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Padmanabhan P, Zwaans BMM, Wu C, Boldt RJ. Percutaneous tibial neuromodulation initial therapy compliance and subsequent third-line treatment patterns. Neurourol Urodyn 2024; 43:1157-1170. [PMID: 38587245 DOI: 10.1002/nau.25448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Percutaneous Tibial Neuromodulation (PTNM) is used to treat Overactive Bladder (OAB). This analysis summarizes patient adherence to PTNM treatment and examines trends of other third-line therapy use during and after PTNM. METHODS Optum's deidentified Clinformatics® Data Mart Database (CDM) and CMS Research Identifiable Files were queried for adults with OAB symptoms and who underwent PTNM treatment (2019-2020). We evaluated the proportion of patients who completed 12 visits within 1 year, and defined patients as treatment compliant if 12 PTNM visits were completed within 12 weeks. We then identified the proportion of patients who used other third-line therapies after PTNM and stratified these patients based on their PTNM therapy compliance status. RESULTS 2302 patients met selection criteria from CDM and 16,473 patients from CMS. The proportion of patients completing a full PTNM treatment course increased over time; from 16% at week 12% to 42% by week 52 (CDM) and 24% to 38% (CMS). Other third-line therapy use increased over time and was higher for PTNM noncompliant versus compliant patients at 52 weeks: onabotulinumtoxinA was 6.5% versus 5.7% for noncompliant versus compliant (CMS, p = 0.0661) and 6.4% versus 4.9% (CDM, p = 0.035), SNM trial procedure was 6.5% versus 2.5% (CDM, p = 0.002) and 4.2% versus 2.0% (CMS, p = 0.010). CONCLUSIONS Most patients are noncompliant with recommended PTNM treatment regimen. Albeit low, third-line therapy was pursued more frequently by noncompliant patients. Given low compliance, the effectiveness of PTNM may be compromised. Alternative implantable technologies may be needed to assure effectiveness of neuromodulation.
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Affiliation(s)
- Priya Padmanabhan
- Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
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Sapouna V, Zikopoulos A, Thanopoulou S, Zachariou D, Giannakis I, Kaltsas A, Sopheap B, Sofikitis N, Zachariou A. Posterior Tibial Nerve Stimulation for the Treatment of Detrusor Overactivity in Multiple Sclerosis Patients: A Narrative Review. J Pers Med 2024; 14:355. [PMID: 38672982 PMCID: PMC11050849 DOI: 10.3390/jpm14040355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Bladder dysfunction, particularly neurogenic detrusor overactivity (DO), poses a substantial challenge in multiple sclerosis (MS) patients, detrimentally impacting their quality of life (QoL). Conventional therapies often fall short, necessitating alternative approaches like posterior tibial nerve stimulation (PTNS) for effective management. This narrative review critically examines the application of PTNS in treating DO among MS patients, aiming to provide a comprehensive synthesis of its efficacy, underlying mechanisms, and clinical outcomes. By evaluating a spectrum of studies, including randomized controlled trials and long-term follow-up research, the review elucidates PTNS's role in enhancing bladder control and ameliorating symptoms of urgency and incontinence, thereby improving patient well-being. Despite its potential, the review acknowledges the limited scope of existing research specific to MS-induced neurogenic DO and calls for further investigation to optimize PTNS protocols and understand its long-term benefits. Highlighting PTNS's minimal invasiveness and favorable safety profile, the review advocates for its consideration as a viable third-line treatment option in MS-related bladder dysfunction management. Through this analysis, the review contributes to the broader narrative of seeking effective, patient-centered therapeutic strategies for MS-related complications, underscoring the importance of personalized care in improving patient outcomes.
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Affiliation(s)
- Vaia Sapouna
- Department of Urology, EV PRATTEIN Rehabilitation Centre, 38222 Volos, Greece; (S.T.); (D.Z.)
| | - Athanasios Zikopoulos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (A.Z.); (I.G.); (N.S.); (A.Z.)
| | - Sofia Thanopoulou
- Department of Urology, EV PRATTEIN Rehabilitation Centre, 38222 Volos, Greece; (S.T.); (D.Z.)
| | - Dimitrios Zachariou
- Department of Urology, EV PRATTEIN Rehabilitation Centre, 38222 Volos, Greece; (S.T.); (D.Z.)
| | - Ioannis Giannakis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (A.Z.); (I.G.); (N.S.); (A.Z.)
| | - Aris Kaltsas
- Third Department of Urology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Bou Sopheap
- Department of Urology, Cambodia-China Friendship Preah Kossamak Hospital, Phnom Penh 120406, Cambodia;
| | - Nikolaos Sofikitis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (A.Z.); (I.G.); (N.S.); (A.Z.)
| | - Athanasios Zachariou
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (A.Z.); (I.G.); (N.S.); (A.Z.)
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Burton CS, Sokol ER. Pilot Study of a Novel At-Home Posterior Tibial Nerve System for Overactive Bladder Syndrome. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:107-113. [PMID: 37493289 PMCID: PMC10805982 DOI: 10.1097/spv.0000000000001399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
IMPORTANCE Urgency urinary incontinence and overactive bladder are common conditions. Third-line therapies are often underutilized because of either being too invasive or being burdensome for the patient. OBJECTIVE We aimed to determine the efficacy and acceptability of a noninvasive, home-based posterior tibial nerve treatment system for the treatment of overactive bladder syndrome. STUDY DESIGN In this pilot study, 10 postmenopausal women with urgency urinary incontinence were given the SoleStim System for home-based posterior tibial nerve stimulation. Symptoms at baseline and completion of the 8-week study were determined by 3-day voiding diary and quality-of-life questionnaire (Overactive Bladder Questionnaire) to assess for reduction in incontinence episodes. RESULTS All patients were 100% adherent to the SoleStim System application over the 8-week period and reported statistically significant reductions in the mean number of voids (-16.3%, P = 0.022), urgency episodes (-31.2%, P = 0.02), and urgency urinary incontinence episodes (-31.4%, P = 0.045). Forty percent of participants reported a decrease of ≥50% in their urgency urinary incontinence episodes. SoleStim was scored a value of 1.8 ± 2.0 (mean ± SD) on a 10-point usability scale, indicating that it was highly acceptable from an ease-of-use perspective. No adverse events were reported. CONCLUSIONS The SoleStim System improved key overactive bladder (frequency, urgency, and urgency urinary incontinence episodes) and quality-of-life metrics. The results from this pilot study suggest that the SoleStim System may be a safe, effective, and highly acceptable at-home overactive bladder therapy.
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Affiliation(s)
- Claire S. Burton
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Eric R. Sokol
- Urogynecology and Pelvic Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA
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Goudelocke C, Sobol J, Poulos D, Enemchukwu E, Zaslau S, Dhir R. A Multicenter Study Evaluating the FREquency of Use and Efficacy of a Novel Closed-Loop Wearable Tibial Neuromodulation System for Overactive Bladder and Urgency Urinary Incontinence (FREEOAB). Urology 2024; 183:63-69. [PMID: 37944596 DOI: 10.1016/j.urology.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of a novel wearable neuromodulation system incorporating embedded electromyographic evaluation, representing the first closed-loop wearable therapy for bladder control. METHODS This 12-week, multicenter, open-label, single-arm study of subjects with overactive bladder assessed response of bladder diary parameters and quality of life (QOL) metrics. Subjects used the transcutaneous tibial neuromodulation system, either once or three times weekly, with evaluations at weeks 1, 4, 8, and 12. Enrolled subjects (N = 96) were assessed for changes in urinary frequency, urgency, and urgency urinary incontinence episodes, and QOL changes using various questionnaires. RESULTS In the intent-to-treat population (N = 96, mean age 60.8 ± 13.0years, 88.5% female), significant reductions in 3-day diary parameters were observed for daily voids, incontinence, and urgency episodes at 12weeks. QOL improvements exceeded the minimal clinically important difference for all QOL questionnaires. Long-term results remained robust at 12months. Device-related adverse events were mild and there were no device-related serious adverse events. Mean therapy compliance at 12weeks was 88.5%. High satisfaction rates were reported for the device overall. CONCLUSION The Avation device demonstrates promising efficacy in treating adults with overactive bladder and urge urinary incontinence. At 12weeks, both diary parameters and QOL indicators showed significant improvement and remained robust at 12months. The device had a favorable safety profile with high compliance and patient satisfaction. This novel, closed-loop wearable tibial neuromodulation system represents a significant advancement in bladder control therapy, offering a noninvasive, patient-centered alternative with improved accessibility and ease of use.
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Affiliation(s)
| | | | | | | | - Stanley Zaslau
- Department of Urology, West Virginia University, Morgantown, WV
| | - Rohit Dhir
- Tranquil Clinical and Research Consulting Services, Webster, TX
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Rejchrt M, Krhut J, Gärtner M, Blok BFM, Zvara P. Effect duration of the initial course of peroneal electrical Transcutaneous NeuroModulation in patients with overactive bladder. World J Urol 2023:10.1007/s00345-023-04394-z. [PMID: 37027023 DOI: 10.1007/s00345-023-04394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023] Open
Abstract
PURPOSE The aim of this prospective 12-month follow-up study is to evaluate the persistence of the treatment effect achieved during the initial course of peroneal electrical Transcutaneous NeuroModulation (peroneal eTNM®) in patients with overactive bladder (OAB). METHODS This study enrolled 21 female patients who participated in two previous clinical studies designed to assess the efficacy and safety of peroneal eTNM®. The patients were left without subsequent OAB treatment and were invited to attend regular follow-up visits every 3 months. The patient's request for additional treatment was considered an indicator of the withdrawal of the treatment effect of the initial course of peroneal eTNM®. The primary objective was the proportion of patients with persisting treatment effect at follow-up visit 12 months after initial course of peroneal eTNM®. Descriptive statistics are presented using median, correlation analyses were computed using a nonparametric Spearman correlation. RESULTS The proportion of patients with persistent therapeutic effect of the initial course of peroneal eTNM® was 76%, 76%, 62% and 48% at 3, 6, 9 and 12 months, respectively. There was a significant correlation between patient reported outcomes and the number of severe urgency episodes with or without urgency incontinence as reported by patients at each follow-up visit (p = 0.0017). CONCLUSION The treatment effect achieved during the initial phase of peroneal eTNM® persists for at least 12 months in 48% of patients. It is likely that the duration of effects is dependent on the length of the initial therapy.
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Affiliation(s)
- Michal Rejchrt
- Department of Urology, 2nd Faculty of Medicine of Charles University and Motol University Hospital, Prague, Czech Republic
- Urological Office, Poliklinika RAVAK, Příbram, Czech Republic
| | - Jan Krhut
- Department of Urology, University Hospital, Ostrava, Czech Republic.
- Department of Surgical Studies, Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
| | | | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter Zvara
- Biomedical Laboratory and Research Unit of Urology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Urology, Odense University Hospital, Odense, Denmark
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Sirls LT, Schonhoff A, Waldvogel A, Peters KM. Development of an implant technique and early experience using a novel implantable pulse generator with a quadripolar electrode array at the tibial nerve for refractory overactive bladder. Neurourol Urodyn 2023; 42:427-435. [PMID: 36573835 DOI: 10.1002/nau.25117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/09/2022] [Accepted: 12/08/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Tibial nerve stimulation is an effective treatment for overactive bladder (OAB) and has been utilized as an in-person recurring session treatment option for many years. The primary objective of this study was to evaluate the safety and efficacy of a long-term implantable device and the method of utilizing a retrograde approach to place the device (a percutaneous implantable pulse generator [pIPG] with integrated quadripolar electrodes) at the tibial nerve (Protect PNS; Uro Medical Corp.). METHODS A novel retrograde implant technique was developed through multiple cadaveric dissections to percutaneously implant a chronic, wireless, minimally invasive pIPG device with integrated quadripolar electrodes (now licensed to Uro Medical) at the tibial nerve. A proof-of-concept pIPG device approved as part of an FDA IDE was designed to gain early experience in subjects with refractory OAB. The pIPG was implanted in the office under local anesthesia using the novel retrograde approach, and stimulation was activated using an external wireless energy source called a transmitter. Initially, a pilot study was designed to compare outcomes in subjects randomized to either percutaneous tibial nerve stimulation (PTNS) or Protect PNS. However, due to the small sample sizes available at this time, it was not possible to compare the two groups. Thus, the purpose of this manuscript is to describe the outcome of subjects who underwent implantation of the Protect PNS system. Twelve-month safety and efficacy were evaluated. RESULTS Nine subjects were enrolled in the randomized pilot study; 5 to the pIPG group and 4 to PTNS, and all completed the 13-week primary endpoint. Subsequently, two subjects in the PTNS group chose to cross over and have the pIPG implanted after 13 weeks. Outcomes of the seven subjects who underwent implantation of the pIPG are described. No complications related to the office procedure were noted. Two of the older model pIPG devices became nonresponsive at 1 and 4 weeks and were replaced. Six minor adverse events were reported and resolved. Subjects reported improvement in urge urinary incontinence (UUI) episodes, OAB symptoms, and quality of life. Subjects impanted with a pIPG reported a 50% reduction in UUI as early as 1 week. CONCLUSIONS Results of this pilot study suggest that retrograde percutaneous implantation of a pIPG is a safe, minimally invasive one-stage office procedure for treatment for urge incontinence related OAB symptoms, without significant complications after 12 months follow-up. Future studies will be required to compare outcomes among treatment modalities.
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Affiliation(s)
- Larry T Sirls
- Department of Urology, Beaumont Health, Royal Oak, Michigan, USA.,Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Amanda Schonhoff
- Department of Urology, Beaumont Health, Royal Oak, Michigan, USA
| | - Angela Waldvogel
- Department of Urology, Beaumont Health, Royal Oak, Michigan, USA
| | - Kenneth M Peters
- Department of Urology, Beaumont Health, Royal Oak, Michigan, USA.,Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Te Dorsthorst M, van Balken M, Janssen D, Heesakkers J, Martens F. Real-life patient experiences of TTNS in the treatment of overactive bladder syndrome. Ther Adv Urol 2021; 13:17562872211041470. [PMID: 34484428 PMCID: PMC8411642 DOI: 10.1177/17562872211041470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction and objectives: Overactive bladder syndrome (OAB) is defined as urinary urgency, with or without urgent
urinary incontinence; it is often associated with urinary frequency and nocturia, in the
absence of any pathological or metabolic conditions that may cause or mimic OAB. The aim
of this study was to evaluate the long-term real-life adherence of transcutaneous tibial
nerve stimulation (TTNS) in the treatment of OAB, patient satisfaction of the treatment,
and reasons for quitting therapy. Materials and methods: In this single center study, all patients who had a positive effect on percutaneous
tibial nerve stimulation (PTNS) and continued to receive home-based treatment with TTNS
since 2012 were included for analysis. Patients were retrospectively asked to fill out a
questionnaire regarding satisfaction, reasons for quitting, and additional or next line
of therapy. Results: We included 42 patients for this study, 81% of these patients were female
(n = 34). The median age was 67 years (range 36–86). Most of the
patients (64%, n = 27) were diagnosed with OAB wet. The median TTNS
treatment persistence was 16 months (range 1–112 months). Reasons and percentages for
stopping therapy were: 55% stopped treatment due to loss of effect, and 24% stopped
because of preferring other type of neuromodulation. The mean satisfaction score (scale
1–10) in patients who continued TTNS was 6.2 (n = 9, SD 1.30)
versus 5.4 (n = 29, SD 2.24) for patients who quit
therapy. We did not find a statistically significant difference between the two groups
(p = 0.174). Conclusion: TTNS, although effective in the short-term, is not effective in the long-term. In
combination with a low satisfaction rate among patients, there is a need for improvement
in terms of OAB treatment modalities.
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Affiliation(s)
| | | | | | - John Heesakkers
- Maastricht University Medical Centre, Maastricht, Netherlands
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8
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Andersen K, Kobberø H, Pedersen TB, Poulsen MH. Percutaneous tibial nerve stimulation for idiopathic and neurogenic overactive bladder dysfunction: a four-year follow-up single-centre experience. Scand J Urol 2021; 55:169-176. [PMID: 33635171 DOI: 10.1080/21681805.2021.1885486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Overactive bladder (OAB) affects hundreds of millions of people worldwide and has significant detrimental effects on quality-of-life. Percutaneous tibial nerve stimulation (PTNS) is endorsed in the European guidelines of Urology as second-line therapy - on par with pharmacological treatment for women with OAB. METHODS This prospective cohort study describes our clinical experience with PTNS in a daily outpatient clinic, on a consecutive cohort. The cohort of 116 patients was mixed; including both men and women with idiopathic (iOAB) and neurogenic (nOAB) overactive bladder. Patients were treated with a 12-week course of PTNS followed by monthly maintenance treatment. Data were collected during 4 years. RESULTS The most common indication for PTNS was OAB with urge incontinence (53%) followed by OAB-dry and nocturia (both 16%). One hundred and ten (95%) patients completed follow-up and 68 patients (62%) continued to maintenance treatment. A total of 68 patients reported an effect on PROM, BD and ICIQ-OAB, which is the same 62% that continue in maintenance PTNS. A significant decline was seen in overall ICIQ-OAB score, with a median drop from 87 to 54, a significant decline in overall frequency and nocturia on bladder diary and a shift in pad test group in 19% of the incontinence patients. CONCLUSION PTNS shows an equally significant effect on men as well as women both in the iOAB and nOAB subgroups in a daily outpatient clinic. In our opinion, PTNS should be a standard treatment option available at urological departments, where both men and women in both sub-groups could benefit from treatment. Further randomized studies focusing on men with iOAB are needed.
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Affiliation(s)
- K Andersen
- Department of Urology, Odense University Hospital, Odense, Denmark
| | - H Kobberø
- Department of Urology, Odense University Hospital, Odense, Denmark
| | - T B Pedersen
- Department of Urology, Odense University Hospital, Odense, Denmark
| | - M H Poulsen
- Department of Urology, Odense University Hospital, Odense, Denmark.,Department of Clinical Institute, University of Southern Denmark, Odense, Denmark
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Du C, Berg W, Siegal AR, Huang Z, Jeong R, Hwang K, Kim J. Real-world Compliance With Percutaneous Tibial Nerve Stimulation Maintenance Therapy in an American Population. Urology 2021; 153:119-123. [PMID: 33581232 DOI: 10.1016/j.urology.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate percutaneous tibial nerve stimulation (PTNS) maintenance therapy dropout rates and identify factors associated with compliance in an American population. METHODS We retrospectively queried our PTNS database for patients from 2014-2019. Demographic, relevant clinical, and visit data were collected. Maintenance therapy was patient-driven and frequency of sessions was tapered based on symptomology. Upon completion of 12 initial sessions, we assessed dropout from maintenance at 3, 6, 9, and 12 months. Multiple variables were tested for correlation with dropout in patients continuing maintenance therapy for 1 year vs those who dropped out. RESULTS One hundred and sixty-three PTNS patients were identified, of which 104 completed initial therapy and 81 proceeded with maintenance therapy. At 3, 6, 9, and 12 months, maintenance continuation rates were 77.8% (63/81), 58.0% (47/81), 45.6% (37/81), and 39.5% (32/41), respectively. Primary reasons for dropout were worsening of urinary symptoms/lack of efficacy (n = 21), time commitment (n = 9), loss of insurance (n = 5), medical comorbidities (n = 4), request for alternative OAB treatment (n = 2), and unknown (n = 8). On both univariate and multivariate analysis, perceived symptom improvement (P<.01; HR = 0.02, P< .01) was associated with continuing maintenance therapy. On only univariate analysis, neurological history (P = .02) and multiple sclerosis history (0.02) were associated with continuing therapy. CONCLUSION Only 39.5% of patients continue to undergo maintenance PTNS therapy after 1 year. Future studies are required to understand and ameliorate factors for low compliance in PTNS maintenance therapy.
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Affiliation(s)
- Chris Du
- Stony Brook Medicine, Department of Urology.
| | | | | | | | - Rosen Jeong
- Stony Brook University, Renaissance School of Medicine
| | - Kuemin Hwang
- Stony Brook University, Renaissance School of Medicine
| | - Jason Kim
- Stony Brook Medicine, Department of Urology
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Brandon C, Oh C, Brucker BM, Rosenblum N, Ferrante KL, Smilen SW, Nitti VW, Pape DM. Persistence in Percutaneous Tibial Nerve Stimulation Treatment for Overactive Bladder Syndrome is Best Predicted by Patient Global Impression of Improvement Rather Than Symptom-Specific Improvement. Urology 2020; 148:93-99. [PMID: 33358753 DOI: 10.1016/j.urology.2020.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate whether progression to maintenance percutaneous tibial nerve stimulation (PTNS) was related to perceived global impression of improvement (PGII) rather than symptom-specific improvement in patient with overactive bladder (OAB). We hypothesize that PGII will predict continuation of PTNS long-term. METHODS This prospective observational study included 90 patients with OAB that initiated PTNS. The PGII and OAB short-form questionnaires (OABq-SF) were used to assess bladder symptom severity and improvement. Those that completed the 12-week induction phase were offered to continue PTNS monthly maintenance or pursue other options. The primary outcome was difference in PGII score between those pursuing maintenance therapy versus other options. Descriptive statistics and mixed effect modeling analysis were employed. RESULTS Seventy patients (78%) completed 12 weeks of PTNS. The majority of completers pursued monthly maintenance (P< .01) and had significantly lower median PGII scores compared with those who sought alternatives (P < .01), while OABq-SF scores did not differ significantly (P = .65). Patients that pursued monthly PTNS maintenance had lower body mass index than those who chose alternative therapies (P < .01). Only 19% continued PTNS therapy for at least 1 year. CONCLUSION More patients pursued PTNS monthly maintenance over any other therapy, and this was significantly associated with lower PGII scores. Global improvement, and not symptom-specific response, predicts long-term PTNS maintenance. No symptom-specific predictors were identified in those who pursued maintenance over other options. One-year continuation rates are low.
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Affiliation(s)
- Caroline Brandon
- New York University Langone Health, Department of Urology and Obstetrics & Gynecology, New York, NY
| | - Cheongeun Oh
- New York University Langone Health, Department of Population Health, New York, NY
| | - Benjamin M Brucker
- New York University Langone Health, Department of Urology and Obstetrics & Gynecology, New York, NY
| | - Nirit Rosenblum
- New York University Langone Health, Department of Urology and Obstetrics & Gynecology, New York, NY
| | - Kimberly L Ferrante
- Kaiser Permanente San Diego, Department of Obstetrics & Gynecology, San Diego, CA
| | - Scott W Smilen
- Jersey Shore University Medical Center, Department of Obstetrics & Gynecology, Neptune City, NJ
| | - Victor W Nitti
- University of California Los Angeles, Department of Urology, Los Angeles, CA
| | - Dominique Malacarne Pape
- New York University Langone Health, Department of Urology and Obstetrics & Gynecology, New York, NY.
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11
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Lee UJ, Ward JB, Feinstein L, Matlaga BR, Martinez-Miller E, Bavendam T, Kirkali Z, Kobashi KC. National Trends in Neuromodulation for Urinary Incontinence Among Insured Adult Women and Men, 2004-2013: The Urologic Diseases in America Project. Urology 2020; 150:86-91. [PMID: 33296698 DOI: 10.1016/j.urology.2020.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine US trends in neuromodulation for urinary incontinence (UI) treatment from 2004 to 2013. METHODS This study utilized 2 data sources: the Optum© de-identified Clinformatics® Data Mart Database for privately insured adults aged 18-64 years with a UI diagnosis (N≈40,000 women and men annually) and the Medicare 5% Sample for beneficiaries aged ≥65 years with a UI diagnosis (N≈65,000 women and men annually). We created annual cross-sectional cohorts and assessed prevalence of UI-related neuromodulation procedures among men and women separately from 2004 to 2013. Analyses were conducted overall and stratified by age, race/ethnicity, and geographic region. RESULTS Nearly all neuromodulation procedures occurred in outpatient settings. Sacral neuromodulation (SNM) procedures for UI in both women and men grew steadily from 2004 to 2013, with more procedures performed in women than men. Among women with UI, SNM prevalence grew from 0.1%-0.2% in 2004 to 0.5%-0.6% in 2013. Posterior tibial nerve stimulation (PTNS) experienced growth from 2011 to 2013. Chemodenervation of the bladder with onabotulinumtoxinA (BTX) combined with other injectable procedures (including urethral bulking) remained stable over time. CONCLUSIONS From 2004 to 2013, SNM procedures remained relatively uncommon but increased consistently. PTNS experienced growth starting in 2011 when PTNS-specific insurance claims became available. BTX trends remain unclear; future studies should assess it separately from other injectable procedures. Neuromodulation has a growing role in UI treatment, and ongoing trends will be important to examine.
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Affiliation(s)
- Una J Lee
- Section of Urology, Virginia Mason Medical Center, Seattle, WA
| | | | | | - Brian R Matlaga
- Johns Hopkins Brady Urological Institute, Department of Urology, Baltimore, MD
| | | | - Tamara Bavendam
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
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Wallace SL, St Martin B, Lee K, Sokol ER. A cost-effectiveness analysis of vaginal carbon dioxide laser therapy compared with standard medical therapies for genitourinary syndrome of menopause-associated dyspareunia. Am J Obstet Gynecol 2020; 223:890.e1-890.e12. [PMID: 32562659 DOI: 10.1016/j.ajog.2020.06.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Topical vaginal estrogen therapy is considered the gold standard treatment for genitourinary syndrome of menopause-associated dyspareunia, but early investigations of energy-based devices show promise for patients with contraindications or those who are refractory to vaginal estrogen cream therapy. Although evaluating safety, efficacy, and long-term outcomes for novel technologies is critically important when new technologies become available to treat unmet healthcare needs, evaluation of the costs of these new technologies compared with existing therapies is also critically important but often understudied. OBJECTIVE We sought to perform a cost-effectiveness analysis of 3 therapies for genitourinary syndrome of menopause, including vaginal estrogen therapy, oral ospemifene therapy, and vaginal CO2 laser therapy and determine if vaginal laser therapy is a cost-effective treatment strategy for dyspareunia associated with genitourinary syndrome of menopause. STUDY DESIGN An institutional review board-exempt cost-effectiveness analysis was performed by constructing a decision tree using decision analysis software (TreeAge Pro; TreeAge Software, Inc, Williamstown, MA) using integrated empirical data from the published literature. Tornado plots and 1-way and 2-way sensitivity analyses were performed to assess how changes in the model's input parameters altered the overall outcome of the cost-effectiveness analysis model. RESULTS All 3 treatment methods were found to be cost-effective below the willingness-to-pay threshold of $50,000.00 per quality-adjusted life year for moderate dyspareunia. The incremental cost-effectiveness ratio for vaginal CO2 laser therapy was $16,372.01 and the incremental cost-effectiveness ratio for ospemifene therapy was $5711.14. Although all 3 treatment strategies were on the efficient frontier, vaginal CO2 laser therapy was the optimal treatment strategy with the highest effectiveness. In a 1-way sensitivity analysis of treatment adherence, vaginal CO2 laser therapy was no longer cost-effective when the adherence fell below 38.8%. Vaginal estrogen cream and ospemifene therapies remained cost-effective treatment strategies at all ranges of adherence. When varying the adherence to 100% for all strategies, oral ospemifene therapy was "dominated" by both vaginal CO2 laser therapy and vaginal estrogen cream therapy. In a 2-way sensitivity analysis of vaginal CO2 laser therapy adherence and vaginal CO2 laser therapy cost, vaginal CO2 laser therapy still remained the optimal treatment strategy at 200% of its current cost ($5554.00) when the adherence was >55%. When the cost fell to 20% of its current cost ($555.40), it was the optimal treatment strategy at all adherence values above 29%. CONCLUSION This study showed that vaginal fractional CO2 laser therapy is a cost-effective treatment strategy for dyspareunia associated with GSM, as are both vaginal estrogen and oral ospemifene therapies. In our model, vaginal CO2 laser therapy is the optimal cost-effective treatment strategy, and insurance coverage should be considered for this treatment option if it is proven to be safe and effective in FDA trials.
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Affiliation(s)
- Shannon L Wallace
- Division of Urogynecology, Department of Obstetrics and Gynecology, Stanford University Hospital, Palo Alto, CA.
| | - Brad St Martin
- Division of Urogynecology, Department of Obstetrics and Gynecology, Stanford University Hospital, Palo Alto, CA
| | - Kyueun Lee
- Department of Health Research and Policy, Stanford University, Palo Alto, CA
| | - Eric R Sokol
- Division of Urogynecology, Department of Obstetrics and Gynecology, Stanford University Hospital, Palo Alto, CA
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Jiang J, Patil D, Traore EJ, Hammett J, Filson CP. Contemporary Patterns of Third-line Treatments for Privately Insured Individuals With Overactive Bladder in the United States. Urology 2020; 142:87-93. [DOI: 10.1016/j.urology.2020.04.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022]
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Te Dorsthorst MJ, Heesakkers JPFA, van Balken MR. Long-term real-life adherence of percutaneous tibial nerve stimulation in over 400 patients. Neurourol Urodyn 2019; 39:702-706. [PMID: 31845404 PMCID: PMC7027784 DOI: 10.1002/nau.24254] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/03/2019] [Indexed: 11/11/2022]
Abstract
Background Percutaneous tibial nerve stimulation (PTNS) is used as a treatment to reduce the complaints of overactive bladder (OAB). Although it is rewarding therapy patients need maintenance treatment to preserve the beneficial effect. Aim This real‐life retrospective study was performed to assess the feasibility of PTNS adherence. Materials & methods All patients who underwent PTNS were retrospectively included. We analyzed the following: indication, kind of treatments (pharmacologic and third‐line therapy) before and after PTNS treatment, time and reason for quitting therapy. Statistical analysis was done by performing competitive‐risk analysis and Kaplan‐Meier curves. Patients were categorized into four groups. Group 1: all patients; group 2: all patients on maintenance PTNS therapy (continuing after 12 weeks); group 3: patients on maintenance PTNS therapy excluding the following: (a) patients with initial good response who seized treatment due to death, (b) patient who successfully switched to transcutaneous stimulation, (c) patients who were cured of their OAB symptoms, or (d) patients who relocated; and group 4: group 3 but excluding those who stopped treatment because of nonmedical reasons (physical strain, inconveniencies associated with visiting the hospital). Results Four‐hundred two patients (70% female) with a median age of 70 years underwent PTNS. Underlying treatment indications were: OAB‐wet (54%) and OAB‐dry (29%). The median follow‐up (FU) of group 1 was 4 months. Fifty‐seven percent (N = 228) of the patients received maintenance PTNS therapy. Median FU in group 4 was 46 months (range, 3‐111 months). Over 40% of the maintenance patients stopped PTNS because of logistic reasons and physical strain during an FU time of 6 years. Conclusion The real‐world data described here with is in line with earlier published work in terms of the success rate of OAB treatment. However, over 40% quit their therapy due to nonmedical reasons.
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Affiliation(s)
- Manon J Te Dorsthorst
- Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
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Feasibility of Self-administered Neuromodulation for Neurogenic Bladder in Spinal Cord Injury. Int Neurourol J 2019; 23:249-256. [PMID: 31607105 PMCID: PMC6790819 DOI: 10.5213/inj.1938120.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/05/2019] [Indexed: 12/28/2022] Open
Abstract
Purpose To determine if self-administered transcutaneous tibial nerve stimulation (TTNS) is a feasible treatment option for neurogenic bladder among people with spinal cord injury (SCI) who utilize intermittent catheterization for bladder management. Methods Four-week observational trial in chronic SCI subjects performing intermittent catheterization with incontinence episodes using TTNS at home daily for 30 minutes. Those using anticholinergic bladder medications were given a weaning schedule to begin at week 2. Primary outcomes were compliance and satisfaction. Secondary outcomes included change in bladder medications, efficacy based on bladder diary, adverse events, and incontinence quality of life (I-QoL) survey. Results All 16 subjects who started the study completed the 4-week trial rating TTNS with high satisfaction and easy to use, without discomfort. Twelve of 14 patients (86%) using anticholinergic bladder medications reduced their dosage and maintained similar frequency and volumes of bladder catheterization and incontinence episodes. Bladder medication reduced by approximately 3.2 mg weekly (95% confidence interval, -5.9 to -0.4) and anticholinergic side effects of dry mouth and drowsiness decreased more than 1 level of severity from baseline (P=0.027, P=0.015, respectively). At 4 weeks, total I-QoL score improved by an average of 3.2 points compared to baseline in all domains. Conclusions This pilot trial suggests TTNS is feasible to be performed at home in people with chronic SCI. Participants were able to reduce anticholinergic medication dosage and anticholinergic side effects while maintaining continence, subsequently improving QoL scores. These results advocate for further randomized, controlled trials with longer duration and urodynamic evaluation to assess long-term efficacy.
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Abstract
Neuromodulation encompassing sacral and peripheral modalities is an established, effective, and safe higher-order treatment option approved in the USA for managing refractory overactive bladder, non-obstructive urinary retention, and fecal incontinence. This review highlights the most recent literature, indications, treatment durability, and the latest innovations in this field. Regarding sacral neuromodulation (SNM), recent work suggests improved parameters for optimal lead placement, increased data to support the lasting effects of treatment, and novel applications of this technology to other pelvic disorders. In addition, there are emerging technologies with smaller MRI compatible devices. Newer data on percutaneous tibial nerve stimulation (PTNS) suggests it may be more beneficial for certain patients. With new technology, implantable tibial nerve stimulators are ushering in a new frontier of nerve stimulation in the comfort of the patient's home.
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Affiliation(s)
- Courtenay K Moore
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA.
| | - Jessica J Rueb
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA
| | - Samir Derisavifard
- Glickman Urologic and Kidney Institute, Cleveland Clinic, 9500 Euclid Avenue, Q-10, Cleveland, OH, 44195, USA
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Kobashi K, Nitti V, Margolis E, Sand P, Siegel S, Khandwala S, Newman D, MacDiarmid SA, Kan F, Michaud E. A Prospective Study to Evaluate Efficacy Using the Nuro Percutaneous Tibial Neuromodulation System in Drug-Naïve Patients With Overactive Bladder Syndrome. Urology 2019; 131:77-82. [PMID: 31199966 DOI: 10.1016/j.urology.2019.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/27/2019] [Accepted: 06/03/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate changes from baseline in urgency urinary incontinence episodes, urinary frequency and quality of life through 12 weeks of percutaneous tibial neuromodulation (PTNM) therapy using NURO in drug-naïve overactive bladder syndrome (OAB) subjects. METHODS Eligible subjects underwent 12 weekly PTNM sessions with the NURO system. Changes in voiding symptoms were evaluated with bladder diaries from baseline through 12 weeks. Analyses were conducted for subjects with data at baseline and follow-up visits (sessions 1, 4, 8, and 12). Safety was evaluated through adverse events (AE) related to the device, procedure, and therapy. RESULTS Of 154 subjects enrolled in the study,120 subjects met study criteria and received PTNM. The mean age was 64.8 years, mean duration of OAB diagnosis was 3.4 years and 86% female subjects. No subjects tried OAB medication prior to enrollment. At baseline, patients had 3.5 ± 2.5 (mean ± SD) UUI episodes/day. Statistically significant improvement in urgency urinary incontinence episodes from baseline was observed at each follow-up visit (P < .0001), with a reduction of 2.4 ± 2.1 episodes after session 12 from baseline. Subjects with urinary frequency at baseline had 11.5 ± 2.9 voids/day. After session 12, a statistically significant reduction of 1.7 ± 2.5 voids/day was observed (P < .0001). Ninety-six percent (116/120) of subjects completed the study with diary data for the primary objective with an average of 11.6 sessions. There were no serious or unanticipated AEs. The most common AEs were medical device site pain (3.3%, 4/121) and extremity pain (3.3%, 4/121). CONCLUSION PTNM using NURO is an effective and safe treatment for drug-naïve patients with OAB.
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Affiliation(s)
| | - Victor Nitti
- David Geffen School of Medicine at UCLA, Los Angeles, SA
| | | | - Peter Sand
- NorthShore University Health-System, Evanston, IL
| | | | | | - Diane Newman
- Division of Urology, Penn Medicine, University of Pennsylvania, Philadelphia, PA
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Palmer C, Nguyen N, Ghoniem G. Clinical experience with percutaneous tibial nerve stimulation in the elderly; do outcomes differ by gender? Arab J Urol 2019; 17:10-13. [PMID: 31258940 PMCID: PMC6583712 DOI: 10.1080/2090598x.2019.1590032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/16/2018] [Indexed: 11/23/2022] Open
Abstract
Objective: To evaluate the use of percutaneous tibial nerve stimulation (PTNS) in an elderly population, as PTNS is a third-line treatment in the management of overactive bladder (OAB) and affects 10–26% of adult males and 8–42% of adult females, increasing in prevalence with age. Patients and methods: We performed a chart review of patients aged ≥ 65 years undergoing PTNS at a single institution over 6 years. We examined clinicopathological variables potentially associated with the outcomes of interest. Results: In total, 52 patients aged ≥ 65 years underwent an induction course of PTNS between 2011 and 2017, comprising 23 men and 29 women. The mean age of the patients was 75.75 years and the mean body mass index (BMI) was 26.33 kg/m2. In all, 36 patients used anticholinergic treatments prior to PTNS, five used a β3-adrenoceptor agonist, and three had Botox injections. After PTNS, 37 patients reported improvement of their symptoms, with 21 using combined therapy during PTNS. Only seven patients used an anticholinergic after PTNS, six used a β3-adrenoceptor agonist, five had Botox injections, and two had sacral neuromodulation. When looking at variables such as age, gender, race, BMI, and comorbidities, we found that an obese BMI was the only statistically significant variable predicting failure of response. A sub-analysis of only women did not demonstrate any predictors of failure. Conclusion: Our subjective response rate of 70% was within the success rates reported in literature. In all, 39% of patients used a concomitant treatment during PTNS and 13.2% required alternative treatment after PTNS. Abbreviations: BMI: body mass index; OAB: overactive bladder; PTNS: percutaneous tibial nerve stimulation; UI: urinary incontinence
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Affiliation(s)
- Cristina Palmer
- Division of Female Urology and Voiding Dysfunction, Department of Urology, University of California Irvine, Orange, CA, USA
| | - Nobel Nguyen
- Division of Female Urology and Voiding Dysfunction, Department of Urology, University of California Irvine, Orange, CA, USA
| | - Gamal Ghoniem
- Division of Female Urology and Voiding Dysfunction, Department of Urology, University of California Irvine, Orange, CA, USA
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Salatzki J, Liechti MD, Spanudakis E, Gonzales G, Baldwin J, Haslam C, Pakzad M, Panicker JN. Factors influencing return for maintenance treatment with percutaneous tibial nerve stimulation for the management of the overactive bladder. BJU Int 2019; 123:E20-E28. [PMID: 30552801 DOI: 10.1111/bju.14651] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To identify factors influencing return for maintenance percutaneous tibial nerve stimulation (PTNS) treatment after successful completion of a 12-week course of treatment for overactive bladder (OAB). PATIENTS AND METHODS Patients with OAB symptoms referred for PTNS treatment underwent 12 sessions of weekly PTNS treatment and were evaluated at baseline and week 12 using the International Consultation on Incontinence Questionnaire on OAB, the International Consultation on Incontinence Questionnaire on lower urinary tract symptom-related quality of life (ICIQ-LUTSqol) and a bladder diary (BD). Responders to treatment, evaluated using two patient-reported outcome measures, were invited to return for maintenance treatment when symptoms returned. A PTNS Service Evaluation Questionnaire was used to evaluate factors influencing return for maintenance treatment. RESULTS Seventy-three patients were evaluated (mean age 58.9 [±14.7] years, 72.6% women) and clustered into three groups: group 1 (n = 25) did not respond to 12 weekly sessions of PTNS treatment; group 2 (n = 17) responded to treatment but did not return for maintenance treatment and group 3 (n = 31) responded to treatment and returned for maintenance treatment. There were no significant differences in demographic characteristics, diagnosis, baseline symptom scores and BD variables among the three groups. Patients belonging to groups 2 and 3 experienced a significant improvement from baseline to week 12 in total OAB scores (group 2: -1.54 ± 1.85; group 3: -1.85 ± 2.28; P < 0.05); however, patients returning for maintenance treatment reported significant improvements specifically in nocturia (BD difference = -0.4 ± 0.7 [P < 0.05] and ICIQ-LUTSqol difference -0.48 ± 0.94 [P < 0.05]), and perceived benefits of the treatment with regard to their OAB symptoms compared to those not returning for maintenance treatment (difference between the two groups 25.6%; P = 0.030). Improvements in nocturia and perceived benefits predicted return for maintenance treatment based on a logistic regression analysis. Factors related to the need for repeat clinic visits, such as transportation, distance and time commitment, were not found to differ between the two groups. CONCLUSIONS Twelve-session weekly PTNS is a safe and effective treatment for OAB. Responders to treatment returning for maintenance PTNS more often reported significant improvements in nocturia and perceived benefits over time, compared to those not returning for maintenance treatment. The BD provides a more objective assessment of treatment outcome after PTNS treatment.
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Affiliation(s)
- Janek Salatzki
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK.,Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martina D Liechti
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Eleonora Spanudakis
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Gwen Gonzales
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Joanne Baldwin
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Collette Haslam
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Mahreen Pakzad
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
| | - Jalesh N Panicker
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, London, UK
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