AUA 2017: Point-Counterpoint Debate: Refractory Urge Incontinence - Which Comes First?

Boston, MA ( At the Society for Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, Dr. Stephen Kraus moderated a Point-Counterpoint debate on Refractory Urge Incontinence - Which Comes First? Debaters were Dr. David Ginsberg arguing the position of using onabotulinumtoxin A first and Dr. Suzette Sutherland arguing the position of sacral neuromodulation first. Dr. Kraus described the case of a 69 year old female presenting to her primary care provider for routine care, who mentions symptoms of overactive bladder syndrome. She is placed on an antimuscarinic medication, fails this therapy and is referred to a urologist for persistent urianry frequency, nocturia, and use of 3 pads per day for urgency incontinence. Dr. Kraus also promoted the use of the SUFU Clinical Care Pathway ( for this patient, which functionalizes the guidelines and simulates a navigator to help the patient get through the pathway to third line therapy.

Dr. Ginsberg took the position of using chemodenervation first with 100U of onabotulinumtoxinA. He discussed the data comparing long term response rates for onabotulinumtoxinA and sacral neuromodulation, and the need to use of all patients undergoing test stimulation for sacral neuromodulation as the denominator, which gives values closer to 43% than the 80+% reported in many long-term studies that only report the denominator of patients who were implanted. He also discussed the technical ease of performing the procedure; botulinum toxin injection uses cystoscopy, that all urologists are familiar with, and the procedure can be performed entirely in the office. He commented on the data from the ROSETTA trial that compared botulinum toxin to sacral neuromodulation, and while there were some issues with the study, it is the best comparison available which showed more significant improvement in incontinence with botulinum toxin. He mentioned some issues with cost studies, and the assumptions made when showing that costs of botulinum toxin and sacral neuromodulation are similar at 5 years, mainly that botulinum toxin was assumed to be done in the operating room.

Dr. Sutherland described the evidence for using sacral neuromodulation first for refractory urgency incontinence. She discussed the advantages of being able to treat a broad patient population more similar to what urologists see in the real world, including patients with multiple conditions such as overactive bladder in combination with urinary retention, fecal incontinence, and (while still off-label) pelvic pain. She also described the advantages of having the trial period prior to implantation, and the ability to crossover to another therapy quickly without having to wait until the effects wear off. Along the same lines, patients can turn the device off if there is a problem with the therapy. Additionally, Dr. Sutherland mentioned the superior efficacy of sacral neuromodulation when compared to medications (InSIte trial) compared with similar efficacy for botulinum toxin when compared with medications (ABC trial). Dr. Sutherland also addressed the ROSETTA trial data, and made note that the lead used in the trial is different than the currently recommended lead, and that the thresholds for successful lead placement were fairly lax. When addressing cost, she mentioned that while cost effectiveness 5 years may be the same, the new rechargeable neuromodulation systems on the horizon will likely skew the long term (10-15 year) costs in favor of neuromodulation.

Written By: Lindsey Cox, MD from the Medical University of South Carolina

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA