NEW ORLEANS, LA USA (UroToday.com) - Dr. Dirk De Ridder outlined the session by reviewing the evidence in the European Association of Urology guidelines for urinary incontinence. The guidelines give onabotulinumtoxinA injection a Grade A recommendation for refractory detrusor overactivity with level 1a evidence. Sacral Neuromodulation is also given a Grade A recommendation with level 1b evidence, setting up the debators to educate the audience on the subtleties of choosing between two therapies that have been proven to be effective.
Christopher P. Smith from Baylor University in Houston,Texas, began the debate from the Con side, against sacral neromodulation and in favor of botulinum toxin injection as the first choice for refractory overactive bladder. He described the shortcomings of cost-effectiveness comparisons of both therapies as hospital-based procedures with anesthetic, and proposed that the cost of office-based botulinum toxin injection is likely less than these estimates. He also described the high rates of persistence with therapy and high patient acceptance rates, and that patients and providers have very acceptable burden with office-based botulinum toxin injection.
Dr. Smith went on to describe that even the most concerning adverse event of needing to catheterize after injection is temporary and does not degrade the quality of life improvements offered by this treatment.
Anurag Das from Beth Isreal Deaconess Medical Center, in Boston, Massachusetts took the pro position that sacral neuromodulation should be the preferred treatment for refractory idiopathic overactive bladder. He described studies that compare the level of incontinence improvement, showing that around twice as many patients are completely dry with sacral neuromodulation compared to botulinum toxin and that heavy leaks are also more significantly improved. He also noted that sacral neuromodulation offers patients the benefits of continued voiding efficiency with improved voided volumes and without the risk for needing to catheterize. Dr. Das also touted the benefits of sacral neuromodulation beyond the bladder with improvements in related pelvic floor symptoms, including constipation and fecal incontinence, as a benefit of neuromodulation that is not possible with botulinum toxin injection.
Michael Chancellor from Beaumont Health System in Royal Oak, Michigan provided the rebuttal for the con side that botulinum toxin should be the preferred treatment by placing the debate in the context of the AUA/SUFU guideline for overactive bladder in that botulinum toxin is a “Standard” for third line therapies for refractory overactive bladder as sacral neruomodulation is considered a “Recommendation.”
Steven Siegel from Woodbury, Minnesota, offered the final rebuttal in favor of sacral neuromodulation. Dr. Siegel described neuromodulation as restorative, with proven effectiveness and safety after over 20-years of use. He also expounded on the role of neuromodulation as comprehensive treatment for pelvic floor disorders including pain and defactory symptoms. He noted the favorable adverse event profile for neuromodulation with the lack of urinary retention and urinary tract infection risk compared with botulinum toxin injection.
Dr. Siegel also noted that for patients who fail a trial of neuromodulation, the treating physician can transition to botulinum toxin immediately, whereas patients who have undergone botulinum toxin may not return to baseline for 6-9 months, causing a delay in treatment with neuromodulation.
Overall, this was a lively crossfire session with noted experts in the field of voiding dysfunction and incontinence who clearly defined the issues clinicians face in choosing between these two therapies.
Debater - Pro: Anurag K. Das, MD
Debater - Pro: Steven W. Siegel, MD
Debater - Con: Michael B. Chancellor, MD
Debater - Con: Christopher P. Smith, MD
Moderated by Dirk De Ridder at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
Leuven University, Belgium
Reported by Lindsey Cox (University of Michigan, Ann Arbor, MI USA), medical writer for UroToday.com