had retention diagnosed when she presented with a UTI four years, and she's been on self-cath for four years. But she tells me that when her bladder is full, she'll get an urge to void and she can urinate a small amount. So she does this study and she attempts to void and nothing happens. She strains the void and nothing happens. So my concern is, you know, I could not get her to do that small amount of voiding that she can do in real life at times. So am I, is this, and you can see her compliance seems to be a little bit impaired, but I have no reason for this. She has no neural, she's been worked up. She has nothing neurological going on with her at all. So I didn't duplicate her urge to void. I didn't duplicate any flow on the study. So should I call this Fowler syndrome and do sacral neuromodulation on her? I wasn't ready to do that because I felt this was non-diagnostic because I could not get her to void. As painful as it can be for both you as the diagnosing physician and for the patient, I said, let's repeat the study. We'll try it again under a different circumstance. Now you may look at this and say, well, it doesn't look that much different, but it's very different. When she, up until that line that says attempt to void, everything's the same. But then she attempts to void, and this time she generates a sustained high pressure contraction for over three minutes. So this is very different. Now there's nothing coming out of, she's not having any urinary flow. She does do some straining on top of the contraction. And then when I pull out the catheter over here, she voids a little bit like she normally does. So this is now diagnostic, but what's going on? Well, this is another case of a primary bladder neck obstruction. The bladder neck never opened. And this patient had a bladder neck incision and never needed to catheterize again. So this goes to show not only the value of the video, but also the value of making sure that you do everything to recreate the patient's symptoms. If she would have had an interstem, it would have for sure been a negative staged implant. This is a paper that we recently published. And the idea behind this paper is not to say how well or how poorly we do with bladder neck incisions. It's just to say that using the video urodynamic criteria for a specific diagnosis, in this case, primary bladder neck obstruction, that intervening with a bladder neck incision in the majority of cases resulted in improvement in symptoms. And that's what, with all of the video urodynamic and urodynamic criteria for female outlet obstruction, there's very little data on outcomes of treating the obstruction based on the diagnostic criteria. So that was the point of this paper, not that we can make patients better with bladder neck incision. That's been known for decades. The last thing I wanna talk about is the hostile bladder. And this is something that's really, again, it's not something that you'll see a lot of, but it's something that's critical to identify. So a hostile bladder is a bladder that places the upper tracts at risk. It's usually associated with lower urinary tract symptoms, incontinence that can be sometimes stress, sometimes urgency, sometimes insensible, sometimes it's just urinary frequency and urgency, and sometimes it's incomplete emptying or urinary retention. Now, sometimes these patients are not immediately recognized but they'll be treated empirically, which is reasonable in a lot of cases, but they're unresponsive or ineffectively treated by conventional methods, and ultimately they come to further diagnostic treatment. Now, if there are clues in the history, such as the patients had radiation or something, sometimes those treatments can put the patient at risk. If somebody has radiation cystitis with incontinence that appears to be stress incontinence and you do an outlet procedure like a sling on them, you could actually put them even at higher risk. But anyway, so we wanna recognize patients at risk, evaluate them, and then how do you treat the hostile bladder? So I'm gonna show you two cases. This first one is, she's 38, and her chief complaint was, the way she presented to me was high-grade incontinence. Now, her complaint was insensible incontinence and urgency incontinence. So it's happening, I don't know why, and I'd sometimes have an urge. She's wearing diapers, essentially. She's never been pregnant, no significant gynecologic history, and she has no significant past medical history, except she has a high BMI, and she's had kidney stones. So, six years ago, she had a nephrectomy for a right staghorn calculus. Recently, she had sepsis, developed left hydronephrosis, had a Foley cap at her place, creatinine normalized, hydronephrosis resolved, but on follow-up imaging, she has recurrent left hydronephrosis. So, this is not a happy picture. She's got, she has a BMI of 48. When I examine her, fixed urethra, but high-grade stress incontinence. So, some of her insensible incontinence is, seems to be related to stress. She has no prolapse, and her post-void residual is zero. So, what's not right here? She's got high-grade incontinence as a 38-year-old with no obvious medical problem, but she also has bilateral kidney issues, and the bilateral kidney issues are the things that make me think video urodynamics is probably going to be ideal. Well, was I right? So, let's look first at her urodynamic tracing, and what we see here is, you know what, her bladder pressure goes up in early fill, so there is some impaired compliance, and she starts to leak. As she, right after she leaks, the pressure goes down a bit. So, it's like the cork is pulled out of the bottle, and the pressure in the bottle gets a little bit less, but the leakage starts, and it persists. A little bit further down the line, I have her cough. She has stress incontinence. So, is this enough information? This doesn't really tell me why she had bilateral kidney issues. I'm not convinced. That's where the video picture, and the video picture is dramatic. So, basically, what I am looking at is not the compliance of her bladder. I'm looking at the compliance of her bladder, her right ureter minus the kidney, and her entire left upper tract. So, this is, that bladder is way less compliant than what we're measuring. So, she has this little walnut-sized bladder with terrible bilateral reflux. This is definitely a hostile bladder. Cystoscopy just shows a small fibrotic bladder. Bladder biopsy, not really very remarkable. She has no occult neurologic disease. So, I'm not really sure the exact etiology, what in her bladder. You know, she didn't have amyloidosis. She didn't have sarcoid. There was no obvious cause for this, but at the end of the day, you have to do something to lower those bladder pressures, and honestly, with a bladder that looks like that, I don't think pharmacologic therapy or botulinum toxin is going to work. This is a person who's either going to need a urinary diversion or a bladder augmentation, but she also has stress incontinence, so she's likely going to need attention to her bladder outlet and attention to, and with that, she might be somebody that's going to be on intermittent catheterization for a lifetime, but this is definitely a hostile bladder situation. If you don't do something to fix that, her other kidney is going to be gone before you know it. So, one of my– so, one of the things I always say is that in the absence of a known cause, meaning some sort of a pelvic mass or retroperitoneal fibrosis, bilateral hydronephrosis is a bladder problem until proven otherwise. Now, she was high-risk for any diversion procedures, so she opted for bariatric surgery. She lost about a hundred pounds, then followed by augmentation, cystoplasty, and pubovaginal sling. That's a really serious problem. I have one more for you. So, this is a 70-year-old woman with high-grade incontinence, mostly insensible, but increased withstanding. It happened acutely a couple months ago, and all of a sudden, she went from being totally continent to wearing two to three large pads a day. Cough stress test is negative, no prolapse. The treating doctor was suspicious for stress incontinence and was considering urethral bulking, mostly because this–or one of the reasons why a quick fix is this patient was getting ready to go on vacation to Europe and wanted the problem fixed or helped as quickly as possible. So, they–so, the treating physician did simple systemetrics, and she really wasn't able to fill the bladder beyond 50 milliliters. Seemed like there was high pressure in the bladder. Cystoscopy was really suboptimal. So, at this point, she was referred for urody–video urodynamics. So, what is going on here? So, what's going on here is that this patient, you can see there, while the bladder is pretty small, the outlet is wide open, and she's just– the pressure goes up a little bit. There's a lot of rectal contractions in there. So, that's not all the TrueZerover activity. It's a lot of rectal contractions, but you can see that with even a small volume in the bladder, the pressure goes up a little bit, and she's leaking. Is this just a bad outlet, or is this impaired compliance? It's hard to tell. So, what was done is the urethra was occluded to allow the bladder to fill, and once the urethra was occluded, look at that pressure. It shot up to almost 100 centimeters of water, or over 100 centimeters of water, because the– the scale has been adjusted. So, this is a horrendously compliant bladder. As soon as she voids, the pressure drops, she empties her bladder completely. We tried the best we could to test her for stress incontinence, and we didn't demonstrate any. This is just the urethral occlusion stretched out, but an important technique. She had bilateral hydronephrosis. So, again, a bladder problem until proven otherwise. No idea why this is happening. Did a cystoscopy, some diffuse bullish changes, three biopsies, and the remarkable thing about this, and it's not what we found, it's just the bladder is hostile. It needs to be treated. She had metastatic cancer in her bladder, which is very unusual, but if left untreated, forgetting the cancer, she would have blown out her upper tracts over time and been incontinent as well. So, be on the lookout for unusual symptoms and findings on simple evaluation. Unexplained bilateral hydronephrosis is a bladder problem until proven otherwise, and treatment usually requires either an indwelling catheter or advanced lower urinary tract reconstruction. I got one more quick case for you that may seem similar, but it's not. So, this is a 23-year-old who had total insensible incontinence after a vaginal delivery. So, her first vaginal delivery, it was a traumatic vaginal delivery, but she is totally incontinent afterwards. So, why video urodynamics in this case? Well, it's because of her history. She had a history of an ectopic ureter as a young child. So, some surgery was done, and some surgery may have been done on her urethra, and also she had incredibly severe incontinence. So, she has a wide-open bladder, neck, with low, with basically just standing. Her bladder holds very little. So, she has a bad outlet. Does she need some sort of a sling procedure? Well, she may, but is there anything else we need to do? And the answer is yes. We need to make sure that her capacity and compliance is okay. So, this is another case where occluding the outlet, either with a finger or with a balloon catheter, is going to allow you to finish and make sure she doesn't have any sort of a hostile bladder. The only thing that would indicate that in her was her previous surgery as a young child, but in this case, she did not have a hostile bladder and underwent a pubovaginal sling. So, final thought, video urodynamics when used in proper circumstances, and it doesn't mean every patient that walks into my office gets video urodynamics. In fact, a very small percent of patients get urodynamics at all, but it can be extremely helpful. It's generally not needed in common urogynecologic conditions. We don't need it for stress incontinence. We don't need it in most cases of overactive bladder incontinence. We don't need it in cases of prolapse. And then three good general principles, and that's decide on questions you want to answer before you start your study, design the study to answer those questions, and customize the study as needed. Thanks for your attention, and I'm happy to take any questions. Wonderful. Thank you, Dr. Nitti, for such a great lecture. We do have some questions from our audience. So, our first one is, do you ever use cystoscopy to evaluate primary bladder neck obstruction? Usually, well, I mean, so a cystoscopy will rule out anything else going on in the bladder neck. I have never seen anything diagnostic about primary bladder neck obstruction. Remember, that's not a fibrotic bladder neck. So, the answer is I do it. Oftentimes, I do it at the time when I do the bladder neck incision, but it's mostly to rule out other things. Okay, and then for the young patient with spina bifida and the young patient with a hostile bladder, you mentioned doing a pubovaginal sling for both of those patients. Why would you not do a mesh sling in these patients? Okay, the reason that I wouldn't do a mesh sling in the patient that, the last patient I showed you, is because her urethra had been reconstructed at the time of her, at the time of her ectopic ureter. Also, there was something that happened. I didn't emphasize it, but there was something that that happened at the time of her vaginal delivery that I think aggravated that urethra to begin with, but if that was a standard, more standard patient, you could do a mid-urethral sling, although a totally fixed, wide-open urethra like that, I still think a pubovaginal sling is the best surgical procedure, but you could think about a synthetic sling. In the other patient, that patient generally, when you're having a bladder augmentation, you are, we know that patient's going to catheterize. Because we know that patient's going to catheterize, that's a patient that I am seeking to make sure nothing comes out of her urethra. So, I'm actually going to do a tight pubovaginal sling with the augment. I don't know that it's advisable to do a tight, extra-tight mid-urethral sling. So, that's why I'd opt for a pubovaginal sling. Now, I'm not, you know, I mean, the vast majority of slings that I do in my practice are mid-urethral slings, but those just happen to be cases, you know, extreme cases where I thought a pubovaginal sling was a better choice. And then, are you sending patients to neurology for the neurologic workups, or are you ordering the imaging and doing that workup? And if so, what would you include? So, the answer is, is both. So, the problem, you know, the problem in our health system is it takes a long time to get evaluated. So, if I was gonna, the answer is yes, I would send them to a neurologist. If I was going, you know, so, you look at the particular patient and what you suspect might be the problem. So, in a young, healthy patient with no symptoms like that, I actually ordered the MRI that showed the tethered cord. I'd go for a lower spinal MRI. If there's any suspicion of MS, you may do an MRI of the whole central nervous system. But, in general, yes, they, I will send them to a neurologist, but if I need some sort of a quick answer that they, I need to, I want to intervene quickly, I might start the workup, and it's usually lower, lumbosacral MRI, and then working up the, working up the spinal cord to even the brain, although the brain won't cause sphincter dysenergia generally, if it's only in the brain. Okay, and then, what are your thoughts or experience on the phenomenon, phenomenon of urine entering the bladder neck area and eliciting D.O. in patients with predominantly strong urinary incontinence withstanding, and is this characterized, is this just a phenomenon, or is this a theory of some practitioners, and have you been able to reproduce standing with leaking on video urodynamics? I have not been able to reproduce visual opening of the bladder neck with triggering of a bladder contraction. This is a theory that has been talked about for probably 50 years. I have no idea if it's true or not. It makes sense. I don't know if it's true. We know that when we treat stress incontinence in a patient that also has urgency and urgency incontinence, a good amount of the time, the urge symptoms will go away. Is it because the bladder neck is closed? I have no idea. So, it's an interesting theory that I would say is absolutely unproven, but I don't think it's wrong to think that it exists and guide your treatment appropriately, because the treatment seemed to work, even if that's not why it's happening. Okay. And then, are there any good alternatives if you don't have access to video urodynamics for patients? Well, I think, you know, you can do urodynamics and a separate voiding systoleurethogram. Now, if the patient is able to void a little bit, and even if it's just a little bit, you know they're voiding, so you can say, okay, here's what they did on the urodynamics, here's what they did on the VCUG, they voided a little bit, the bladder neck isn't very open, or there's a spinning top urethra. The problem is if they don't, if no urine at all comes out, you don't really know during the VCUG if they're truly having a contraction, but that's gonna, you know, it's certainly worth a try to do them separately if you don't have the ability to get the two together. Okay, and then let's see, a couple other questions. How often do you see true bladder outlet obstruction in women, and what leads you down this path of workup with video urodynamics? Well, I mean, so true bladder outlet, we see it a lot, you know, in obstructing sling, prolapse, but functional bladder neck obstruction, now I probably see it a little bit more than is typical because it's also part of my referral base. So, I get these types of patients referred to me, so I probably see functional obstruction in women or surprise anatomic obstruction in women a few times a month. But, you know, I mean, a lot of times patients will have symptoms, we'll do a non-invasive uroflow, and if it's normal and the post-void residual is not high, I'm not doing urodynamics on that patient because I don't think that, you know, it would be highly unlikely that they had, you know, it would have to be way down the line after they failed a bunch of other stuff. So, it's, you know, pretty select in choosing the patients who we evaluate, and that's probably why the yield is high, but that comes with decades of experience and knowing, okay, I don't have to do urodynamics on that patient. Okay, and then, are there conservative treatments for the hostile bladder? So, if it's truly a hostile bladder, the only conservative treatment is an indwelling catheter. I mean, unless, and well, if you can calm it down with medication or Botox, I mean, so, and you can have a neurogenic hostile bladder that responds very well to botulinum toxin or even medication. They'll likely need to be beyond self-catheterization, but if it's a hostile bladder from radiation, that's the thing I see most commonly. It's after radiation for GYN or colorectal cancers. You know, there's, I mean, you can try, but no. If it's really like the two I showed you, those patients, an indwelling catheter, which is not ideal, or a major reconstructive procedure, if it's truly hostile. Mm-hmm. Well, wonderful. That kind of wraps up our time. So, thank you again, Dr. Nitti, for those amazing cases in this lecture. I know we all learned so much. So, on behalf of Oggs, I'd like to thank you for this webinar. For our audience, be sure to register for our upcoming Oggs educational webinar on June 18th, where Dr. James Simon is presenting a webinar titled Menopause Medicine and Neurogynecologic Health. To stay up-to-date on everything Oggs, follow us on Instagram and X, and check our website for information on all upcoming webinars. Thank you, everyone, for joining, and thank you, Dr. Nitti, and everyone have a great evening. Good night, everyone. Thanks.

video urodynamics

urogynecology

lower urinary tract dysfunction

bladder outlet obstruction

dysfunctional voiding

hostile bladder

anatomic abnormalities

neurological conditions

radiation cystitis

bladder underactivity