SUFU WM 2015 - Panel: Management of refractory overactive bladder: What to do when third line therapies fail - Session Highlights

SCOTTSDALE, AZ USA (UroToday.com) - Dr. Steven Siegel moderated a panel of clinicians with expertise in refractory overactive bladder. While there is some controversy noted in the definition, refractory idiopathic OAB was defined as a patient who had inadequate response or was unable to tolerate first and second line therapies.

Dr. Sandip Vasavada advocated for the use of Onabotulinumtoxin A (BOTOX®). He reviewed patient selection. He noted that most studies were done in patients with moderate severity (4-5 incontinence episodes per day). Additionally, there are limited data on OAB dry subpopulations. Data were reviewed which demonstrated that patient success was durable after multiple injections. The FDA approved dose for non-neurogenic OAB is 100 units. In one trial comparing BOTOX® 100 units to oral anticholinergics demonstrated similar efficacy, but higher patient quality-of-life in the BOTOX® group despite higher urinary retention rates. Data assessing injection technique demonstrated no difference in success with 10 vs 20 vs 40 injections. Trigone injection of BOTOX® versus trigone sparing techniques also showed no advantage of one technique over the other. He recommended considering higher injection doses for patients with partial responses to BOTOX® who are willing to accept a higher risk of UTI and urinary retention. He stressed that in any treatment modality it is important to discuss realistic patient expectations for success.

sufuDr. Steven Siegel advocated for sacral neuromodulation (SNM). For SNM after failed BOTOX® he recommends a 6-9 month waiting period after the last BOTOX® injection to prevent false positive/negative testing. There are no data regarding the efficacy of SNM after failed posterior tibial nerve stimulation. He does not consider patients who had prior success with SNM who developed loss of efficacy a treatment failure. For this group he recommends lead revision if reprogramming fails. X-ray can be used to assess lead placement. His goal placement is as high and medial as possible in the S3 foramen with good response on all 4 leads. If PNE was successful and stage 1 was unsuccessful he always suspects that the patient had a suboptimal lead placement.

Dr. Kenneth Peters advocated for pudendal neuromodulation (PNM). He gave the caveat that PNM is an off-label use of neuromodulation as it is not FDA approved. The leads are placed in the ischiorectal space at Alcock’s canal. The external landmark for placement is just medial to ischial tuberosity. EMG leads are used in conjunction with an “anal wink” to ensure good placement. He discussed his institution’s 10-year data where 80% of patients felt their success was greater with PNM compared to SNM. Overactive bladder and pelvic pain accounted for approximately 52% of indications for PNM. Lead time placement took 48 minutes. They had a 93.8% response rate in patients with a failed prior SNM trial. Eleven patients required 12 surgeries for lack of efficacy and lead migration. He recommended multicenter randomized controlled trials to prove efficacy.

Dr. Stephen Krauss presented the benefits of augmentation/diversion for patients who failed BOTOX® and SNM. He feels the data support a > 75% durable success for augmentation/diversion, but their use has been limited to rare and severely refractory cases due to the invasive nature of the procedure. He noted a significant reduction in the number of augmentation/diversion cases with the increasing utilization of BOTOX®.

Moderated by Steven W. Siegel, MD at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) Winter Meeting - February 24 - 28, 2015 - JW Marriott Camelback Inn Resort & Spa - Scottsdale, AZ USA

Panelists:
Sacral Neuromodulation: Steven W. Siegel, MD
Pudendal: Kenneth M. Peters, MD
Onabotulinumtoxin A: Sandip P. Vasavada, MD
Augmentation/Diversion: Stephen R. Kraus, MD

sufu freilich squareReported for UroToday by Drew Freilich, MD. Dr. Freilich is a graduate of the University of Massachusetts Medical School and completed his urology residency at New York Medical College/Westchester Medical Center. He is currently a fellow in Female Urology, Neurourology and Reconstructive Urology at Medical University of South Carolina. He has authored more than 40 peer-reviewed articles, monographs, abstracts, and book chapters and abstracts. Dr. Freilich is a member of the American Urological Association and the Society for Urodynamics and Female Urology.