SNS vs. botulinum: Caveats, considerations

AUA/SUFU clinical guidelines for OAB, updated in 2014, suggest third-line treatment options of: intradetrusor onabotulinumtoxinA (100 U) Standard (Evidence Strength Grade B), peripheral tibial nerve stimulation (PTNS) Recommendation (Evidence Strength Grade C), or sacral neuromodulation (SNS) Recommendation (Evidence Strength Grade C). 

The 24-month ROSETTA trial data suggest that UUI episode reduction was the same for botulinum toxin and sacral neuromodulation, but treatment satisfaction and endorsement favored botulinum toxin.

There are some caveats to this conclusion: A higher dose (vs. guidelines) of 200 U was used in the botulinum toxin arm. The 24-month data are true for the SNS group but are <1 year in 35% to 70% of patients who underwent a second injection of botulinum toxin. Finally, 30% of patients in both arms opted for a secondary treatment.

The practical considerations for choosing one of these three treatments include: Patient age, mobility, mentation, and hand dexterity are important, as each of these arms need a good understanding of possible side effects, ability to self-cath, and learn programming. In a recent study of women with refractory urge incontinence, younger patients experienced greater absolute continence, symptom improvement, and fewer UTIs than older patients (Am J Obstet Gynecol Oct 11, 2017 [Epub ahead of print]). A similar study found older women with multiple comorbidities and decreased functional and health-related quality of life had decreased treatment response and satisfaction with botulinum toxin versus sacral SNS (J Urol 2017; 198:890-6).

Insurance approval is improving for both botulinum toxin and SNS but is an issue for PTNS. SNS also has a caution regarding MRI if needed for associated neurologic conditions (less of a concern with the new generator) and requires two OR visits, whereas long-term success is a plus with SNS.

Office-based use of botulinum toxin has appeal for patients, but the need for repeated injections at variable intervals and the possible need for CIC are deterrents. The interval between injections is impressive in this trial, and if the retention rate is not increased, then an initial higher dose may be worthwhile.

Ultimately, there is a physician bias in suggesting one of these options.

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