A prospective assessment of the validity of the CUA neurogenic bladder guideline.

INTRODUCTION: The Canadian Urological Association (CUA) neurogenic bladder guideline surveillance strategy for neurogenic lower urinary tract dysfunction (NLUTD) has not been formally evaluated. Our objective was to evaluate the validity of the risk stratification suggested in these guidelines. METHODS: This was a prospective, observational cohort study of adult NLUTD patients with spinal cord injury, multiple sclerosis, or spina bifida who required urodynamics. Patients with a requirement for immediate bladder surgery (not suitable for surveillance) were excluded. Patients completed standardized medical history/questionnaires, baseline urodynamics, renal imaging, and creatinine tests. The primary outcome was the need for different types of urological management between the high-risk and moderate-risk groups. RESULTS: We enrolled 68 patients; most commonly, these were spinal cord injury patients, and most people were using intermittent catheters. At baseline, 62% (40/68) were classified as high-risk. In this group, there was a numerically greater proportion who received a recommendation for a new urological medication (48% vs. 25%, p=0.06) or a change to their bladder management (45% vs. 36%, p=0.44). A total of 26 high-risk and 23 medium-risk NLUTD patients had a one- year followup visit. A larger proportion of the high-risk patients had a recommendation for a new bladder medication (15.4% vs. 8.7% p=0.47), intravesical onabotulinum toxin (34.6% vs. 13% p=0.08), or an alternate method of bladder management (15.4% vs. 4.3%, p=0.2). Mean creatinine change was slightly greater in the high-risk group (+6.1 vs. +0.4 umol/L, p=0.05). Approximately 1/3 of both high-risk and moderate-risk patients didn't accept the recommended interventions. CONCLUSIONS: A higher proportion of high-risk NLUTD patients had urology-relevant interventions recommended, both at baseline and at their one-year followup visit. This supports the general concept of risk stratification and the variables used to define high-risk in the CUA's neurogenic bladder guideline.

Retroperitoneal hematoma post percutaneous sacral nerve evaluation: A case report.

Sacral neuromodulation is an accepted therapy for various voiding dysfunction. We report a 71-year-old male with a history of BPH post TURP and overactive bladder. He was on anticoagulants for atrial fibrillation. He underwent uneventful percutaneous sacral nerve evaluation. Five days later, he showed no improvement. Temporary lead was removed in clinic without complications. On day ten, he developed lower abdominal, and genital skin bruising. CT scan showed presacral retroperitoneal hematoma. His Hemoglobin dropped. He was admitted, managed conservatively and discharged with a stable hemoglobin. Retroperitoneal hematoma post PNE is rare. Management is conservative. Angioembolization is reserved for unstable patients.

Multicenter Study for the Effect of COVID-19 Lockdown on Patients With Sacral Neuromodulation Implants.

INTRODUCTION: The massive spread of COVID-19 affected many aspects of medical and surgical services. Many patients with sacral neuromodulation (SNM) devices needed integrated follow-up and close communication regarding the programming of the device. In this study, we aimed to explore the effect of COVID-19 lockdown on patients with SNM devices. MATERIALS AND METHODS: This was a multicenter study designed and conducted in four centers performing SNM (Toronto Western Hospital, Toronto, Canada; King Abdulaziz University Hospital, Jeddah, Saudi Arabia; Al-Amiri Hospital, Kuwait City, Kuwait; and Austin and Western Health, University of Melbourne, Australia). An online questionnaire was created through Google Forms and circulated among patients with SNM devices in all four mentioned centers. The questionnaire was sent to patients during the forced lockdown period in each country. RESULTS: A total of 162 responses were received by September 2020. Data showed that most patients had their device implanted before the lockdown period (92.5%, 150/162). Most patients did not experience any contact difficulties (91.9%, 149/162). When patients were requested for their preference of programming, 89.5% (145/162) preferred remote programming. Correlation analysis did not show any significant relation between patient diagnosis and COVID-19-related difficulties or preferences. CONCLUSION: The difficulties with access to care experienced during the pandemic and the patient's expressed willingness to participate in virtual care should provide impetus for manufacturers of SNM devices to move forward with developing remote programming capabilities.

Spinal cord injury patients: Effect of urinary intervention therapy type on quality of life, questionnaire-based study.

OBJECTIVE: The objective of the study is to assess the quality of life (QoL) with or without surgical intervention in patients with spinal cord injury (SCI) with neurogenic bladder. MATERIAL AND METHODS: A prospective study was conducted on SCI patients with neurogenic bladder. The questionnaires used to assess the QoL were the 36-Item Short-Form Health Survey questionnaire (SF-36), the Incontinence questionnaire [Urogenital Distress Inventory (UDI-6)], the International Index of Erectile Function (IIEF-5), and the Female Sexual Function Index (FSFI). Patients were categorized into two groups: the first group consisted of patients who underwent a surgical procedure and the second group included patients managed by a conservative treatment option: clean intermittent bladder catheterization. RESULTS: Total of 29 patients included in the study, 13 patients underwent urinary diversion (mean age: 45.84±16.41 years) and 16 patients had a conservative treatment (mean age: 47.61±13.90 years). The SF-36 questionnaire evaluation revealed that the bodily pain component was significantly lower in patients who underwent urinary diversion (p=0.009), whereas vitality (p=0.045) and social functioning (p=0.005) components were significantly lower in patients who underwent any type of urinary surgical procedure. The incontinence questionnaire (UDI-6) revealed significantly lower scores in patients who underwent urinary diversion (17.84±5.2) than patients who underwent a conservative treatment (47.05±5.8; p=0.001). CONCLUSION: Urinary surgical intervention improved the QoL in SCI patients with neurogenic bladder as per the UDI-6 scores. However, contrasting results of the SF-36 assessment warrant its further validation by conducting studies with a larger sample size.

The history of sacral neuromodulation in Canada.

Sacral neuromodulation (SNM) has been used for the past 30 years, with significant improvements in the implantation technique and technology over the last several years. Canadian centers were involved with this technique from the very beginning by participating in several multicenter clinical trials and engaging in basic and clinical research. Presently, six Canadian centers continue to have SNM implantation programs.

Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Context: Urinary tract infections (UTI) are the most frequent secondary health condition following spinal cord injury or disease (SCI/D) that adversely impact overall health and quality of life, and often result in rehabilitation service interruptions, emergency department visits, and urinary sepsis. Methods: Experts in Urohealth and/or UTI recognition and management and the SCI-High Project Team used a combination of evidence synthesis and consensus methods for developing the UTI indicators. A systematic search and a Driver diagram analysis were applied to identify key factors influencing UTI. This Driver diagram guided the UTI Working Group when defining the construct, specifying the aim for the UTI SCI/D quality indicators, and developing the UTI diagnostic checklist and fever definition. Results: The structure indicator was the proportion of patients with a health care professional (i.e. family physician or urologist) able to follow-up with the patient regarding urine culture and sensitivity results within 48-72 h of collection. The Working Group knowingly adopted a single checklist for UTI diagnosis, recognizing the stark contrast in the complexity of diagnosis in acute versus community settings. The process indicator is the proportion of SCI/D rehabilitation inpatients with UTI as defined by the UTI diagnostic checklist. The outcome indicator is the proportion of SCI/D rehabilitation inpatients with inappropriate antibiotic prescription. Conclusion: UTI can be diagnosed using the developed symptoms and signs checklist. These structure, process, and outcome quality indicators will ultimately reduce inappropriate antibiotic therapy for UTI and the rising incidence of antibiotic resistance among community-dwelling individuals with chronic SCI/D.

Patients with Sacral Neuromodulation: What Are the Factors Affecting Their Therapy Satisfaction?

INTRODUCTION AND OBJECTIVES: Technology has brought about changes to the sacral neuromodulation (SNM) therapy and has rendered it as a minimally invasive procedure. The presence of tined lead, smaller implantable pulse generator, and the different available patient programmers are the factors new modifications this procedure; however, no enough data are available about patient satisfaction comparing these different parameters. We therefore conducted our study among SNM-implanted patients, assessing factors affecting long-term satisfaction. PATIENTS AND METHODS: We conducted a cross-sectional study with a survey questionnaire for all SNM-implanted patients from December 2011 to May 2012. The survey questionnaire included information on patient demographics, level of satisfaction, and the need for combined medical therapy for symptom control, type of programmer used by patient, and their ability to use it efficiently. RESULTS: A total of 117 patients visited the clinic in that duration, and 71 patients filled up the survey questionnaire, with a response rate of 60.7%, diagnosis OAB 41 (57.7%), chronic non-obstructive retention 15 (21.1%) and frequency-urgency syndrome 15 (21.1%). Forty-nine (69%) of patients were on SNM therapy alone, while 31% patients needed other forms of therapy for symptoms control. The types of patient programmers used were old programmers in 10 (14.1%), new programmers in 44 (62%), and twin programmers in 4 patients. Patient SNM therapy satisfaction level was 95.8%, while 3 patients (4.2%) were not satisfied. SNM therapy satisfaction showed that it was correlated with the need for combined therapy for symptoms control (correlation coefficient 0.341, p value = 0.004), but there was no correlation with age, duration of therapy, complication, or programmer type. CONCLUSION: SNM satisfaction in patients is mainly correlated with the need for additional medications for symptom control.

International Continence Society best practice statement for use of sacral neuromodulation.

AIMS: Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. METHODS: Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. RESULTS: The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. CONCLUSIONS: These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.

Characterizing the transcutaneous electrical recruitment of lower leg afferents in healthy adults: implications for non-invasive treatment of overactive bladder.

BACKGROUND: As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg. METHODS: In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 µs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance. RESULTS: All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve. CONCLUSIONS: Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

The role of the neurometer CPT/C in sacral neuromodulation.

OBJECTIVE: The aim of the current research project was to study the role of the Neurometer® as a tool to predict responders to sacral neuromodulation therapy (SNM). MATERIAL AND METHODS: This was a prospective, open study in male and female patients, aged 18 and over with voiding dysfunction [non-obstructive retention and/or frequency/ urgency syndrome]. The first group underwent a screening test to evaluate percutaneous nerve functions (PNE) and to determine whether they are candidates for SNM with the InterStim®. Prior to PNE testing, all patients were evaluated with the pain tolerance test (PTT) using the electro-diagnostic Neurometer® CPT/C device. An InterStim® implant was placed in patients who were responders to PNE testing underwent. On the other hand, non-responders underwent a staged implant placement. The second group consisted of patients who already had InterStim® implanted for voiding dysfunction. During the routine office follow-up, the patients implanted with Interstim® underwent a PTT using the Neurometer® CPT/C device. All the testing using the Neurometer CPT/C was performed on the day of the PNE for the first group, and the day of the routine follow-up visit for the second group. All of the results for the Neurometer® testing were kept blinded from the PNE results, and those of the outcome of the follow-up visit. The study received approval by the Research Ethics Board of the University Health Network (No. 14-8196). RESULTS: We recruited a total of 123 patients. The results presented here include 110 patients who completed the study, 48 of whom were in the first group, and 62 in the second group. The statistical analysis used was as follows: Group 1: Simple linear regression analysis and the linear discriminate analysis were preformed. It was found that for patients without the InterStim® implant with a combined CPT/CPD of 800 and above, the Neurometer® could predict the test screening results with an accuracy of 71%. Group 2: Same analysis and tests were conducted for patients with the InterStim® implant, and the results showed that if the patient had a combined CPT/CPD of 600 and above, the Neurometer® could predict the patients satisfaction or dissatisfaction with an accuracy of 72%. CONCLUSION: Neurometer® may play a role in predicting test trial positive responders and patient satisfaction after the placement of InterStim® implant.

Does Psychological Disturbance Predict Explantation in Successful Pelvic Neuromodulation Treatment for Bladder Dysfunction? A Short Series.

INTRODUCTION: Sacral neuromodulation (SNM) is a safe and effective therapy for patients with lower urinary tract dysfunction (LUTD). It is used in patients who have exhausted conservative and first line therapeutic options. The selection of eligible candidates could predict a successful therapeutic outcome. Although many factors have been identified, psychological/psychiatric disturbances are neither well understood nor are routinely evaluated prior to implantation. CASE REPORTS: We report three cases where identified psychological/psychiatric disturbances post-implantation could have influenced explantation in an otherwise successful implantation of SNM device assessed both subjectively and objectively. The device had to be explanted in two of the three. One more patient has requested but has not-yet undergone explantation and is receiving treatment for severe depression. One of the explanted cases has successfully undergone re-implantation after successful treatment of her diagnosed psychological condition, while the other's request for re-implantation has not yet been fulfilled. CONCLUSIONS: Psychological/psychiatric disturbance have possibly affected the treatment outcome and explantation of SNM in our patients despite a high success in resolution of the urinary symptoms. Addressing such disturbances when determining patient eligibility for SNM therapy could reduce the explantation rate after a successful therapeutic response, and is an interesting point of interest for future research into predictors of successful SNM implantation and therapy.

Radiographic Position of the Electrode as a Predictor of the Outcome of InterStim Therapy.

PURPOSE: Sacral neuromodulation (SNM) therapy is indicated for some refractory urological conditions. The electrode lead position in sacral x-rays during routine follow-up may predict the outcome of SNM therapy. To determine whether the radiographic position of the electrode in the sacral foramen predicted the long-term outcome of SNM therapy. METHODS: This was a retrospective study of patients who underwent InterStim SNM at Toronto Western Hospital by 2 surgeons from July 2013 to March 2014. The position of electrodes in relation to the sacral bone was assessed on follow-up sacral x-rays. In the lateral view, we determined the location of the radio-opaque marker of the electrode relative to the inner surface of the sacrum (P3, D3, P2, D2, P1, D1, P0, and D0). In the anteroposterior view, the angle between a line through the spinous process shadow and the electrode was measured (0°-30°, 30°-60°, 60°-90°, >90°, or medial). Dissatisfied patients were defined as those who did not improve based on a voiding diary or those who needed salvage treatment after SNM. The primary endpoint was to determine whether the electrode lead position on sacral x-rays predicted the outcome of SNM therapy. RESULTS: A total of 69 patients (61 female and 8 male patients) were included, with a median age of 55 years. Forty-two of the patients (60.9%) had refractory overactive bladder, 21 (30.4%) suffered from chronic urinary retention, and 6 (8.7%) had lower urinary tract symptoms and chronic pelvic pain syndrome. The univariate analysis did not show any correlation between SNM response and the electrode position or angle. Dummy regression analysis using response to implantation as the dependent outcome variable did not show any significance for any of the predictors. CONCLUSIONS: Our study did not show a correlation between the long-term response to SNM and the electrode position on follow-up sacral x-rays. In this study, electrode lead position in sacral x-ray at follow-up was not correlated with the outcome of SNM therapy.

Exploring daily blood pressure fluctuations and cardiovascular risk among individuals with motor complete spinal cord injury: a pilot study.

BACKGROUND: Clinically silent autonomic dysfunction with bowel and bladder care, are postulated to contribute to cardiovascular disease after chronic spinal cord injury (SCI). OBJECTIVE: We describe the frequency and severity of dysreflexic episodes, termed transient blood pressure elevations (T-BPE) over 48 hours in adults with cervical or high-thoracic motor-complete SCI. SETTING: Tertiary SCI Rehabilitation Centre in Toronto, Canada. PARTICIPANTS: Individuals with chronic SCI, C1-T3 AIS A or B, >1 year post-injury, living in the community (n=19). OUTCOME MEASURES: Data were obtained via 48-hour ambulatory blood pressure (BP) and heart rate (HR) monitoring, with data captured at 10-minute intervals and a concurrent diary describing activities of daily living, and bladder/bowel routines. T-BPE were defined as a ≥ 40 mmHg elevation in systolic blood pressure (SBP) above the participant's supine baseline. Severe (≥ 60-79 mmHg) and Extreme ≥80 mmHg elevations in SBP were described. RESULTS: Thirteen participants experienced T-BPE within the assessment period, with 7/13 experiencing "severe", and 3/13 experiencing "extreme" SBP elevations. The median number of T-BPE was 8 (IQR = 3), and the mean ± SD SBP during T-BPE was 150 ± 16 mmHg, These T-BPE were verified as dysreflexic events using a conservative definition of a >40 mmHg increase in SBP, with a concurrent 10 bpm decrease in HR, above the 48-hour average SBP, yielding 12/19 participants with T-BPE. CONCLUSIONS: T-BPE were frequent, often with severe or extreme elevations in SBP, despite few reported symptoms. Recognition and management of these dysreflexic events associated with T-BPE are needed, which may ameliorate cardiovascular disease risk.

Percutaneous Nerve Evaluation Test Versus Staged Test Trials for Sacral Neuromodulation: Sensitivity, Specificity, and Predictive Values of Each Technique.

PURPOSE: InterStim device is an U.S. Food and Drug Administration approved minimal invasive therapy for sacral neuromodulation for lower urinary tract dysfunction. Before InterStim implantation, a trial with the appropriate screening tests is required to determine patient therapy eligibility. There are two different techniques for patient screening: percutaneous nerve evaluation (PNE) test and staged test. Few studies have reported success and failure rates for each technique. However, test sensitivity and predictive values of either test have not been studied. The aim of our study was to determine the sensitivity and specificity of each test and to establish a decision algorithm for the most appropriate testing method to be used as a screening test. METHODS: This cross-sectional study was conducted from August 2009 to February 2012 and included patients with lower urinary tract dysfunction who participated in the stimulation test trial. Patients underwent PNE as the first stimulation test, while those who encountered technical difficulty during PNE or electrode migration underwent staged testing. RESULTS: A total of 213 patients, including 172 female and 41 male subjects, underwent PNE. The patients' diagnoses included refractory overactive bladder (47.9%), nonobstructive urinary retention (29.6%), and frequency urgency syndrome (22.1%). A total of 202 patients were screened with PNE and 10 patients with staged testing. Overall sensitivity of PNE was 87.3%, and it was 90% for staged test. PNE specificity was 98.5% as compared to 92.9% for staged test. Positive and negative predictive values for PNE were 99% and 82.1% and for staged test were 90% and 92.9%, respectively. CONCLUSIONS: PNE test has high specificity and positive predictive value. We recommend PNE, a simple office-based, less expensive procedure as the first option for screening.

Sacral Neuromodulation in Patients With a Cardiac Pacemaker.

The objective of this study was to describe our experience using sacral neuromodulation to treat urinary urgency, frequency, urge incontinence, and chronic urinary retention in patients with cardiac pacemakers. With the increasingly widespread use of InterStim for bladder function restoration, we are seeing more complex patients with multiple comorbidities, including cardiac conditions. Herein, we report 3 cases of individuals with cardiac pacemakers who underwent InterStim implantation to treat urinary conditions. This study is a case series of 3 patients with cardiac pacemakers who underwent sacral neuromodulation to treat refractory voiding dysfunction. The initial patient screening for InterStim therapy involved percutaneous nerve evaluation (PNE), in which a temporary untined lead wire was placed through the S3 foramen. Patients who did not respond to PNE proceeded to a staged implant. All patients in this study had a greater than 50% improvement of their urinary symptoms during the initial trial and underwent placement of the InterStim implantable pulse generator (IPG). Postoperative programming was done under electrocardiogram monitoring by a cardiologist. No interference was observed between the Inter- Stim IPG and the cardiac pacemaker. In this group of patients, sacral neuromodulation in the presence of a cardiac pacemaker appears to have been safe.

A Phase-Based Electrical Plethysmography Approach to Bladder Volume Measurement.

Neuromodulation approaches to treating lower urinary tract dysfunction could be substantially improved by a sensor able to detect when the bladder is full. A number of approaches to this problem have been proposed, but none has been found entirely satisfactory. Electrical plethysmography approaches attempt to relate the electrical impedance of the bladder to its volume, but have previously focused only on the amplitudes of the measured signals. We investigated whether the phase relationships between sinusoidal currents applied through a pair of stimulating electrodes and measured through a pair of recording electrodes could provide information about bladder volume. Acute experiments in a rabbit model were used to investigate how phase-to-volume or amplitude-to-volume regression models could be used to predict bladder volumes in future recordings, with and without changes to the saline conductivity. Volume prediction errors were found to be 6.63 ± 1.12 mL using the phase information and 8.32 ± 3.88 mL using the amplitude information (p = 0.44 when comparing the phase and amplitude results, n = 6), where the volume of the filled bladder was about 25 mL. When a full/empty binary decision rule was applied based on the regression model, the difference between the actual threshold that would result from this rule and the desired threshold was found to be 4.24 ± 0.65 mL using the phase information and 106.92 ± 189.82 mL using the amplitude information (p = 0.03, n = 6). Our results suggest that phase information can form the basis for more effective and robust electrical plethysmography approaches to bladder volume measurement.

Sacral Neuromodulation for Genitourinary Problems.

Sacral neuromodulation (SNM) is a minimally invasive therapeutic option for many voiding dysfunction conditions. It is approved by the US FDA for refractory overactive bladder with and without incontinence and nonobstructive retention. Since SNM has shown a favorable response for these approved indications, other therapeutic applications have been proposed for various conditions such as painful bladder syndrome, chronic pelvic pain and neurological voiding dysfunction in both adult and pediatric age groups. SNM therapy with the most commonly used dedicated SNM device (InterStim) involves insertion of electrode(s) in the third and/or fourth sacral foramen next to the nerve root. The electrode is then connected to a battery-operated pulse generator. All patients need to have a test trial period before definitive device insertion. Here we discuss SNM therapy in functional urinary disorders and the technique of device insertion with the potential pitfalls.

Economic evaluation of sacral neuromodulation in overactive bladder: A Canadian perspective.

INTRODUCTION: Refractory overactive bladder (OAB) with urge incontinence is an underdiagnosed condition with substantial burden on the healthcare system and diminished patient's quality-of-life. Many patients will fail conservative treatment with optimized medical-therapy (OMT) and may benefit from minimally invasive procedures, including sacral-neuromodulation (SNM) or botulinum-toxin (BonT-A). The goal of this study was to estimate the cost-efectiveness of SNM vs. OMT and BonT-A as important parameters from coverage and access to a therapy. METHODS: A Markov model with Monte-Carlo simulation was used to assess the incremental cost effectiveness ratio (ICER) of SNM vs. BonT-A and OMT both in deterministic and probabilistic analysis from a provincial payer perspective over a 10-year time horizon with 9-month Markov-cycles. Clinical data, healthcare resource utilization, and utility scores were acquired from recent publications and an expert panel of 7 surgeons. Cost data (2014-Dollars) were derived from provincial health insurance policy, drug benefit formulary, and hospital data. All cost and outcomes were discounted at a 3% rate. RESULTS: The annual (year 1-10) incremental quality-adjusted life years for SNM vs. BonT-A was 0.05 to 0.51 and SNM vs. OMT was 0.19 to 1.76. The annual incremental cost of SNM vs. BonT-A was $7237 in year 1 and -$9402 in year 10 and was between $8878 and -$11 447 vs. OMT. In the base-case deterministic analysis, the ICER for SNM vs. BonT-A and OMT were within the acceptable range ($44 837 and $15 130, respectively) at the second year of therapy, and SNM was dominant in consequent years. In the base-case analysis the probability of ICER being below the acceptability curve (willingness-to-pay $50 000) was >99% for SNM vs. BonT-A at year 3 and >95% for OMT at year 2. CONCLUSION: SNM is a cost-effective treatment option to manage patients with refractory OAB when compared to either BonT-A or OMT. From a Canadian payers' perspective, SNM may be considered a first-line treatment option in management of patients with OAB with superior long-term outcomes. Similar to all economic analysis, this study has limitations which are based on the assumptions of the used model.