Real life persistence rate with antimuscarinic treatment in patients with idiopathic or neurogenic overactive bladder: a prospective cohort study with solifenacin

[Invasive neurostimulation in neuro-urology: state of the art]

Modulation or stimulation of the nerves supplying the lower urinary tract is a possible treatment option for dysfunction of the lower urinary tract, pelvic floor and rectum if conservative or minimally invasive treatment approaches fail. This overview shows the possibilities and limitations of sacral neuromodulation, sacral deafferentation with sacral anterior root stimulation and conus deafferentation.Sacral neuromodulation (SNM) is a procedure for the treatment of refractory pelvic floor dysfunction of various origins (idiopathic, neurogenic or post-operative), such as overactive bladder, non-obstructive retention and faecal incontinence. A particular advantage of SNM is the possibility of prior test stimulation with a high prognostic value. The procedure is minimally invasive, reversible and associated with relatively low morbidity rates.Following the introduction of MRI-compatible SNM systems, there has been renewed interest in the treatment of neurogenic bladder dysfunction. A recent meta-analysis reports similar success rates as in the idiopathic patient population.Sacral deafferentation with implantation of a sacral anterior root stimulator (SARS/SDAF) is an excellent therapeutic option for patients with spinal cord injury, which can significantly improve the quality of life of those affected and, in addition to treating neurogenic lower urinary tract dysfunction, can also have a positive effect on neurogenic bowel dysfunction, neurogenic sexual dysfunction or autonomic dysreflexia. If conservative or minimally invasive treatment fails, it is crucial for the success of this procedure to consider SDAF/SARS at an early stage in order to avoid irreversible organic damage.Conus deafferentation (KDAF) is a less invasive surgical treatment option for patients with spinal cord injury for whom sacral deafferentation would be indicated but who would not benefit from the simultaneous implantation of a sacral anterior root stimulator. In principle, these patients also have the option of being subsequently treated with an extradural implant and thus utilising the advantages of anterior root stimulation. Indications for KDAF are autonomic dysreflexia, therapy-refractory detrusor overactivity, recurrent urinary tract infections, urinary incontinence and spasticity triggered by detrusor overactivity. With KDAF, we have a safe and efficient procedure with great potential for improving the spectrum of paraplegiological and neuro-urological treatment.

Detrusor relaxing agents for neurogenic detrusor overactivity: a systematic review, meta-analysis and network meta-analysis

OBJECTIVE

To evaluate the evidence regarding the therapeutic benefits and safety of oral detrusor relaxing agents (DRAs) in treating neurogenic detrusor overactivity (NDO).

METHODS

A comprehensive search was performed on 1 September 2022. Two authors independently reviewed the articles to extract data using a pre-designed form. The meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A common-effect or random-effects model was used based on the heterogeneity among studies. Bayesian network meta-analysis (NMA) was further performed to make indirect comparisons of antimuscarinics and mirabegron.

RESULTS

A total of 23 randomised controlled trials (RCTs) comprising 1697 patients were included in our analysis. Compared to placebo, the clinical benefits of oral DRAs, along with more adverse events (AEs), were demonstrated in the treatment of NDO. In the subgroup analysis, antimuscarinics significantly improved both urodynamic and bladder diary outcomes (including urinary incontinence episodes, urinary frequency, and residual volume), with a higher rate of AEs, such as xerostomia. Mirabegron improved some of the parameters and had fewer bothersome side-effects in patients with NDO. The NMA showed that none of the antimuscarinics or mirabegron was superior or inferior to the other.

CONCLUSIONS

Detrusor relaxing agents are associated with improved outcomes in patients with NDO and our analysis has added new evidence regarding antimuscarinics. Evidence concerning mirabegron as first-line therapy for NDO is still limited. Well-designed RCTs are still required in this specific population.

Reduced versus standard intradetrusor OnabotulinumtoxinA injections for treatment of overactive bladder

BACKGROUND

Intradetrusor onabotulinumtoxinA injection is an effective advanced treatment for overactive bladder. While the effective dosages have been well studied, very little data exist on treatment efficacy using differing injection techniques. The objective of this study was to determine whether the efficacy of a reduced injection technique of 5 injection sites was noninferior to the standard technique of 20 injection sites of intradetrusor onabotulinumtoxinA for treatment of overactive bladder.

METHODS

In this randomized noninferiority trial, men and women seeking treatment of overactive bladder with intradetrusor onabotulinumtoxinA injections were randomized to receive 100 units administered via either a reduced injection technique of 5 injection sites or a standard injection technique of 20 injection sites. Subjects completed a series of standardized questionnaires at baseline and at 4-12 weeks postprocedure to determine symptom severity and treatment efficacy. The primary outcome was treatment efficacy as determined by Overactive Bladder Questionnaire-Short Form with a noninferiority margin of 15 points. Secondary outcomes were incidence of urinary tract infection and urinary retention requiring catheterization.

RESULTS

Data from 77 subjects were available for analysis with 39 in the control arm (20 injections) and 38 in the study arm (5 injections). There was a significant improvement in both arms from baseline to follow-up in Overactive Bladder Questionnaire-Short Form and International Consultation on Incontinence Questionnaire scores (p < 0.001). Overall treatment success was 68% with no statistically significant difference between arms. A significant difference between arms was found on the Overactive Bladder Questionnaire-Short Form quality of life survey favoring the control arm (confidence interval [CI]: 0.36-20.5, p = 0.04). However, there were no significant differences between arms in the remaining validated questionnaires. The study arm did not demonstrate noninferiority to the control arm. Subjects in the study arm were significantly more likely to express a willingness to undergo the procedure again (odds ratio = 3.8, 95% CI: 1.42-10.67, p = 0.004). Adverse events did not differ between arms.

CONCLUSIONS

A reduced injection technique for administration of intradetrusor onabotulinumtoxinA demonstrates similar efficacy to the standard injection technique but did not demonstrate noninferiority. Subjects preferred the reduced injection technique over the standard technique. A reduced injection technique is a safe and effective alternative to the standard technique.

Does gabapentin impact response to anticholinergics for overactive bladder?

INTRODUCTION AND HYPOTHESIS

It is unknown whether gabapentin modulates the therapeutic effect of anticholinergics (AC) in patients with overactive bladder. We hypothesized that pre-existing gabapentin use would improve response rates in these patients.

METHODS

Female patients treated with AC between 2010-2018 were identified. Data were collected on gabapentin use, indication, dose and duration of use as well as demographic and clinical characteristics. Patients were stratified by those that only took AC and those that took both AC and gabapentin ("combination therapy"). Response was determined through chart review. Descriptive statistics were expressed as medians and interquartile ranges (IQR). Pairwise analysis was performed using Wilcoxon rank-sum. Multivariable logistic regression was used to identify independent variables predicting response. A subgroup analysis was performed in patients with chronic pain disorders.

RESULTS

Seven hundred fifty-six subjects met all criteria; 16.5% (n = 125) were on combination therapy. Those taking gabapentin were more likely to have chronic (49.6% vs. 22.5%, p < 0.001) or neuropathic pain (25.6% vs. 9.4%, p < 0.001) and to use narcotics (41.6% vs. 15.5%, p < 0.001). Patients taking combination therapy were not more likely to improve compared to patients taking AC alone (41.6% vs. 47.7%, p = 0.211), which persisted after adjusting for confounders (aOR = 1.02, 95% CI: 0.63-1.65). In the 182 patients with chronic pain, those receiving combination therapy were more likely to respond than those taking AC alone (35.2% vs. 21.9%, p = 0.0015), although this did not persist after adjusting for confounders (aOR = 1.15, 95% CI: 0.70-1.90).

CONCLUSIONS

Pre-existing gabapentin use does not seem to influence response to AC in patients with overactive bladder.

Systematic Literature Review and Meta-Analysis of Sacral Neuromodulation (SNM) in Patients with Neurogenic Lower Urinary Tract Dysfunction (nLUTD): Over 20 Years' Experience and Future Directions

INTRODUCTION

Sacral neuromodulation (SNM) has been used in carefully selected patients with neurogenic lower urinary tract dysfunctions (nLUTD) for over two decades.

METHODS

The aim of the current work was to perform a systematic literature review and meta-analysis of studies reporting the safety and effectiveness of SNM in patients with nLUTD (neurogenic detrusor overactivity, non-obstructive urinary retention, or a combination of both). For this purpose a systematic literature research was conducted using Embase (OvidSP), MEDLINE (OvidSP), MEDLINE In-Process Citations & Daily Update (OvidSP), MEDLINE (OvidSP) e-Pub ahead of print, Cochrane Central Register of Controlled Trials (CENTRAL), NIH Clinicaltrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) between 1998 and March 2020, supplemented by a hand search.

RESULTS

Forty-seven studies were included in the systematic literature review. Twenty-one studies comprising a total of 887 patients were included in the meta-analysis of test SNM. The pooled success rate of SNM test stimulation was 66.2% (95% CI 56.9-74.4). Depending on neurogenic conditions test success rates varied greatly. Twenty-four studies with a total of 428 patients were included in the meta-analysis of permanent SNM. The success rate of pooled permanent SNM was 84.2% (95% CI 77.8-89.0). Among the identified studies, the most common adverse events (AEs) were loss of effectiveness, infection, pain at implant site, and lead migration with AE rates of 4.7%, 3.6%, 3.2%, and 3.2%, respectively. Limitations entail lower level of evidence (Oxford classification 3-4) of included studies, significant risk of bias, small sample sizes in some studies, the inclusion of retrospective case series, substantial between-study heterogeneity, heterogeneous patient populations, insufficient disease classification, and variations in terms of outcome parameters as well as techniques. Furthermore, long-term data are limited.

CONCLUSION

This meta-analysis supports not only the benefits of permanent SNM for various nLUTDs but also high overall success rates, similar to idiopathic patients. Current data of the analyzed studies showed that SNM is safe for these patients. However, more vigorous studies and/or registries are needed before definitive conclusions can be drawn.

Efficacy and safety of mirabegron for the treatment of neurogenic detrusor overactivity resulting from traumatic spinal cord injury: A prospective study

OBJECTIVE

To assess the clinical, urodynamic efficacy, and safety of mirabegron in patients with neurogenic detrusor overactivity (NDO) consequent to traumatic spinal cord injury (SCI).

METHODS

This prospective cohort study was performed between January 2018 and July 2019 and included adult patients with stable traumatic suprasacral SCI, performing clean intermittent catheterization (CIC), and demonstrating NDO on urodynamic study (UDS). A 3-day bladder diary was made at the baseline after which all patients were started on Mirabegron 50 mg. They were followed up at 6 weeks with a repeat bladder diary and UDS which were compared with those at the baseline.

RESULTS

A total of 30 patients (4 females, 26 males, mean age: 30.07 years) were included. After 6 weeks of treatment, 5 out of the 29 incontinent patients became completely dry. The mean frequency of CIC decreased from 6.63 at the baseline to 5.37 at 6 weeks (p = .002), the mean CIC volume increased from 275 ml to 341 ml (p = .0002), the mean number of incontinence episodes in between CIC reduced from 3.97 to 2.27 (p < .0001) and time from CIC to leakage increased from 1.73 h to 2.75 h (p < .0001). The mean cystometric capacity increased from 348 ml to 406 ml (p = .008) and the maximum amplitude of NDO decreased from 54 cm H₂ O to 41 cm H₂ O (p = .005) at 6 weeks. Only two patients reported new onset dry mouth. No major adverse events were noted and none discontinued treatment.

CONCLUSION

Mirabegron is efficacious and safe in patients with NDO consequent to traumatic SCI.

Treatment of neurogenic lower urinary tract symptoms: main contributions from 2018 and 2019

PURPOSE OF REVIEW

This review aims to update the studies involving the treatment of lower urinary tract symptoms (LUTS) in neurogenic patients, published in the last two years.

RECENT FINDINGS

Treatment of neurogenic LUTS (NLUTS) patients with β3 adrenoreceptor agonists was investigated in real-life conditions. A randomized controlled trial compared the efficacy of antimuscarinics versus onabotulinum toxin A in neurogenic patients. The use of desmopressin to treat nocturia in multiple sclerosis patients is also reported. The long-term treatment with BontA efficacy, its discontinuation, and possible strategies to maintain patients on treatment were also evaluated. Sacral neuromodulation and tibial nerve stimulation are continuously being evaluated in neurogenic patients, especially in the last years.

SUMMARY

The management of urinary tract infections and vesical lithiasis, two common complications in NLUTS patients, and the management of both these patients was assessed in clinical trials.A trial evaluating the use of the anti-Nogo-A antibody after a spinal cord injury to facilitate neuronal rewiring and prevent or improve NLUTS was reported for the first time.

Are 200 units of onabotulinumtoxin A sufficient for the suppression of neurogenic detrusor overactivity in individuals with established 300-unit botulinum toxin treatment? A retrospective cohort study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the effects of 200-unit onabotulinumtoxin A detrusor injections on neurogenic detrusor overactivity (NDO) in patients who have previously been treated with 300-unit injections.

SETTING

Tertiary urologic referral center in Switzerland.

METHODS

The patient database was screened for patients with NDO as a result of chronic (≥ 12 months) spinal cord injury (SCI), who had been treated with 300- followed by 200-unit onabotulinumtoxin A detrusor injections. Patient characteristics, bladder management data and concurrent bladder medication as well as urodynamic data were collected. The percent changes in the urodynamic parameters from the 300- to the 200-unit treatment phase were calculated to test for non-inferiority of the 200-unit treatment.

RESULTS

The data of 61 individuals with a mean age of 44 ± 15 years (range 18-73 years) and a mean 13.2 ± 9.5 years (range 2-43 years) since SCI were analyzed. The 200-unit treatment was not inferior regarding the urodynamic parameters compared to the 300-unit treatment. Furthermore, the proportion of patients with urinary incontinence was similar for both doses. There was no significant difference in the number of daily bladder evacuations (p = 0.13) or used incontinence pads (p = 0.43) between the two dosage phases. Moreover, there was no significant (p = 0.19) increase in the use of concurrent NDO medication (antimuscarinics or mirabegron) during the 200-unit treatment.

CONCLUSIONS

The treatment of NDO with 200 units of onabotulinumtoxin A was not inferior to a 300-unit treatment regarding urodynamic parameters in patients with chronic SCI.

Efficacy and safety of mirabegron for the treatment of low compliance bladder resulting from sacral/infrasacral lesions: A prospective study

OBJECTIVE

To assess the efficacy and safety of mirabegron in patients with sacral/infrasacral lesions who have an acontractile detrusor and develop a low compliance bladder.

METHODS

This prospective study included adult patients with acontractile detrusor as a result of sacral/infrasacral lesions who develop a low compliance bladder (compliance <20 mL/cmH₂ O). All patients were asked to make a 48-h clean intermittent catheterization diary and underwent invasive urodynamics evaluation at the baseline, and were started on mirabegron 50 mg once daily. Patients were re-evaluated at 6 weeks with a repeat clean intermittent catheterization diary and invasive urodynamics, and the efficacy and safety of mirabegron was assessed.

RESULTS

A total of 17 patients were included. After 6 weeks of mirabegron therapy, the number of patients reporting leakage in between clean intermittent catheterization reduced from seven to two (P = 0.02), the end filling pressures reduced from 41.4 to 15.1 cmH₂ O (P = 0.003), the compliance increased from 9.8 to 99.9 mL/cmH₂ O (P = 0.000), and the number of patients where the end filling pressure was >40 cmH₂ O reduced from eight to one (P = 0.02). The cystometric bladder capacity did not change significantly. Similar effects were noted in patients who were already on clean intermittent catheterization or were started on clean intermittent catheterization at inclusion in the study. Mirabegron was well tolerated, none of the patients discontinued therapy or reported major side-effects.

CONCLUSIONS

Mirabegron reduces end filling pressure, improves compliance and is safe in patients with a low compliance bladder resulting from a sacral/infrasacral lesion.

Anticholinergic Drugs for Overactive Bladder in Frail Older Patients: The Case Against

Urinary incontinence (UI) is a common and disabling problem among older people. Anticholinergic drugs (ADs) are a pharmacological option recommended for overactive bladder or mixed UI when non-pharmacological approaches have failed. However, UI is a more prevalent and complex condition in frail older people and to simply assume that AD actions are the same across all age groups would be wrong. This article reviews evidence for the efficacy and safety of these drugs, especially when prescribed for frail older people. Although ADs have a small but statistically significant benefit for UI in non-frail people, the vast majority choose to discontinue treatment because they feel that the beneficial effects do not outweigh the burden of taking the medication. Not only are the most frail older people more likely to experience adverse effects but there is also no evidence that these drugs are effective for UI. In addition, there is a mounting body of evidence that they impair cognitive function. The continued use of ADs in frail older people simply does not hold water.