OAB Debate: Botulinum toxin or sacral neuromodulation for chronic LUTS?

The jury is still out when it comes to the query-- which is more effective: botulinum toxin (Botox) or sacral neuromodulation (SNM) for patients with refractory lower urinary tract problems?

“The question remains unanswered and perhaps we need to come back next year with more mature data,” said Prof. John Heesakkers (NL) who moderated the debate between Profs. Francisco Cruz (PT) and Karel Everaert (BE), the latter arguing for sacral neuromodulation.Cruz fired the first shot insisting that Botox has “a sound mechanism of action and the drug administration is simple.” He added that the treatment is highly effective on both the long and short-term.

“There are few side effects and the costs are acceptable,” added Cruz as he mentioned that Botox is a “flexible treatment” that “parallels the wax-and-wane history” of the patient’s OAB problems. He also cited the recent randomised study results from Nitti and Chapple which showed excellent results.

“Onabotulinum toxin should be the next treatment option for OAB patients who do not tolerate oral medications,” concluded Cruz while underscoring that SNM is a treatment that incurs higher costs.

Everaert, meanwhile, hammered on the issue that there is no value in comparing features or benefits of the treatments due to the mixed profiles of patients with OAB. “We can’t compare these patients since there are aspects that differ from one patient to another,” he said as he noted that what is more important for clinicians is to treat the problem in a more holistic manner.

“OAB patients often have other voiding and defecation problems…and SNM treatment enhances the voiding and defecation cycle,” according to Everaert as he emphasised that SNM might even improve the patient’s bowel problems.

“In the end it should be patient’s preference, not the doctor’s preference. We have to inform our patients what is best for their problems, but they have to make the choice,” he said.

“The success of SNM, as shown in studies, decreases with time. Besides doctors and patients should be prepared for serious therapy-related adverse events which may require surgical interventions. Patients don’t want that and besides when patient’s ask us how SNM works, we can’t give a reply because we don’t know how it works,” said Cruz in his rebuttal.

“Let’s cut the crap,” retorted Everaert in his own rebuttal as he again stressed that sacral neuromodulation is a treatment that enhances the voiding and defecation cycles. “Botox disrupts the voiding cycle. And again, it should be the patient’s preference with the doctor only providing guidance,” he added.