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 >50% improvement on bladder diary evaluation. There was a significant increase in void volume (p < 0.001), decrease in postvoid residual (p < 0.001), decrease in voiding frequency (p < 0.001), decrease in incontinence episodes (p = 0.002), and decrease in pad number (p < 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.

Keywords

Urinary bladder / Neurogenic lower urinary tract dysfunction / Electric stimulation therapy / Lower urinary tract symptoms

Acknowledgments

None.

Statement of ethics

This study was approved by the Northern Sydney Local Health District Human Research Ethics Committee (2021/ETH01209). A waiver of participants' consent was granted. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of interest statement

No conflict of interest has been declared by the authors.

Funding source

None.

Author contributions

CTP, DD, AC: Conception and design;

CTP, YY: Administrative support, collection and assembly of data;

CTP, YY, DD, AC: Provision of study materials;

CTP, SY: Data analysis and interpretation;

CTP, JK, CJP, SY, DD, AC: Manuscript writing;

CTP, JK, CJP, SY, YY, DD, AC: Final approval of manuscript.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

[1] Fowler CJ, Griffiths D, de Groat WC. The neural control of micturition. Nat Rev Neurosci 2008; 9(6):453-466.

[2] Matzel KE, Chartier-Kastler E, Knowles CH, et al. Sacral neuromodulation: Standardized electrode placement technique. Neuromodulation 2017; 20(8):816-824.

[3] De Wachter S, Vaganee D, Kessler TM. Sacral neuromodulation: Mechanism of action. Eur Urol Focus 2020; 6(5):823-825.

[4] Blok BF, Groen J, Bosch JL, Veltman DJ, Lammertsma AA. Different brain effects during chronic and acute sacral neuromodulation in urge incontinent patients with implanted neurostimulators. BJU Int 2006; 98(6):1238-1243.

[5] Vaganée D, Voorham J, van de Borne S, Voorham-van der Zalm P, Fransen E, de Wachter S. Pelvic floor activation upon stimulation of the sacral spinal nerves in sacral neuromodulation patients. Neurourol Urodyn 2020; 39(6):1815-1823.

[6] Kessler TM, Fowler CJ. Sacral neuromodulation for urinary retention. Nat Clin Pract Urol 2008; 5(12):657-666.

[7] van Ophoven A, Engelberg S, Lilley H, Sievert KD. 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. Adv Ther 2021; 38(4):1987-2006.

[8] Averbeck MA, Moreno-Palacios J, Aparicio A. Is there a role for sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction? Int Braz J Urol 2020; 46(6):891-901.

[9] Ruud Bosch JL, Groen J. Treatment of refractory urge urinary incontinence with sacral spinal nerve stimulation in multiple sclerosis patients. Lancet 1996; 348(9029):717-719.

[10] Nitti VW. Pressure flow urodynamic studies: The gold standard for diagnosing bladder outlet obstruction. Rev Urol 2005; 7(suppl 6):S14-S21.

[11] Blaivas JG, Groutz A. Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn 2000; 19(5):553-564.

[12] Rosier PFWM, Schaefer W, Lose G, et al. International Continence Society good urodynamic practices and terms 2016: Urodynamics, uroflowmetry, cystometry, and pressure-flow study. Neurourol Urodyn 2017; 36(5):1243-1260.

[13] Goldman HB, Lloyd JC, Noblett KL, et al. International Continence Society best practice statement for use of sacral neuromodulation. Neurourol Urodyn 2018; 37(5):1823-1848.

[14] Abrams P, Andersson KE, Apostolidis A, et al. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourol Urodyn 2018; 37(7):2271-2272.

[15] Blok B, Castro-Diaz D, del Popolo G, et al. European Association of Urology (EAU) Neuro-Urology Guidelines. Available at: https://uroweb.org/guideline/neuro-urology/#6. Accessed October 1, 2021.

[16] Peters KM, Kandagatla P, Killinger KA, Wolfert C, Boura JA. Clinical outcomes of sacral neuromodulation in patients with neurologic conditions. Urology 2013; 81(4):738-743.

[17] Wöllner J, Krebs J, Pannek J. Sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction. Spinal Cord 2016; 54(2):137-140.

[18] Lombardi G, Musco S, Celso M, del Corso F, del Popolo G. Sacral neuromodulation for neurogenic non-obstructive urinary retention in incomplete spinal cord patients: A ten-year follow-up, single-centre experience. Spinal Cord 2014; 52(3):241-245.

[19] Chaabane W, Guillotreau J, Castel-Lacanal E, et al. Sacral neuromodulation for treating neurogenic bladder dysfunction: Clinical and urodynamic study. Neurourol Urodyn 2011; 30(4):547-550.

[20] Watt A, Cameron A, Norman R. Sacral Nerve Stimulation for Urinary Indications: Medical Services Advisory Committee Assessment Report. Canberra, Australia: Medical Services Advisory Committee; 2008.

[21] Australian Government Department of Health. MBS online: Medicare benefits schedule. Mbsonline.gov.au. Available at: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home. Accessed October 1, 2021.

[22] D'Ancona C, Haylen B, Oelke M, et al. The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction. Neurourol Urodyn 2019; 38(2):433-477.

[23] Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology in lower urinary tract function: Report from the standardisation sub-committee of the International Continence Society. Urology 2003; 61(1):37-49.

[24] Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29(1):4-20.

[25] Osman N, Mangera A, Hillary C, Inman R, Chapple C. The underactive bladder: Detection and diagnosis. F1000Res 2016;5:F1000 Faculty Rev-102.

[26] Osman NI, Chapple CR, Abrams P, et al. Detrusor underactivity and the underactive bladder: A new clinical entity? A review of current terminology, definitions, epidemiology, aetiology, and diagnosis. Eur Urol 2014; 65(2):389-398.

[27] van Koeveringe GA, Vahabi B, Andersson KE, Kirschner-Herrmans R, Oelke M. Detrusor underactivity: A plea for new approaches to a common bladder dysfunction. Neurourol Urodyn 2011; 30(5):723-728.

[28] Chapple CR, Osman NI, Birder L, et al. Terminology report from the International Continence Society (ICS) working group on underactive bladder (UAB). Neurourol Urodyn 2018; 37(8):2928-2931.

[29] Lehur PA, Sørensen M, Dudding TC, et al. Programming algorithms for sacral neuromodulation: Clinical practice and evidence—Recommendations for day-to-day practice. Neuromodulation 2020; 23(8):1121-1129.

[30] Amend B, Khalil M, Kessler TM, Sievert KD. How does sacral modulation work best? Placement and programming techniques to maximize efficacy. Curr Urol Rep 2011; 12(5):327-335.

[31] Noblett K. Neuromodulation and female pelvic disorders. Curr Opin Urol 2016; 26(4):321-327.

[32] Knüpfer SC, Liechti MD, Mordasini L, et al. Protocol for a randomized, placebo-controlled, double-blind clinical trial investigating sacral neuromodulation for neurogenic lower urinary tract dysfunction. BMC Urol 2014;14:65.