Elsevier

European Urology

Volume 58, Issue 6, December 2010, Pages 865-874
European Urology

Review – Neuro-urology
Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction: Systematic Review and Meta-analysis

https://doi.org/10.1016/j.eururo.2010.09.024Get rights and content

Abstract

Context

Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear.

Objective

To assess the efficacy and safety of SNM for neurogenic LUTD.

Evidence acquisition

Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis.

Evidence synthesis

Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half (n = 13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase (n = 4) or permanent SNM (n = 9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50–87) and 92% (95% CrI, 81–98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0–2%) for the test phase and 24% (95% CrI, 6–48%) for permanent SNM.

Conclusions

There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.

Introduction

The control of the lower urinary tract is a complex, multilevel process that involves both the peripheral and central nervous systems [1]. Thus, patients with neurologic disease and/or injury often suffer from lower urinary tract symptoms, which frequently have a negative impact on the patients’ health-related quality of life (QoL). The prevalence of neurogenic lower urinary tract dysfunction (LUTD) depends on the type and duration of neurologic disease and/or injury and may approach 100% (for instance, in patients with multiple sclerosis [MS]) [2]. Moreover, neurogenic LUTD is a challenge, because all available treatment modalities (ie, conservative, minimally invasive, and invasive therapies) may fail.

Sacral neuromodulation (SNM) has become a well-established and widely accepted treatment modality in recent years for patients with refractory nonobstructive chronic urinary retention, urgency–frequency syndrome, and urgency incontinence [3], [4], [5], [6]. Originally, SNM was not considered an option for neurogenic LUTD; however, some studies have suggested that SNM is also effective in this group of patients [7], [8]. Taking into account that SNM is minimally invasive and completely reversible, it is of great interest whether this treatment option is valuable for patients with neurogenic LUTD before resorting to more invasive procedures. Thus, we systematically assessed all available evidence on the efficacy and safety of SNM for the treatment of patients with neurogenic LUTD.

Section snippets

Data sources and searches

This systematic review was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement [9]. After elaboration of a review protocol, which is available upon request from the authors, we systematically searched the PubMed, EMBASE, and ScienceDirect databases (Appendix A). No language or date restrictions were applied. The last search was performed on 15 April 2010. We hand searched the reference list of all included studies and any relevant review articles.

Study selection

Search results

The flow diagram of literature searches and results is shown in Fig. 1. After screening abstracts, full-text articles, and reference lists, 34 eligible reports [7], [8], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43] were identified. Three articles [12], [31], [38] not clearly distinguishing between neurogenic and non-neurogenic LUTD and another [37]

Main findings

A pooled success rate of 68% for the test phase and of 92% for permanent SNM as well as a pooled adverse event rate of 0% for the test phase and of 24% for permanent SNM indicate that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, although the results of this systematic review are promising, the evidence level of the included studies is generally low, and randomised, controlled trials (RCTs) are lacking.

Findings in the context of existing evidence

SNM for neurogenic LUTD has not been

Conclusions

At this time, no definitive conclusions can be drawn from the available evidence regarding the general use of SNM for neurogenic LUTD. There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low, with high between-study heterogeneity, and there is a lack of RCTs. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can

References (60)

  • W.A. Scheepens et al.

    Predictive factors for sacral neuromodulation in chronic lower urinary tract dysfunction

    Urology

    (2002)
  • M. Spinelli et al.

    New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience

    J Urol

    (2003)
  • D. Minardi et al.

    Lower urinary tract and bowel disorders and multiple sclerosis: role of sacral neuromodulation: a preliminary report

    Neuromodulation

    (2005)
  • G. Lombardi et al.

    Clinical female sexual outcome after sacral neuromodulation implant for lower urinary tract symptom (LUTS)

    J Sex Med

    (2008)
  • P. Bertapelle et al.

    Detrusor acontractility in urinary retention: detrusor contractility test as exclusion criteria for sacral neurostimulation

    J Urol

    (2008)
  • G. Lombardi et al.

    Sacral neuromodulation for lower urinary tract dysfunction and impact on erectile function

    J Sex Med

    (2008)
  • D. Moher et al.

    The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials

    Lancet

    (2001)
  • J.J. Wyndaele et al.

    Influence of sacral neuromodulation on electrosensation of the lower urinary tract

    J Urol

    (2000)
  • S. Malaguti et al.

    Neurophysiological evidence may predict the outcome of sacral neuromodulation

    J Urol

    (2003)
  • C.J. Fowler et al.

    Studies of the latency of pelvic floor contraction during peripheral nerve evaluation show that the muscle response is reflexly mediated

    J Urol

    (2000)
  • U. Jonas et al.

    Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation

    J Urol

    (2001)
  • W.W. Leng et al.

    How sacral nerve stimulation neuromodulation works

    Urol Clin North Am

    (2005)
  • R. Dasgupta et al.

    Changes in brain activity following sacral neuromodulation for urinary retention

    J Urol

    (2005)
  • J. Groen et al.

    Sacral neuromodulation in women with idiopathic detrusor overactivity incontinence: decreased overactivity but unchanged bladder contraction strength and urethral resistance during voiding

    J Urol

    (2006)
  • W.C. de Groat et al.

    Mechanisms underlying the recovery of lower urinary tract function following spinal cord injury

    Prog Brain Res

    (2006)
  • B.F. Blok et al.

    The pontine micturition center in rat receives direct lumbosacral input. An ultrastructural study

    Neurosci Lett

    (2000)
  • M. Spinelli et al.

    Latest technologic and surgical developments in using InterStim™ Therapy for sacral neuromodulation: impact on treatment success and safety

    Eur Urol

    (2008)
  • K. Everaert et al.

    A prospective randomized trial comparing the 1-stage with the 2-stage implantation of a pulse generator in patients with pelvic floor dysfunction selected for sacral nerve stimulation

    Eur Urol

    (2004)
  • T.M. Kessler et al.

    Prolonged sacral neuromodulation testing using permanent leads: a more reliable patient selection method?

    Eur Urol

    (2005)
  • C.J. Fowler et al.

    The neural control of micturition

    Nat Rev Neurosci

    (2008)
  • Cited by (184)

    • Detrusor Sphincter Dyssynergia

      2024, Urologic Clinics of North America
    View all citing articles on Scopus
    View full text