الفهرس 
INTRODUCTION
PathophysiologyOnly 14 pages are availabe for public view
 |  | from | 97 |  |  |
| | | from | 97 | | |
Abstract
The present study provides comprehensive analyses of most of the possible exposures that could affect the outcomes of sacral neuromodulation and addresses multiple questions that need answers from many of the female urologists’ perspective. A main finding in the study is the dissociation found to certain point between the subjective failures and objective failures meaning that not all patients who fail treatment seek InterStim removal or getting BTX treatment for their symptoms. We also found that older age patients and non-White are at higher odds of encountering subjective failures, while patients with neurological issues and those with prior hysterectomy were associated with reduced risk of subjective failures during the course of our study.Overall, eighty patients out of 83 patients proceeded to implantation (96%) in our series, which is slightly higher than a recent multi-institutional study where 91% of 864 progressed to the second stage [161]. In the ROSETTA trial, 184 out of 194 patients completed SNM treatment phase (94.8%) [162]. In another study, only 82% of the patients reached the implantation stage [163]. This shows a wide range of proportions of successful implantations in patients with overactive bladder. Nevertheless, the exclusion of patients with incomplete records in our study might have caused some inflation in the number of implants During the first 6 months, 13 patients (16.2%) encountered a subjective failure. Within the following 6 months, additional 13 patients failed bringing the total to 26 patients within the first year (32.5%). Within a 2-year follow-up, a total of 35 patients were found to experience treatment failure (43.5%). At 6 months follow-up, Singh et al reported only 10.8% SNM failure [163]. In a study by Amundsen and colleagues, about 41%, and 51% did not achieve ≥ 50% improvement after 6 months and two years of follow-up; respectively [164]. The high rate of failure at 6 months in this study could be explained by only including patients who completed a 2-year follow-up. Overall, objective failure was found in 23 patients (28.7%) with a median time of 24 months (IQR: 12, 30). To our knowledge, we are the first study to define objective failure as either device removal or post-SNM BTX, or both. A study by High and her colleagues looked at any additional therapy including starting or continuing medication, BTX, pelvic floor muscle therapy, or device removals due to decreased efficacy [161]. We opted to use the occurrence of invasive procedures as criteria for objective failure rather than including non-invasive measures to augment the treatment response. Some patients would seek additional medications even with 50% improvement looking for more optimal outcomes Patients who were older than 55 years were associated with higher odds subjective failure at 1 year and 2 years, but reduced odds of objective failure. Multiple studies showed that older age > 55 years was associated with lower cure and therefore higher rates of failure. Amundsen et al. in 2005 concluded that younger patients were associated with 65% improvement as compared to only 37% in older patients[165]. Recently, High et al reported that implanted patients have lower median age. Being a decade older was associated with lower odds (0.73) of implantation as well as lower odds (0.87) of post-implantation treatment response [161]. Also, Richter et al found that older patients were associated with lower odds of symptoms reduction > 50% (aOR 0.44 per decade, 95% CI 0.30, 0.65) [166]. Also, Komesu and colleagues concluded that younger patients were found to have greater continence and symptom improvement as compared to older patients [167]. In another study, younger patients showed more improvement in quality-of-life scores [168]. On the contrary, younger patients experienced more device removals or post-SNM BTX treatment in our study 37.5% vs. 25% without a statistically significant difference. A possible explanation that older patients have less tendency to seek additional surgeries because of additional comorbidities and have higher tendency of satisfaction with lower response than younger patients. Also, younger patients may have a higher expectation of well-being resulting in a higher rate of re-operation [169].