Cost profiles and budget impact of rechargeable versus non-rechargeable sacral neuromodulation devices in the treatment of overactive bladder syndrome

Long-term cost-effectiveness analysis of sacral neuromodulation in the treatment of severe faecal incontinence

AIM

The aim of this study was to evaluate the long-term cost-effectiveness of sacral neuromodulation in the treatment of severe faecal incontinence as compared with symptomatic management.

METHODS

In the public health field, a micro-costing evaluation method was conducted from the perspectives of the health system and the society. The incremental cost-effectiveness ratio was used as a decision index, and we considered various scenarios to evaluate the impact of the cost of symptomatic management and percutaneous nerve evaluation success rate in its calculation. Clinical data were retrieved from a consecutive cohort of 93 patients with severe faecal incontinence undergoing sacral neuromodulation after a failure of conservative (pharmacological and biofeedback) and/or surgical (sphincteroplasty) first-line treatments were considered.

RESULTS

The long-term incremental cost-effectiveness ratio comparing sacral neuromodulation versus symptomatic management was 14347€/QALY and 28523€/QALY from the societal and health service provider's perspectives, respectively. If the definitive pulse generator implant success rate was 100%, incremental cost-effectiveness would correspond to 6831€/QALY and 16761€/QALY, respectively.

CONCLUSIONS

Sacral neuromodulation may be considered a cost-effective technique in the long-term treatment of severe faecal incontinence from the societal and health care sector perspectives. Improving patient selection and determining the predictive outcome factors for successful sacral neuromodulation in the treatment of faecal incontinence would improve cost-effectiveness.

Evaluation of clinical performance and safety for the rechargeable InterStim Micro device in overactive bladder subjects: 6-month results from the global postmarket ELITE study

AIMS

Sacral neuromodulation (SNM) is an advanced therapy option for the treatment of overactive bladder (OAB), nonobstructive urinary retention, and fecal incontinence. The aim of this ongoing prospective, multicenter, global, postmarket study is to confirm safety and clinical performance of the InterStim^TM Micro system for SNM in all indications. Reported here are the results for the OAB cohort through 6-month follow-up.

METHODS

Eligible OAB subjects that had a successful therapy evaluation were enrolled after implant of an InterStim Micro implantable pulse generator (IPG). Subjects completed voiding diaries and the Overactive Bladder Quality of Life questionnaire (OAB-q) at baseline and follow-up visits occurring at 3 months and 6 months postimplant. Safety was evaluated as device-, procedure-, or therapy-related adverse events. The primary objective for the OAB cohort was to demonstrate an improvement in OAB-q Health Related Quality of Life (HRQL) total score at 3 months postimplant compared to baseline.

RESULTS

Sixty-eight OAB subjects were enrolled and implanted with an InterStim Micro IPG. Of those, 67 and 66 subjects completed the 3- and 6-month follow-up visits, respectively. The OAB-q HRQL demonstrated a statistically significant improvement from baseline to 3-month follow-up with an average increase of 33 ± 24 points (n = 67, p < 0.001). The change was also observed at 6-months with an average increase of 31 ± 23 points (n = 65) compared to baseline. Eighty-two percent of subjects achieved the minimally important difference in HRQL score at 3- and 6-month, respectively, with a change of 10 points or greater. The majority of subjects reported that their bladder condition was better at 3-month (92.5%, 62/67) and 6-month (89%, 59/66) compared to before they were treated with SNM therapy delivered by the InterStim Micro system. For subjects with urgency urinary incontinence (UUI), the average change from baseline to follow-up in UUI episodes/day was -3.6 (95% CI: -4.7, -2.6; n = 62) at 3-month and -3.7 (95% CI: -4.7, -2.7; n = 61) at 6-month. Among subjects with urgency-frequency (UF), the average change from baseline to follow up in voids/day was -4.5 (95% CI: -6.3, -2.7; n = 52) at 3-months and -4.4 (95% CI: -6.0, -2.7; n = 52) at 6-month. The cumulative incidence of device-, procedure-, or therapy- related adverse events was 7.4% (5/68). Out of these five related adverse events, there was one serious adverse event (1.5%, implant site pain) at the time of database snapshot.

CONCLUSIONS

These data confirm the safety and clinical performance of the InterStim Micro device for subjects with OAB by demonstrating a significant improvement in OAB-q HRQL score at 3-month. Similar improvements were observed at 6 months in addition to an incidence of adverse events that is comparable to previously reported rates for SNM.

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.

Update on the management of overactive bladder

Overactive bladder (OAB) syndrome is a common condition characterised by urinary urgency, with or without urgency incontinence, frequency and nocturia, in the absence of any other pathology. Clinical diagnosis is based upon patient self-reported symptomology. Currently there is a plethora of treatments available for the management of OAB. Clinical guidelines suggest treatment via a multidisciplinary pathway including behavioural therapy and pharmacotherapy, which can be commenced in primary care, with referral to specialist services in those patients refractory to these treatments. Intradetrusor botulinum A and sacral neuromodulation provide safe and efficacious management of refractory OAB. Percutaneous tibial nerve stimulation and augmentation cystoplasty remain available and efficacious in a select group of patients. Unfortunately, there remains a high rate of patient dissatisfaction and discontinuation in all treatments and thus there remains a need for emerging therapies in the management of OAB.

Two-year outcomes of the ARTISAN-SNM study for the treatment of urinary urgency incontinence using the Axonics rechargeable sacral neuromodulation system

AIMS

Sacral neuromodulation (SNM) is a guideline-recommended treatment with proven therapeutic benefit for urinary urgency incontinence (UUI) patients. The Axonics® System is the first Food and Drug Administration-approved rechargeable SNM system and is designed to deliver therapy for a minimum of 15 years. The ARTISAN-SNM study was designed to evaluate UUI participants treated with the Axonics System. Two-year follow-up results are presented.

METHODS

One hundred and twenty-nine UUI participants underwent implantation with the Axonics System. Therapeutic response rate, participant quality of life (QoL), and satisfaction were determined using 3-day voiding diaries, ICIQ-OABqol, and satisfaction questionnaires. Participants were considered responders if they had a 50% or greater reduction in UUI episodes post-treatment. As-treated and Completers analyses are presented.

RESULTS

At 2 years, 93% of the participants (n = 121 Completers at 2 years) were therapy responders, of which 82% achieved ≥ 75% reduction in UUI episodes and 37% were dry (100% reduction). Daily UUI episodes reduced from 5.6 ± 0.3 at baseline to 1.0 ± 0.2 at 2 years. Statistically significant improvements in ICIQ-OABqol were reported. All participants were able to recharge their device and 94% of participants reported that the recharging frequency and duration were acceptable. Participant demographics nor condition severity were correlated with clinical outcomes or recharging experience. No unanticipated or serious device-related adverse events occurred.

CONCLUSIONS

At 2 years, participants treated with the Axonics System demonstrated sustained safety and efficacy, high levels of satisfaction with therapy and recharging. Participant-related factors were not associated with efficacy or recharging outcomes, indicating the reported results are applicable to a diverse population.

Cost Effectiveness of Sacral Neuromodulation and OnabotulinumtoxinA in Managing Refractory Idiopathic Overactive Bladder

Little information from clinical and modelled studies are available on cost effectiveness of OnabotulinumtoxinA and SNM for the treatment of idiopathic overactive bladder. We aimed to summarize the evidence in this regard from different healthcare systems. Seven studies from 5 countries were reviewed. Some modelled studies with a 10-year time frame showed that sacral neuromodulation became dominant long-term; others suggested OnabotulinumtoxinA was more cost effective at <5 years. There was considerable heterogeneity in the base case/sensitivity analysis and statistical modelling among the studies. Clinical studies with longer term follow-up will help determine cost effectiveness more accurately.

Treatment of Fecal Incontinence With a Rechargeable Sacral Neuromodulation System: Efficacy, Clinical Outcome, and Ease of Use-Six-Month Follow-Up

OBJECTIVE

Sacral neuromodulation is an effective treatment for fecal incontinence (FI) after conservative treatments have failed. A new rechargeable sacral neuromodulation system (r-SNM) includes a rechargeable implantable neurostimulator (INS). No data is available of the use of this technology in patients with fecal incontinence.

MATERIALS AND METHODS

Fifteen patients with FI were implanted with the Axonics rechargeable SNM system in a single-stage implant procedure and prospectively followed. Primary outcome was fecal incontinence episodes at four weeks and six months measured with stools diary. Success was defined as at least 50% improvement of fecal incontinence episodes. Additionally, quality of life and ease of use were evaluated.

RESULTS

At four weeks, 13 participants (87%) were test responders based on ≥50% reduction in FI episodes as documented on their bowel diary. Weekly FI episodes decreased from a median (25%-75% range) of 8 (5.8-20.3) at baseline to a median of 1.5 (0.4-4.5) at four weeks (p = 0.001), and 1.5 (0-2.6) at six months (p = 0.001), corresponding to 75% and 79% reduction in weekly FI episodes. Of the 13 subjects having ≥50% reduction in FI episodes at four weeks, 12 (PP = 92%) were therapy responders at six months. There were no unanticipated device or procedure-related adverse events. Mean time to recharge the system was 37 ± 3 min once or twice per week. All patients were moderately or very satisfied with the system and its effect.

CONCLUSIONS

The r-SNM system provides safe and effective therapy in patients with FI at six months.

Sacral neuromodulation system for treating refractory overactive bladder

Sacral neuromodulation (SNM) is a therapy system used to improve bladder function, including in people with overactive bladder (OAB). It is safe and can improve quality of life. SNM helps improve symptoms through direct modulation of nerve activity; it involves electrically stimulating the sacral nerves that carry signals between the pelvic floor, spinal cord and the brain and is thought to normalise neural communication between the bladder and brain. If patients with OAB do not respond to non-surgical and conservative options, minimally invasive procedures can be offered, including SNM. SNM is performed in two stages: the trial phase, to assess whether it would be effective in the long term; and permanent implantation. This year, the National Institute for Health and Care Excellence (NICE) released guidance on the Axonics SNM System® for treating refractory OAB. The Axonics System is rechargeable and lasts at least 15 years, minimising the need for repeat surgery. NICE suggests the Axonics System may have cost advantages for the NHS. Having more than one SNM therapy option available increases options for patients, offering them a choice of handsets and rechargeable versus non-rechargeable implants. Three case studies illustrate how the system works in practice.

Recent advances in managing overactive bladder

Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. In this review, we focus on recent advances in the management of OAB. We examine the evidence on the effect of anticholinergic load on OAB patients. Advances in medical treatment include a new beta-3 agonist, vibegron, which is thought to have fewer drug interactions than mirabegron. Treatment of genitourinary syndrome of the menopause with oestrogens and ospemifene have also shown promise for OAB. Botulinum toxin has been shown to be an effective treatment option. We discuss the new implantable neuromodulators that are on the market as well as selective bladder denervation and laser technology.

One-year outcomes of the ARTISAN-SNM study with the Axonics System for the treatment of urinary urgency incontinence

Aims

Sacral neuromodulation (SNM) is a guideline‐recommended treatment for voiding dysfunction including urgency, urge incontinence, and nonobstructive retention as well as fecal incontinence. The Axonics® System is a miniaturized, rechargeable SNM system designed to provide therapy for at least 15 years, which is expected to significantly reduce revision surgeries as it will not require replacement as frequently as the non‐rechargeable SNM system. The ARTISAN‐SNM study is a pivotal study designed to treat patients with urinary urgency incontinence (UUI). Clinical results at 1‐year are presented.

Methods

A total of 129 eligible UUI patients were treated. All participants were implanted with a quadripolar tined lead and neurostimulator in a single procedure. Efficacy data were collected using a 3‐day bladder diary, a validated quality of life questionnaire (ICIQ‐OABqol), and a participant satisfaction questionnaire. Therapy responders were defined as participants with ≥50% reduction in UUI episodes compared to baseline. Data were analyzed on all 129 participants.

Results

At 1 year, 89% of the participants were therapy responders. The average UUI episodes per day reduced from 5.6 ± 0.3 at baseline to 1.4 ± 0.2. Participants experienced an overall clinically meaningful improvement of 34 points on the ICIQ‐OABqol questionnaire. All study participants (100%) were able to recharge their device at 1 year, and 96% of participants reported that the frequency and duration of recharging was acceptable. There were no serious device‐related adverse events.

Conclusions

The Axonics System is safe and effective at 1 year, with 89% of participants experiencing clinically and statistically significant improvements in UUI symptoms.

Two-year safety and efficacy outcomes for the treatment of overactive bladder using a long-lived rechargeable sacral neuromodulation system

AIMS

Sacral neuromodulation (SNM) therapy for overactive bladder (OAB) has proven long-term safety and efficacy. Historically, the only commercially available SNM device was nonrechargeable requiring replacement surgery due to battery depletion. The Axonics System is the first rechargeable SNM device and is qualified to last a minimum of 15 years in the body. The study objective was to evaluate the safety and efficacy of this rechargeable SNM system. This study reports 2-year outcomes.

METHODS

A total of 51 subjects were implanted with the Axonics System in a single nonstaged procedure. Subjects had OAB, confirmed on a 3-day voiding diary (≥8 voids/day and/or ≥2 incontinence episodes over 72 hours). Test Responders were defined as subjects that were responders at 1 month postimplant. The efficacy analysis included therapy responder rates, change in the quality of life, and subject satisfaction reported in Test Responders (n = 30) and all implanted subjects (n = 37) that completed the follow-up visits. Adverse events (AEs) are reported in all implanted subjects.

RESULTS

At 2 years, 90% of the Test Responders continued to respond to the therapy based on voiding diary criteria. Satisfaction with therapy was reported by 93% of subjects and 86% found their charging experience acceptable. Of the urinary incontinence Test Responders, 88% continued to be responders at 2 years, and 28% were completely dry. There were no unanticipated (AEs) or serious device-related AEs.

CONCLUSIONS

The Axonics System® provides sustained clinically meaningful improvements in OAB subjects at 2 years. There were no serious device-related AEs. Subjects reported continued satisfaction with their therapy.

Electrical stimulation in the treatment of bladder dysfunction: technology update

The urinary bladder has two functions: urine storage and voiding. Clinically, two major categories of lower urinary tract symptoms can be defined: storage symptoms such as incontinence and urgency, and voiding symptoms such as feeling of incomplete bladder emptying and slow urinary stream. Urgency to void with or without incontinence is called overactive bladder (OAB). Slow urinary stream, hesitancy, and straining to void with the feeling of incomplete bladder emptying are often called underactive bladder (UAB). The underlying causes of OAB or UAB can be either non-neurogenic (also referred to as idiopathic) and neurogenic, for example due to spinal cord injury or multiple sclerosis. OAB and UAB can be treated conservatively by lifestyle intervention or medication. In the case that conservative treatment does not provide sufficient benefit, electrical stimulation can be used. Sacral neurostimulation or neuromodulation (SNM) is offered as a third-line therapy to patients with non-neurogenic OAB or UAB. In SNM, the third or fourth sacral nerve root is stimulated and after a test period, a neuromodulator is implanted in the buttock. Until recently only a non-rechargeable neuromodulator was approved for clinical use. However, nowadays, a rechargeable sacral neuromodulator is also on the market, with similar safety and effectiveness to the non-rechargeable SNM system. The rechargeable device was approved for full body 1.5T and 3T MRI in Europe in February 2019. Regarding neurogenic lower urinary tract dysfunction, electrical stimulation only seems to benefit a selected group of patients.

[Sacral neuromodulation in under- and overactive detrusor-quo vadis? : Principles and developments]

BACKGROUND

Sacral neuromodulation (SNM) has been used in the treatment of refractory overactive bladder syndrome, nonobstructive urinary retention and faecal incontinence for almost 40 years now. It is not to be confused with the sacral anterior root stimulation which is exclusively used for bladder dysfunction due to spinal paraplegia.

MECHANISM OF ACTION

The principles of SNM are yet to be fully understood. Nevertheless, there is proof of modulating the activity of several micturition-associated, afferent neurons in the spine, brainstem and cerebrum. Thus, premature detrusor contractions are suppressed, the desire to void is delayed and detrusor-sphincter coordination improves.

TECHNIQUES OF IMPLANTATION AND STIMULATION

Motor reactions are an important indicator of correct electrode placement. The implantation procedure consists of two stages with an initial trial phase to determine the best possible treatment response through an external generator before implanting the whole stimulating device. Yearly check-up examinations are recommended; wireless adjustments allow for long-lasting symptom reduction.

INDICATION AND OUTCOME

Success rates in the treatment of the refractory overactive bladder syndrome and the non-obstructive urinary retention lie above 70% and can still be perceived as sufficient after 5 years of ongoing SNM therapy. There is also profound evidence of SNM being an effective option for patients with faecal incontinence or chronic obstipation.

CONTRAINDICATIONS AND RISKS

Children, pregnant women and patients in need of frequent MRI examinations are usually not eligible for SNM therapy. Infection of the implant, technical failure (including lead displacement and battery depletion) and pain in the implantation site are important adverse effects which might require surgical revision.

CONCLUSIONS

The indications for SNM in the German health care system can be expected to be expanded upon the chronic pelvic pain syndrome, erectile dysfunction and additional gastrointestinal conditions. Technical progress will continue to improve the risk-benefit ratio of SNM.

Programming settings and recharge interval in a prospective study of a rechargeable sacral neuromodulation system for the treatment of overactive bladder

AIMS

The RELAX-OAB study is designed to confirm the safety, efficacy, and technical performance of the Axonics r-SNM System, a miniaturized, rechargeable SNM system approved in Europe and Canada for the treatment of bladder and bowel dysfunction. The purpose of this article is to describe study subjects' ability to charge the rechargeable neurostimulator and to document their neurostimulator program settings and recharge interval over time.

METHODS

Fifty-one OAB patients were implanted in a single-stage procedure. These results represent the 3-month charging experience for 48 subjects who completed the 3-month follow-up. Recharge intervals were estimated using therapy stimulation settings and subject experience was evaluated using questionnaires.

RESULTS

Forty-seven of forty-eight (98%) subjects were able to successfully charge their device prior to follow-up within 1-month post-implant. At 3-month post-implant, 98% of subjects were able to charge prior to their follow-up visit. Average stimulation amplitude across all subjects was 1.8 mA (±1.1 mA). A total of 69% of subjects had ≥14-day recharge intervals (time between charging) and 98% of subjects had ≥7-day recharge interval. No charging related adverse events occurred.

CONCLUSIONS

Study subjects were able to charge the Axonics r-SNM System and stimulation settings provided 2 weeks of therapy between recharging for most subjects. Subject satisfaction indicates that subjects are satisfied with rechargeable SNM therapy.

Three month clinical results with a rechargeable sacral neuromodulation system for the treatment of overactive bladder

AIMS

The primary aim of the RELAX-OAB study is to confirm the safety and efficacy of the Axonics r-SNM System, a miniaturized, rechargeable SNM system.

METHODS

A total of 51 OAB patients were implanted in a single-stage implant procedure. These results represent the 3-month outcomes. Subject outcomes were evaluated using 3-day bladder diaries and quality of life questionnaires.

RESULTS

A total of 31 of 34 patients (91%) that responded during an initial trial period ("Test Responders") continued to benefit from therapy with the Axonics r-SNM System at 3-months, defined as symptom improvement of ≥50% reduction in urinary voids or incontinence episodes or a return to <8 voids per day. Subjects who were Test Responders showed a statistically and clinically meaningful improvement in all aspects of quality of life (ICIQ-OABqol). No serious device-related adverse events (SADEs) occurred, and there were no unanticipated adverse events (UAEs). One subject was explanted due to an infection at the implant site and 19.6% of subjects experienced device related adverse events, most notably discomfort due to stimulation, which was resolved with reprogramming.

CONCLUSIONS

The Axonics r-SNM System provides safe and effective SNM therapy with objective improvement in 91% of subjects. The data also demonstrates a significant improvement in all domains of quality of life. This miniaturized, rechargeable system is designed to last 15 or more years and is expected to provide clinical and cost benefits over current non-rechargeable systems by eliminating replacement surgeries.

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.