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Diane Newman: Welcome to the UroToday's Bladder Health Center of Excellence. I'm Diane Newman, the Center's editor, and here with me today is Professor Hashim Hashim, a world-renowned functional urological surgeon and honorary professor of urology. He is the director of the UK's most active urodynamics unit located at the Bristol Urological Institute. A site with an international reputation. Professor Hashim has trained a number of surgeons from the UK and around the world on urologic and urodynamic surgical techniques. He has over 190 publications and has lectured worldwide. I asked him here today because he is the course director of the two-day virtual live streaming Certificate in the Urodynamics Course, which is being held on two days, May 1st and 2nd. This course is recognized and approved by the International Continence Society, or the ICS. This virtual live streaming event has been created specifically for specialists in North and South America and it's being offered in both English and Spanish. So, welcome Professor.

Hashim Hashim: Thank you Diane for this kind invitation and this kind introduction. I will be talking to you today about urodynamics and the course and the implications of urodynamics. So before we start, I thought it would be good to actually talk about the classification of lower urinary tract symptoms and the micturition cycle, because that really forms the framework of what we try to do in urodynamics.

So we spend about 23 hours and 58 minutes in the storage phase. This is when the bladder is storing urine. The symptoms that you can get when people are in the storage phase are urgency, incontinence, increased daytime frequency, and nocturia, which forms the overactive bladder.  They can have pain. And then once the storage cycle is finished, they go into the voiding phase. That is when they empty their bladder. And two minutes are spent in that phase at different times of the day. And normally the flow should be a good flow. If they have a slow stream, an intermittent stream, or there is hesitancy, then these are problems in voiding. And then once the voiding is finished, the post micturition phase comes in, and actually, that phase is very short. And then you go back into the storage phase.

So why did I say that we spend about two minutes voiding? Well, basically there is this law of urination which says that all mammals bigger than a hamster, weighing more than three kilograms, all void at about 20 seconds to empty their bladder. So whether it's an elephant or a dog, they will both empty their bladders in about 20 seconds. So if you say that you pass urine six times a day at 20 seconds, that's about two minutes. But when we're looking at the pelvic floor and lower urinary tract symptoms, we should not forget the erectile function in men and pelvic organ prolapse in women. So these are the things that we actually look at and assess.

So what is urodynamics? Well, urodynamics is a general term. It is any term that is used to assess the function or the dysfunction of the lower urinary tract by any appropriate methods and to look at physiological parameters. So it is basically assessing how the bladder and the pelvic floor behave. We have invasive urodynamics, this is any test that involves the insertion of catheters or needles into the body cavity. And then we have the International Continence Society Standard Urodynamics Protocol and that protocol basically is everything we do in urodynamics, which includes taking a history, examining the patient, doing a bladder diary, quality of life questionnaire. There is non-invasive urodynamics such as your uroflowmetry and also doing invasive urodynamics, which are the pressure-flow studies and the filling cystometry. So people normally say, "Well, we are having urodynamics." And what they mean is that they are having invasive urodynamics. Because even a bladder diary is part of urodynamics protocol.

So all the invasive urodynamics is done usually in the patient's preferred position. So what that means is that if a patient voids sitting, then we would do the urodynamics in the sitting position. If the patient voids standing, we will do the urodynamics in the standing position. And the aim of urodynamics is to reproduce the patient's symptoms in their most common day-to-day activity.

So the philosophy of urodynamics is it is a clinical diagnostic test. And I always emphasize That. That it's a diagnostic test, it is not an outcomes measure. It won't tell you whether you will do good from one operation or the other. It may direct the type of operation, but essentially it tells you how the bladder is behaving, how the urethra is behaving. And then we come up with a diagnosis. And it shouldn't be done immediately. It is a test. The invasive part is a test that should be done if it's going to change your management. So a patient comes in with overactive bladder symptoms, they will be first treated conservatively and medically with medications after having a thorough history and examination. And then if you plan to go into invasive measures, then to confirm the diagnosis, you would want to do urodynamics.

So the most important part of urodynamics is what is the urodynamic question? You have to have a question before you do the invasive urodynamics. And then at the end of the test, we always ask patients, "Have we reproduced your symptoms?" And that could be yes, no, or partially.

So the aim of urodynamics is to reproduce the patient's symptoms. It allows us to define the bladder and urethral function. So it gives you tracings where the bladder and the [inaudible 00:06:53] pressure is measured. The abdominal or rectal pressure is measured. And then the subtraction of the two. By defining the bladder and urethral function, it would define the most significant abnormality. Which then, giving us a precise diagnosis, which allows us to select the most appropriate treatment. So if a woman comes in with mixed incontinence, we treat them conservatively, medically. If they are still not better, we proceed with urodynamics and we confirm that they have stress incontinence and the treatments would be aimed at that.

It may help to predict postoperative problems. So someone with voiding dysfunction may do worse off with certain types of surgery. And as well as assessing the results of treatment and can be used in research. So if someone has a treatment for, let's say, stress incontinence and they are continuing to have leakage, then you may want to assess the results of your surgery. So these are really the principles of urodynamics. And over time, urodynamics hasn't really changed in terms of principles. What has changed is the equipment that we use. So this is a picture of probably the simplest form of urodynamics. And this is a picture on the top left-hand corner of a modern urodynamics machine. But what you have is a bladder, you have tubing that connects the bladder to a fluid-filled system and then you have something to measure the height of that fluid and you have an exit tubing. And that is essentially the principle of urodynamic, where you are trying to measure the pressure inside the bladder in a fluid-filled system.

But the most important principle of urodynamics is quality. And this is Bristol Aerospace, so it was the home of the Concorde. And they had this quote in there, which I quite like because it really applies to urodynamics. And Bristol is famous for engineering. It has two engineering tourist attractions, which include the Bristol Suspension Bridge and the SS Great Britain. Both were designed by Isambard Kingdom Brunel who is a famous British engineer. But the Concord, as well, parts of it has been built in Bristol. And this quote really lends itself to urodynamics because quality has to be the best. The quality of urodynamics must be the best. It has to be accurate. And it has to be free from faults. Because if you don't do good quality urodynamics, you don't get accurate results, which could result in faults, which may lead to loss of life. But essentially it could give you the wrong diagnosis resulting in the wrong operation.

So what we say is to keep the standard of urodynamics supreme. So the way to do that, the ICS has published its Good Urodynamic Practice Protocol in 2016. The United Kingdom Continence Society has also published the minimum training standards, which have been adopted by the ICS very recently. Prior to that, in 2010, the UKCS published the minimum training standards in the UK. And one of the main parameters in that is that there should be a minimum of six months of supervised participation in a urodynamics clinic and attendance at an accredited theoretical course. So coursework and attending a course is really very important as part of training in urodynamics.

And what we have done is the Certificate in Urodynamics Course. This is probably the most international course worldwide and the oldest course worldwide which has been approved by the ICS for training. And you can see here that where we started off was in the UK. We run 12 courses in the UK in five different cities. And since 2004, we have expanded and covered the rest of the world, including Europe, the Middle East, Asia, the Far East, and Australia. And since August last year, we did the first virtual course for South America. And we are going to be doing the first virtual course for North America, as well as South America, in May of this year. And that, therefore, means that we have covered every continent in the world, except Antarctica. Thank you for your attention.

Diane Newman: Thank you very much. That was really informative. So this course, you have done it all over the world. Are you looking at individuals, clinicians who know urodynamics, or who are new to urodynamics, or who just may want to refresh? Who are you recommending who attends?

Hashim Hashim: So the Certificate in Urodynamics specifically is for people who have some knowledge of urodynamics. So they have either been to clinics or it is part of their training or those who are already established. It looks at the core concepts of urodynamics and the practical aspects of urodynamics. We do have other courses for people who have no knowledge, that is the Basic Urodynamics Course. And there is also an Advanced Urodynamics Course for those who have been doing urodynamics for a long time and want to expand their knowledge into more complex cases. But the Certificate Course is really, almost the trademark or the flagship of urodynamic courses because it mainly looks at the Good Urodynamic Practice and aims to bridge the gap between those who have no knowledge and those who have a lot of knowledge.

Diane Newman: Now this is a virtual course, so I'm sure there are some challenges with that. Do you actually do urodynamics with a patient during the virtual course? Is that how you are running it? I was wondering because I know you have gone out to these different countries and actually held the courses there. But this one is going to be virtual. So how are you going to do that?

Hashim Hashim: Yeah, that's a very interesting question. So when we started doing the urodynamic courses, and this course has been running for over 20 years now, we used to do live demonstrations. We found that actually doing the live demonstrations in Bristol, or in London, or in any of the other UK cities can be challenging for the person doing it and for the audience. And you run into problems sometimes and you can't do it, for example.

So what we have been doing since almost 2005 is showing recorded videos of the whole test. And especially when we've gone abroad, it has become very difficult to actually do the urodynamic test. So what we do is we show a recorded video of the whole urodynamic test, one in men and one in women. And we go through every step of the urodynamic test. So now, since August last year, we've gone to virtual and we found that actually playing those videos and discussing them hasn't been a problem. And with all the new technology and also the links and Zoom and everything else, it is quite easy actually now to do virtual urodynamic courses.

Diane Newman: Now, as part of the course, are you going to look at the interpretation of results as I'm sure that is part of the course also?

Hashim Hashim: Yeah, so there is a whole session on the interpretation of traces. So there are talks on urodynamics in men, urodynamics in women, video urodynamics, the science of urodynamics. But also the interpretation of results and tests. So we will have a lot of slides and traces including troubleshooting. So whenever there is a problem, we would say, "How would you manage it?" And we try to make it as interactive as possible and we are getting good feedback. So we have now done about 10 virtual courses and every time it is getting better and better with more interaction and people are engaging with it more than before.

Diane Newman: I have to tell you that we have urodynamics at the University of Pennsylvania, which is where I practice and it is a difficult test. And you really want someone with that expertise because you know that patients can be fearful of that. So you are really providing a wonderful service for education because a lot of people learn it on the job. So it is great that you have the Certificate Course that they can take. So I really appreciate you sharing this information with us.

Hashim Hashim: Thank you, Diane. And we hope it will be a very successful course, especially in the US. And hopefully, it will start a new trend.

Diane Newman: Thanks so much. Okay. Have a good evening.

Hashim Hashim: Thank you. You too.