Review – Neuro-urologyTibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review
Introduction
Neurogenic lower urinary tract dysfunction (NLUTD) is highly prevalent, affects the lives of millions of people worldwide, and imposes a substantial economic burden on health care systems [1], [2]. The prevalence of NLUTD may approach 100%, depending on the type and duration of the neurological disorder (eg, in multiple sclerosis [MS]) [3], [4]. Quality of life is a major issue, and lower urinary tract function becomes one of the most challenging issues in a patient's life [5]. NLUTD may cause storage and/or voiding symptoms [1]. Although many different treatments are available, the management of NLUTD is challenging, not the least because the standard treatment modalities often have limitations.
Tibial nerve stimulation (TNS), introduced by Stoller in the late 1990s [6], is a promising therapy for nonneurogenic lower urinary tract dysfunction [7]. The tibial nerve is stimulated by an electrode inserted 4–5 cm cephalad to the medial malleolus. The flexion of the big toe or the movement of the other toes as well as a sensory response confirm the correct position of the needle electrode. TNS was found to be effective and safe for treating idiopathic overactive bladder in randomized controlled trials (RCTs) [8], [9], [10]. TNS might also be a valuable option in patients with an underlying neurological disorder. We performed a systematic review to assess and appraise the available evidence on the efficacy and safety of TNS for treating NLUTD.
Section snippets
Data sources and searches
This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [11]. The protocol for the review is available on PROSPERO (CRD42014008678; http://www.crd.york.ac.uk/PROSPERO). We systematically searched Embase, Medline, the Cochrane Central Register of Controlled Trials, and the Health Technology Assessment Database (from January 1, 1946, to January 23, 2015). No language restrictions were applied. We additionally
Search results
Figure 1 shows the PRISMA flow diagram of the literature search and results. After screening of 1943 abstracts, 16 studies were included in a narrative synthesis [14] (Table 1, Table 2, Table 3; Fig. 2A–2F): four RCTs [15], [16], [17], [18], nine prospective cohort studies [19], [20], [21], [22], [23], [24], [25], [26], [27], two retrospective case series [28], [29], and one case report [30].
Study and patient characteristics
Overall, the 16 included studies enrolled a total of 469 patients: 283 women (60%) and 186 men (40%).
Conclusions
Some preliminary evidence indicates that TNS is effective and safe for treating patients with NLUTD. However, the overall quality of the evidence was low. Most of the studies were small and hence underpowered to measure the main outcomes with a significant risk of bias and confounding. In addition, it is unclear which stimulation parameters and maintenance regime are most effective. This review, although suggesting that TNS appears to be a promising and novel treatment for NLUTD, has
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These authors contributed equally and share the first authorship.