Outcome Of Sacral Neuromodulation Research Articles

Is Our Limited Understanding of the Effects of Nerve Stimulation Resulting in Poor Outcomes and the Need for Better "Rescue Programming" in SNM and PTNS, and Lost Opportunities for New Sites of Stimulation? ICI-RS 2024.

Sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) are strongly recommended by international guidelines bodies for complex lower urinary tract dysfunctions. However, treatment failure and the need for rescue programming still represent a significant need for long-term follow-up. This review aimed to describe current strategies and future directions in patients undergoing such therapies. This is a consensus report of a Think Tank discussed at the Annual Meeting of the International Consultation on Incontinence - Research Society (ICI-RS), June 6-8, 2024 (Bristol, UK): "Is our limited understanding of the effects of nerve stimulation resulting in poor outcomes and the need for better 'rescue programming' in SNM and PTNS, and lost opportunities for new sites of stimulation?" Rescue programming is important from two different perspectives: to improve patient outcomes and to enhance device longevity (for implantable devices). Standard SNM parameters have remained unchanged since its inception for the treatment of OAB, nonobstructive urinary retention, and voiding dysfunction. SNM rescue programming includes intermittent stimulation (cycling on), increased frequency and changes in pulse width (PW). The effect of PW setting on SNM outcomes remains unclear. Monopolar configurations stimulate more motor nerve fibers at lower stimulation voltage; hence, this could be an option in patients who failed bipolar stimulation in the long term. Unfortunately, there is little evidence for rescue programming for PTNS. However, the development of implantable devices for intermittent stimulation of the tibial nerve may increase long-term adherence to therapy and increase interest in alternative programming. There has been recent promising neurostimulation targeting the pudendal nerve (PNS), especially in BPS/IC. More recently, preliminary data addressed the benefits of high-frequency bilateral pudendal nerve block for DESD and adaptive PNS on both urgency and stress UI in women. The exploration of rescue programming and new stimulation sites remains underutilized, and there are opportunities that could potentially expand the therapeutic applications of nerve stimulation. By broadening the range of target sites, clinicians may be able to tailor treatments according to individual patient needs and underlying conditions, thereby improving overall outcomes. However, further studies are still needed to increase the level of evidence, potentially allowing for an individualized treatment both in patients who are candidates for electrostimulation and in those who have already received surgical implants but seek a better outcome.

Long-term outcomes of sacral neuromodulation for low anterior resection syndrome after rectal cancer surgery.

This study assessed the long-term outcomes and quality of life in patients who underwent sacral neuromodulation (SNM) due to low anterior resection syndrome (LARS). This single-center retrospective study, conducted from 2005 to 2021, included 30 patients (21 men; median age, 70 years) who had undergone total mesorectal excision with stoma closure and had no recurrence at inclusion. All patients were diagnosed with LARS refractory to conservative treatment. We evaluated clinical and quality-of-life outcomes after SNM through a stool diary, Wexner score, LARS score, the Fecal Incontinence Quality of Life (FIQL) questionnaire, and EuroQol-5D (EQ-5D) questionnaire. Peripheral nerve stimulation was successful in all but one patient. Of the 29 patients who underwent percutaneous nerve evaluation, 17 (58.62%) responded well to SNM and received permanent implants. The median follow-up period was 48 months (range, 18-153 months). The number of days per week with fecal incontinence episodes decreased from a median of 7 (range, 2-7) to 0.38 (range, 0-1). The median number of bowel movements recorded in patient diaries fell from 5 (range, 4-12) to 2 (range, 1-6). The median Wexner score decreased from 18 (range, 13-20) to 6 (range, 0-16), while the LARS score declined from 38.5 (range, 37-42) to 19 (range, 4-28). The FIQL and EQ-5D questionnaires demonstrated enhanced quality of life. SNM may benefit patients diagnosed with LARS following rectal cancer surgery when conservative options have failed, and the treatment outcomes may possess long-term sustainability.

Sacral neuromodulation in the golden years: Treatment outcomes in elderly 75 years and older.

Despite high prevalence and increased severity and burden of overactive bladder (OAB) and fecal incontinence (FI) in the elderly, sacral neuromodulation (SNM) is often overlooked as a potential treatment option for this demographic. In this study, we report the outcomes of SNM in patients aged 75 years or older at the time of surgery. We conducted a retrospective cohort study of patients who underwent SNM implantation between 2013 and 2022 performed by a single, high-volume urologist at a tertiary center. Success, complication, and adjunct therapy rates were analyzed by Fisher's or Wilcox rank-sum test as appropriate. We compared outcomes between patients aged 75-79 years and octogenarians. Of 632 patients, 50 were ≥75 years. Patients had a mean age of 78.4±2.6 years and were predominantly female (84%). The indications for SNM were 66% OAB, 16% FI, 16% non-obstructive urinary retention, and 4% pelvic pain. Within the first year, 94% of patients reported satisfaction and improvement in symptoms, while 76% continued to experience improvement beyond one year. SNM insertion led to reduced oral medication use from 68% to 24% (p<0.0001). The complication rate was 16% and mostly included device pain. No significant difference was observed in treatment success, complication, or adjunct therapy rate between age groups. SNM is a safe and effective option in well-selected patients over the age of 75 years. Treatment success rate is comparable to younger cohorts. Advanced age should not preclude third-line therapy options in this population.

The Long-term Outcomes of Sacral Neuromodulation for Fecal Incontinence: A Single Center Experience.

Sacral neuromodulation is an effective treatment for fecal incontinence. This study aimed to assess the long-term outcomes of sacral neuromodulation and establish the outcomes of patients with inactive devices. This is an observational study of patients treated for more than 5 years. A positive outcome was defined as a >50% reduction in fecal incontinence episodes or improvement in a symptom severity score. Data were reviewed from a prospectively managed database. This study was conducted at a single tertiary referral center. Data from 74 patients (72 female) were available at long-term follow up. Bowel diary, St. Mark's incontinence score, and Manchester Health Questionnaire data were prospectively recorded at baseline, after peripheral nerve evaluation, and at last follow-up. Patients were analyzed in cohorts based on time since sacral neuromodulation implantation: Group 1: 5-10 years (n = 20), Group 2: >10 years (n = 35), and Group 3: inactive SNM devices (n = 19). Median St. Mark's incontinence score and Manchester Health Questionnaire improved from baseline to last follow-up in Group 1 (p ≤ 0.05) and Group 2 (p ≤ 0.05), but in Group 3 results returned to baseline levels at last follow-up. Similarly, weekly fecal incontinence episodes improved in both active device groups at last follow-up. However, in Group 3 incontinence episodes were no different from baseline (p = 0.722). Despite active devices, fecal urgency episodes increased at last follow-up after more than 10 years since peripheral nerve evaluation (p ≤ 0.05). Complete continence was reported by 44% of patients, and at least a 50% improvement in 77% with active devices. This study is retrospective with some gaps in the available data at last follow-up. Sacral neuromodulation is an effective treatment for fecal incontinence in the long term, but all outcomes are adversely affected by device inactivity. Therefore, ongoing stimulation is required for continued benefit..

Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function

Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients’ baseline median Cleveland Clinic Incontinence Score was 15 (10–18); it decreased to 2 (1–4) and 1 (1–2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.

Sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction

Abstract Background Limited published data exist regarding the utility of sacral neuromodulation (SNM) for neurogenic lower urinary tract dysfunction (NLUTD), consisting of only small case series, and, to our knowledge, no Australian data have been published. The aim of this study was to evaluate the clinical outcomes of SNM for treatment of NLUTD in Australian patients. Methods A retrospective analysis was conducted of patients who received a permanent SNM implant between December 2014 and March 2021. Patients completed a urodynamic test preoperatively. They completed a 3-day bladder diary, uroflowmetry, and postvoid residual measurement preoperatively and at 6-month intervals postoperatively following SNM insertion. Urinary function, patient-reported outcome measures, and adverse events were assessed. Results A total of 36 patients received a permanent SNM implant. The mean duration of follow-up was 25 ± 20 months, with the majority (89%, n = 32) of patients reporting a &gt;50% improvement on bladder diary evaluation. There was a significant increase in void volume (p &lt; 0.001), decrease in postvoid residual (p &lt; 0.001), decrease in voiding frequency (p &lt; 0.001), decrease in incontinence episodes (p = 0.002), and decrease in pad number (p &lt; 0.001). There was no significant difference in peak flow (p = 0.21). There was no significant difference in SNM efficacy between patients with progressive or nonprogressive neurological conditions. Conclusions Sacral neuromodulation is a safe and effective therapy for NLUTD in the context of both progressive and nonprogressive neurological conditions. It should be offered more readily to patients with NLUTD as a minimally invasive treatment option with the potential to make clinically meaningful improvements in quality of life.

MP37-07 COGNITIVE IMPAIRMENT, TECHNOPHILIA, AND SACRAL NEUROMODULATION DEVICE USE IN AN OLDER PATIENT POPULATION WITH OVERACTIVE BLADDER

You have accessJournal of UrologyCME1 Apr 2023MP37-07 COGNITIVE IMPAIRMENT, TECHNOPHILIA, AND SACRAL NEUROMODULATION DEVICE USE IN AN OLDER PATIENT POPULATION WITH OVERACTIVE BLADDER Chen Shenhar, Jacquelyn Booher, Lauren Gleich, Sarah Martin, Glenn T. Werneburg, Emily Slopnick, Sandip P. Vasavada, Bradley Gill, Howard B. Goldman, and Jacqueline Zillioux Chen ShenharChen Shenhar More articles by this author , Jacquelyn BooherJacquelyn Booher More articles by this author , Lauren GleichLauren Gleich More articles by this author , Sarah MartinSarah Martin More articles by this author , Glenn T. WerneburgGlenn T. Werneburg More articles by this author , Emily SlopnickEmily Slopnick More articles by this author , Sandip P. VasavadaSandip P. Vasavada More articles by this author , Bradley GillBradley Gill More articles by this author , Howard B. GoldmanHoward B. Goldman More articles by this author , and Jacqueline ZilliouxJacqueline Zillioux More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003275.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Anticholinergics, a common treatment for overactive bladder (OAB), are associated with new-onset dementia and their use for >3 months was recently cautioned against in all age groups. Non-anticholinergic therapies, including sacral neuromodulation (SNM), should therefore be optimized; however, data on SNM in older or cognitively impaired (CI) populations are limited. The aim of this study was to assess cognitive impairment, technophilia, and device utilization in an older population undergoing SNM for refractory OAB. METHODS: This is a secondary analysis of an ongoing IRB-approved prospective study on cognitive function and SNM outcomes, focusing on technophilia and device utilization. Patients aged ≥60 years undergoing test-phase SNM for refractory OAB were recruited. Cognitive function was assessed using the validated Montreal Cognitive Assessment (MoCA) tool, with scores <26/30 considered CI. Baseline functional status and technology comfort/use were assessed using a novel questionnaire, and OAB symptoms were assessed initially and at follow-up utilizing validated questionnaires (OAB-q SF, IIQ7, UDI-6, PGI-I). Patient device utilization, familiarity with communicator and ability to adjust amplitude/program were recorded at follow-up. Baseline technology use/comfort and post-implant device utilization were compared based on CI. RESULTS: Fifty-eight patients underwent test-phase (36 PNE, 22 Stage 1). Mean age was 73±8 years and 95% were women. Mean MoCA score was 23.1±4.4, and 67% met CI criteria. Forty-nine (85%) had successful test-phase, of which 45 patients have undergone full implant and 38 have available follow-up data. At baseline, patients with CI had lower use and comfort levels with various technologies (Table 1). At mean 4.1±2 months follow-up, patients with CI were less involved in changing programs (p=0.004) or amplitudes (p=0.007) on their own, but patient-reported improvement did not differ (Table 1). CONCLUSIONS: Older patients presenting for SNM for OAB have a high incidence of CI. Despite lower baseline self-reported use/comfort with technology and lower SNM device utilization post-implant among those with CI, patient-reported outcomes appear similar over short-term follow-up. Source of Funding: Investigator initiated Medtronic research grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e515 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chen Shenhar More articles by this author Jacquelyn Booher More articles by this author Lauren Gleich More articles by this author Sarah Martin More articles by this author Glenn T. Werneburg More articles by this author Emily Slopnick More articles by this author Sandip P. Vasavada More articles by this author Bradley Gill More articles by this author Howard B. Goldman More articles by this author Jacqueline Zillioux More articles by this author Expand All Advertisement PDF downloadLoading ...

Sacral neuromodulation in the management of chronic pelvic pain: A systematic review and meta-analysis.

Sacral neuromodulation (SNM) is a treatment approved for use in several conditions including refractory overactive bladder (OAB) and voiding dysfunction. Chronic pelvic pain (CPP) is a debilitating condition for which treatment is often challenging. SNM shows promising effect in patients with refractory CPP. However, there is a lack of clear evidence, especially in long-term outcomes. This systematic review will assess outcomes of SNM for treating CPP. A systematic search of MEDLINE, Embase, Cochrane Central and clinical trial databases was completed from database inception until January 14, 2022. Studies using original data investigating SNM in an adult population with CPP which recorded pre and posttreatment pain scores were selected. Primary outcome was numerical change in pain score. Secondary outcomes were quality of life assessment and change in medication use and all-time complications of SNM. Risk of bias was assessed using the Newcastle Ottawa Tool for cohort studies. Twenty-six of 1026 identified articles were selected evaluating 853 patients with CPP. The implantation rate after test-phase success was 64.3%. Significant improvement of pain scores was reported in 13 studies; three studies reported no significant change. WMD in pain scores on a 10-point scale was -4.64 (95% confidence interval [CI] = -5.32 to -3.95, p < 0.00001) across 20 studies which were quantitatively synthesized: effects were maintained at long-term follow-up. Mean follow-up was 42.5 months (0-59). Quality of life was measured by RAND SF-36 and EQ-5D questionnaires and all studies reported improvement in quality of life. One hundred and eighty-nine complications were reported in 1555 patients (Clavien-Dindo Grade I-IIIb). Risk of bias ranged from low to high risk. Studies were case series and bias stemmed from selection bias and loss to follow-up. Sacral Neuromodulation is a reasonably effective treatment of Chronic Pelvic Pain and significantly reduces pain and increases patients' quality of life with immediate to long-term effects.

Sacral Neuromodulation Outcomes in Male Patients With Pelvic Pain and Fecal Incontinence

Sacral neuromodulation (SNM) is an effective third line treatment however there is limited data involving male patients with OAB or non-bladder conditions (chronic pelvic pain and fecal incontinence (FI)). In this retrospective study, we followed 17 male patients with non-bladder conditions to assess efficacy, personal satisfaction, need for other treatments and complications.

Sacral Neuromodulation Outcomes in Male Patients With Overactive Bladder (Neurogenic and Non-Neurogenic)

Sacral neuromodulation (SNM) is an effective, guidelines supported, third line treatment for overactive bladder (OAB). While the prevalence of OAB is similar between males and females, no studies assess the outcomes of SNM in male patients alone. In this retrospective study, we followed 53 male patients with neurogenic and idiopathic OAB to assess efficacy, personal satisfaction, complications and need for other treatments.

Implementation of sacral neuromodulation for urinary indications. A Danish prospective study during the initial 15 months of a new service in a tertiary referral hospital

Objective Sacral neuromodulation (SNM) is a well-established treatment modality for idiopathic overactive bladder and urgency incontinence, idiopathic fecal incontinence and non-obstructive urinary retention. This study describes the start-up phase of establishing the SNM service. Primary objective: To investigate the patient-reported outcome measures of SNM on lower urinary tract dysfunction symptoms. Secondary objectives: To investigate bowel function, sexual satisfaction and to monitor SNM safety. Materials and methods Twenty-two patients with refractory idiopathic and neurogenic lower urinary tract dysfunction were offered a two-stage test-phase procedure and SNM device implantation. On completing the study, the patients rated their satisfaction with the treatment using a five-point Likert scale and a bother score of urinary, bowel and sexual symptoms on a scale of 1–10 (the worst). Their complications were assessed. Results Nineteen patients (86%) were responders during the test phase and had the pulse generator implanted. Seventeen patients were very satisfied/satisfied. A statistically significant change in urinary symptoms bother score was observed in the idiopathic and neurogenic patients, a reduction from 10 to 4 (p = .0057) and 10 to 3 (p = .014), respectively. Eleven patients (58%) had symptoms from two or three pelvic compartments. Nine patients (47%) had complications. All but one event was resolved. Conclusions SNM is safe in this heterogeneous group of patients with refractory lower urinary tract dysfunction of various etiologies. A substantial improvement was observed in the pelvic organ dysfunction, demanding a multidisciplinary approach. More studies are required to standardize the evaluation of the subjective and objective outcomes of SNM.

Efficacy and Safety of Sacral Neuromodulation by Converting Constant Frequency Stimulation Into Variable Frequency Stimulation in Patients With Detrusor Overactivity and Impaired Contractility: A Single-Center Prospective Study

ObjectivesIn patients with detrusor overactivity with impaired contractility (DOIC), it is difficult to relieve abnormal lower urinary tract symptoms during both storage and voiding using sacral neuromodulation (SNM) with constant frequency stimulation (CFS). We sought to evaluate the efficacy and safety of SNM using variable frequency stimulation (VFS) in patients with DOIC by comparing it with outcomes of SNM with CFS. Materials and MethodsBetween September 2020 and May 2021, we prospectively enrolled 20 patients with DOIC, confirmed on urodynamic examination, and administered SNM with VFS. The patients were followed up and required to maintain voiding diaries and record scale scores of overactive bladder symptoms, psychology and quality of life, uroflowmetry, ultrasonic postvoid residual urine, and adverse events at baseline and during the CFS and VFS phases. ResultsThe average testing phase was 26.3 ± 4.1 days. Compared with baseline values, overactive bladder symptom, psychologic health questionnaire, and quality of life scores, in addition to voiding frequency, urgency incontinence frequency, daily catheterization volume of voiding diary, and ultrasonic postvoid residual (PVR) decreased significantly during both the CFS and VFS phases (p < 0.05). The average voided volume, functional bladder capacity, and maximum urine flow rate significantly increased during the CFS and VFS phases (p < 0.05). In the VFS phase, voiding frequency, urgency incontinence frequency, daily catheterization volume of voiding diary, and ultrasonic PVR further decreased (p < 0.05), whereas functional bladder capacity, maximum urine flow rate, quality of life score, overactive bladder symptom score, and psychologic health questionnaire score further improved compared with results obtained in the CFS phase (p < 0.05). In the VFS phase, the success rate of further improvement of symptoms was 85.0%, and no new complications were noted. ConclusionsSNM that converts CFS into VFS may be an effective treatment option for patients with DOIC, exhibiting no increase in adverse events.

PD34-05 DOES COGNITIVE IMPAIRMENT IMPACT SACRAL NEUROMODULATION IN OLDER PATIENTS WITH OVERACTIVE BLADDER?

You have accessJournal of UrologyCME1 May 2022PD34-05 DOES COGNITIVE IMPAIRMENT IMPACT SACRAL NEUROMODULATION IN OLDER PATIENTS WITH OVERACTIVE BLADDER? Jacqueline Zillioux, Kevin Lewis, Daniel Hettel, Sarah Martin, Lauren Gleich, Howard B. Goldman, and Bradley Gill Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Kevin LewisKevin Lewis More articles by this author , Daniel HettelDaniel Hettel More articles by this author , Sarah MartinSarah Martin More articles by this author , Lauren GleichLauren Gleich More articles by this author , Howard B. GoldmanHoward B. Goldman More articles by this author , and Bradley GillBradley Gill More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002585.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Overactive bladder (OAB) and cognitive impairment (CI) are both increasingly prevalent with age. Given the association between anticholinergics and dementia, there is need to optimize other therapies. Though AUA/SUFU OAB guidelines cite intact cognitive ability as necessary to maintain sacral neuromodulation (SNM), the impact of cognitive function on SNM outcomes remains unknown. This study assessed the impact of CI diagnosis on SNM in older patients. METHODS: A retrospective review was completed of patients ≥55 years old who underwent test-phase SNM (peripheral nerve evaluation (PNE) or stage 1) for urge-frequency or urgency urinary incontinence between 1/2014-3/2021 within a large regional health system. Patient demographics, comorbidities, CI diagnoses (dementia or mild CI), OAB medication and/or botulinum toxin use, and SNM procedures were recorded. SNM procedures and outcomes were categorized as implant, explant, and/or revision. Uni- and multivariable logistic regression modeling assessed for the impact of CI on implantation rates. RESULTS: A total of 510 patients underwent SNM test-phase (161 PNE, 349 Stage 1). Mean age was 71.0 (8.5) years and the majority (79.6%) were female. Overall, 52 (10.1%) patients had a CI diagnosis at the time of SNM, and 30 (6.0%) were diagnosed after SNM at a median 18.5 [9.25, 39.5] months. Patients with CI were older with more comorbidities and were more likely to undergo PNE (Table 1). Univariable analysis found no difference in implantation rate based on pre-SNM CI (85.4% vs 76.9%, p=0.16). Multivariable modeling identified PNE (OR 0.42, 95%CI 0.26-0.70) and age (OR 0.95, 95%CI 0.93-0.98), but not CI or dementia, as independent negative predictors of implantation. Implanted patients had median follow-up of 12 [4.0, 39.5] months. Patients with CI were more likely to continue B3 agonists (37.1% vs 16.0%, p=0.04) following implant but rates of anticholinergic or new intradetrusor botulinum toxin use did not differ. Explant (12.1%), revision (10.4%), and battery replacement (3.4%) rates also did not differ according to CI. CONCLUSIONS: Patients with CI and OAB proceed to SNM implant at rates that do not differ from patients without cognitive deficits. CI should not preclude providers from offering SNM for refractory OAB. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e561 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacqueline Zillioux More articles by this author Kevin Lewis More articles by this author Daniel Hettel More articles by this author Sarah Martin More articles by this author Lauren Gleich More articles by this author Howard B. Goldman More articles by this author Bradley Gill More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD34-04 IMPACT OF COGNITIVE FUNCTION IN OLDER PATIENTS UNDERGOING SACRAL NEUROMODULATION FOR OVERACTIVE BLADDER: A PROSPECTIVE STUDY

You have accessJournal of UrologyCME1 May 2022PD34-04 IMPACT OF COGNITIVE FUNCTION IN OLDER PATIENTS UNDERGOING SACRAL NEUROMODULATION FOR OVERACTIVE BLADDER: A PROSPECTIVE STUDY Jacqueline Zillioux, Sarah Martin, Lauren Gleich, Glenn T. Werneburg, Emily Slopnick, Raymond R. Rackley, Sandip Vasavada, Bradley Gill, and Howard B. Goldman Jacqueline ZilliouxJacqueline Zillioux More articles by this author , Sarah MartinSarah Martin More articles by this author , Lauren GleichLauren Gleich More articles by this author , Glenn T. WerneburgGlenn T. Werneburg More articles by this author , Emily SlopnickEmily Slopnick More articles by this author , Raymond R. RackleyRaymond R. Rackley More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , Bradley GillBradley Gill More articles by this author , and Howard B. GoldmanHoward B. Goldman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002585.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Overactive bladder (OAB) and cognitive impairment (CI) are both increasingly prevalent with age. Given the association between anticholinergics and dementia, there is need to optimize other therapies. SUFU/AUA OAB guidelines cite adequate cognitive function as necessary for sacral neuromodulation (SNM); however, the impact of CI on SNM in older patients remains unknown. This is an interim analysis of a prospective study assessing the impact of cognitive function on outcomes of SNM for refractory OAB. METHODS: With IRB-approval, we recruited patients aged ≥60 years scheduled for test-phase (peripheral nerve evaluation (PNE) or stage 1) SNM for refractory OAB. Baseline cognitive function was assessed using the validated Montreal Cognitive Assessment (MoCA) screening test. Scores ≥26/30 are considered normal and <26 considered CI. Patients completed validated questionnaires (OAB-q SF, IIQ7, UDI-6, PGI-I) at baseline and 1-month follow-up (if implanted). Number of program adjustments performed by the patient and whether patients demonstrated appropriate device use (i.e. familiarity with communicator/programmer) were recorded. Implant rate, patient-reported questionnaires, and SNM utilization were compared based on MoCA/CI. RESULTS: 27 patients underwent test-phase (17 PNE, 10 Stage 1). Mean age was 71.9 (6.7) years. Median baseline MoCA was 24 [21.5,26.5], ranging 14-29. Although 5 (19%) patients had a pre-existing CI diagnosis, 16 (59%) demonstrated CI per MoCA. The table compares patient characteristics, baseline questionnaires and utilization outcomes based on CI. Overall, 23 (85%) patients underwent permanent implant after successful test-phase. Implant rates did not differ based on MoCA or CI. Among 15 patients with 1-month follow-up, those demonstrating appropriate device use had significantly higher MoCA scores (26 vs 17, p=0.004). Postoperative change in validated questionnaires scores, however, did not differ. CONCLUSIONS: Despite few pre-existing diagnoses, there is a high incidence of CI in older patients with OAB undergoing SNM. While implant rate did not differ based on MoCA/CI, patients with lower MoCA scores were less likely to demonstrate appropriate device use on follow-up. Impact on clinical efficacy of SNM remains to be determined. Source of Funding: Medtronic © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e560 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jacqueline Zillioux More articles by this author Sarah Martin More articles by this author Lauren Gleich More articles by this author Glenn T. Werneburg More articles by this author Emily Slopnick More articles by this author Raymond R. Rackley More articles by this author Sandip Vasavada More articles by this author Bradley Gill More articles by this author Howard B. Goldman More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP16-07 FRAILTY AS A PREDICTOR OF SACRAL NEUROMODULATION OUTCOMES

You have accessJournal of UrologyCME1 May 2022MP16-07 FRAILTY AS A PREDICTOR OF SACRAL NEUROMODULATION OUTCOMES Colby Souders, Mary Enoh Adakama, Allison Sih, Seth Cohen, Maude Carmel, Jennifer Anger, Karyn Eilber, and Kai Dallas Colby SoudersColby Souders More articles by this author , Mary Enoh AdakamaMary Enoh Adakama More articles by this author , Allison SihAllison Sih More articles by this author , Seth CohenSeth Cohen More articles by this author , Maude CarmelMaude Carmel More articles by this author , Jennifer AngerJennifer Anger More articles by this author , Karyn EilberKaryn Eilber More articles by this author , and Kai DallasKai Dallas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Geriatric patients with overactive bladder or urge incontinence (UUI) are often medically under-treated. Concerns regarding anticholinergic side effects, polypharmacy, and cost of beta-3 agonists result in limited treatment options. Sacral neuromodulation (SNM) is a minimally invasive and non-pharmacological option. Geriatric patients considered frail may not be offered SMN due to concerns of surgery complications, treatment efficacy, and complexity of device operations. Thus, the purpose of this study is to investigate SNM outcomes in geriatric patients who meet frailty criteria. METHODS: We reviewed California Office of Statewide Health Planning and Development (OSHPD) from 1/1/2012-12/31/2018. Using Current Procedural Terminology (CPT) codes, we identified patients who underwent Stage 1 (CPT:64581) and Stage 2 (CPT:64590) SNM surgery. Treatment was considered successful if a patient proceeded to Stage 2 from Stage 1. Patient age, gender, ethnicity, academic status surgery facility, and payor status were obtained. The SNM patient population was then analyzed using a validated claims-based frailty index (Kim, 2018). Univariate (chi-square/ T-test) and multivariate analysis were performed to assess for associations between variables of interest and completion of Stage 2. RESULTS: We identified 2,400 patients who underwent Stage 1, and 1,132 patients successfully proceeded to Stage 2. Rates of Stage 2 were higher in females compared to males (36.6% vs. 50.5%, p<0.001), those who had surgery at academic medical centers (58.6% vs. 20.8%, p<0.001), and those with a diagnosis of urgency (52.1% vs. 45.3%, p=0.003). These findings remained significant with multivariate analysis. Of the 2,400 patients identified 363 (15.1%) met frailty criteria and 165 (45.5%) underwent Stage 2. For non-frail patients, SNM success rate was 47.5% (p=0.514) (Table 1). There were no significant associations between patient age, ethnicity, payor status, and completion of Stage 2. CONCLUSIONS: Our work demonstrates that frailty had no significant adverse impact on success of SNM treatment. However, female gender, surgery at an academic center, and a diagnosis of UUI were more likely to have treatment success than patients with other indications. This data supports recommendation of SNM to older, frail patients, especially those with UUI. Source of Funding: The Medical Student Training in Aging Research Program and the National Institute on Aging (T35AG026736) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e277 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Colby Souders More articles by this author Mary Enoh Adakama More articles by this author Allison Sih More articles by this author Seth Cohen More articles by this author Maude Carmel More articles by this author Jennifer Anger More articles by this author Karyn Eilber More articles by this author Kai Dallas More articles by this author Expand All Advertisement PDF DownloadLoading ...

Trends and Outcomes of Sacral Neuromodulation: A Saudi Tertiary Care Center Experience

Trends and Outcomes of Sacral Neuromodulation: A Saudi Tertiary Care Center Experience

Machine learning provides an accurate prognostication model for refractory overactive bladder treatment response and is noninferior to human experts.

The increasing wealth of clinical data may become unmanageable for a physician to assimilate into optimal decision-making without assistance. Utilizing a novel machine learning (ML) approach, we sought to develop algorithms to predict patient outcomes following the overactive bladder treatments OnabotulinumtoxinA (OBTX-A) injection and sacral neuromodulation (SNM). ROSETTA datasets for overactive bladder patients randomized to OBTX-A or SNM were obtained. Novel ML algorithms, using reproducing kernel techniques were developed and tasked to predict outcomes including treatment response and decrease in urge urinary incontinence episodes in both the OBTX-A and SNM cohorts, in validation and test sets. Blinded expert urologists also predicted outcomes. Receiver operating characteristic curves were generated and AUCs calculated for comparison to lines of ignorance and the expert urologists' predictions. Trained algorithms demonstrated outstanding accuracy in predicting treatment response (OBTX-A: AUC 0.95; SNM: 0.88). Algorithms accurately predicted mean decrease in urge urinary incontinence episodes (MSE < 0.15) in OBTX-A and SNM. Algorithms were superior to human experts in response prediction for OBTX-A, and noninferior to human experts in response prediction for SNM. Novel ML algorithms were accurate, superior to expert urologists in predicting OBTX-A outcomes, and noninferior to expert urologists in predicting SNM outcomes. Some aspects of the physician-patient interaction are subtle and uncomputable, and thus ML may complement, but not supplant, a physician's judgment.

Long-term outcomes of sacral neuromodulation for lower urinary tract dysfunction: A 23-year experience.

To evaluate the long-term outcomes of sacral neuromodulation (SNM), and patient characteristics that may predict long-term success or complications. A single-center retrospective cohort study was performed of all patients who underwent SNM testing and implantation. Outcome results, resolution of symptoms, and device removal were reported. Multivariable logistic regression was used to identify predictors of success. Cox proportional hazards model was used to identify predictors for device removal. Four hundred and thrity four patients underwent SNM test phase of which 241 (median age 48.0 years, 91.7% [221/241] female) had device implantation and were followed up for median [range] time of 4.0 (3 months-20.5 years) years. Multivariable logistic regression showed that male gender (odds ratio: 0.314; 95% confidence interval: 0.164-0.601, p = .0005) was independently associated with decreased peripheral nerve evaluation success. At final follow-up for patients who originally had device implantation, median (interquartile range) percent of symptoms resolution of all patients was 60.0% (0%-90%) and 69.3% (167/241) had SNM successful outcomes. Cox proportional hazards model showed no difference for time to SNM device removal with respect to patient age, gender, or diagnosis. 69.3% (167/241) patients had at least 1 surgical re-intervention. The most common reason at first surgical re-intervention was lead change only (26.3%, 44/167). SNM is a minimally invasive procedure with good long-term success rates. There is a high revision rate but overall, SNM has a good safety profile and excellent long-term outcomes.

523 - Do failure of posterior tibial nerve stimulation precludes to use sacral neuromodulation in patient with overactive bladder?

Purpose To evaluate the outcomes of sacral neuromodulation (SNM) after failure of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with overactive bladder (OAB). Methods A retrospective study was conducted in 3 university hospitals and included all patients with OAB and treated with SNM after TPTNS had been tried between October 2008 and May 2018. The primary endpoint was the proportion of definitive SNM device implantation in patients with 50% objective and/or subjective improvement after a test period (stage 1). The secondary outcomes of interest were changes of the number of diurnal voids and nocturia episodes per 24 hours between the end of TPTNS and the end of stage 1. Results Overall, 28 of the 43 patients included achieved at least 50% objective and/or subjective improvement during stage 1 and underwent an Interstim II implantation (65.1%). The mean daytime frequency decreased significantly from 10.3/day at the end of TPTNS to 7.8 diurnal voids/day at the end of SNM stage 1 (P=0.01). The mean number of nocturia episodes decreased from 2.5/night at the end of TPTNS to 2.1/night at the end of stage 1, but this did not reach statistical significance (P=0.18). There was no other parameter significantly associated with response to SNM. Conclusion SNM might improve OAB symptoms in most patients who experienced no or poor efficacy with TPTNS. History of failed TPTNS should not preclude the use of SNM in OAB patients.

976 - Clinical outcomes of sacral neuromodulation in non-neurogenic, non-obstructive dysuria: A retrospective, multicentre study in China

976 - Clinical outcomes of sacral neuromodulation in non-neurogenic, non-obstructive dysuria: A retrospective, multicentre study in China