Dr. Syan summarizes the AUA 2024 sessions on urodynamics and PTNS devices

In this interview Raveen Syan, MD, highlights 2 sessions she attended at the 2024 American Urological Association (AUA) Annual Meeting in San Antonio, Texas on urodynamics in the context of the VALUE trial (NCT00803959) and the new wave of percutaneous tibial nerve stimulation (PTNS) devices. . Syan is an assistant professor of clinical urology at the University of Miami in Florida.

This transcript has been edited for clarity.

At this year’s edition of AUA, you took part in the session “UDS and the SUI Woman in the era of VALUE testing: is it necessary? Debate and panel discussion on cases with audience reaction. Could you provide an outline of this discussion?

Urodynamics is a test that assesses bladder function. It is minimally invasive, but still invasive; requires a catheter in the bladder. It is not a painful procedure, but unpleasant. This requires patients to interact with doctors while urinating, so patients look forward to the examination. However, it provides an excellent diagnostic understanding of how the bladder functions during filling and emptying. So it’s a really valuable tool, but we also don’t want to overuse it. The guidelines published by the AUA and SUFU (Society of Urodynamics, Women’s Pelvic Medicine and Urogenital Reconstruction) focused on the uncomplicated patient with stress urinary incontinence. Do they really need to undergo urodynamic testing before undergoing surgical treatment for stress urinary incontinence? This is exactly what the VALUE study was intended to do (understand). They had quite stringent criteria to define an uncomplicated, simple patient with stress urinary incontinence. They were randomly selected to undergo most procedures in a sling, mass or urodynamic procedures, followed by suspension. They show that the urodynamic study had no impact on the treatment results, the patient’s quality of life or the success of the surgery. So, really in an uncomplicated patient, there is no need to perform a urodynamic study.

Currently, the uncomplicated patient is a minority. Most patients have some degree of other bladder problems. It may be overactivity, it may be underactivity, there may be some element of obstruction. Even in the VALUE trial, only 33% of patients met the criteria for an uncomplicated patient. So the debate really is, “Okay, so how far can we push the findings from the VALUE study? How much can we avoid unnecessary procedure in our patient population?” I also argue that we should use diagnostics when there are indications of possible underlying conditions because this will help us counsel patients and manage postoperative outcomes if they choose surgery and other treatment options if they exist.

At AUA, you also participated in the session “Panel Discussion: Management of Refractory OAB – A New Crop of Implantable PTNS Device.” Could you provide an outline of this discussion?

Overactive bladder is a very common condition that people suffer from and unfortunately it can be quite resistant to treatment. Many oral therapies exist, but their effectiveness is limited. Fortunately, we have amazing innovations in the development of devices that can really improve an overactive bladder. One of them is classic transcutaneous stimulation of the tibial nerve. The way I describe it to patients is that it’s like a little acupuncture needle; does not cause bleeding. We insert it right next to the ankle, where the tibial nerve is located. The tibial nerve connects back at the level of the spinal cord to the large S3 nerve, which leads to the bladder. Coming to the clinic once a week for 30 minutes for 12 weeks, patients simply undergo a small session of electrical therapy, (may) bring a book, and for 30 minutes they experience a slight tingling sensation in their ankle. It’s quite effective; is 70% and is effective in treating overactive bladder.

The big challenge is that patients have to travel once a week. Visits to the clinic are really burdensome, and we are talking about 3 months of weekly visits. Moreover, as we know, in America, access to specialized care outside major cities is very limited. Fortunately, companies have created opportunities for implantable devices. There are 2 FDA approved devices called BlueWind Revi and Valencia eCoin. (They are) very similar in that they require a small piece to be implanted. With BlueWind, you wear a small ankle sock that allows you to do therapy for yourself. When you’re at home, you just turn it on. Once you implant eCoin, you don’t have to think about it. eCoin turns itself on and off. In fact, the emergence of these new therapies is intended to improve patients’ access to care and (provide) less burdensome care in terms of transportation and time off work. The debate is to decide which one is better. Working in a field that offers so much innovation is both a blessing and a curse. This is a blessing because innovation is good for patients, doctors and everyone. Curse, because how do we decide which one? That’s really what this debate has been about: helping clinicians decide which drug to choose or which one is right for one patient and which for another.

How can we determine which device will be better suited to each patient?

I think that’s really a challenge, right? Some patients like the idea of ​​having complete control. BlueWind Revi allows this. It’s almost like a little capsule that we put under the skin. You can barely feel it. The patient decides when he wants to undergo therapy. They actually wear this little ankle brace and turn it on and off. In this situation, they have complete control.

Some other patients may not want to think about it at all. They want this little device to do the work for them. This would be Valencia eCoin, which, as I mentioned, turns itself on and off. The patient has no control over this. It really comes down to how patients feel about the control, or lack thereof, they expect from their device. As someone who often performs implants, especially sacrum neuromodulation, I can say that patients know what they want. They know whether they want to be conscious or unconscious. Again, it’s really great to be able to provide patients with this opportunity.

Are there any new applications for these devices or additional potential in this field?

One innovation that I think needs attention in this field is the effectiveness of neuromodulation in the neurogenic bladder. We really avoided studying neuromodulation in this population because previously these devices were not compatible with MRI and patients with neurological diseases often required MRI imaging. Other problems occur when you have a lack of sensation and may not feel pain or infection. So this is a really under-researched area. I think that by implementing these small and low-risk procedures and placing them in the clinic, the opportunity to study the effectiveness of neuromodulation in various neurological conditions – multiple sclerosis, stroke, Parkinson’s disease, spinal cord injury, incomplete spinal cord injury – really exists. we should pay our attention and investigate.