Sacral neuromodulation for the treatment of refractory urinary urge ...

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2086 Sherman et al Table II Comparison of surgical, incontinence, and urodynamic parameters between younger and older respondents Young Older responders responders P- Measurements N (%) (%) value Time since incontinence surgery (O4 y) 20 25.0 33.3 .69 Pelvic floor muscle %2 20 37.5 41.6 .85 Prepad weight (g) O400 20 50.0 50.0 .99 Incontinence episodes (no.) O5 20 12.5 66.7 .02 Pads/day (no.) R5 20 62.5 50.0 .58 Void volume (mL) R150 20 75.0 75.0 .99 Frequency (no. voids/ day) O10 20 50.0 50.0 .99 Pdet@Qmax (cm H2O) O20 9 60.0 50.0 .76 Flow rate (mL/s) !12 11 57.1 50.0 .99 Presence of detrusor overactivity 19 71.4 50.0 .36 Pdet@Qmax, Detrusor pressure (cm H2O) at maximum flow (mL/ second). Table III Comparison of surgical, incontinence, and urodynamic measurements for older respondents and nonrespondents Older Older non responders responders P- Measurements N (%) (%) value Time since incontinence surgery (O4 y) 21 15.4 62.5 .03 Pelvic floor muscle %2 21 15.4 62.4 .03 Prepad weight (g) O400 21 38.5 75.0 .10 IE/day (no.) O5 21 61.5 50.0 .60 Pads/day (no.) R5 21 69.2 25.0 .05 Void volume (mL) R150 20 50.0 87.5 .09 Frequency (no. voids/day) O10 20 50.0 37.5 .58 Pdet@Qmax (cm H2O) O20 11 50.0 80.0 .30 Flow rate (mL/s) !12 11 60.0 33.3 .38 Presence of detrusor overactivity 21 69.2 62.5 .75 retention is believed to be due to a primary failure of relaxation of the striated urethral sphincter. 19,23 The mechanism of action for neuromodulation in retention patients is believed to be an activation of somatic afferent axons in the sacral spinal roots causing an inhibition of reflex pathways to the urethral outlet. This ultimately relieves pelvic floor spasticity, releasing the detrusor from inhibition to allow for spontaneous voiding. 24 Table IV Nonrespondent rates for age and pelvic muscle floor measurements Percentage Factor nonresponse Age alone O55 y 48% nonresponse PFM alone PFM = 0 or 1 80% nonresponse PFM %2 50% nonresponse Age and PFM in combination PFM = 0 or 1 and Age O55 y 100% nonresponse PFM %2 and Age O55 y 71% nonresponse PFM, Pelvic floor measurement. In this study, the overall response to sacral neuromodulation is similar to that which is reported by other groups treating refractory idiopathic urge incontinence with neuromodulation. 22 There are no pretest stimulation urodynamic variables to predict success of sacral neuromodulation and similarly in this cohort no urodynamic variables seemed predictative of success. This study duplicates our earlier results, specifically, that younger women responded better to sacral neuromodulation. 7 In addition, the presence of pelvic floor neuromuscular activity, evaluated by voluntarily contracting the pelvic floor, was also found to predict a positive response to neuromodulation in our cohort. Because the believed mechanism of action of sacral neuromodulation relies on afferent input from the pelvic floor, this might explain the better response in these women compared with those who demonstrated no voluntary pelvic floor muscle contractile ability. Our data show that a short duration between stress incontinence surgery and sacral neuromodulation was predictive of a positive response to neuromodulation in both the younger and older groups. There may be unidentified pathologic or neurologic bladder changes that occur and limit success when time to intervention is prolonged. This is a small cohort study and findings regarding correlation with time from surgery, pelvic floor muscle denervation, and age need to be confirmed with a larger cohort. Our results have led us to offer test stimulation for sacral neuromodulation to women who have refractory OAB symptoms after a SUI procedure. Nevertheless, older women with no pelvic floor activity who are remote from their incontinence surgery may be counseled to a probable suboptimal response. Conclusion Response to sacral neuromodulation for the treatment of refractory urge incontinence after SUI surgery is comparable to its use in idiopathic urge incontinence.
Sherman et al 2087 The type of stress incontinence surgery, incontinence parameters, and preimplantation urodynamics do not help predict response to neuromodulation. Our study suggests that a younger age, a shorter time from the incontinence surgery and evidence of pelvic floor muscular activity appear to predict a better response. Sacral neuromodulation should be considered in women with severe OAB symptoms after SUI surgery having failed medical and behavioral therapy and after urethral obstruction has been ruled out. References 1. Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR, Luber KM. Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. J Urol 1997;158:875-80. 2. Jarvis GJ. Stress incontinence. In: Mundy AR, Stephenson TP, Wein AJ, editors. Urodynamics: principles, practice and application. 2nd ed. New York: Churchhill Livingston; 1994. p. 299-326. 3. Amundsen CL, Visco AG, Ruiz H, Webster GD. Outcome in 104 pubovaginal slings using freeze-dried allograft fascia lata from a single tissue bank. Urology 2000;56:2-8. 4. Chou EC, Flisser AJ, Panagopoulos G, Blaivas J. Effective treatment for mixed urinary incontinence with a pubovaginal sling. J Urol Aug 2003;170:494-7. 5. Kobashi KC, Leach GE, Chon J, Govier FE. Continued multicenter followup of cadaveric prolapse repair with sling. J Urol 2002;168:2063-8. 6. Frederick RW, Carey JM, Leach GE. Transvaginal surgery for the treatment of pelvic prolapse and stress incontinence in the octogenarian patient. Issues Incontinence 2004;S/S:3-9. 7. Diokno AC, Appell RA, Sand PK, Dmochowski RR, Gburek BM, Klimberg IW, et al. Prospective, randomized, double-blind study of the efficacy and tolerability of the extended-release formulations of oxybutynin and tolterodine for overactive bladder: results of the OPERA trial. The OPERA Study Group. Mayo Clin Proc 2003;78:687-95. 8. Siegel SW, Catanzaro F, Dijkema HE, Elhilali MM, Fowler CJ, Gajewski JB, et al. Long-term results of a multicenter study on sacral nerve stimulation for treatment of urinary urge incontinence, urgency-frequency, and retention. Urology 2000;56(supp 6A):87-91. 9. Brink CA, Wells TJ, Sampselle CM, Taillie ER, Mayer R. A digital test for pelvic muscle strength in women with urinary incontinence. Nurs Res 1994;43:352-6. 10. Amundsen CL, Webster GD. Sacral neuromodulation in an older, urge-incontinent population. Am J Obstet Gynecol 2002;187: 1462-5. 11. Janknegt RA, Weil EHJ, Eerdmans PHA. Improving neuromodulation technique for refractory voiding dysfunctions: twostage implant. Urology 1997;49:358-62. 12. Wang AC. Burch colposuspension vs. Stamey bladder neck suspension: a comparison of complications with special emphasis on detrusor instability and voiding dysfunction. J Reprod Med 1996;41:529-33. 13. Deval B, Jeffry L, Al Najjar F, Soriano D, Darai E. Determinants of patient dissatisfaction after a tension-free vaginal tape procedure for urinary incontinence. J Urol May 2002;167:2093-7. 14. Arunkalaivanan AS, Barrington JW. Randomized trial of porcine dermal sling (Pelvicol implant) vs. tension-free vaginal tape (TVT) in the surgical treatment of stress incontinence: a questionnairebased study. Int Urogynecol J 2003;14:17-23. 15. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. J Urol 1998;160:1312-6. 16. Fulford SCV, Flynn R, Barrington J, Appanna T, Stephenson TP. An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol 1999;162:135-7. 17. Sand PK, Bowen LW, Osyergard DR, Brubaker L, Panganiban R. The effects of retropubic urethropexy on detrusor instability. Obstet Gynecol 1988;71:818-22. 18. Cardozo LD, Stanton SL, Williams JE. Detrusor instability following surgery for genuine stress urinary incontinence. Br J Urol 1979;51:204-7. 19. FitzGerald MP, Brubaker L. The etiology of urinary retention after surgery for genuine stress incontinence. Neurourol Urodyn 2001;20:13-21. 20. Leng WW, Davies BJ, Tarin T, Sweeney DD, Chancellor MB. Delayed treatment of bladder outlet obstruction after sling surgery: association with irreversible bladder dysfunction. J Urol 2004;172:1379-81. 21. Jonas U, Fowler J, Chancellor MB, Elhilali MM, Fall M, Gajewski JB, et al. Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation. J Urol 2001; 165:15-9. 22. Schmidt RA, Jonas U, Oleson KA, Janknegt RA, Hassouna MM, Siegel SW, et al. Sacral nerve stimulation for treatment of refractory urinary urge incontinence. J Urol 1999;62:352-7. 23. Swinn MJ, Oliver J, Wiseman EL, Fowler CJ. The cause and natural history of isolated urinary retention in young women. J Urol 2002;167:151-6. 24. 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