Clinical utility of neurostimulation devices in the treatment of overactive bladder: current perspectives

Dick Aw Janssen, Frank Mj Martens, Liesbeth L de Wall, Hendrikje Mk van Breda, John Pfa Heesakkers, Dick Aw Janssen, Frank Mj Martens, Liesbeth L de Wall, Hendrikje Mk van Breda, John Pfa Heesakkers

Abstract

Objectives: This review describes the evidence from established and experimental therapies that use electrical nerve stimulation to treat lower urinary tract dysfunction.

Methods: Clinical studies on established treatments such as percutaneous posterior tibial nerve stimulation (P-PTNS), transcutaneous electrical nerve stimulation (TENS), sacral nerve stimulation (SNS) and sacral anterior root stimulation (SARS) are evaluated. In addition, clinical evidence from experimental therapies such as dorsal genital nerve (DGN) stimulation, pudendal nerve stimulation, magnetic nerve stimulation and ankle implants for tibial nerve stimulation are evaluated.

Results: SNS and P-PTNS have been investigated with high-quality studies that have shown proven efficacy for the treatment for overactive bladder (OAB). SARS has proven evidence-based efficacy in spinal cord patients and increases the quality of life. TENS seems inferior to other OAB treatments such as SNS and P-PTNS but is noninvasive and applicable for ambulant therapy. Results from studies on experimental therapies such as pudendal nerve stimulation seem promising but need larger study cohorts to prove efficacy.

Conclusion: Neurostimulation therapies have proven efficacy for bladder dysfunction in patients who are refractory to other therapies.

Significance: Refinement of neurostimulation therapies is possible. The aim should be to make the treatments less invasive, more durable and more effective for the treatment of lower urinary tract dysfunction.

Keywords: PTNS; implant; neuromodulation; overactive bladder syndrome; sacral anterior root stimulation; sacral nerve stimulation.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Summary of therapeutic options (clinical and experimental) for electrical nerve stimulation for lower urinary tract dysfunction. Notes: (A) Different sites where electrical nerve stimulation is applied for the treatment of lower urinary tract dysfunction. (B) An X-ray image (AP) of the right ankle area of a patient who has an Urgent-SQ™ implantable device for on demand posterior tibial nerve stimulation. The yellow arrow depicts the wire electrode fixation near the posterior tibial nerve. (C) An X-ray image (lateral) of a right ankle of a patient with a BlueWind® implantable device for on demand posterior tibial nerve stimulation. The electrodes are positioned on the upper and lower sides of the device (green arrows). (D) An X-ray (AP) of the pelvic area from a patient undergoing the PNE test phase for evaluation if SNS is effective. The green arrow is the percutaneously placed wire electrode that is inserted through the left S3 foramen. If effective, the patient will receive a permanent tined lead electrode and in a later phase an InterStim implant. Abbreviations: AP, anterior posterior view; CNS, central nervous system; DGN, dorsal genital nerve; PNE, percutaneous nerve evaluation; SNS, sacral nerve stimulation; PMC, pontine micturition center.
Figure 2
Figure 2
Pelvic nerve anatomy and lower urinary tract neural control. Notes: (A) A model of the different nerves that innervate and control the lower urinary tract. (B) Pelvic nerve anatomy. Abbreviations: CNS, central nervous system; PMC, pontine micturition center.
Figure 3
Figure 3
SARS therapy for spinal cord injury patients. Notes: (A) How anterior roots S2, S3 and S4 are connected to electrodes in an electrode book. The electrodes are guided to an internal receiver (called a Chimney procedure). The receiver can be activated with an external controller. The two “X” depict a laminectomy to gain access to the nerves (for the intradural procedure) and a rhizotomy of the dorsal horn of S2–S4. (B) An X-ray image (AP) of the upper pelvic area of a patient with a Finetech–Brindley System. The yellow arrow depicts the electrode book where the electrodes are connected to the anterior roots of S2, S3 and S4. The wire electrodes are guided to the internal electrical pulse receiver plate that is shown as the green triangle. Abbreviations: AP, anterior posterior view; SARS, sacral anterior root stimulation.
Figure 4
Figure 4
Sacral nerve stimulation with InterStim® device and pelvic anatomy for dorsal genital nerve (DGN) stimulation and percuteneous tibial nerve stimulation. Notes: (A) A schematic diagram of how sacral nerve stimulation (SNS) works with a tined lead electrode that is placed through sacral foramen S3. The nerve fibers from the posterior tibial nerve are part of the large sciatic nerve that descends from the pelvic region toward the lower extremities. Also the pudendal nerve is shown, which contains the nerve fibers from the DGN, which branches from this nerve and can be used for electrical DGN stimulation. (B) An X-ray of the pelvic region from a patient with an InterStim SNS device with the green arrow pointing at the tined lead. The pulse generator is seen in the upper right corner of the image. (C) An image of an SNS device that was explanted. This was the first SNS device that was implanted in Europe in 1989. Abbreviations: DGN, dorsal genital nerve; SNS, sacral nerve stimulation.

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