Equipment: What the Clinician Needs to Know to Set Up the Lab

Laborie

Medtronic

Medical Measurement Systems International

Cooper Surgical

Dantec Medical

NeoMedix

SRS Medical

AyMed

Status Medical Equipments

Andromeda

MediPlus

TIC Medizintechnik

The Prometheus Group

Schippers-Medizintechnik

It is paramount that the room and personnel are dedicated to urodynamics. Urodynamic programs are doomed to fail if the lab, institution, and/or personnel are not dedicated to the urodynamic practice. Sadly, many large institutions spend as much as $250,000 on UDS equipment only to house the equipment in an operating room, radiology , or cystoscopy suite without appointing a urodynamic director or technician. Consequently, the UDS service may perform 0–4 low quality UDS studies/month. Certainly these institutions would have been better served by referring their patients to a high volume center or to utilize the services of a mobile unit.

The UDS room should be an isolated space that remains quiet without distraction during the study, as well as protect the privacy of the patient during a sensitive and potentially embarrassing procedure. Every effort should be made to create a testing environment that allows the patient to feel comfortable so that the most physiologically accurate and “natural” results are displayed. If the room is remote from the urology clinic such as in a radiology suite or operating room, and the staff consists of personnel from a float pool or other departments, then the UDS program may fail due to a large amount of inconvenience for both the patient and practitioner. Therefore, if VUDS is going to be utilized it is paramount that this performed in a urology suite. Urodynamics is an intimate part of the patient’s evaluation and the patient is more comfortable in a familiar, safe, and private environment. Patients generally find it uncomfortable and embarrassing to have UDS performed in congested areas by personnel that are not proficient in investigating private and intimate issues involving pelvic health. The room should also allow adequate space for the UDS equipment, UDS chair/table as well as ample space for the patient, urotechnician, and the clinician. Accessibility for patients with physical limitations and appropriate space for storage of personal assistive devices such as walkers, crutches/canes, or wheelchairs is necessary.

A discussion of setting up an Urodynamic Service would be incomplete without addressing the personnel required to perform a meaningful urodynamic evaluation. Having a trained, supportive, attentive staff is vital to obtaining UDS that will provide accurate clinical information. The staff’s proper attention to correct calibration, zeroing of equipment, placement of catheters and electrodes, and interpretation and documentation of events is vital in obtaining a quality study. The staff, bioengineering, or UDS vendor should perform calibration of equipment regularly in order to ensure accurate measurement. The urotechnician should have a detailed understanding of catheter placement and study protocols in order to assist with any necessary troubleshooting. Typically the UDS personnel are either a physician extender, a nurse, or medical assistant trained in the performance of UDS known as a urotechnician. A physician extender is usually not required unless they plan on operating radiology equipment or interpreting the study. What is most important is that the person performing the study is well trained and proficient in UDS. The leading UDS manufacturers conduct formal training seminars, and organizations such as the Society of Urologic Nurses and Associates (SUNA) also offer continuing education opportunities (Table 2).

Table 2

Necessary items for creating a friendly atmosphere that creates a private environment for the patient

1. A dedicated bathroom and changing facilities within a secure area

2. A dedicated UDS procedure room with a door lock and curtains around the entrance and exit to the room

3. Control over the flow of personnel into and out of the room

4. Dedicated, well-trained UDS personnel

Preparing for a Urodynamic Study

Before the UDS appointment the patient’s records should be reviewed in advance to determine if there are any special needs (lift, interpreter, etc.). The patient should arrive to their urodynamic appointment with a 3–7 day bladder log, pad weight test when applicable and a completed validated urinary questionnaire such as the UDI-6, AUA symptom score, or Kings Health. Urine analysis and pre-procedure antibiotics are never required for basic UDS as this is non invasive (See chapter “The Clinical Evaluation of the Patient Who Requires Urodynamics”).

Correlation with clinical data is the most important part of the urodynamic study. Most urodynamic practitioners insist on performing a consultation that would include history and physical and evaluation of other objective measures before performing the urodynamic study. The urodynamic study is unlike a radiologic study that may be performed in isolation remote from the practitioner. Rather, the urodynamicist should interact with the patient regularly and have a report with the patient to fully understand the goals of the study in order to properly design the study, make a diagnosis and formulate a treatment plan.

Types of Urodynamic Investigation

In this section we will review the typical setting in which each of UDS modalities are best utilized. We will discuss the room, equipment and personnel needed. We will comment on the cost, advantages and disadvantages of each modality and how to best incorporate each into your practice.

The urodynamic equipment and organization of an urodynamic unit for evaluation of urinary dysfunction varies based on the level of investigation. Each level of urodynamics investigation requires different equipment, room design and personnel. There are three sections of investigation:

Basic Urodynamics : this would include measurement of simple uroflow (Q), measurement of post void residual (PVR) and single channel cystometry
Advanced Urodynamics (UDS): this would include a multi-channel study along with patch EMG electrodes
Video Urodynamics : would include all components of advanced urodynamics with the addition of fluoroscopy fluro-urodynamics (FUDS) or more commonly video urodynamics (VUDS)

Basic urodynamics can be performed in almost any size urology or urogynecology office/clinic and even in some primary care, neurology, spine and rehabilitation clinics. A bladder scanner is a non-invasive method that uses ultrasound to measure pos-void residual. It is widely available in hospital emergency rooms, recovery rooms, and medical-surgical wards. The space required for basic urodynamics is minimal, and in most instances can be wall-mounted in a bathroom (Fig. 1). The technical equipment is simple and inexpensive and accessible to most office settings. The personal required would be the existing medical assistant with supervision of a physician or physician extender.

Fig. 1

Demonstrates a non-invasive uroflow with wall-mounted unit and output/printer

Uroflowometry

Uroflowometry is another non-invasive part of the urodynamic process that measures the flow rate. Flow rates are generally reported in milliliters per second (mL/s), though measurements generally are recorded in either kilograms per second (kg/s) or cubic meters per second (m³/s). Most uroflowometers are calibrated for water (1 g/mL) that allows for calculations that operate under the assumption that the mass of the fluid in grams equals the volume in milliliters. This becomes important when using instillation agents other than water, such as contrast medium for video studies, as the true density of the fluid may alter the actual flow rate compared to the calculated, reported flow rate. In the case of a denser fluid, such as contrast medium, this would lead to an artificially elevated calculated flow rate relative to the actual flow rate. Detailed calibration can assist with limiting any potential discordance between calculated and actual flow rates. Additional calibration standards per ICS guidelines allow for expected delays between initiation of voiding and initiation of the study, though advancements in automation have improved detection of study initiation in new uroflowometers [1]

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