Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Brain Response Induced by Peroneal Electrical Transcutaneous Neuromodulation Invented for Overactive Bladder Treatment, as Detected by Functional Magnetic Resonance Imaging

OBJECTIVES

In this study, we aimed to investigate whether peroneal electrical Transcutaneous Neuromodulation invented for overactive bladder (OAB) treatment elicits activation in brain regions involved in neural regulation of the lower urinary tract.

MATERIALS AND METHODS

Among 22 enrolled healthy female volunteers, 13 were eligible for the final analysis. Functional magnetic resonance imaging (fMRI) (Siemens VIDA 3T; Erlangen, Germany) was used to compare the brain region activation elicited by peroneal electrical Transcutaneous Neuromodulation with the activation elicited by sham stimulation. Each subject underwent brain fMRI recording during eight 30-second periods of rest, alternating with 30-second periods of passive feet movement using the sham device, mimicking the motor response to peroneal nerve stimulation. Subsequently, fMRI recording was performed during the analogic "off-on" stimulation paradigm using peroneal electrical transcutaneous neuromodulation. Magnetic resonance imaging data acquired during both paradigms were compared using individual and group statistics.

RESULTS

During both peroneal electrical Transcutaneous Neuromodulation and sham feet movements, we observed activation of the primary motor cortex and supplementary motor area, corresponding to the cortical projection of lower limb movement. During peroneal electrical Transcutaneous Neuromodulation, we observed significant activations in the brain stem, cerebellum, cingulate gyrus, putamen, operculum, and anterior insula, which were not observed during the sham feet movement.

CONCLUSIONS

Our study provides evidence that peroneal electrical Transcutaneous Neuromodulation elicits activation of brain structures that have been previously implicated in the perception of bladder fullness and that play a role in the ability to cope with urinary urgency. Our data suggest that neuromodulation at the level of supraspinal control of the lower urinary tract may contribute to the treatment effect of peroneal electrical Transcutaneous Neuromodulation in patients with OAB.

Two-Staged Sacral Neuromodulation for the Treatment of Nonobstructive Urinary Retention: A Multicenter Study Assessing Predictors of Success

OBJECTIVES

The aims of this study were to 1) determine the success rate of the tined lead test phase in patients with nonobstructive urinary retention (NOUR), 2) determine predictive factors of a successful test phase in patients with NOUR, and 3) determine long-term treatment efficacy and satisfaction in patients with NOUR.

MATERIALS AND METHODS

The first part was a multicenter retrospective study at two centers in The Netherlands. Patients with NOUR received a four-week tined lead test phase. Success was defined as a ≥50% reduction of clean intermittent catheterization frequency or postvoid residual. We analyzed possible predictors of success with multivariable logistic regression. Second, all patients received a questionnaire to assess efficacy, perceived health (Patient Global Impression of Improvement), and treatment satisfaction.

RESULTS

This study included 215 consecutive patients (82 men and 133 women) who underwent a tined lead test phase for the treatment of NOUR. The success rate in women was significantly higher than in men, respectively 62% (83/133) and 22% (18/82, p < 0.001). In women, age per ten years (odds ratio [OR] 0.74, 95% CI: 0.59-0.93) and a history of psychiatric illness (OR 3.92, 95% CI: 1.51-10.2), including posttraumatic stress disorder (PTSD), significantly predicted first stage sacral neuromodulation (SNM) success. In men, age per ten years (OR 0.43, 95% CI: 0.25-0.72) and previous transurethral resection of the prostate and/or bladder neck incision (OR 7.71, 95% CI: 1.43-41.5) were significant predictors of success. Conversely, inability to void during a urodynamic study (for women, OR 0.79, 95% CI: 0.35-1.78; for men, OR 3.06, 95% CI: 0.83-11.3) was not predictive of success. Of the patients with a successful first stage, 75% (76/101) responded to the questionnaire at a median follow-up of three years. Of these patients, 87% (66/76) continued to use their SNM system, and 92% (70/76) would recommend SNM to other patients.

CONCLUSIONS

A history of psychiatric illness, including PTSD, in women with NOUR increased the odds of first stage SNM success 3.92 times. A previous transurethral resection of the prostate and/or bladder neck incision in men increased the odds of success 7.71 times. In addition, a ten-year age increase was associated with an OR of 0.43 in men and 0.74 in women, indicating a 2.3- and 1.3-times decreased odds of success, respectively.

Long-term beneficial effects of mirabegron in pediatric patients with therapy-refractory neurogenic lower urinary tract dysfunction

INTRODUCTION

Neurogenic lower urinary tract dysfunction (NLUTD) in children can cause renal failure and urinary incontinence if not treated sufficiently. Antimuscarinics (AM) and intradetrusor botulinum toxin injections (BoNT-A) with clean intermittent catheterization (CIC) are widely used treatment options for children with NLUTD. However, a considerable number will become refractory to these treatment options. This study aimed to evaluate the efficacy and long-term outcomes of mirabegron in children with NLUTD as an add-on and as a stand-alone treatment.

MATERIAL AND METHODS

Patients under 18 years of age with NLUTD who were refractory to AM and/or BoNT-A and were treated with mirabegron 50 mg were retrospectively studied. Mirabegron was either used as monotherapy or in addition to AM and/or BoNT-A. Video-urodynamic studies (VUDSs) were performed before and after treatment with mirabegron. Changes in video-urodynamic parameters, the need for other NLUTD therapy during follow-up, patient-reported side effects, and urinary incontinence were outcomes of interest.

RESULTS

A total of 34 patients with NLUTD were included. All patients were on CIC and the median age was 13.1 years (IQR 15.9-10.3). Median follow-up was 31.4 months (IQR 57.4-11.4). Bladder compliance improved by 89.9%, from 14.9 to 28.3 ml/cm H2O (p-value<0.001). Maximum cystometric capacity, end-filling detrusor pressure, volume at first detrusor overactivity, vesicoureteral reflux, and urinary incontinence significantly improved after mirabegron. The add-on therapy group showed more significant improvements in video-urodynamic outcomes compared to the monotherapy group. The median time of requiring other NLUTD therapy was 25.5 months (IQR 39.8-14.8). None of the included patients reported side effects.

CONCLUSIONS

Mirabegron is an effective treatment for children with therapy-refractory NLUTD with an average efficacy of 2 years after which additional therapy is required. Despite the retrospective character of this study, our results confirm the beneficial effect of mirabegron in children with therapy-refractory NLUTD, in particular when mirabegron is used as add-on therapy in those with low-compliance bladders.

A Green Prescription: Integrating Environmental Sustainability in Urology Guidelines

Against the background of the climate crisis, there is an urgent need to include environmental sustainability recommendations in clinical practice guidelines. We highlight five domains for which suitable recommendations could help in mitigating the environmental impact of urology practice. PATIENT SUMMARY: Climate change is an urgent issue that requires global action. Guidelines published by urological societies should include recommendations for minimizing the impact of urology practice on the environment.

Transcutaneous Electrical Stimulation of the Abdomen, Ear, and Tibial Nerve Modulates Bladder Contraction in a Rat Detrusor Overactivity Model: A Pilot Study

PURPOSE

The global prevalence of overactive bladder (OAB) is estimated at 11.8%. Despite existing treatment options such as sacral neuromodulation, a substantial number of patients remain untreated. One potential alternative is noninvasive transcutaneous electrical stimulation. This form of stimulation does not necessitate the implantation of an electrode, thereby eliminating the need for highly skilled surgeons, expensive implantable devices, or regular hospital visits. We hypothesized that alternative neural pathways can impact bladder contraction.

METHODS

In this pilot study, we conducted transcutaneous electrical stimulation of the abdominal wall (T6-L1), the ear (vagus nerve), and the ankle (tibial nerve) of 3 anesthetized female Sprague-Dawley rats. Stimulation was administered within a range of 20 Hz to 20 kHz, and its impact on intravesical pressure was measured. We focused on 3 primary outcomes related to intravesical pressure: (1) the pressure change from the onset of a contraction to its peak, (2) the average duration of contraction, and (3) the number of contractions within a specified timeframe. These measurements were taken while the bladder was filled with either saline or acetic acid (serving as a model for OAB).

RESULTS

Transcutaneous stimulation of the abdominal wall, ear, and ankle at a frequency of 20 Hz decreased the number of bladder contractions during infusion with acetic acid. As revealed by a comparison of various stimulation frequencies of the tibial nerve during bladder infusion with acetic acid, the duration of contraction was significantly shorter during stimulation at 1 kHz and 3 kHz relative to stimulation at 20 Hz (P = 0.025 and P = 0.044, respectively).

CONCLUSION

The application of transcutaneous electrical stimulation to the abdominal wall, ear, and tibial nerve could provide less invasive and more cost-effective treatment options for OAB relative to percutaneous tibial nerve stimulation and sacral neuromodulation. A follow-up study involving a larger sample size is recommended.

Differences between brain responses to peroneal electrical transcutaneous neuromodulation and transcutaneous tibial nerve stimulation, two treatments for overactive bladder

OBJECTIVES

To compare brain responses to peroneal electrical transcutaneous neuromodulation (peroneal eTNM®) and transcutaneous tibial nerve stimulation (TTNS), two methods for treating overactive bladder (OAB), using functional magnetic resonance imaging (fMRI). The present study was not designed to compare their clinical efficacy.

MATERIALS AND METHODS

This study included 32 healthy adult female volunteers (average age 38.3 years (range 22-73)). Brain MRI using 3 T scanner was performed during three 8-min blocks of alternating sequences. During each 8-min block, the protocol alternated between sham stimulation (30 s) and rest (30 s) for 8 repeats; then peroneal eTNM® stimulation (30 s) and rest (30 s) for 8 repeats; then, TTNS stimulation (30 s) and rest (30 s) for 8 repeats. Statistical analysis was performed at the individual level with a threshold of p = 0.05, family-wise error (FWE)-corrected. The resulting individual statistical maps were analyzed in group statistics using a one-sample t-test, p = 0.05 threshold, false discovery rate (FDR)-corrected.

RESULTS

During peroneal eTNM®, TTNS, and sham stimulations, we recorded activation in the brainstem, bilateral posterior insula, bilateral precentral gyrus, bilateral postcentral gyrus, left transverse temporal gyrus, and right supramarginal gyrus. During both peroneal eTNM® and TTNS stimulations, but not sham stimulations, we recorded activation in the left cerebellum, right transverse temporal gyrus, right middle frontal gyrus, and right inferior frontal gyrus. Exclusively during peroneal eTNM® stimulation, we observed activation in the right cerebellum, right thalamus, bilateral basal ganglia, bilateral cingulate gyrus, right anterior insula, right central operculum, bilateral supplementary motor cortex, bilateral superior temporal gyrus, and left inferior frontal gyrus.

CONCLUSIONS

Peroneal eTNM®, but not TTNS, induces the activation of brain structures that were previously implicated in neural control of the of bladder filling and play an important role in the ability to cope with urgency. The therapeutic effect of peroneal eTNM® could be exerted, at least in part, at the supraspinal level of neural control.

Effect duration of the initial course of peroneal electrical Transcutaneous NeuroModulation in patients with overactive bladder

PURPOSE

The aim of this prospective 12-month follow-up study is to evaluate the persistence of the treatment effect achieved during the initial course of peroneal electrical Transcutaneous NeuroModulation (peroneal eTNM^®) in patients with overactive bladder (OAB).

METHODS

This study enrolled 21 female patients who participated in two previous clinical studies designed to assess the efficacy and safety of peroneal eTNM^®. The patients were left without subsequent OAB treatment and were invited to attend regular follow-up visits every 3 months. The patient's request for additional treatment was considered an indicator of the withdrawal of the treatment effect of the initial course of peroneal eTNM^®. The primary objective was the proportion of patients with persisting treatment effect at follow-up visit 12 months after initial course of peroneal eTNM^®. Descriptive statistics are presented using median, correlation analyses were computed using a nonparametric Spearman correlation.

RESULTS

The proportion of patients with persistent therapeutic effect of the initial course of peroneal eTNM^® was 76%, 76%, 62% and 48% at 3, 6, 9 and 12 months, respectively. There was a significant correlation between patient reported outcomes and the number of severe urgency episodes with or without urgency incontinence as reported by patients at each follow-up visit (p = 0.0017).

CONCLUSION

The treatment effect achieved during the initial phase of peroneal eTNM^® persists for at least 12 months in 48% of patients. It is likely that the duration of effects is dependent on the length of the initial therapy.

Prospective, Randomized, Multicenter Trial of Peroneal Electrical Transcutaneous Neuromodulation vs Solifenacin in Treatment-naïve Patients With Overactive Bladder

PURPOSE

We investigated the safety and efficacy of peroneal electrical transcutaneous neuromodulation using the URIS neuromodulation system in a home-based setting in comparison with standard treatment using solifenacin in treatment-naïve female patients with overactive bladder.

MATERIALS AND METHODS

A total of 120 patients were screened, of whom 77 were randomized in a 2:1 ratio to 12 weeks of treatment with daily peroneal electrical transcutaneous neuromodulation or solifenacin 5 mg. The primary endpoint was safety; efficacy assessments included proportion of responders, defined as subjects with ≥50% reduction in bladder diary-derived variables; Overactive Bladder-Validated 8-question Screener, and European Quality of Life-5 Dimensions questionnaire; and treatment satisfaction after 12 weeks of therapy.

RESULTS

Seventy-one out of 77 randomized patients completed the study. In the peroneal electrical transcutaneous neuromodulation group 6/51 (12%) patients reported a treatment-related adverse event vs 12/25 (48%) in the solifenacin group (P < .001). No clinically significant changes were observed in any other safety endpoint. The proportions of responders in the peroneal electrical transcutaneous neuromodulation group vs the solifenacin group were 87% vs 74% with respect to Patient Perception of Intensity of Urgency Scale grade 3 urgency episodes, 87% vs 75% with respect to grade 3+4 urgency episodes, and 90% vs 94% with respect to urgency incontinence episodes. In post hoc analyses we observed significant improvement over time in multiple efficacy variables in both treatment arms.

CONCLUSIONS

Peroneal electrical transcutaneous neuromodulation is a safe and effective method for overactive bladder treatment associated with a significantly lower incidence of treatment-related adverse events compared to solifenacin and a considerably better benefit-risk profile.

Androgen receptors in the forebrain: A study in adult male cats

Androgens and their receptors are present throughout the body. Various structures such as muscles, genitals, and prostate express androgen receptors. The central nervous system also expresses androgen receptors. Androgens cross the blood-brain barrier to reach these central areas. In the central nervous system, androgens are involved in multiple functions. The current study investigated in which forebrain areas androgens are expressed in the male cat. Androgen receptor immunoreactive (AR-IR) nuclei were plotted and the results were quantified with a Heidelberg Topaz II + scanner and Linocolor 5.0 software. The density and intensity of the labeled cells were the main outcomes of interest. The analysis revealed a dense distribution of AR-IR nuclei in the preoptic area, periventricular complex of the hypothalamus, posterior hypothalamic area, ventromedial hypothalamic, parvocellular hypothalamic, infundibular, and supramammillary nucleus. Numerous AR-IR cells were also observed in the dorsal division of the anterior olfactory nucleus, lateral septal nucleus, medial and lateral divisions of the bed nucleus of the stria terminalis, lateral olfactory tract nucleus, anterior amygdaloid area, and the central and medial amygdaloid nuclei. AR-IR nuclei were predominantly observed in areas involved in autonomic and neuroendocrinergic responses which are important for many physiological processes and behaviors.

Neuro-Urology: Call for Universal, Resource-Independent Guidance

Neurogenic lower urinary tract dysfunction (NLUTD), the abnormal function of the lower urinary tract in the context of neurological pathology, has been the subject of multiple efforts worldwide for the development of clinical practice guidelines. These guidelines are based on the same body of evidence, and are therefore subject to the same gaps. For example, sexual and bowel dysfunction in the context of NLUTD, optimal renal function assessment in those who are non-ambulatory or with low muscle mass, optimal upper tract surveillance timing, and modification of diagnostic and treatment modalities for low-resource nations and communities are inadequately addressed. In addition, many aspects of the conclusions and final recommendations of the guidelines are similar. This duplicative work represents a large expenditure of time and effort, which we believe could be focused instead on evidence gaps. Here, we call for a global unified approach to create a single, resource-independent, comprehensive guidance on NLUTD, neurogenic sexual, and neurogenic bowel dysfunction. Targeted research addressing the evidence gaps should be called for and pursued. This will allow for focus to shift to filling the gaps in the evidence for future guidelines.

Regional variation in urinary catheter use in the Netherlands from 2012 to 2021: a population-based cohort

Objectives

Our aim was to evaluate trends and regional differences in the use of indwelling and intermittent urinary catheters in the community setting in the Netherlands from 2012 to 2021.

Design and methods

For this population-based cohort study, data on catheter use was collected from the Drug and Medical Devices Information System of the National Healthcare Institute of the Netherlands. This database contains information on the Dutch insured population, which was 100% of the total population in 2018. Users were divided into 12 provinces according to the Nomenclature of Territorial Units for Statistics codes. The number of catheter users was adjusted for the total population of the provinces by sex and age, and was expressed by users per 100,000 people. Negative binomial regression (NBR) was used to test for differences in clean intermittent catheter (CIC) and indwelling catheter (IDC) users across Dutch provinces.

Results

Between 2012 and 2021, IDC users increased by 44.6% from 41,619 to 60,172, and CIC users increased by 27.3% from 34,204 to 43,528. The greatest increases were mainly observed among IDC users over 85 years old and male CIC users over 65 years old. NBR showed significant differences for IDC and CIC users between the 12 provinces. CIC incidence was higher in Drenthe and Groningen (Northern Netherlands) compared to Zuid-Holland (Southern Netherlands). IDC incidence was higher in seven provinces dispersed throughout the Netherlands compared to Noord-Holland.

Conclusion

CIC and IDC users have continued to increase in recent years; this was especially observed among older men. In addition, there were regional differences in the number of CIC and IDC users; CIC was more prominent in the northern region of the Netherlands, and IDC varied between multiple provinces. Practice variation in urinary catheterization may result from patient population differences or healthcare provider preferences and their alignment with guidelines.

Variation of diagnosis and treatment of catheter-associated urinary tract infections: an online survey among caretakers involved

Background

The diagnosis of a clinically significant catheter-associated urinary tract infection (CAUTI) in patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IC) can be challenging.

Objective

To get an insight into the variation of the used definition, diagnosis and management of CAUTIs by relevant healthcare workers in the Netherlands.

Design

An online clinical scenario-based survey.

Methods

The survey was built in Limesurvey and distributed to healthcare workers from randomly selected urology departments, rehabilitation departments/centres and general practice offices between January and May 2022. Questions regarding their field of experience, management strategies, used guidelines and two hypothetical cases with clinical scenarios of a possible CAUTI were included.

Results

A total of 172 individuals participated, of which 112 completed the survey. In all, 32 individuals who completed the survey partially were also included. Participants consisted of 68 [44 urologists, 22 rehabilitation doctors (RDs) and 2 general practitioners (GPs)] doctors, 60 nurses (46 from the urology department and 14 from rehabilitation centres/departments) and 16 medical assistants (13 from urology department and 3 from GP offices). The majority consulted patients with an IC or on CIC on a daily/weekly or monthly basis. In all, 35 urologists (79.5%), 9 RDs (40.9%), 21 (45.7%) nurses in the urology department and 6 (42.9%) nurses from a rehabilitation department/centre indicated bladder irrigation as a treatment option for prevention/treatment of CAUTIs, treatment of symptoms or treatment of blockage of the catheter. In the clinical scenarios presented, treatment discrepancies were seen between subspecialties and healthcare workers. Various guidelines were named for the definition of CAUTIs.

Conclusion

A considerable variation in diagnoses and management of CAUTIs between the healthcare workers involved was seen. Uniformity in diagnosing and managing CAUTIs, to prevent overtreatment and possible resistance to antibiotics, is advised. Suitable multidisciplinary guidelines are preferred.

Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review

CONTEXT

Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group.

OBJECTIVE

To present all used definitions of UTIs in neurourological patients.

EVIDENCE ACQUISITION

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated.

EVIDENCE SYNTHESIS

After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low.

CONCLUSIONS

Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

PATIENT SUMMARY

Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE  HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

Kilohertz alternating current neuromodulation of the pudendal nerves: effects on the anal canal and anal sphincter in rats

The first two objectives were to establish which stimulation parameters of kilohertz frequency alternating current (KHFAC) neuromodulation influence the effectiveness of pudendal nerve block and its safety. The third aim was to determine whether KHFAC neuromodulation of the pudendal nerve can relax the pelvic musculature, including the anal sphincter. Simulation experiments were conducted to establish which parameters can be adjusted to improve the effectiveness and safety of the nerve block. The outcome measures were block threshold (measure of effectiveness) and block threshold charge per phase (measure of safety). In vivo, the pudendal nerves in 11 male and 2 female anesthetized Sprague Dawley rats were stimulated in the range of 10 Hz to 40 kHz, and the effect on anal pressure was measured. The simulations showed that block threshold and block threshold charge per phase depend on waveform, interphase delay, electrode-to-axon distance, interpolar distance, and electrode array orientation. In vivo, the average anal pressure during unilateral KHFAC stimulation was significantly lower than the average peak anal pressure during low-frequency stimulation (p < 0.001). Stimulation with 20 kHz and 40 kHz (square wave, 10 V amplitude, 50% duty cycle, no interphase delay) induced the largest anal pressure decrease during both unilateral and bilateral stimulation. However, no statistically significant differences were detected between the different frequencies. This study showed that waveform, interphase delay and the alignment of the electrode along the nerve affect the effectiveness and safety of KHFAC stimulation. Additionally, we showed that KHFAC neuromodulation of the pudendal nerves with an electrode array effectively reduces anal pressure in rats.

Single use versus reusable catheters in intermittent catheterisation for treatment of urinary retention: a protocol for a multicentre, prospective, randomised controlled, non-inferiority trial (COMPaRE)

INTRODUCTION

Chronic urinary retention is a common lower urinary tract disorder, mostly neurogenic or idiopathic in origin. The preferred treatment is clean intermittent urinary self-catheterisation (CISC) four to six times a day. In most European countries, virtually all patients use single use catheters, which is in contrast to several countries where the use of reusable catheters is more common. The available literature on the use of reusable catheters is conflicting and until now, no randomised controlled trial with sufficient power has been performed to investigate if reusable catheters for CISC is as safe as single use catheters.

METHODS AND ANALYSIS

We described this protocol for a prospective, randomised controlled non-inferiority trial to investigate if the use of reusable catheters is as safe as single use catheters for CISC patients, measured by symptomatic urinary tract infections (sUTIs). Secondary objectives are adverse events due to a sUTI, urethral damage, stone formation, quality of life and patient satisfaction. A cost-effectiveness analysis will also be performed. 456 Participants will be randomised into two groups stratified for age, gender, menopausal status and (non-)neurogenic underlying disorder. The intervention group will replace the reusable catheter set every 2 weeks for a new set and replace the cleaning solution every 24 hours. The control group continues to use its own catheters. The primary outcome (amount of sUTIs from baseline to 1 year) will be tested for non-inferiority. Categorical outcome measures will be analysed using χ² tests and quantitative outcome variables by t-tests or Mann-Whitney U tests. Two-sided p values will be calculated.

ETHICS AND DISSEMINATION

This protocol was reviewed and approved by the Medical Ethics Committee of the Erasmus MC (MEC 2019-0134) and will be performed according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist for non-inferiority trials. The results of this randomised controlled non-inferiority trial will be published in a peer-reviewed journal and will be publicly available.

TRIAL REGISTRATION NUMBER

NL8296.

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review

CONTEXT

Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).

OBJECTIVE

To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.

EVIDENCE ACQUISITION

A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

EVIDENCE SYNTHESIS

A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.

CONCLUSIONS

The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.

PATIENT SUMMARY

Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.

Urinary catheterization from 1997 to 2018: a Dutch population-based cohort

Background:

Our aim was to evaluate the use of indwelling, intermittent and external urinary catheters in neurogenic and non-neurogenic bladder patients in the Netherlands from 1997 to 2018.

Methods:

Data were retrieved from a population-based cohort containing information about the extramural use of medical devices in the insured population in the Netherlands. The insured population increased from 9.9 million people in 1997 to 17.1 million people in 2018 (64–100% of the Dutch population). Users are expressed by users per 100,000 insured people and total users, corrected for the overall Dutch population. The expenditures are corrected for inflation and expressed by total costs and costs per user.

Results:

During this 21-year period, indwelling catheter (IC) users doubled from 159 per 100,000 people (24,734 users) to 315 per 100,000 people (54,106 users). Clean intermittent catheter (CIC) users increased from 92 per 100,000 people (14,258 users) in 1997 to 267 per 100,000 people (45,909 users) in 2018. Of all users, 20.7% had an associated neurogenic disorder and 44.9% a non-neurogenic disorder in 2018. The total expenditure on extramural use of urinary catheters increased from 27.7 million euros in 1997 to 84.4 million euros in 2018. IC costs increased from 6.0 million euros in 1997 to 6.7 million euros in 2018, while CIC costs rose from 16.4 million euros to 74.6 million euros. Urine drainage bag costs decreased from 17.2 million in 2001 to 5.3 million in 2018.

Conclusions:

IC use has increased substantially over the past 21 years, despite the fact that CIC use increased as well. It seems that the main driver behind the prevalence in IC and CIC use, is the rise in incontinence care in older patients and the adaption of preferred CIC use in professional guidelines. At least one fifth of all users catheterize due to neurogenic reasons.

Trends in the use and costs of intermittent urinary catheters in the Netherlands from 1997 to 2018: A population-based observational study

AIM

To obtain insight into the the use and costs of clean intermittent catheterization (CIC) in the Netherlands from 1997 to 2018.

METHODS

For this population-based study, data on the use and costs of disposable catheters were provided by the Drug Information Project database. This database contains information about the Dutch insured population, which increased from 9.9 to 17.1 million persons between 1997 and 2018 (64%-100% of the Dutch population). The following trends were evaluated: (1) CIC users, (2) distribution of users by gender and age-group, (3) distribution of users by neurogenic and non-neurogenic cause for CIC, (4) total costs, and (5) costs per user. Total users are adjusted for the Dutch population. Costs are corrected for inflation and expressed in euros.

RESULTS

Extramural use of CIC increased from 14,258 users in 1997 to 45,909 users in 2018. CIC users per 100,000 persons nearly tripled from 92 users to 267 users. Male CIC users almost quadrupled from 92 to 334 per 100,000 insured persons, whereas female users more than doubled from 91 to 201 per 100,000 insured persons. In 2018, 49% of the users had a non-neurogenic cause for CIC. Total costs increased from 16.4 million euros in 1997 to 74.6 million euros in 2018. Costs per user rose from 1151 to 1624 euros (41.1%).

CONCLUSIONS

The use and costs of disposable catheters in the Netherlands increased substantially over the past two decades. Non-neurogenic bladder patients represent 49% of the population on CIC, which has not been described before in the literature.

Androgen receptors in areas of the spinal cord and brainstem: A study in adult male cats

Sex hormones, including androgens and estrogens, play an important role in autonomic, reproductive and sexual behavior. The areas that are important in these behaviors lie within the spinal cord and brainstem. Relevant dysfunctional behavior in patients with altered androgen availability or androgen receptor sensitivity might be explained by the distribution of androgens and their receptors in the central nervous system. We hypothesize that autonomic dysfunction is correlated with the androgen sensitivity of spinal cord and brainstem areas responsible for autonomic functions. In this study, androgen receptor immunoreactive (AR‐IR) nuclei in the spinal cord and brainstem were studied using the androgen receptor antibody PG21 in four uncastrated young adult male cats. A dense distribution of AR‐IR nuclei was detected in the superior layers of the dorsal horn, including lamina I. Intensely stained nuclei, but less densely distributed, were found in lamina X and preganglionic sympathetic and parasympathetic cells of the intermediolateral cell column. Areas in the caudal brainstem showing a high density of AR‐IR nuclei included the area postrema, the dorsal motor vagus nucleus and the retrotrapezoid nucleus. More cranially, the central linear nucleus in the pons contained a dense distribution of AR‐IR nuclei. The mesencephalic periaqueductal gray (PAG) showed a dense distribution of AR‐IR nuclei apart from the most central part of the PAG directly adjacent to the ependymal lining. Other areas in the mesencephalon with a dense distribution of AR‐IR nuclei were the dorsal raphe nucleus, the retrorubral nucleus, the substantia nigra and the ventral tegmental area of Tsai. It is concluded that AR‐IR nuclei are located in specific areas of the central nervous system that are involved in the control of sensory function and autonomic behavior. Furthermore, damage of these AR‐IR areas might explain related dysfunction in humans.

A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition

Purpose

Functional neuroimaging is a powerful and versatile tool to investigate central lower urinary tract (LUT) control. Despite the increasing body of literature there is a lack of comprehensive overviews on LUT control. Thus, we aimed to execute a coordinate based meta-analysis of all PET and fMRI evidence on descending central LUT control, i.e. pelvic floor muscle contraction (PFMC) and micturition.

Materials and methods

A systematic literature search of all relevant libraries was performed in August 2020. Coordinates of activity were extracted from eligible studies to perform an activation likelihood estimation (ALE) using a threshold of uncorrected p <0.001.

Results

20 of 6858 identified studies, published between 1997 and 2020, were included. Twelve studies investigated PFMC (1xPET, 11xfMRI) and eight micturition (3xPET, 5xfMRI). The PFMC ALE analysis (n = 181, 133 foci) showed clusters in the primary motor cortex, supplementary motor cortex, cingulate gyrus, frontal gyrus, thalamus, supramarginal gyrus, and cerebellum. The micturition ALE analysis (n = 107, 98 foci) showed active clusters in the dorsal pons, including the pontine micturition center, the periaqueductal gray, cingulate gyrus, frontal gyrus, insula and ventral pons. Overlap of PFMC and micturition was found in the cingulate gyrus and thalamus.

Conclusions

For the first time the involved core brain areas of LUT motor control were determined using ALE. Furthermore, the involved brain areas for PFMC and micturition are partially distinct. Further neuroimaging studies are required to extend this ALE analysis and determine the differences between a healthy and a dysfunctional LUT. This requires standardization of protocols and task-execution.

Transcutaneous Electrical Nerve Stimulation and Percutaneous Tibial Nerve Stimulation to Treat Idiopathic Nonobstructive Urinary Retention: A Systematic Review

CONTEXT

Transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS) provide minimally invasive ways to treat idiopathic nonobstructive urinary retention (NOUR).

OBJECTIVE

To assess the efficacy of TENS and PTNS for treating idiopathic NOUR.

EVIDENCE ACQUISITION

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Embase, Medline, Web of Science Core Collection, and the Cochrane CENTRAL register of trials were searched for all relevant publications until April 2020.

EVIDENCE SYNTHESIS

A total of 3307 records were screened based on the title and abstract. Eight studies met the inclusion criteria and none of the exclusion criteria. Five studies, all from the same group, reported the efficacy of PTNS and two that of TENS in adults with idiopathic NOUR. One study reported the efficacy of TENS in children with idiopathic NOUR. Objective success was defined as a ≥50% decrease in the number of catheterizations per 24 h or in the total catheterized volume in 24 h. The objective success rate of PTNS ranged from 25% to 41%. Subjective success was defined as the patient's request for continued chronic treatment with PTNS, and ranged from 46.7% to 59%. Eighty percent of women who underwent transvaginal stimulation reported an improvement such as a stronger stream when voiding. TENS in children reduced postvoid residual and urinary tract infections.

CONCLUSIONS

The efficacy of TENS and PTNS in the treatment of idiopathic NOUR is limited and should be verified in larger randomized studies before application in clinical practice.

PATIENT SUMMARY

The outcomes of transcutaneous electrical nerve stimulation and percutaneous tibial nerve stimulation for the treatment of urinary retention of unknown origin were reviewed. Whether these treatments are superior to other treatments could not be established.

European Association of Urology Guidelines Office Rapid Reaction Group: An Organisation-wide Collaborative Effort to Adapt the European Association of Urology Guidelines Recommendations to the Coronavirus Disease 2019 Era

The coronavirus disease 2019 (COVID-19) pandemic is unlike anything seen before by modern science-based medicine. Health systems across the world are struggling to manage it. Added to this struggle are the effects of social confinement and isolation. This brings into question whether the latest guidelines are relevant in this crisis. We aim to support urologists in this difficult situation by providing tools that can facilitate decision making, and to minimise the impact and risks for both patients and health professionals delivering urological care, whenever possible. We hope that the revised recommendations will assist urologist surgeons across the globe to guide the management of urological conditions during the current COVID-19 pandemic.

Acute effect of sacral neuromodulation for treatment of detrusor overactivity on urodynamic parameters

Aim

The aim of this study is to evaluate the acute effects of sacral neuromodulation (SNM) on various urodynamic parameters.

Methods

Patients with overactive bladder and detrusor overactivity (DO) who were planned for percutaneous nerve evaluation (PNE) were included. Directly after the PNE, a urodynamic study (UDS) was performed. The stimulation was turned off during the first UDS (UDS 1), and during the second filling cycle, stimulation was turned on (UDS 2). The UDS was followed by a test phase of 1 week and the bladder diaries were evaluated during an outpatient clinic visit. Primary outcome measures were the differences in UDS parameter values with SNM off and on.

Results

Ten female patients were included in the study and completed the study protocol. Eight patients showed ≥50% improvement of symptoms following a test phase. There were no differences between UDS 1 and UDS 2 in the UDS parameters; bladder volume at first sensation, bladder volume at first DO, highest DO pressure, bladder capacity, maximum flow rate, and pressure at maximum flow rate.

Discussion

None of the aforementioned urodynamic parameters was influenced by acute SNM in patients who responded to SNM. To the best of our knowledge, this is the first study investigating the acute effects of SNM on bladder function.

Whole brain 7T-fMRI during pelvic floor muscle contraction in male subjects

Aim

The primary aim of this study is to demonstrate that 7‐tesla functional magnetic resonance imaging (7T‐fMRI) can visualize the neural representations of the male pelvic floor in the whole brain of a single subject.

Methods

In total, 17 healthy male volunteers (age 20‐47) were scanned in a 7T‐MRI scanner (Philips Achieva). The scanning protocol consisted of two functional runs using a multiband echo planar imaging sequence and a T1‐weighted scan. The subjects executed two motor tasks, one involving consecutive pelvic floor muscle contractions (PFMC) and a control task with tongue movements.

Results

In single subjects, results of both tasks were visualized in the cortex, putamen, thalamus, and the cerebellum. Activation was seen during PFMC in the superomedial and inferolateral primary motor cortex (M1), supplementary motor area (SMA), insula, midcingulate gyrus (MCG), putamen, thalamus, and in the anterior and posterior lobes of the cerebellum. During tongue movement, activation was seen in the inferolateral M1, SMA, MCG, putamen, thalamus, and anterior and posterior lobes of the cerebellum. Tongue activation was found in the proximity of, but not overlapping with, the PFMC activation. Connectivity analysis demonstrated differences in neural networks involved in PFMC and tongue movement.

Conclusion

This study demonstrated that 7T‐fMRI can be used to visualize brain areas involved in pelvic floor control in the whole brain of single subjects and defined the specific brain areas involved in PFMC. Distinct differences between brain mechanisms controlling the pelvic floor and tongue movements were demonstrated using connectivity analysis.

Multiuse Catheters for Clean Intermittent Catheterization in Urinary Retention: Is There Evidence of Inferiority?

In Europe, urinary retention is managed with single-use catheters but there is uncertainty regarding their superiority over multiuse catheters.

Long-term results of continent catheterizable urinary channels in adults with non-neurogenic or neurogenic lower urinary tract dysfunction

Objectives: To evaluate the long-term results after the construction of a Continent Catheterizable Urinary Conduit (CCUC) in adults. Methods: This study retrospectively reviewed the charts of 41 adults from two tertiary centers who received a CCUC. The demographics, underlying diseases, indications for a CCUC and outcomes such as the reoperation rate and the occurrence of complications were extracted. The patient reported outcome was measured with the Patient Global Impression of Improvement (PGI-I) scale and four additional questions about continence, leakage and stomal problems. Results: Twenty-nine patients were women. The median age at surgery was 32 years, with a median follow-up of 52 months. Twenty-six patients had a neurogenic bladder. The reoperation rate was 48.8%, with a median of 10.5 months after constructing the CCUC. Superficial stomal stenosis was the most common registered complication (20 times) and stoma revision was the most often performed reoperation (12 times). Twenty-four patients completed the PGI-I; the mean improvement rating was 2 (=much better). Conclusion: The construction of a CCUC in adults is associated with a high complication and reoperation rate. The high reoperation rate is in accordance with the sparse literature. Despite this, patients reported 'much better' on the PGI-I.

Outcome and complications of adjustable continence therapy (ProACTTM ) in the treatment of urinary incontinence after transurethral resection of the prostate: A multicenter study

Aim

To evaluate the outcome of adjustable continence balloons in the treatment of stress urinary incontinence (SUI) after transurethral resection of the prostate (TURP).

Methods

In two tertiary centers, adjustable continence balloons were implanted in 29 patients with post‐TURP SUI between 2007 and 2018. Endpoints of this retrospective multicenter study were patient‐reported changes in pad count and complications. Dry was defined as no pad or one security pad.

Results

Preoperative urinary incontinence was mild in 7 (24%), moderate in 12 (41%), and severe in 10 (35%) patients. The median follow‐up duration was 21 (interquartile range [IQR], 11‐43) months. Within 30 days postoperatively, a Clavien‐Dindo grade less than or equal to II complication occurred in 24% of the patients. Reintervention rate was 24%. Six and 12 months after implantation, the International Prostate Symptom Score (IPSS) quality‐of‐life item improved significantly from 5 (IQR, 5‐6) preoperatively to 3 (IQR, 1‐4.5) and 1 (IQR, 0‐3), respectively. At last visit (median 21 months after implantation), the outcome on continence had improved in 76% of the patients, including, 45% dry patients. After a median follow‐up of 28 months (IQR, 13‐63; N = 23), all but one patient reported improvement on the Patient Global Impression of Improvement (PGI‐I) scale. In detail, 10 patients reported “very much better” condition compared with before the implantation, 10 patients “much better,” two patients “a little better,” and one patient “no change.” Daily pad use decreased from three (IQR, 2‐5) to one (IQR, 0‐2) pads/day (P < 0.001).

Conclusions

This is hitherto, the first study reporting results of adjustable continence balloons in the treatment of post‐TURP SUI. The therapy was found to be safe and efficient. The majority of our study population reported improvement on their condition and greater than or equal to 50% reduction in daily pad use.

Long-term follow-up of bladder outlet procedures in children with neurogenic urinary incontinence

INTRODUCTION

Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions.

OBJECTIVE

The objective of this study was to evaluate the long-term outcome on continence and re-intervention rate of bladder outlet procedures in children with neurogenic urinary incontinence at the study institution.

DESIGN

All children who underwent a bladder neck procedure between 1992 and 2017 at the study institution were retrospectively reviewed. Continence at the end of follow-up was the primary endpoint, defined as 'dry' when there was an interval of a minimum of 4 h without urinary leakage. Non-parametric tests were used for statistical analysis.

RESULTS

During this 25-year period, a total of 60 children underwent a bladder outlet procedure, either a bladder neck sling (n = 43) or a bladder neck reconstruction (n = 17). The median age at surgery was 11.6 years (interquartile range [IQR] 7.8-13.9). Concomitant surgery consisted of bladder augmentation in 80% and continent catheterizable urinary channel in 97% of children. Dry rate within 1 year was 38%. After a median follow-up of 10.4 years (IQR 6.5-15.5), 77% of all children were dry. Twenty-five children (42%) needed one or more re-interventions, including redo of the bladder outlet procedure, other type of outlet procedure, bulking agents, bladder augmentation, and bladder neck closure.

DISCUSSION

This study confirms that achieving continence is a challenge. The inconsistent use of the definition of urinary continence creates confusion in the literature and makes comparison of outcome with other studies difficult. Openness of (long-term) results in achieving urinary continence is important and helpful for future patients.

CONCLUSION

On the long term, the majority of children with neurogenic urinary incontinence were dry after a bladder outlet procedure, but a considerable number of patients had a re-intervention. The initial outcome on continence was slightly disappointing. Reporting long-term results is essential and helpful for patient counseling.

Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review

AIM

The main goals of neurogenic lower urinary tract dysfunction (NLUTD) management are preventing upper urinary tract damage (UUTD), improving continence, and quality of life. Here, we aimed to systematically assess all available evidence on urodynamics predicting UUTD in patients with NLUTD.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in March 2017. Only neuro-urological patients assessed by urodynamics were included. Any outcome of upper urinary tract function were evaluated.

RESULTS

Forty-nine studies (1 randomized controlled trial, 9 prospective, and 39 retrospective case series) reported urodynamic data on 4930 neuro-urological patients. Of those, 2828 (98%) were spina bifida (SB) children. The total number of adults was 2044, mainly having spinal cord injury (SCI) (60%). A low bladder compliance was found in 568 (46.3%) and 341 (29.3%) of the paediatric and adult population, respectively. Hydronephrosis (HDN) was detected in 557 children (27.8%) in 19/28 studies and 178 adults (14.6%), mainly SCI, in 14/21 studies. Nine out of 30 multiple sclerosis (MS) patients affected by HDN (16.8%) showed low compliance in 4/14 studies.

CONCLUSIONS

Patients with SB and SCI have a higher risk of developing UUTD (mainly reported as HDN) compared to those with MS. Reduced compliance and high DLPP were major risk factors for UUTD. Although our findings clarify the mandatory role of urodynamics in the management of NLUTD, standardization and better implementation of assessments in daily practice may further improve outcomes of neuro-urological patients based on objective measurements, that is, urodynamics.

Outcome and complications of adjustable continence therapy (ProACT™) after radical prostatectomy: 10 years' experience in 143 patients

AIMS

To evaluate our outcomes of the adjustable continence balloons ProACT™ for the treatment of male stress urinary incontinence after radical prostatectomy.

METHODS

Between May 2007-August 2016 the ProACT™ was implanted in 143 patients without a history of radiotherapy. Endpoints were patient-reported changes in pad counts and complications. Treatment was considered successful if no pad or just one "security" pad per day sufficed, and improved if daily pad use was reduced by ≥50%.

RESULTS

Incontinence before implantation was mild in 36 (25%), moderate in 57 (40%), and severe in 50 (35%) patients. Complications within 30 days were classified by the Clavien-Dindo classification; eight (5.6%) grade I, three (2.1%) grade II, three (2.1%) grade IIIb, and 129 (90.2%) patients had no complication. Revision was done in 43 (30%) patients. The IPSS quality of life item improved significantly from 5.0 (IQR 4.0-5.0) preoperative to 2.0 (IQR 1.0-4.0) and 1.0 (IQR 0.0-3.0) 6 and 12 months after implantation, respectively. After a median follow up of 56 months (range 28 to 79, n = 112), 72 (64%) patients were improved, including 51 (45%) patients were successful. Daily pad use decreased from 3.0 to 1.0 (67% reduction). The median outcome on the Patient Global Impression of Improvement scale was "much better," and 97 (87%) patients perceived improvement.

CONCLUSIONS

The minimally invasive ProACT™ device showed a clear beneficial continence outcome in patients with stress urinary incontinence after radical prostatectomy. The majority of the patients were satisfied and perceived improvement ≥50% on daily pad use on the long term.

A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review

CONTEXT

Impaired sexual function has a significant effect on quality of life. Various patient-reported outcome measures (PROMs) are available to evaluate sexual function. The quality of the PROMs to be used for neurologic patients remains unknown.

OBJECTIVE

To systematically review which validated PROMs are available to evaluate sexual function in neurologic patients and to critically assess the quality of the validation studies and measurement properties for each identified PROM.

EVIDENCE ACQUISITION

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The included publications were assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist.

EVIDENCE SYNTHESIS

Twenty-one studies for PROMs regarding sexual function were identified for the following patient groups: spinal cord injury (11 studies), multiple sclerosis (MS; 6 studies), Parkinson's disease (2 studies), traumatic brain injury (1 study), and epilepsy (1 study). The evidence for the quality of PROMs was found to be variable, and overall evaluation of measurement properties was lacking in 71% of the studies. The measurement error and responsiveness were not studied in any of the publications.

CONCLUSIONS

Several PROMs have been identified to evaluate sexual function in neurologic patients. Strong evidence was found only for the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 for patients with MS, although evidence was lacking for certain measurement properties as well. Future research should focus on identifying relevant PROMs and establishing adequate quality for all measurement properties in studies with high methodological quality.

PATIENT SUMMARY

A quality assessment of patient-reported outcome measures (PROMs) for sexual function in neurologic patients was made. The evidence found for good PROMs was limited. Studies with high methodological quality are needed to improve the quality of PROMs to evaluate sexual function in neurologic patients.

The validation of the Dutch SF-Qualiveen, a questionnaire on urinary-specific quality of life, in spinal cord injury patients

BACKGROUND

Optimizing the patients' quality of life is one of the main goals in the urological management of spinal cord injury (SCI) patients. In this study we validated the Dutch SF-Qualiveen, a short questionnaire that measures the urinary-specific quality of life, in SCI patients. No such measure is yet available for this patient group.

METHODS

In 2015-2016 SCI patients with urinary symptomatology who visited the outpatient clinics of Urology at the Erasmus Medical Centre and Rehabilitation at Rijndam Revalidation completed the SF-Qualiveen and UDI-6 during the visit and 1-2 weeks later. The UDI-6, a urinary tract symptom inventory, served as gold standard. Controls, recruited from the Otolaryngology outpatient clinic, completed the questionnaires once. Content-, construct-, and criterion validity and reliability (internal consistency and reproducibility) of the SF-Qualiveen were determined.

RESULTS

Fifty seven SCI patients and 50 controls were included. 12 SCI patients asserted that the SF-Qualiveen covered their bladder problems (good content validity). Patients' SF-Qualiveen scores being positively associated with severity of urinary symptoms and patients' scores being higher than those of controls indicated good construct validity. The positive association that was found between SF-Qualiveen and UDI-6 in patients (r = 0.66-0.67, P < 0.001) and controls (r = 0.63, P < 0.001) confirmed good criterion validity. Internal consistency (Cronbach's alpha 0.89-0.92) and reproducibility (intraclass correlation coefficient 0.94) of the SF-Qualiveen were good.

CONCLUSIONS

The Dutch SF-Qualiveen is a valid and reliable tool to measure the urinary-specific quality of life in SCI patients.

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review

AIMS

To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients.

METHODS

This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017.

RESULTS

A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found.

CONCLUSIONS

We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.

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

Background

Several studies have shown that the antimuscarinic treatment of overactive bladder is characterized by low long-term persistence rates. We have investigated the persistence of solifenacin in real life by means of telephonic interviews in a prospective cohort. We included both patients with idiopathic overactive bladder as well as neurogenic overactive bladder.

Methods

From June 2009 until July 2012 patients with idiopathic or neurogenic overactive bladder who were newly prescribed solifenacin were included. In total 123 subjects were followed prospectively during one year by means of four telephonic interviews, which included questions about medication use and adverse events.

Results

After one year 40% of all patients included was still using solifenacin, 50% discontinued and 10% was lost to follow-up. In the neurogenic group 58% was still using solifenacin versus 32% in the idiopathic group after one year (p < 0,05). The main reasons to stop solifenacin were lack of efficacy, side effects and a combination of both.

Conclusions

This prospective cohort study showed a real life continuation rate of 40% after 12 months. This continuation rate is higher than found in most other studies.

The use of regular telephonic evaluation might have improved medication persistence. The findings of this study also suggest that patients with neurogenic overactive bladder have a better persistence with this method of evaluation compared to patients with idiopathic overactive bladder.

Trial registration

This study was retrospectively registered on march 17, 2017 at the ISRCTN registry with study ID ISRCTN13129226.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0216-4) contains supplementary material, which is available to authorized users.

Long-term effectiveness and complication rates of bladder augmentation in patients with neurogenic bladder dysfunction: A systematic review

AIMS

To systematically evaluate effectiveness and safety of bladder augmentation for adult neuro-urological patients.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement was followed for review of publications. The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched until January 2015. No limitations were placed on date or language. Non-original articles, conference abstracts, and publications involving children and animals were excluded. Risk-of-bias and confounder assessment was performed.

RESULTS

A total of 20 studies including 511 patients were eligible for inclusion. The level of evidence for the included studies was low, most level 4 studies with only one level 3 study. The data were narratively synthesized. Across all studies high risk-of bias and confounding was found. Primary outcomes were assessed in 16 of the 20 studies and showed improved quality of life and anatomical changes as well as stable renal function. The secondary outcomes were reported in 17 of the 20 studies and urodynamic parameters and continence all demonstrated improvement after bladder reconstruction. Long-term complications continued up to 10 years post-operatively, including bowel dysfunction in 15% of the patients, stone formation in 10%, five bladder perforations and one bladder cancer.

CONCLUSIONS

Available studies are not plentiful and of relatively poor quality, appropriately designed prospective studies are urgently needed. Despite this, bladder augmentation appears to be a highly effective procedure at protecting the upper urinary tract and improving quality of life. However, it is associated with relatively high morbidity in both the short and long term.

Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review

AIMS

To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients.

METHODS

The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO).

RESULTS

After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies.

CONCLUSIONS

CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.

Maximum Urethral Closure Pressure Increases After Successful Adjustable Continence Therapy (ProACT) for Stress Urinary Incontinence After Radical Prostatectomy

OBJECTIVE

To evaluate changes of the urethral pressure profile (UPP) after implantation of adjustable continence therapy (ProACT), a minimally invasive procedure in which 2 volume-adjustable balloons are placed periurethrally for treatment of male stress urinary incontinence. The working mechanism of the ProACT to achieve continence has not been fully understood. We hypothesized that successful treatment with ProACT improves urinary continence by inducing a significant increase in static urethral pressure.

MATERIALS AND METHODS

We included patients who underwent UPP before and after ProACT implantation. UPPs were initially performed with the Brown-Wickham water perfusion method and later with the T-DOC Air-Charged catheter method. Pre- and postoperative UPPs and International Prostate Symptom Scores were evaluated. UPP measurements of successfully (no or 1 precautionary pad per day) and unsuccessfully treated patients were compared.

RESULTS

Twenty-seven patients were included in the study; 23 patients were successfully and 4 patients were unsuccessfully treated. Maximum urethral closure pressure (MUCP) increased significantly from median 58.0 to 79.0 cmH2O in the successfully treated group (P = .001). Within the subgroup of unsuccessfully treated patients, MUCP did not change significantly (P = .715). The change in MUCP was statistically significantly different between the successful and unsuccessful group (P = .034). Total score of the International Prostate Symptom Scores did not change significantly after ProACT implantation (P = .097).

CONCLUSION

Successful treatment with ProACT is associated with a significant increase of MUCP. This implies that increased static urethral pressure contributes to the working mechanism of the ProACT device to achieve continence.

Intermittent sacral neuromodulation for idiopathic urgency urinary incontinence in women

AIMS

SNM has been proven to be effective in the treatment of refractory UUI. Total costs and patient burden due to regular battery changes may prevent broad implementation of this treatment. The aim was to achieve a minimal improvement of 50% in incontinence episodes compared to pre-SNM by using iSNM.

METHODS

This prospective cohort study was performed in women with UUI receiving treatment with SNM for a minimum of 6 months. The neurostimulator was programmed to 8 hr "on" and 16 hr "off" per day for 12 weeks. Prior to iSNM, data were collected during no SNM and cSNM. Bladder diaries and various patient reported outcome measures were collected at predetermined time points: 1-5 weeks, and 8, 12, and 16 weeks. Nonparametric tests were used for the statistical analysis.

RESULTS

Of the 19 patients 63% showed an improvement of >50% of incontinence episodes during iSNM compared to pre-SNM. Bladder diary parameters showed a difference between pre-SNM and iSNM median (P-value); incontinence episodes/24 hr, 4.1-1.0 (P = 0.04), incontinence severity, 2.0-1.0 (P = 0.001), voiding episodes/24 hr, 13.0-8.0 (P = 0.001), and voided volume, 149-219 ml (P = 0.04). The UDI-6, 50.0-27.8 (P = 0.03), and the IIQ-7 scores, 50.0-9.5 (P = 0.04) also showed a significant improvement. No difference was demonstrated between iSNM and cSNM.

CONCLUSIONS

Compared to pre-SNM parameters, iSNM shows an improvement in both objective and subjective outcomes. Specifically no difference was found between iSNM and cSNM, indicating that iSNM could be a feasible and cost-effective alternative. Neurourol. Urodynam. 36:385-389, 2017. © 2015 Wiley Periodicals, Inc.

Validation of a Dutch version of the Actionable 8-item screening questionnaire for neurogenic bladder overactivity in multiple sclerosis: an observational web-based study

Background

In patients with multiple sclerosis (MS) the impact of urological symptoms on quality of life and daily activities is considerable. Yet, a substantial percentage of patients may not be urologically evaluated and thus fail to be treated concordantly. The 8-item Actionable questionnaire is a validated English screening tool for the detection of neurogenic bladder overactivity in MS. To enable the use of the 8-item Actionable in The Netherlands and Belgium we translated the questionnaire into the Dutch language and investigated the test-retest reliability and the concurrent validity of the Dutch version.

Methods

The process of translating the English Actionable questionnaire into the Dutch language included forward translations and back-translations. Then, in an online observational study, MS patients completed the Dutch Actionable at Days 1 and 8, and the Multiple Sclerosis Quality of Life 54-Items (MSQoL-54) and Multiple Sclerosis Impact Profile (MSIP) questionnaires at Day 1; the Expanded Disability Status Scale (EDSS) score was assessed by phone at Day 1. For assessment of the test-retest reliability Pearson’s correlation coefficient (r) between the Day 1 and Day 8 Actionable scores was calculated. For assessment of the concurrent validity r values were calculated between the Day 1 Actionable score and the EDSS score, the Physical and Mental MSQoL-54 composites, and the MSIP domain and symptom disability scores.

Results

Study population: N = 141 (106 female, 35 male) (80 relapsing remitting, 48 progressive, 13 unknown), mean age 47.8 (standard deviation [SD] 10.4) years, mean EDSS score 4.7 (SD 1.8); 137 patients completed the Day 8 assessment. Pearson’s r between Actionable scores Day 1 and Day 8: 0.85 (P < .0001). Pearson’s r between Actionable score Day 1 and scores for EDSS 0.41 (P < 0.0001), MSQoL-54 Physical −0.31 (P = 0.0002), MSQoL-54 Mental −0.29 (P = 0.0005), MSIP Excretion and Reproductive Functions 0.44 (P < 0.0001), Muscle and Movement Functions 0.39 (P < .0001), Basic Movement Activities 0.37 (P < 0.0001), Activities of Daily Living 0.32 (P < 0.0001), Participation in Life Situations 0.29 (P = 0.0006) and Mental Functions 0.20 (P = 0.0189).

Conclusions

The Dutch version of the Actionable urological screening tool for MS shows a good test-retest reliability and a good concurrent validity with disabilities and HRQoL.

The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12): validation of the Dutch version

Objectives and hypothesis

To establish the reliability and validity of the Dutch version of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) in women with pelvic floor dysfunction.

Methods

The PISQ-12 was translated into Dutch following a standardized translation process. A group of 124 women involved in a heterosexual relationship who had had symptoms of urinary incontinence, fecal incontinence and/or pelvic organ prolapse for at least 3 months were eligible for inclusion. A reference group was used for assessment of discriminative ability. Data were analyzed for internal consistency, reproducibility, construct validity, responsiveness, and interpretability. An alteration was made to item 12 and was corrected for during the analysis.

Results

The patient group comprised 70 of the 124 eligible women, and the reference group comprised 208 women from a panel representative of the Dutch female population. The Dutch PISQ-12 showed an adequate internal consistency with a Cronbach’s alpha of 0.57 – 0.69, increasing with correction for item 12 to 0.69 – 0.75, for the reference and patient group, respectively. Scores in the patient group were lower (32.6 ± 6.9) than in the reference group (36.3 ± 4.8; p = 0.0001), indicating a lower sexual function in the patient group and good discriminative ability. Reproducibility was excellent with an intraclass correlation coefficient for agreement of 0.93 (0.88 – 0.96). A positive correlation was found with the Short Form-12 Health Survey (SF-12) measure representing good criterion validity. Due to the small number of patients who had received treatment at the 6-month follow-up, no significant responsiveness could be established.

Conclusions

This study showed that the Dutch version of the PISQ-12 has good validity and reliability. The PISQ-12 will enable Dutch physicians to evaluate sexual dysfunction in women with pelvic floor disorders.

Supraspinal Control of Urine Storage and Micturition in Men--An fMRI Study

Despite the crucial role of the brain in the control of the human lower urinary tract, little is known about the supraspinal mechanisms regulating micturition. To investigate the central regulatory mechanisms activated during micturition initiation and actual micturition, we used an alternating sequence of micturition imitation/imagination, micturition initiation, and actual micturition in 22 healthy males undergoing functional magnetic resonance imaging. Subjects able to micturate (voiders) showed the most prominent supraspinal activity during the final phase of micturition initiation whereas actual micturition was associated with significantly less such activity. Initiation of micturition in voiders induced significant activity in the brainstem (periaqueductal gray, pons), insula, thalamus, prefrontal cortex, parietal operculum and cingulate cortex with significant functional connectivity between the forebrain and parietal operculum. Subjects unable to micturate (nonvoiders) showed less robust activation during initiation of micturition, with activity in the forebrain and brainstem particularly lacking. Our findings suggest that micturition is controlled by a specific supraspinal network which is essential for the voluntary initiation of micturition. Once this network triggers the bulbospinal micturition reflex via brainstem centers, micturition continues automatically without further supraspinal input. Unsuccessful micturition is characterized by a failure to activate the periaqueductal gray and pons during initiation.

Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction

BACKGROUND

The most common type of functional bladder outlet obstruction in patients with neurogenic bladder is detrusor-sphincter dyssynergia (DSD). The lack of co-ordination between the bladder and the external urethral sphincter muscle (EUS) in DSD can result in poor bladder emptying and high bladder pressures, which may eventually lead to progressive renal damage.

OBJECTIVES

To assess the effectiveness of different surgical therapies for the treatment of functional bladder outlet obstruction (i.e. DSD) in adults with neurogenic bladder dysfunction.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, and handsearching of journals and conference proceedings (searched 20 February 2014), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing a surgical treatment of DSD in adults suffering from neurogenic bladder dysfunction, with no treatment, placebo, non-surgical treatment, or other surgical treatment, alone or in combination.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included five trials (total of 199 participants, average age of 40 years). The neurological diseases causing DSD were traumatic spinal cord injury (SCI), multiple sclerosis (MS), or congenital malformations.One trial compared placement of sphincteric stent prosthesis with sphincterotomy. For urodynamic measurements, results for postvoid residual urine volume (PVR) and cystometric bladder capacity were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy at three, six, 12, and 24 months. Results for maximum detrusor pressure (Pdet.max) were also inconclusive at three, six, and 12 months; however, after two years, the Pdet.max after sphincterotomy was lower than after stent placement (mean difference (MD) -30 cmH2O, 95% confidence interval (CI) 8.99 to 51.01).Four trials considered botulinum A toxin (BTX-A) injection in the EUS, either alone or in combination with other treatments. The comparators included oral baclofen, oral alpha blocker, lidocaine, and placebo. The BTX-A trials all differed in protocols, and therefore we did not undertake meta-analysis. A single 100 units transperineal BTX-A injection (Botox®) in patients with MS resulted in higher voided urine volumes (MD 69 mL, 95% CI 11.87 to 126.13), lower pre-micturition detrusor pressure (MD -10 cmH2O, 95% CI -17.62 to -2.38), and lower Pdet.max (MD -14 cmH2O, 95% CI -25.32 to -2.68) after 30 days, compared to placebo injection. Results for PVR using catheterisation, basal detrusor pressure, maximal bladder capacity, maximal urinary flow, bladder compliance at functional bladder capacity, maximal urethral pressure, and closure urethral pressure at 30 days were inconclusive and consistent with benefit of either BTX-A injection or placebo injections. In participants with SCI, treatment with 200 units of Chinese manufactured BTX-A injected at eight different sites resulted in better bladder compliance (MD 7.5 mL/cmH2O, 95% CI -10.74 to -4.26) than participants who received the same injections with the addition of oral baclofen. Results for maximum uroflow rate, maximal cystometric capacity, and volume per voiding were inconclusive and consistent with benefit of either BTX-A injection or BTX-A injection with the addition of oral baclofen. However, the poor quality of reporting in this trial caused us to question the relevance of bladder compliance as an adequate outcome measure.In participants with DSD due to traumatic SCI, MS, or congenital malformation, the results for PVRs after one day were inconclusive and consistent with benefit of either a single 100 units transperineal BTX-A (Botox®) injection or lidocaine injection. However, after seven and 30 days of BTX-A injection, PVRs were lower (MD -163 and -158 mL, 95% CI -308.65 to -17.35 and 95% CI -277.57 to -39.03, respectively) compared to participants who received lidocaine injections. Results at one month for Pdet.max on voiding, EUS activity in electromyography, and maximal urethral pressure were inconclusive and consistent with benefit of either BTX-A or lidocaine injections.Finally, one small trial consisting of five men with SCI compared weekly BTX-A injections with normal saline as placebo. The placebo had no effect on DSD in the two participants allocated to the placebo treatment. Their urodynamic parameters were unchanged from baseline values until subsequent injections with BTX-A once a week for three weeks. These subsequent injections resulted in similar responses to those of the three participants who were allocated to the BTX-A treatment. Unfortunately, the report presented no data on placebo treatment.Only the trial that compared sphincterotomy with stent placement reported outcome measures renal function and urologic complications related to DSD. Results for renal function at 12 and 24 months, and urologic complications related to DSD at three, six, 12, and 24 months were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy.Adverse effects reported were haematuria due to the cystoscopic injection and muscle weakness, of which the latter may be related to the BTX-A dose used.All trials had some methodological shortcomings, so insufficient information was available to permit judgement of risk of bias. At least half of the trials had an unclear risk of selection bias and reporting bias. One trial had a high risk of attrition bias, and another trial had a high risk of reporting bias.

AUTHORS' CONCLUSIONS

Results from small studies with a high risk of bias have identified evidence of limited quality that intraurethral BTX-A injections improve some urodynamic measures after 30 days in the treatment of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. The necessity of reinjection of BTX-A is a significant drawback; a sphincterotomy might therefore be a more effective treatment option for lowering bladder pressure in the long-term.However, because of the limited availability of eligible trials, this review was unable to provide robust evidence in favour of any of the surgical treatment options. More RCTs are needed, measuring improvement on quality of life, and on other types of surgical treatment options for DSD since these are lacking. Future RCTs assessing the effectiveness of BTX-A injections also need to address the uncertainty about the optimal dose and mode of injection for this specific type of urological condition.

Sacral neuromodulation as treatment for refractory idiopathic urge urinary incontinence: 5-year results of a longitudinal study in 60 women

PURPOSE

We evaluated the results of sacral neuromodulation after 5-year followup in women with refractory idiopathic urge urinary incontinence.

MATERIALS AND METHODS

A neuromodulation system with an original (nontined) lead was implanted by open surgery after a positive percutaneous nerve evaluation in 60 women from 1990 to 2004. Voiding incontinence diary parameters were used to evaluate efficacy. Success was defined as at least a 50% decrease in the number of incontinence episodes or pads used daily. Safety was also evaluated.

RESULTS

The success rate gradually decreased from 52 patients (87%) at 1 month to 37 (62%) at 5 years. Complete continence persisted in 15% of patients. The system was still used by 80% of patients at 5 years. In 32 patients a total of 57 adverse events occurred, which were not severe (Clavien grade I and IIIb in 61% and 39%, respectively).

CONCLUSIONS

Sacral neuromodulation appears to be a safe technique for refractory idiopathic urge urinary incontinence in women. The success rate gradually decreased to 62% after 5 years with 15% of patients completely continent.