Comparing the Efficacy of OnabotulinumtoxinA, Sacral Neuromodulation, and Peripheral Tibial Nerve Stimulation as Third Line Treatment for the Management of Overactive Bladder Symptoms in Adults: Systematic Review and Network Meta-Analysis.

Chi-Wen Lo,Mei-Yi Wu,Stephen Shei-Dei Yang,Shang-Jen Chang,Fu-Shan Jaw

doi:10.3390/toxins12020128

Abstract

The American Urological Association guidelines for the management of non-neurogenic overactive bladder (OAB) recommend the use of OnabotulinumtoxinA, sacral neuromodulation (SNM), and peripheral tibial nerve stimulation (PTNS) as third line treatment options with no treatment hierarchy. The current study used network meta-analysis to compare the efficacy of these three modalities for managing adult OAB syndrome. We performed systematic literature searches of several databases from January 1995 to September 2019 with language restricted to English. All randomized control trials that compared any dose of OnabotulinumtoxinA, SNM, and PTNS with each other or a placebo for the management of adult OAB were included in the study. Overall, 17 randomized control trials, with a follow up of 3–6 months in the predominance of trials (range 1.5–24 months), were included for analysis. For each trial outcome, the results were reported as an average number of episodes of the outcome at baseline. Compared with the placebo, all three treatments were more efficacious for the selected outcome parameters. OnabotulinumtoxinA resulted in a higher number of complications, including urinary tract infection and urine retention. Compared with OnabotulinumtoxinA and PTNS, SNM resulted in the greatest reduction in urinary incontinence episodes and voiding frequency. However, comparison of their long-term efficacy was lacking. Further studies on the long-term effectiveness of the three treatment options, with standardized questionnaires and parameters are warranted.

Highlights

Overactive bladder (OAB) syndrome is defined as “the presence of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology” [1]
Third line therapy is undertaken if the patient desires further treatment and is willing to engage in treatment, and/or further treatment is determined by clinicians to be in the patient’s best interests
A total of 5738 articles were excluded based on their title and/or abstract, while another 185 articles were removed after a full-text assessment

Summary

Introduction

Overactive bladder (OAB) syndrome is defined as “the presence of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology” [1]. Non-neurogenic OAB impairs the patient’s quality of life (QoL) and behavioral therapy is recommended as the first line treatment. Oral medications, including antimuscarinics and β3 agonists, are recommended as the second line therapy [3]. When there is inadequate symptom control or intolerable side effects due to second line management, the American Urological Association (AUA) guidelines recommend either OnabotulinumtoxinA, sacral neuromodulation (SNM), or peripheral tibial nerve stimulation (PTNS) as third line therapy options for OAB symptoms. Third line therapy is undertaken if the patient desires further treatment and is willing to engage in treatment, and/or further treatment is determined by clinicians to be in the patient’s best interests. The decision on which third line therapy to perform is based on the clinicians’ and patient’s preference, and there is not an evidence-based hierarchy available for guidance [3]

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Conclusion