Surgical Procedures for NDO

Sacral neuromodulation. When sacral neuromodulation is considered, patients who respond to neuromodulation during the test phase proceed to full implantation of pulse generators and leads. Programming is required.37 Sacral neuromodulation is not approved for NDO. Patients with defined neurologic abnormalities such as multiple sclerosis or spinal cord injury may benefit from sacral neuromodulation, but studies in this population of patients have been few38,39 and sacral neuromodulation for NDO is an off-label use.

Augmentation cystoplasty. This reconstruction may be indicated for patients with refractory symptoms and those with risk or progression of upper tract deterioration. There is a high likelihood that lifelong intermittent catheterization will ultimately be required. Risks such as stones, metabolic and nutritional abnormalities, renal insufficiency, and malignancy are best treated through early recognition and prompt therapy.40,41

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Evaluating Outcomes

For OAB, clinicians should use a voiding diary and global response for QoL to determine effect of treatment as well as validated OAB-specific questionnaires, and should query patients about AEs.

Although global response scales for QoL and a voiding diary to determine effect of treatment for NDO are important, the clinician also may need to know urodynamic testing outcomes, especially in patients with elevated detrusor pressures, to assess that there is no risk of future upper tract damage.


“Treatment success” is complex and based on individual patient expectations. Communicating with and explaining all appropriate options to the patient, based on the differing efficacy and AE profiles of the treatments available for OAB and NDO as well as eliciting patient input, can enhance outcomes.

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  1. Elwyn G, Frosch D, Thomson R, et Al. Shared 
decision making: a model for clinical practice. 
J Gen Intern Med. 2012;20(10):1361-1367.

  2. Elwyn G, Laitner S, Coulter A, et al. Implementing shared decision making in the NHS. BMJ. 2010;341:C5146.

  3. Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report of the standardisation sub-committee of the International Continence Society. Urology. 2003;61(1):37-49.

  4. Gormley EA, Lightner DJ, Burgio KL, et al; American Urological Association; Society of Urodynamics, Female Pelvic Medicine, & Urogenital Reconstruction. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol. 2012;188(6 Suppl):2455-2463.

  5. Fantl JA, Wyman JF, McClish DK, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA. 1991;265(5):609-613.

  6. Jarvis GJ. A controlled trial of bladder drill and drug therapy in the management of detrusor instability. 
Br J Urol. 1981;53(6):565-566.

  7. Burgio KL, Goode PS, Johnson TM, et al. Behavioral versus drug treatment for overactive bladder in men: the Male Overactive Bladder Treatment in Veterans (MOTIVE) trial. J Am Geriatr Soc. 2011;59(12):2209-2216.

  8. Vissers D, Neels H, Vermandel A, et al. The effect of non-surgical weight loss interventions on urinary incontinence in overweight women: a systematic review and meta-analysis. Obes Rev. 2014 Apr 22. doi: 10.1111/obr.12170.

  9. Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am Geriatr Soc. 2000;48(4):370-374.

  10. Burgio KL, Kraus SR, Menefee S, et al; Urinary Incontinence Treatment Network. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med. 2008;149(3):161-169.

  11. Rai BP, Cody JD, Alhasso A, Stewart L. Anticholinergic drugs versus non-drug active therapies for non-neurogenic overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2012 Dec 12;12:CD003193. doi: 10.1002/14651858.CD003193.pub4.

  12. Borello-France D, Burgio KL, Goode PS, et al. Adherence to behavioral interventions for urge incontinence when combined with drug therapy: adherence rates, barriers, and predictors. Phys Ther. 2010;90(10):1493-1505.

  13. Chapple CR, Khullar V, Gabriel Z, et al. The effects of antimuscarinic treatments in overactive bladder: an update of a systematic review and meta-analysis. 
Eur Urol. 2008;54(3):543-562.

  14. Sternberg SA, Wershof Schwartz A, Karunananthan S, et al. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129-2138.

  15. Donnellan CA, Fook L, McDonald P, Playfer JR. Oxybutynin and cognitive dysfunction. BMJ. 1997;315(7119):1363-1364.

  16. Tsao JW, Heilman KM. Transient memory impairment and hallucinations associated with tolterodine use. 
N Engl J Med. 2003;349(23):2274-2275.

  17. Nitti VW, Khullar V, van Kerrebroeck P, et al. Mirabegron for the treatment of overactive bladder: a prespecified pooled efficacy analysis and pooled safety analysis of three randomized, double-blind, placebo-controlled, phase III studies. Int J Clin Pract. 2013;67(7):619-632.

  18. Groen J, Blok BF, Bosch JL. Sacral neuromodulation as treatment for refractory idiopathic urge urinary incontinence: 5-year results of a longitudinal study in 60 women. J Urol. 2011;186(3):954-959.

  19. van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP, et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol. 2007;178(5):2029-2034.

  20. Siegel S, Noblett K, Mangel J, et al. Results of a prospective, randomized, multicenter study evaluating sacral neuromodulation with InterStim therapy compared to standard medical therapy at 6-months in subjects with mild symptoms of overactive bladder. Neurourol Urodyn. 2014 Jan 10. doi: 10.1002/nau.22544. [Epub ahead of print]

  21. Peters KM, MacDiarmid SA, Wooldridge LS, et al. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. J Urol. 2009;182(3):1055-1061.

  22. MacDiarmid SA, Peters KM, Shobeiri SA, et al. Long-term durability of percutaneous tibial nerve stimulation for the treatment of overactive bladder. J Urol. 2010;183(1):234-240.

  23. Nitti VW, Dmochowski R, Herschorn S, et al; EMBARK Study Group. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial. J Urol. 2013;189(6):2186-2193.

  24. Chapple C, Sievert KD, MacDiarmid S, et al. OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2013;64(2):249-256. 

  25. Reitz A, Denys P, Fermanian C, et al. Do repeat intradetrusor botulinum toxin type a injections yield valuable results? Clinical and urodynamic results after five injections in patients with neurogenic detrusor overactivity. Eur Urol. 2007;52(6):1729-1735.

  26. Duthie JB, Vincent M, Herbison GP, et al. Botulinum toxin injections for adults with overactive bladder syndrome. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD005493. doi: 10.1002/

  27. Sahai A, Cortes E, Seth J, et al. Neurogenic detrusor overactivity in patients with spinal cord injury: evaluation and management. Curr Urol Rep. 2011;12(6):404-412.

  28. Campbell JD, Gries KS, Watanabe JH, et al. Treatment success for overactive bladder with urinary urge incontinence refractory to oral antimuscarinics: a review of published evidence. BMC Urol. 2009;9:18.

  29. Kennelly MJ, Devoe WM. Overactive bladder: pharmacologic treatments in the neurogenic population. Rev Urol. 2008;10(3):182-191.

  30. Pannek J, et al. Guidelines on neurogenic lower urinary tract dysfunction. European Association of Urology (EAU); 2011 Mar. Accessed March 28, 2012.

  31. Weld KJ, Dmochowski RR. Association of level of injury and bladder behavior in patients with post-traumatic spinal cord injury. Urology. 2000;55(4):490-494.

  32. Wein AJ, Dmochowski RR. Neuromuscular dysfunction of the lower urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, et al (eds). Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012:1909-1946.

  33. Yamaguchi O, Nishizawa O, Takeda M, et al; Neurogenic Bladder Society. Clinical guidelines for overactive bladder. Int J Urol. 2009;16(2):126-142.

  34. Ginsberg D, Gousse A, Keppenne V, et al. Phase 3 efficacy and tolerability study of onabotulinumtoxinA for urinary incontinence from neurogenic detrusor overactivity. J Urol. 2012;187(6):2131-2139.

  35. Cruz F, Herschorn S, Aliotta P, et al. Efficacy and safety of onabotulinumtoxinA in patients with urinary incontinence due to neurogenic detrusor overactivity: a randomised, double-blind, placebo-controlled trial. Eur Urol. 2011;60(4):742-750.

  36. Ghalayini IF, Al-Ghazo MA, Elnasser ZA. Is efficacy of repeated intradetrusor botulinum toxin type A (Dysport) injections dose dependent? Clinical and urodynamic results after four injections in patients with drug-resistant neurogenic detrusor overactivity. Int Urol Nephrol. 2009;41(4):805-813.

  37. Leong RK, De Wachter SG, van Kerrebroeck PE. Current information on sacral neuromodulation and botulinum toxin treatment for refractory idiopathic overactive bladder syndrome: a review. Urol Int. 2010;84(3):245-253. 

  38. Bosch J, Groen J. Treatment of refractory urge urinary incontinence with sacral spinal nerve stimulation in multiple sclerosis patients. Lancet. 1996;348(9029):717-719.

  39. Hassouna M, Siegel S, Nyeholt A, et al. Sacral 
neuromodulation in the treatment of urgency- 
frequency symptoms: a multicenter study on 
efficacy and safety. J Urol. 2000:163;1849-1854.

  40. Obermayr F, Szavay P, Schaefer J, Fuchs J. Outcome of augmentation cystoplasty and bladder substitution in a pediatric age group. Eur J Pediatr Surg. 2011;21(2):116-119.

  41. Gurung PM, Attar KH, Abdul-Rahman A, et al. Long-term outcomes of augmentation ileocystoplasty in patients with spinal cord injury: a minimum of 10 years of follow-up. BJU Int. 2012;109(8):1236-1242.