Sacral neuromodulation in patients with refractory overactive bladder symptoms after failed Botulinum toxin therapy: Results in a large cohort of patients

Sacral and Implantable Tibial Neuromodulation for the Management of Overactive Bladder: A Systematic Review and Meta-analysis

INTRODUCTION

Implantable tibial neuromodulation (iTNM) systems have recently become commercially available in the US, and offer a new method of neurostimulation for the treatment of overactive bladder (OAB). In the absence of head-to-head studies, the aim of this meta-analysis was to indirectly compare the efficacy and safety of sacral neuromodulation (SNM) and implantable tibial neuromodulation (iTNM) for the treatment of OAB.

METHODS

A comprehensive search was performed using terms for OAB and neuromodulation. Primary efficacy measures included a ≥ 50% reduction in urgency urinary incontinence (UUI) episodes, urinary frequency, and/or OAB symptoms. Primary safety measures included the rate of device-related adverse events (AEs).

RESULTS

A total of 20 studies met selection criteria, encompassing 1416 patients treated with SNM and 350 patients treated with iTNM. No comparative or placebo-controlled studies for SNM and iTNM were identified, and therefore the analysis was completed using single-arm results. Weighted averages showed that the UUI responder rate was similar for both SNM and iTNM (71.8% and 71.3%, respectively). Similarly, weighted averages of OAB responder rates were 73.9% for SNM and 79.4% for iTNM. Similar rates of device-related AEs were also observed.

CONCLUSIONS

This meta-analysis found similar efficacy and safety of SNM and iTNM for the treatment of OAB and UUI, including UUI and OAB symptom response rates, reduction in UUI episodes, significant improvements in quality-of-life (QoL), and low rates of procedure and device-related adverse events. Notably, this comparable efficacy was seen without the use of a trial phase of neuromodulation in the iTNM studies versus SNM studies.

A Five-Year Retrospective Study on the Clinical Outcomes of Sacral Nerve Stimulation for Neuromodulation of the Lower Urinary Tract in a Tertiary Hospital

AIM

To assess clinical outcomes in terms of first to second-stage conversion rates, revision rates, and complications for all patients undergoing sacral neuromodulation of the lower urinary tract for the past five years at the Queen Elizabeth Hospital Birmingham.

METHOD

This is a retrospective observational study. Only patients with the first stage of sacral neuromodulation between January 2017 and January 2023 were included in the study. The data collected included age, type of first-stage trial, that is, percutaneous nerve evaluation (PNE) vs. tined lead, response after the first stage, whether a second trial was carried out, response after the second trial, indication for sacral nerve stimulation (SNS), complications, revisions, etc. Results: 94% of the total (198) patients had PNE at the first trial, while 11 (6%) had tined lead. 129 (65%) patients had a positive response after the first trial, 49 (24%) had a negative response, and 20 (10%) had an equivocal response. 15 (8%) patients from the equivocal and negative response group had a second trial with a tined lead, with 53.3% (104) receiving a positive response, making our total conversion rate 69% (136). 100 (50%) patients had permanent implants fitted, 25 (13%) had complications, and 15 (7.5%) required revision. The indications for the revisions were lead migration (66, 33.33%), pain around the battery site (66, 33.33%), connection failure (40, 20%), battery charging problem (13, 6.67%), and device infection (13, 6.67%).

CONCLUSION

The conversion and complication rates are comparable to national standards and documentation in the literature, while the infection rates were lower. Higher conversion rates may be attained when tined lead is used at the first trial.

Real-world onabotulinumtoxinA treatment patterns in patients with overactive bladder

PURPOSE

Utilization patterns of third-line onabotulinumtoxinA for overactive bladder (OAB) symptoms-including discontinuation and use of other therapeutic options during or after treatment-are not well understood. This retrospective analysis of administrative claims was designed to characterize the unmet need for OAB treatment.

MATERIALS AND METHODS

A retrospective claims analysis of Optum's deidentified Clinformatics® Data Mart Database (2009-2021) was performed among patients with diagnosis of OAB newly starting onabotulinumtoxinA injection (2015-2017). Study measures were evaluated during an 18-month pretreatment baseline and over a minimum of 36 months of follow-up. These included number of injections, days between injections, other measures of onabotulinumtoxinA utilization, use of second-line pharmacologic treatments, use of device and surgical treatment options, and complications.

RESULTS

Of 2505 eligible patients, 535 (21.4%; 66.8 ± 13.3 y, 87.3% females) continued onabotulinumtoxinA throughout the study. The remaining 1970 (78.6%; 71.4 ± 11.6 y, 79.1% females) were considered discontinuers. Of continuers, 57% received ≥5 treatments. Of discontinuers, 84% received ≤2 treatments. Anticholinergics and β3-adrenoceptor agonist medication use declined in all patients from baseline to follow-up; however, the absolute reduction in the proportion with any medication fill was similar across continuers versus discontinuers (21% vs. 18%, p < 0.0001). Sacral neuromodulation was initiated by 15/535 (3%) of continuers and 137/1970 (7%) of discontinuers (p < 0.0001). No patients initiated percutaneous tibial neuromodulation.

CONCLUSIONS

Early discontinuation of onabotulinumtoxinA therapy for OAB is common and most discontinuers do not receive alternative treatments. Providers have the opportunity to educate OAB patients with un- or undertreated symptoms regarding alternative options.

Progress in overactive bladder: novel avenues from psychology to clinical opinions

Rationale

Overactive bladder (OAB) is a common, distressing condition that worsens with age and impacts quality of life significantly. As a results of its clinical symptoms, patients suffer from serious physical and mental health issues, have a poor quality of life, and participate in a serious economic burden. The key social-psychological factors include living habits, eating habits, and personality characteristics on this disease, even though the pathogenesis of OAB is complex. However, there is few cognitions and research on OAB in the field of psychology.

Methods/Search Strategy

Between 2000 and 2022, two electronic databases were systematically searched in accordance with Cochrane library guidelines (PubMed/Medline, Web of Science). An analysis of the remaining articles with relevant information was conducted using a data extraction sheet. An itemized flow diagram was adopted and used to report systematic reviews and meta-analysis. A systematic review of studies published from 2000 to 2022 in English language were conducted and included in the review.

The intended audience

Urological surgeon and psychologists majoring in urinary diseases.

Implication

As a result of this information, we are able to develop a better understanding of the role of psychological factors in the development of OAB and suggest potential therapeutic directions for OAB patients. This may benefit the recovery of OAB patients.

Comparison of Two Treatment Modalities in Overactive Bladder: A Rapid Overview

Background

Overactive bladder is a syndrome of urgency with the absence of infection and is usually accompanied by frequency and nocturia. Both sacral neuromodulation (SNM) and intravesical botulinum toxin (BTX) injection are used contentiously in overactive bladder after failure of conservative management.

Objective

We aimed to provide an updated comparative overview of BTX injection versus SNM in the treatment of overactive bladder.

Methods

PubMed and Google scholar databases were explored starting from 2016 to 2022 to obtain relevant articles. English studies on adult population were included.

Results

Six articles included 648 participants were included in the current overview. Both BTX and SNM are comparable for the treatment of overactive bladder, with no major complications were reported. However, the use of SNM for refractory overactive bladder after failure of BTX was more successful and effective and resulted in patient satisfaction compared to the use of BTX after failure of SNM.

Conclusion

Our update provides the latest comparative overview of outcomes of BTX versus SNM in the treatment of overactive bladder.

Clinical Application of Botulinum Neurotoxin in Lower-Urinary-Tract Diseases and Dysfunctions: Where Are We Now and What More Can We Do?

Botulinum toxin A (Botox) had been considered a promising drug that has an effect on functional disorders of the lower urinary tract. Because Botox exhibits anti-inflammatory and antispasmodic effects, Botox injection into the bladder can decrease detrusor contractility, reduce bladder hypersensitivity, and eliminate painful sensations. Injecting Botox into the bladder outlet can relax the hyperactivity of the bladder neck, and of the urethral smooth and striated muscles. Based on these therapeutic effects, Botox has been widely applied to treat lower-urinary-tract dysfunctions (LUTDs) such as overactive bladder and neurogenic detrusor overactivity. However, this treatment has not been licensed for use in other LUTDs such as interstitial cystitis, voiding dysfunction due to benign prostatic hyperplasia in men, and dysfunctional voiding in women. Botox has also not been approved for the treatment of children with overactive bladder and dysfunctional voiding; in patients with spinal cord injuries with detrusor sphincter dyssynergia and autonomic dysreflexia; or for poorly relaxed external sphincter in non-neurogenic patients. This article reviews the current knowledge regarding Botox treatment for LUTDs and discusses the potential clinical applications of Botox, as well as work that can be conducted in the future.

Sacral neuromodulation in patients with refractory overactive bladder symptoms after failed Botulinum toxin therapy: Results in a large cohort of patients

Aims

Sacral neuromodulation (SNM) and Botulinum toxin A (BoNT‐A) injections are well‐known third‐line treatment options in patients with refractory overactive bladder (OAB). Our aim is to evaluate the success rate of SNM in patients who received prior therapy with BoNT‐A injections.

Methods

All patients with OAB symptoms referred for SNM between 2006 and 2019 were included. History taking and 3‐day voiding diaries assessed the complaints and suitability for SNM. The success rate of SNM in patients who received prior BoNT‐A was compared with BoNT‐A naive patients. Success was defined as an improvement of 50% or greater in voiding diary parameters. Satisfaction was registered at their most recent visit.

Results

A total of 263 patients underwent SNM test stimulation, of which 75 (16 male/57 female) received prior BoNT‐A and 188 (46 male/142 female) were BoNT‐A naive. Success rate for SNM in BoNT‐A naive patients was 72.9% and in BoNT‐A patients 66.7% (p = 0.316). Success rate after ≤2 BoNT‐A injections was 68.5%, compared to 61.1% after ≥3 injections (p >  0.05). Success rate in patients perceiving lack of efficacy of BoNT‐A was 67.4% (p > 0.05), subjected to temporary CISC was 73.7% (p > 0.05) and with temporary effect of BoNT‐A was 50% (p > 0.05). In 86% of BoNT‐A patients the system was still activated and used to their satisfaction at their last follow‐up visit (mean FU, 40.70 months).

Conclusion

SNM in patients with refractory OAB who failed prior BoNT‐A is an excellent approach. The number of injections nor reason of BoNT‐A discontinuation have predictive value for success with SNM.