Role of neurostimulation in urology is on the rise

The use of neurostimulation in urology has evolved over the years, as new modalities have emerged and new indications are explored. With ongoing research, neurostimulation's role in treating patients with urologic disease will continue to expand, according to one of its long-time practitioners, Kenneth M. Peters, MD. In this exclusive interview, Dr. Peters, chair of urology at Beaumont Hospital in Royal Oak, MI, discusses the various forms of neurostimulation, current research efforts, and potential future uses for this modality. Dr. Peters was interviewed by Urology Times Editorial Consultant Philip M. Hanno, MD, MPH, professor of urology at the University of Philadelphia, Pennsylvania. Dr. Peters is a consultant or researcher for Medtronic, Johnson & Johnson, EMKinetics, and Boston Scientific.

Q How did you become interested in neurostimulation?

A Currently, sacral nerve stimulation is FDA approved for overactive bladder, urgency incontinence, non-obstructive urinary retention, and fecal incontinence. Tibial nerve stimulation is FDA approved for overactive bladder and in Europe is used extensively for fecal incontinence. Pudendal nerve stimulation is a distal branch of the sacral nerve roots, but there are currently no products on the market specifically for this site of stimulation.

Q Please compare sacral nerve, pudendal nerve, and tibial nerve stimulation.

A Unfortunately, there have been no head-to-head-to-head trials of these modalities. Sacral nerve modulation using the InterStim device has been around the longest and certainly has the most data.

We believe that neurostimulation occurs from the nerve to the brain, so the potential benefit of going a little further downstream, like the pudendal nerve, is that you get stimulation through three different sacral nerve roots, which may augment the micturition centers of the brain and improve symptoms. It's been our experience that patients who don't do well with sacral neurostimulation do very well with pudendal; about 90% will respond to pudendal. In my institution's head-to-head trial, patients preferred a pudendal lead using the InterStim device.

Tibial nerve stimulation using the Urgent PC Neuromodulation System is the new kid on the block. It's been talked about since the 1980s, but it wasn't until recently that randomized, controlled clinical trials were conducted. I see tibial stimulation as a means of opening up neuromodulation to the masses-to all those patients who don't get better with drugs and behavioral therapies.

Q In the treatment of overactive bladder, how do you compare neurostimulation to other forms of treatment?

Neurostimulation is not offered enough to patients. Those of us who do it offer it frequently and early in the course of the disease. That's where it really impacts the patient's quality of life.

Q What is the place of neurostimulation in nonobstructive retention?

A The most common treatment for nonobstructive retention is intermittent catheterization. There are very good data showing that neurostimulation can be beneficial for idiopathic nonobstructive retention. This is quality of life driven, so if a patient really wants to get off the catheter and there are no medications that make them better, neurostimulation is the next step. Sacral neuromodulation is the form of neurostimulation that has been studied the most and is FDA approved for this indication.