Understanding the dissemination of sacral neuromodulation

Axonics Sacral Neuromodulation System for Treating Refractory Overactive Bladder: A NICE Medical Technologies Guidance

The Axonics sacral neuromodulation (SNM) system can be used by people with refractory overactive bladder (OAB) to reduce symptoms of urge urinary incontinence and urinary frequency, where conservative treatments have failed or are not suitable. It is the first system for this indication that makes use of a rechargeable battery to prolong the lifespan of the implanted device, with the potential advantage of reducing the frequency of surgical replacement procedures and associated complications. We describe the evidence considered by the UK National Institute of Health and Care Excellence (NICE) in their evaluation of this evidence, supported by Cedar Healthcare Technology Research Centre. Two observational studies provided descriptive data that suggested improvement in control of symptoms after implantation of the Axonics SNM system; however, there was no peer-reviewed evidence that directly compared rechargeable and non-rechargeable SNM systems. In the absence of long-term data, economic modelling relies on the accuracy of battery life estimates. The evidence supports the case for adopting the Axonics SNM system for treating refractory OAB, when conservative treatment or treatment with medicines has not worked. This conclusion is consistent with other relevant NICE guidelines. Use of Axonics SNM technology in the UK National Health Service (NHS) is associated with a potential cost saving of £6025 per person over a 15-year period when compared with an equivalent non-rechargeable SNM system, assuming the claimed battery life estimate (a minimum of 15 years) is accurate. The cost savings are estimated to start around 6 years after implantation.

National Trends in Neuromodulation for Urinary Incontinence Among Insured Adult Women and Men, 2004-2013: The Urologic Diseases in America Project

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.

Influence of patient sex on the effectiveness of sacral neuromodulation: A cohort study from China

BACKGROUND

Sacral neuromodulation (SNM) has been widely used to treat lower urinary tract dysfunction. Studies have shown a higher conversion rate among female patients than among male patients. However, the influence of gender on the clinical effectiveness of SNM remains unclear. We aimed to confirm whether patients of both genders show similar benefits after SNM treatment.

MATERIALS AND METHODS

Clinical data of patients with lower urinary tract symptoms associated with pelvic floor dysfunction (overactive bladder, neurogenic bladder, interstitial cystitis/painful bladder syndrome, idiopathic urinary retention) treated with SNM in 10 medical centres in China between January 2012 and December 2016 were retrospectively collected. The patients were classified by gender. Variations in objective (voiding diary) and subjective scores in the baseline, testing, and last follow-up periods were compared. Data were analysed using statistical measures.

RESULTS

The study included 203 patients (93 males, 110 females). There were no statistical differences in baseline information between the two groups, both groups showed improvement over time. Unsatisfactory improvement was observed in the quality of life and sexual life scores of both groups over the entire treatment period (all p＞0.05). Although there was a difference in the maximum voiding volume between the groups at baseline, no difference was observed at the last follow-up (p = 0.004, p = 0.044, p = 0.124), unlike in the average volume where a difference was noted at the last follow-up (p = 0.085, p = 0.964, p = 0.031). While there were no differences in quality of life, sexual life, or pelvic pain and urinary urgency frequency scores at baseline, a significant difference was observed at the last follow-up, and the degree of improvement was less among female patients (p = 0.836, p = 0.131, p = 0.015; p = 0.294, p = 0.265, p = 0.013; p = 0.299, p = 0.087, p = 0.015).

CONCLUSION

SNM treatment elicited a similar effect on patients of both gender; however, a significant difference was observed regarding patient satisfaction with the treatment. Further preoperative patient education, especially, for female patients with interstitial cystitis/painful bladder syndrome may improve patient satisfaction.

Trends and Clinical Practice Patterns of Sacral Neuromodulation for Overactive Bladder

OBJECTIVES

The aim of this study was to investigate surgical practice patterns of American urologists treating refractory overactive bladder (OAB) over the past decade. Refractory OAB remains a management challenge to urologists. When multiple medical therapies have failed, treatment options may include sacral neuromodulation (SNM) or surgery such as augmentation cystoplasty (AC).

METHODS

Data on SNM and AC performed between 2003 and 2012 by certifying and recertifying urologists were obtained in the form of annualized case logs from the American Board of Urology (ABU). Associations between surgeon characteristics (type of certification, annual volume, practice type, and location) and these procedures were evaluated.

RESULTS

Over the past decade, 756 of 6355 urologists certified with the ABU performed SNM or AC for the treatment of refractory OAB. Forty-five (6%) of these surgeons completed fellowships in female urology and 71 surgeons (9%) completed another type of fellowship program. Surgeons recertifying with ABU performed 76% of all SNM procedures. Although SNM and AC have increased from 64 to 2086 between 2003 and 2012, however, this is mainly driven by the increase of SNM from 48 to 2068 cases. Rates of AC have remained stable with 14 to 38 cases reported annually. However, they have declined relative to the total, from 25% in 2003 to less than 1% in 2012.

CONCLUSIONS

Sacral neuromodulation has increased dramatically over the past decade in surgeons certified with the ABU. This is in contrast to AC, which while remaining stable in number of procedures.

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction

INTRODUCTION

Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

Physician Use of Sacral Neuromodulation Among Medicare Beneficiaries With Overactive Bladder and Urinary Retention

OBJECTIVE

To identify physician-level factors associated with high rates of sacral neuromodulation testing.

MATERIALS AND METHODS

We performed a retrospective cohort study using a 20% sample of national Medicare claims to identify physicians who performed sacral neuromodulation procedures between 2005 and 2010. Physician-level rates of device testing were determined based on the number of patients seen for overactive bladder and urinary retention diagnoses in the office in each calendar year. These rates were then used to fit a Poisson model to examine factors associated with high rates of device testing.

RESULTS

The number of physicians performing test procedures increased 4-fold from 2005 to 2010. Average rates of test procedures increased from 4.0 to 6.4 procedures per physician per year (P <.001), whereas rates of device implantation remained stable (P = .23). Physicians who had higher rates of device testing were associated with lower rates of device implantation (estimate, -1.76, P <.01). Other predictors of physicians with higher test rates included more recent calendar year, testing done in any setting other than an ambulatory surgery center, gynecology subspecialty, and geographic location in the South and West (all P values <.01).

CONCLUSION

Over time, physicians are testing more patients but are not implanting more devices. Additionally, there is an inverse relationship between rates of device testing and implantation, suggesting opportunities to improve efficiency and resource utilization.

Disparities in the Use of Sacral Neuromodulation among Medicare Beneficiaries

PURPOSE

Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries.

MATERIALS AND METHODS

We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software.

RESULTS

A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p <0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p <0.0001) were more likely to be treated. Minority patients (OR 0.38, p <0.0001) and those living in the western United States (OR 0.52, p <0.0001) were less likely to receive treatment.

CONCLUSIONS

Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.