British Journal of Urology (1982), 54, 635-637 6 1982 British Association of Urological Surgeons

0007-133 1 /82/ 10860635$02.00

The Clinical Value and Cost of a District Hospital Urodynamic Unit

R. A. MILLER, R . K. BAROD, J. CHAPMAN and J. N. FERGUS Department of Urology, Northampton General Hospital, Northamp ton

Summary-A retrospective review has shown that urodynamic studies were useful in the diagnosis of 87% of our patients and were diagnostic in 43%. The cost per patient was €43, which compares favourably with urography (€35) and in-patient cystoscopy ( € 104).

Provided that more than 200 patients a year are studied, the expense and effort of running the urodynamic unit are justified. We now perform urodynamic studies routinely in patients with complex lower urinary tract symptoms, prior to intravenous urography and cystoscopy.

Since the basic techniques and interpretation of urodynamic studies were established in the late 1960s, an increasing number of district general hospitals have acquired urodynamic facilities. This trend is reflected in the progressively rising sales of the principal manufacturers of this equip- ment, despite the current recession.

In 1974 the Norfolk and Norwich group pre- sented the first comprehensive review of peripheral hospital urodynamic studies (Crisp et al. , 1976). Five years later McGuire (1979) assessed the cost of urodynamic studies in the United States. An up-to-date review, both to indicate the diagnostic value and the cost of such a unit in a district general hospital, seemed necessary.

We have, therefore, reviewed 200 consecutive patients with complex lower urinary tract symp- toms attending the Urodynamic Clinic at North- ampton.

Patients and Methods Two hundred patients were studied; the average age was 45 years. Each patient was seen in the out-patient clinic by a consultant with a special interest in urology, who subsequently referred them for intravenous urography, cystoscopy and urodynamic studies as was appropriate to the individual; 72% had initially been referred by their general practitioners, 25% by the gynaeco- logical department and 3% came from general surgical colleagues.

In each case cystometry was carried out using ~

Read at the 38th Annual Meeting of the British Association of Urological Surgeons in Newcastle upon Tyne, July 1982.

normal saline at room temperature through a 12F Nelaton filling catheter. Two 6F Vygon pressure catheters, one in the rectum and one in the blad- der, were used to record the bladder and rectal pressures. Video recordings were not performed.

At a second out-patient consultation all of the investigations were reviewed by the referring con- sultant, who formulated the final diagnosis on which subsequent treatment was planned.

Results Symptoms The results were divided into 4 general groups (Table 1). Fifty per cent suffered from combinations of frequency, urgency, urge incon- tinence and nocturnal enuresis; 20% complained of stress incontinence; 17% had suprapubic pain and dysuria and 13% had symptoms of outflow obstruction. Obstructive symptoms were com- moner in males, while suprapubic pain and dysuria were more common in females. Frequency and urgency were the most common symptoms in both sexes. Table 1 Symptoms: 200 Patients

Symptoms YO

Frequency Urgency Urge incontinence Nocturnal enuresis (17

Stress incontinence 20

Suprapubic pain Dysuria Obstructive outflow symptoms 13

patients)

} l 7

63 5

636 BRITISH JOIJRNAL OF UROLOGY

Intravenous Urography One hundred and sixty- one urograms were performed (56 male and 105 female). Nineteen were reported as abnormal in some respect. Only 10 contributed to a final diagnosis.

Diagnostic Cystoscopy One hundred and twenty- nine patients were cystoscopied (37 male and 92 female). Eighty-six examinations were entirely normal, 43 were abnormal, and 9 cases of inter- stitial systitis were diagnosed on endoscopic find- ings and compatible histology. It was not possible to make a firm diagnosis on any other presenting symptom without complementary urodynamic studies. No case of bladder tumour was found in this study.

Urodynamic Studies All patients underwent cystometric testing. Thirty-six per cent were found to be normal and the remaining 64% had a uro- dynamic diagnosis (Table 2). The ICS definitions have been adopted throughout. We have classified patients with bladder capacity below 200 ml in the small bladder group.

Final Diagnosis

Table 3 Final Diagnosis

Final diagnosis Numbers

Male Female Total

Unstable bladder 3 5 3 1 72 No organic cause 18 52 70 Outflow obstruction 27 I 5 42 Stress incontinence 0 18 18 Recurrent infection 2 8 10 Neurogenic bladder 3 7 10 Low compliance bladder 2 6 8 Interstitial cystitis 1 7 8 Small bladder 4 3 7 High compliance bladder 0 2 2

on urodynamic studies, in contrast to Group 2 where the final diagnosis depended on cystoscopy alone. Group 3 patients had both urodynamic studies and cystoscopy performed. Group 4 patients required additional radiological or bac- teriological information. Group 5 patients all had clinically demonstrable stress incontinence and were subsequently shown to be stable on uro- dynamic testing.

cost

Table 2 Urodynamic Diagnosis: 200 Patients

Urodynamic diannosis %

Unstable 3 6 Normal 35 Outflow obstruction 21 Neurogenic 5 Low compliance 4 Small bladder 3 High compliance 1

Group Investigation No. of %

1 Urodynamic 86 43

patients

2 Cystoscopic 8 4 3 Urodynamic + cystoscopic 78 39

investigations 10 5

(stable on cystometry) 18 9

4 Urodynamic, cystoscopic t other

5 Demonstrable stress incontinence

THE CLINICAL VALUE AND COST OF A DISTRICT HOSPITAL URODYNAMIC UNIT 637

Table 5 Cost of the Urodynamic Unit in Northampton 1981

Item cost in f s

Salaries Materials Depreciation Room Total Cost per patient

6900

1500

1250

1200

10,850

43

Discussion The 200 cases reviewed represent a typical cross- section of patients referred to a urodynamic unit in a district general hospital. The patient popula- tion will undoubtedly differ from that of an established urodynamic unit acting as a regional referral centre.

A consultant with considerable experience in urodynamic studies not only vetted all referrals but also interpreted the investigation results. It is hoped thereby to prevent misuse of the facility and to ensure appropriate treatment.

The low diagnostic return of radiology is not surprising. Intravenous urography, however, should be continued as a standard diagnostic investigation owing to its value in excluding alter- native pathology.

Diagnostic cystoscopy was equally disappoint- ing in this study. Only patients with interstitial cystitis were diagnosed with confidence; the remainder all required confirmatory urodynamic

studies. The value of cystoscopy, however, in demonstrating unexpected bladder pathology is not disputed.

The cost of the urodynamic service must be balanced against the benefit of sparing a sub- stantial number of patients (38) unnecessary and expensive treatment as well as providing a logical basis for patient management.

It is concluded that a district general hospital urodynamic unit is cost effective if more than 200 patients are investigated annually. We recom- mend that urodynamic studies are carried out prior to intravenous urography and cystoscopy in patients presenting with complex lower urinary tract symptoms.

References Crisp, J. C., Green, N. A. and Ashken, M. H. (1976). Uro-

dynamic studies in a district general hospital. British Journal of Urology, 48, 383-387.

McGuire, E. J. (1979). Patient costs for urodynamic testing. Urology, 14, 424-426.

The Authors R. A. Miller, FRCS, Registrar in Urology. (Currently work-

ing as a Research Lecturer at the Institute of Urology, London.)

R. K. Barod, FRCS, Hospital Practitioner. J . Chapman, FRCS, Consultant Surgeon with a special

J. N. Fergus, FRCS, Consultant Surgeon with a special interest in Urology.

interest in Urology.

Requests for reprints to: J . N. Fergus, Department of Urology, Northampton General Hospital, Northampton.