Sacral Neuromodulation in Children: Prospective evaluation of voiding symptom scores in successes and failures
Abby S. Taylor, MD, Chelsea Lauderdale, MS, Mark C. Adams, MD, John W. Brock, III, MD, Douglass B. Clayton, MD, Stacy T. Tanaka, MD, John C. Thomas, MD, Chevis N. Shannon, PhD, John C. Pope, MD.
Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
BACKGROUND: The use of sacral neuromodulation for refractory pediatric lower urinary dysfunction is now an accepted adjunct to standard therapy. We prospectively collected validated voiding symptom scores in patients before and after implantation of a sacral neuromodulation (SNM) device. Thus, we hypothesized that implantation of a SNM device leads to both objective improvement in validated voiding symptom scores and subjective improvement as reported by the patient.
METHODS: Following IRB approval, we prospectively enrolled all patients undergoing implantation of a SNM device. A redcap database was used for de-identified data collection. We administered validated Vancouver Non-neurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome (NLUTD/DES) questionnaires preoperatively, and at every post-operative follow-up visit. Overall success was defined as a subjective report of improvement by patients of >50%. As defined by ICCS, initial success was further categorized into no-response (<50% reduction in symptoms), partial response (50 to 99% reduction), or complete response (100% reduction). Statistical analysis was carried out on R software 3.1.1 using Wilcoxon and Pearson paired test. A p-value of <0.05 was considered significant.
RESULTS: Since 2010, we prospectively enrolled a total of 45 patients in our study, of which 41 had completed preoperative and postoperative questionnaires. The primary indication for device placement was urinary urge incontinence (uninhibited contractions (UIC) on UDS) in 83% (34/41), urinary incontinence without UIC in 10% (4/41) and 7% (3/41) had urinary retention requiring catheterization. Median length of device placement was 39 months (20-58 IQR), median time from device placement to most recent questionnaire was 21.5 months (11-30 IQR). Overall, we noted a success rate of 80%. Using the categorical description of initial success, 20% (8/41) had no response and therefore failed therapy, 49% (20/41) showed partial response, while 32% (13/41) had a complete response to sacral neuromodulation. As shown in Table 1, we found no difference between successes and failures regarding gender, age and pre-operative NLUTD/DES score. When compared to failures, successes showed a statistically significant lower NLUTD/DES score at most recent visit (p = 0.013), in addition to a larger overall score reduction (p = 0.012).
CONCLUSIONS: In this larger cohort with longer follow-up, we have confirmed our previous findings that all patients undergoing implantation of sacral neuromodulation show a significant and durable improvement in validated voiding symptom scores. However, when we compare success versus failure as reported by the patient, a smaller change in symptom score correlates to a worse clinical outcome. Our next step is to determine if early changes in symptom score can predict long-term success and aid in appropriate selection of future patients.
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