Editorial
Retrospective studies in lower urinary tract dysfunction do matter
Estudos retrospectivos sobre DTUI
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The first issue that is recognized is the need for a consistent terminology in this field. The authors use the term urinary retention to describe what is defined in the International Children's Continence Society (ICCS) standardization document as voiding postponement: Children who habitually postpone micturition using holding maneuvers suffer from voiding postponement. This creates ambiguity for the reader and makes it difficult to perform an accurate literature search to do future studies in the topic. We need to have a concerted effort by all the authors to use standardized terminology to help the profession continue to advance scientifically.</p><p id="par0010" class="elsevierStylePara elsevierViewall">I have respect for the editors of this journal being willing to accept a retrospective study, which has become a “pariah” in academic circles and journals. There has been a concerted bias in clinical medicine to downplay retrospective studies as poor quality medical research in lieu of other prospective studies that are of marginal value. I have seen an inordinate number of papers and abstracts being presented based on database reviews of billing or diagnostic data, with no input of patient information. The pediatric urology conferences are rife with these studies, with conference coordinators enamored by the fact that these are prospective studies and are rated higher than retrospective studies. The other form of study that has become prevalent is the prospective database study, with the authors rating subjective findings themselves. We are seeing numerous studies like this come to conferences and publication because they are prospective, so they surely must be better. How can someone reviewing his or her own outcomes, while already knowing what the hypothesis is, really produce an unbiased study? For some reason, editors and those in charge of conferences have given these studies greater relevance than the retrospective reviews. Good respective reviews, such as this one, can offer a tremendous amount of knowledge. Yes, there are limitations with retrospective studies, but as long as they are recognized and appropriately acknowledged, they should not prevent the presentation of novel data. In some cases, retrospective reviews can reduce bias. How? If the patients were treated with no prior intent to publish the data, the likelihood that the practitioners would be pushed to achieve a hypothesis outcome are lower. If the person reviewing the data is different from the caretaker, it also tends to reduce the risk of bias. We need retrospective reviews to give us pilot studies with novel concepts; without this, we would have to wait years for the perfect study. Having been involved in clinical trials for drugs attempting to achieve approval in the US and Europe, it can take a long time for these studies to come to fruition. It is even more devastating if the wrong hypothesis is established; then, the whole study could be for naught. In some cases, what could have been a novel concept can go unrecognized. There is a place for well-done and thorough retrospective reviews, such as this study.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The other important aspect of this paper is that the authors have concluded what I have been advocating and others have shown: that there is a limited role for the use of urodynamics in the evaluation of children with LUTD. They noted that 36/38 patients had urodynamic abnormalities and two did not have any abnormalities. Let us analyze this further and see if it really was necessary to perform these procedures. As the authors have shown that a good history is critical and very valuable in obtaining a diagnosis, the fact is that overactivity as evidenced by urgency, urge incontinence, and frequency would more than likely be evidence of detrusor instability on urodynamics. Even if the child has urodynamically proven detrusor instability, is the treatment going to be any different? The answer is an emphatic no. We would treat overactive symptoms the same way whether detrusor instability was or was not present. Why do urodynamics and put a child through an uncomfortable procedure unnecessarily. Could the dysfunctional voiding have been detected without urodynamics? Of course it could. The use of uroflowmetry with electromyography (EMG) of the perineum and concomitant EMG of the abdomen provides good proof of dysfunctional voiding, negating the need to do urodynamics. We can even diagnosis internal sphincter dyssynergia by utilizing lag times, as described by Combs and Glassberg.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Bladder overactivity has been found to correlate with short lag times and tower voiding patterns, making it more likely to make the diagnosis of diagnose overactive bladder (OAB) noninvasively.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Our recent publication<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> defining a quantitative approach to uroflowmetry helps remove much of the subjectivity in reading curves. We know that there is great subjectivity in the process of determining whether curves are bell <span class="elsevierStyleItalic">vs.</span> plateau and bell <span class="elsevierStyleItalic">vs.</span> tower. Using a flow index as we have devised removes that subjectivity and makes the interpretation of uroflowmetry more objective, rendering it a more powerful tool. The use of the flow index can lead to the ability to follow patients longitudinally, irrespective of age or volume voided; this combined with EMG of the perineum and abdomen creates a tool that is just as powerful as or more so than urodynamics. The authors show us that they have reached a high concordance of 85% by making the diagnosis of detrusor instability with history and non-invasive tests. This confirms our own beliefs and the work of Bael et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> that there is a limited place in the management of children with OAB with urodynamics. There are some refractory patients in whom urodynamics are called for; these are the patients whom the practitioners suspect may have a neurogenic bladder, or in some cases, they wish to perform video-urodynamics because there is a need for a voiding cystourethrogram and the urodynamics is done concomitantly. But, even this is something that I would not look favorably upon, since to perform urodynamics a rectal balloon catheter needs to be inserted and sedation can not be given, making the procedure worse than a stand-alone voiding cystourethrogram (VCUG) which can be done using an amnestic or propofol anesthesia.</p><p id="par0020" class="elsevierStylePara elsevierViewall">If the practitioners seriously suspect that the patient may have a neurogenic bladder, then it is probably advisable to do a magnetic resonance imaging (MRI) of the spine before performing urodynamics. If the MRI is normal, then the need to perform urodynamics is almost nil, as evidenced by a Stone et al.,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> who showed that all patients that had normal MRIs did not have anything besides detrusor instability on urodynamics. If one is worried about non-neurogenic neurogenic bladder that diagnosis can be made with a VCUG showing evidence of severe trabeculation, Christmas tree shape, and external sphincter dyssynergia or internal sphincter dyssynergia on the VCUG. Therefore, the need to use invasive urodynamics should be severely restricted in children with routine symptoms of OAB.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Another fact that was interesting in the article is that the authors made note that they did not find an association between obesity and voiding symptoms, as has been noted in the literature. This may be explained by a recent article by Wang et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> that looked at behavioral problems in early adolescence in a cohort of patients in Hong Kong. They did not find a link between obesity and emotional and behavioral problems. We know there is a link between emotional and behavioral problems and urinary incontinence in children and adults. Therefore, by extension, we can presume that the lack of obesity and LUTD in this cohort of patients may be geographic, ethnic, societal, and/or possibly due to cultural variations that could preclude the development of obesity in certain areas of the world. In this case, if the group of children in this study was drawn from a population of children with less access to food, then we could see a lower incidence of obesity in this study, and possibly negate the findings that have been observed in the United States and Europe, where obesity is an epidemic.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">Prof. Israel Franco is a consultant and clinical investigator for Astellas, Allergan, and Laborie Medical Technologies.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Franco I. Retrospective studies in lower urinary tract dysfunction do matter. J Pediatr (Rio J). 2016;92:109–10.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">See paper by Lebl et al. in pages 129–35.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical course of a cohort of children with non-neurogenic daytime urinary incontinence symptoms followed at a tertiary center" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Lebl" 1 => "S.N. Fagundes" 2 => "V.H. Koch" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Pediatr (Rio J)" "fecha" => "2016" "volumen" => "92" "paginaInicial" => "129" "paginaFinal" => "135" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary bladder neck dysfunction in children and adolescents I: pelvic floor electromyography lag time—a new noninvasive method to screen for and monitor therapeutic response" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.J. Combs" 1 => "N. Grafstein" 2 => "M. Horowitz" 3 => "K.I. 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Schooling" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpeds.2015.02.039" "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "2015" "volumen" => "166" "paginaInicial" => "1404" "paginaFinal" => "1409" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25805154" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00217557/0000009200000002/v1_201603250033/S0021755716000073/v1_201603250033/en/main.assets" "Apartado" => array:4 [ "identificador" => "10177" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/00217557/0000009200000002/v1_201603250033/S0021755716000073/v1_201603250033/en/main.pdf?idApp=UINPBA000049&text.app=https://jped.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0021755716000073?idApp=UINPBA000049" ]
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| 2023 April | 15 | 5 | 20 |
| 2023 March | 11 | 15 | 26 |
| 2023 February | 11 | 12 | 23 |
| 2023 January | 16 | 15 | 31 |
| 2022 December | 16 | 33 | 49 |
| 2022 November | 16 | 24 | 40 |
| 2022 October | 24 | 30 | 54 |
| 2022 September | 11 | 26 | 37 |
| 2022 August | 25 | 22 | 47 |
| 2022 July | 13 | 29 | 42 |
| 2022 June | 19 | 26 | 45 |
| 2022 May | 18 | 31 | 49 |
| 2022 April | 26 | 23 | 49 |
| 2022 March | 16 | 24 | 40 |
| 2022 February | 12 | 16 | 28 |
| 2022 January | 12 | 15 | 27 |
| 2021 December | 11 | 20 | 31 |
| 2021 November | 5 | 12 | 17 |
| 2021 October | 15 | 15 | 30 |
| 2021 September | 3 | 11 | 14 |
| 2021 August | 5 | 10 | 15 |
| 2021 July | 4 | 4 | 8 |
| 2021 June | 3 | 8 | 11 |
| 2021 May | 6 | 6 | 12 |
| 2021 April | 10 | 25 | 35 |
| 2021 March | 5 | 7 | 12 |
| 2021 February | 4 | 15 | 19 |
| 2021 January | 5 | 9 | 14 |
| 2020 December | 8 | 8 | 16 |
| 2020 November | 5 | 10 | 15 |
| 2020 October | 4 | 8 | 12 |
| 2020 September | 8 | 14 | 22 |
| 2020 August | 3 | 3 | 6 |
| 2020 July | 1 | 3 | 4 |
| 2020 June | 8 | 5 | 13 |
| 2020 May | 6 | 4 | 10 |
| 2020 April | 7 | 10 | 17 |
| 2020 March | 2 | 4 | 6 |
| 2020 February | 7 | 10 | 17 |
| 2020 January | 10 | 14 | 24 |
| 2019 December | 7 | 8 | 15 |
| 2019 November | 3 | 6 | 9 |
| 2019 October | 4 | 10 | 14 |
| 2019 September | 4 | 9 | 13 |
| 2019 August | 8 | 9 | 17 |
| 2019 July | 11 | 7 | 18 |
| 2019 June | 9 | 9 | 18 |
| 2019 May | 12 | 10 | 22 |
| 2019 April | 12 | 8 | 20 |
| 2019 March | 8 | 9 | 17 |
| 2019 February | 8 | 6 | 14 |
| 2019 January | 7 | 5 | 12 |
| 2018 December | 4 | 6 | 10 |
| 2018 November | 6 | 2 | 8 |
| 2018 October | 18 | 10 | 28 |
| 2018 September | 9 | 1 | 10 |
| 2018 August | 3 | 5 | 8 |
| 2018 July | 7 | 4 | 11 |
| 2018 June | 4 | 2 | 6 |
| 2018 May | 12 | 6 | 18 |
| 2018 April | 6 | 1 | 7 |
| 2018 March | 6 | 3 | 9 |
| 2018 February | 3 | 2 | 5 |
| 2018 January | 7 | 1 | 8 |
| 2017 December | 5 | 2 | 7 |
| 2017 November | 3 | 1 | 4 |
| 2017 October | 11 | 4 | 15 |
| 2017 September | 4 | 4 | 8 |
| 2017 August | 3 | 1 | 4 |
| 2017 July | 2 | 3 | 5 |
| 2017 June | 5 | 0 | 5 |
| 2017 May | 3 | 3 | 6 |
| 2017 April | 5 | 3 | 8 |
| 2017 March | 10 | 1 | 11 |
| 2017 February | 3 | 3 | 6 |
| 2017 January | 6 | 2 | 8 |
| 2016 December | 10 | 11 | 21 |
| 2016 November | 6 | 16 | 22 |
| 2016 October | 11 | 17 | 28 |
| 2016 September | 13 | 8 | 21 |
| 2016 August | 17 | 4 | 21 |
| 2016 July | 17 | 8 | 25 |
| 2016 June | 15 | 6 | 21 |
| 2016 May | 39 | 28 | 67 |
| 2016 April | 53 | 38 | 91 |
| 2016 March | 28 | 23 | 51 |
| 2016 February | 19 | 15 | 34 |
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