Dr. Dreyfuss discusses sacral neuromodulation in nursing home residents

In this video, Leo Dreyfuss, MD, shares the background and notable findings from the Neurourology and Urodynamics paper, “Sacral neuromodulation in nursing home residents: Predictors of success and complications in a national cohort of older adults.” Dreyfuss is a urology resident at NewYork-Presbyterian Hospital/Weill Cornell Medical, New York, New York.

Transcription:

Please describe the background for this study.

Overactive bladder is a common problem, particularly for older adults. And for these patients, management can be challenging. They're on many medications, which can have interactions, and they're at particularly high risk for cognitive side effects associated with some anticholinergic medications. And for these reasons, actually, the new OAB guidelines, which were released just a couple of weeks ago, have gone away from this regimented, stepwise approach and introduced a more patient-centered approach, where the clinician can engage in shared decision-making. [The guidelines] actually state that, for patients who are unable or unwilling to try out behavioral or pharmacologic therapy, which are historically the first- and second-line options, clinicians can actually go straight into previously known as third-line therapies, or minimally invasive therapies for overactive bladder is what they're called now, sacral neuromodulation being one of these options. Unfortunately, for clinicians who treat a lot of older adults, there's actually quite limited literature to support the use of these minimally invasive therapies in this population. The reason for this is because most studies that have been performed in these therapies tend to focus on younger individuals who are under the age of 65. This is likely due to some clinician bias or concern for adverse events following these minimally invasive therapies in older adults who we know are at higher risk for complications after invasive procedures. So with this in mind, we thought it would be beneficial to perform this study in a population of nursing home residents. These patients tend to be highly frail, older adults who we think stand to greatly benefit from these therapies.

What were some of the notable findings? Were any of them surprising to you and your coauthors?

Overall, we looked at about 1089 nursing home residents who were included in this study. The mean age was around 78, and about 30% were moderately to severely frail. So right off the bat, this is one of the largest series of older adults who underwent sacral neuromodulation. Of those patients, despite their preoperative comorbidities and characteristics, about 58% went on from test neuromodulation procedure, PNE, or stage 1 permanent tine lead placement, to device implant. Looking at some of the other single-institution retrospective series that have focused on older adults, that rate of 58% is a little bit lower. But it's important to recognize that those studies are single-institution, centers of excellence reports, and this study reflects real-world data across the entire United States. If you compare those findings to other studies that have used claims-based analyses to ask similar questions, the rates are actually higher in this population of nursing home residents. Moving on to one of our other secondary outcomes, device explantation, of the 58% of residents who were implanted, about 10% had an explant or revision procedure within a year after implant. And again, this is quite comparable to other claims-based analyses as well as prospective studies that have focused on younger individuals. So I think these findings overall are reassuring and support the use of neuromodulation in this population. That said, we did find there was a 30-day complication rate of about 40%, which I think jumps out of the page and seems quite high. If you look at the individual complications, the majority of them were urinary tract infections, and a lot of them were sort of minor complications. We also can't necessarily know if all of these complications are directly attributable to the index procedure. In this population of advanced age, highly frail adults, it's possible that there's some expected level of just coincident adverse events unrelated to these procedures. So it's good to keep that in mind. And again, while we don't have access to certain important data such as patient-reported outcomes, this is a limitation of any claims-based analysis. We do think that these data are reassuring and support the use of neuromodulation in a population who may have limited options otherwise.

This transcription was edited for clarity.