AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 1 | 2024 | Advanced Management Options for Refractory Overactive Bladder success rate of 67%. 32 Intersim was found to have been effective, improved quality of life and was reasonably safe. 32 A prospective, multi-center RCT that compared SNM to standard medical therapy (SMT) found that SNM was superior to standard medical treatment. 33 Single-center studies on Axonics r-SNM devices have found these devices safe and effective for refractory idiopathic OAB. 34, 35 The most successful results that have been reported are for the Axonics r-SNM System that found success rates of 89%. 34 While SNM is effective, it has various disadvantages. First, the implantation requires surgery, which increases the risk of complications such as bleeding, infection, malfunction, and a need for revision. Secondly, the process of the procedure is staged; the first stage is used to determine if a patient will benefit from full implantation, this is determined by a 50% improvement in baseline symptoms). 11, 16, 24 After this stage, full implantation is done. This can result in attrition for some patients and requires long-term followup. Thirdly, the procedure is contraindicated in patients who need frequent MRI. 11, 16, 24 Posterior tibial nerve stimulation (PTNS) is done by stimulating the posterior tibial nerve above the medial aspect of the ankle using a small needle electrode. In the United States, PTNS was first approved in 2005. 9, 12, 16, 24, 36-38 There is no standard for the ideal duration of the sessions; however, it is estimated the impact of 30-minute sessions for three months may last up to 1 year. The efficacy of PTNS can sustained by repeating the sessions. The reported success rate ranges between 60% and 80%. 9, 12, 16, 24, 36-38 The main advantage of PTNS is that it is associated with minimal side effects, and no severe side effects have been reported. Similar to SNM, PTNS is contraindicated for pregnant patients and patients with implantable defibrillators, pacemakers, and tibial nerve damage. 11 Augmentation cystoplasty and urinary diversion: Augmentation cystoplasty and urinary diversion are considered fourth-line therapies that should only be considered in special cases and with well-informed and highly motivated patients. 23 Cystoplasty is performed by a 10-15 cm loop of small bowel to the intraluminal surface area of the bladder, 23 while urinary diversion is performed by implanting the ureters in an ileal segment of the bladder and creating a skin stoma. 13, 16, 24 Both these surgical approaches are associated with complications, which include electrolyte disturbances, renal failure, urinary tract stones and ischemia of the ileum and ureteric stricture. This approach should be considered if none of the other treatment options have worked because they are irreversible and associated with high morbidity. 13, 16, 24 Conclusion Overactive bladder syndrome is a serious and disabling condition that affects millions of patients physically, socially, and psychologically. The symptoms and response to treatment to treatment vary from patient to patient; a correct diagnosis is therefore imperative. While a significant number of studies report favourable outcomes of conservative non- pharmacological management and anticholinergic treatment, there are patients who do not respond or experience serious adverse side effects. Consequently, progress has been made to devise advanced treatment approaches for patients who do not respond well to conservative treatment approaches. Research on modalities such as Botox and neuromodulation shows that these modalities are effective for managing refractory OAB. However, the efficacy and risk of adverse events varies from patient to patient. It is, therefore, best practice to select treatment modalities in a progressive manner, starting with conservative management followed by pharmacological management and eventually Botox and neuromodulation. The complexities of managing OAB require a multidisciplinary approach and high commitment from the patients. REFERENCES ¢ ¢ ¢ ® ¢ § ¡ § « ® ¢ ´ ¯ _ § « ¢ ³ ¢ ¡ § ¡ ¢ ¢ ¥ ³ ¢ § ¨ ¢ § ¡ § ¥§ § ¢ § ¢ African J urnal of Obst trics and Gynaecology | Volume 2 | Issue 1 | 2024 | 13