UDS in BPE Current status

The evaluation and management of benign prostatic enlargement (BPE) is based on the severity of lower urinary tract symptoms (LUTS) and degree of bother. Over the years, medical treatment of BPH has increased from 2% to 43% and TURP has decreased by 65%, now reserved for patients with failed medical therapy or complicated LUTS.(1) Despite limited indications for intervention, few patients remain dissatisfied postoperatively, often due to underlying detrusor underactivity (DU) or detrusor overactivity (DO) due to prolonged bladder outlet obstruction (BOO), underscoring the need for timely de-obstruction before bladder decompensation. Although multichannel invasive urodynamic study (UDS) is the gold standard for early diagnosis of these changes, its routine use in evaluation of BPE remains debated. 

According to current EAU guidelines, UDS should be selectively performed in men prior to invasive treatment for BPE and is recommended in patients with prior unsuccessful interventions, inability to void more than 150 mL, bothersome voiding LUTS with a Qmax >10 mL/s or a post-void residual volume >300 mL, and cases involving men under 50 or over 80 years. Above conditions might suggest alternative diagnosis or bladder decompensation due to BOO, ensuring prognostication before intervention.(2) 

The UPSTREAM randomized trial in 2021, revealed that at 18-month and 5-year follow-up that routine UDS did not improve symptom scores or reduce the surgery rates, arguing against its universal use.(3,4) However, exploratory analysis from the trial suggested that men with higher IPSS (>16), younger age (<74 years), low Qmax, high BOO index, and preserved bladder contractility derived greater benefit from surgery. Thus, the latter two criteria indicate that surgical de-obstruction is more beneficial for patients with early BOO.(4) 

The presence of DO or DUA secondary to BOO can have postoperative prognostic implications. As per Mitchell et al, 1 in 5 (21%) patients with preoperative impaired contractility voided by valsalva after HoLEP and the rest 79% had regained contractility.(5) 

To conclude, UDS, though useful in improving the patient selection, timely intervention and prognostication prior to TURP, is currently not recommended for all men with BPH due to its invasiveness. Its current status is that of a selective tool, particularly in equivocal cases. 

by Dr Venkatesh Chander Singhal, Artemis Health Institute, Gurugram