Third-line treatment options for refractory urgency urinary incontinence in women—a commentary to ROSETTA trial

According to the American Urological Association (AUA) and Society of Urodynamics and Female Urology (SUFU) guidelines third-line treatment options for refractory overactive bladder (OAB) include: intradetrusor onabotulinumtoxinA injections (100 units, Botox, Allergan) or sacral neuromodulation (SNS), or peripheral tibial nerve stimulation (PTNS). Intravesical onabotulinumtoxinA injections are ranked as standard treatment (evidence strength: grade B), which is equally to the strongest statement. AUA/SUFU guidelines rank SNS and PTNS as recommended option (evidence strength: grade C). Patients qualified for intravesical onabotulinumtoxinA injections should be warned about the potential risk of urine retention and must be willing to perform clean intermittent self-catheterization (CISC). Sacral neuromodulation may be offered to selected patients, who are willing to undergo two-step surgical procedure (1). SNS is also benefit for patients with idiopathic urinary retention and with urgency symptoms. However, there is still a lack of evidence, which third-line treatment option is superior in patients with refractory overactive bladder (OAB). Interestingly, in the recent study published by Hashim et al. (2) 34% patients with refractory OAB were willing to try sacral neuromodulation and only 9% of patients preferred intravesical Botox injections as a third-line treatment option. On the other hand it is much easier for physicians to inject the detrusor with onabotulinumtoxinA than implant the neurostimulator (the learning curve for Botox is very short and interestingly enough treatment effectiveness does not depend on the experience of performing physician). We should also remember about the cost of procedures. In many countries there is still no health reimbursement either for onabotulinumtoxinA nor SNS.