Heesakkers_EU_Genito.qxp 25/2/08 2:52 pm Page 45
Overactive Bladder
Percutaneous Tibial Nerve Stimulation for Treatment of
Refractory Overactive Bladder Syndrome
a report by
Michael R van Balken
1
and John PFA Heesakkers
2
1. Department of Urology, Rijnstate Hospital, Arnhem; 2. Department of Urology, Radboud University Medical Centre
Lower urinary tract disorders, including overactive bladder syndrome placed on the same leg near the arch of the foot. The needle and
(OAB), have an enormous impact on the quality of life (QoL) of patients. electrode are connected to a 9V stimulator (Urgent PC
®
, Uroplasty Inc.,
Neuromodulative treatment may fill the gap between conservative US) with an adjustable pulse intensity of 01–10mA, a fixed pulse width of
measures and surgery. Several stimulation locations of the human body 200 microseconds and a frequency of 20Hz. The amplitude is slowly
have been investigated and various kinds of stimulation therapy are increased until the large toe starts to curl or toes start to fan. If the large
available. The best-known therapy is sacral nerve stimulation (SNS). A toe does not curl or pain occurs near the insertion site, the stimulation
fairly new method is percutaneous tibial nerve stimulation (PTNS). PTNS device is switched off and the procedure is repeated. Stimulation is
is a neuromodulation technique that is minimally invasive and easy to applied at an intensity well tolerated by the patient. If necessary, the
perform. Stimulation is carried out through a percutaneously placed amplitude can be increased during the session. In general, patients
needle cephalad to the medial malleolus in 12 weekly sessions of undergo 12 weekly outpatient treatment sessions, each lasting
30 minutes each. Success can be achieved in around two-thirds of 30 minutes. If a good response occurs, the patient is offered chronic
patients. To develop a more patient-friendly stimulation modality, a small treatment. Depending on the durability of the response, patients are
implant may be the next step in the development of the technique. offered a treatment scheme that fits with their needs. Some patients
come back once a week, others every two or three weeks.
10
Lower urinary tract dysfunction (LUTD) is a common urological problem
that strongly affects QoL. The most debilitating kind of LUTD is OAB. OAB Presumed Mechanisms of Action
comprises urgency and frequency, with or without urge incontinence or Most of what is known about the mechanisms of action of
nocturia. In most patients the aetiology of these complaints remains neuromodulation is derived from SNS. In chronic pelvic pain its working
unclear.
1
Conservative treatment options for OAB consist of behavioural mechanism is believed to be a gate-control mechanism. A gate-control
techniques with or without biofeedback, bladder re-education, pelvic mechanism may also play a part in OAB.
11
Neuromodulation is suggested
muscle exercises or pharmacotherapy. Anticholinergics are the mainstay of to treat OAB by restoring the balance between inhibitory and excitatory
pharmacotherapeutical treatment. For refractory cases of OAB more control systems, peripherally and centrally.
12
For example,
aggressive surgical procedures, including bladder distension, ileocystoplasty neuromodulation at the sacral level is believed among others to inhibit
or urinary diversion, have been advocated. However, high recurrence and spinal tract neurons and inhibit neurons involved in spinal segmental
complication rates limit the widespread application of these treatments.
Michael R van Balken is a Staff Urologist in the
Therefore, other treatment modalities that are able to fill the gap
Department of Urology at the Rijnstate Hospital in
between conservative measures and surgical procedures are urgently
Arnhem. His main interest is functional urology, and he is
needed. The increased popularity of intravesical Botulinum toxin injection
the author or co-author of over 20 peer-reviewed
publications and nearly 50 abstracts. He earned his MD
therapy, first applied in neurological patients only,
2
but now in from the Catholic University Nijmegen, The Netherlands,
non-neurological patients with overactive bladder as well,
3
can be seen
and received his urological training at the Radboud
University Medical Centre in Nijmegen and the Policlinico
in that light. The same goes for neuromodulation, especially for its most
GB Rossi, Verona, Italy. In 2007 he completed his PhD
successful representative so far: continuous SNS (Medtronic, Inc., thesis at the Free University Amsterdam on the subject ‘Percutaneous tibial nerve
Minneapolis).
4–6
Although effective in selected patients, this technique
stimulation in lower urinary tract disorders’.
requires explicit surgical skill and is costly. Therefore, not surprisingly, the
John PFA Heesakkers is Chief Clinician and a full-time
quest for alternatives has been ongoing for some years now. Inspired by
Staff Urologist in the Department of Urology at the
previous work on transcutaneous tibial nerve stimulation by McGuire et Radboud University Medical Center in Nijmegen, The
al.,
7
Stoller started PTNS as neuromodulative treatment in LUTD. After
Netherlands. He heads the Unit of Functional Urology and
is also a Consultant Urologist in the St Maartenskliniek
initial testing in pig-tailed monkeys,
8
PTNS was later investigated in
Rehabilitation Centre, Nijmegen, and the MS Centre,
humans with promising results.
9
Nijmegen. He is the author or co-author of approximately
50 peer-reviewed publications, 200 abstracts and 100
lectures on urology. He is a reviewer for several journals,
Technical Application
including European Urology, Neurourology and Urodynamics, The Journal of Urology and
PTNS is performed in patients placed in the supine position with the soles
Urology. Dr Heesakkers completed his PhD thesis on dynamic graciloplasty, and earned his
MD from the Catholic University, Nijmegen and his MBA from Erasmus University,
of the feet together and the knees abducted and flexed (‘frog position’).
Rotterdam. He completed residencies in surgery and urology at Maastricht University
A 34-gauge stainless steel needle is inserted approximately 3–4cm about Hospital, The Netherlands.
three fingerbreadths cephalad to the medial malleolus, between the
E: j.heesakkers@uro.umcn.nl
posterior margin of the tibia and soleus muscle. A stick-on electrode is
© TOUCH BRIEFINGS 2007 45