Elsevier

European Urology

Volume 68, Issue 5, November 2015, Pages 859-867
European Urology

Review – Neuro-urology
Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review

https://doi.org/10.1016/j.eururo.2015.07.001Get rights and content

Abstract

Context

Tibial nerve stimulation (TNS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option for patients with an underlying neurological disorder.

Objective

We systematically reviewed all available evidence on the efficacy and safety of TNS for treating neurogenic lower urinary tract dysfunction (NLUTD).

Evidence acquisition

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Evidence synthesis

After screening 1943 articles, 16 studies (4 randomized controlled trials [RCTs], 9 prospective cohort studies, 2 retrospective case series, and 1 case report) enrolling 469 patients (283 women and 186 men) were included. Five studies reported on acute TNS and 11 on chronic TNS. In acute and chronic TNS, the mean increase of maximum cystometric capacity ranged from 56 to 132 mL and from 49 to 150 mL, and the mean increase of bladder volume at first detrusor overactivity ranged from 44 to 92 mL and from 93 to 121 mL, respectively. In acute and chronic TNS, the mean decrease of maximum detrusor pressure during the storage phase ranged from 5 to 15 cm H2O and from 4 to 21 cm H2O, respectively. In chronic TNS, the mean decrease in number of voids per 24 h, in number of leakages per 24 h, and in postvoid residual ranged from 3 to 7, from 1 to 4, and from 15 to 55 mL, respectively. No TNS-related adverse events have been reported. Risk of bias and confounding was high in most studies.

Conclusions

Although preliminary data of RCTs and non-RCTs suggest TNS might be effective and safe for treating NLUTD, the evidence base is poor, derived from small, mostly noncomparative studies with a high risk of bias and confounding. More reliable data from well-designed RCTs are needed to reach definitive conclusions.

Patient summary

Early data suggest tibial nerve stimulation might be effective and safe for treating neurogenic lower urinary tract dysfunction, but more reliable evidence is required.

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.

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