Advances in sacral neuromodulation support more individualized treatment pathways

Sacral neuromodulation continues to evolve as a treatment option for patients with overactive bladder (OAB), offering an effective alternative when conservative and pharmacologic approaches fall short. Advances in device technology, expanding indications, and shifting guideline recommendations are reshaping how urologists incorporate neuromodulation into clinical practice. As these therapies become less invasive and more patient-friendly, clinicians are increasingly reconsidering where and how early they should be introduced in the treatment algorithm.

In this interview, Brett Trockman, MD, FACS, a urologist with UroPartners in Illinois, shares his perspective on patient selection and how traditional stepwise approaches are evolving. He emphasizes that although many patients still opt for medications first, newer guidelines and improved device profiles are supporting earlier use of neuromodulation in appropriately selected individuals.

Trockman also reflects on the most impactful technological advancements in the field, including MRI-compatible devices and longer battery life, as well as emerging programming strategies such as intermittent stimulation. He addresses ongoing barriers to broader adoption, including patient acceptance and insurance coverage. He wraps up the discussion by looking ahead to a future defined by increasing device options and more personalized treatment pathways, where sacral and tibial neuromodulation strategies can be tailored to meet individual patient needs.

Urology Times: Today, we are talking about updates and future directions for sacral neuromodulation. How do you typically approach patient selection for sacral neuromodulation?

Trockman: I see a lot of patients with OAB, and I work them up like I would any patient: get a good history, assess their symptoms and the bother from their symptoms, and make sure there aren't any reversible causes of the symptoms that need to be treated, like an infection. I also make sure there aren't any serious health-threatening causes that need to be addressed. For instance, someone who has never been diagnosed with diabetes and has frequency related to that, or perhaps bladder cancer or unusual presentation of stone; I want to make sure I haven't missed any of those things.

It’s also important to at least make sure that they're drinking enough and not too much and avoiding bladder irritants. I also look at their medications to see if there's anything that we can do to make an adjustment to decrease diuretics, etc, in collaboration with their other doctors. If that's not working, most of my patients will then choose to have pharmacologic therapy first, and if they fail that, then we go on to neurostimulation. Especially with the new guidelines, it's not necessary to do medications first. I do offer neuromodulation earlier in the pathway than I ever have. Most patients still choose medical therapy first and that's probably what I'm most comfortable with, just because it's what we've always done. But things are changing because the neuromodulation is becoming less invasive, and [there are] a lot of options for that.

Urology Times: What are some of the most important advancements in sacral neuromodulation technology or programming over the past few years?

Trockman: From my perspective, the biggest [advance] would be the MRI compatibility of the devices. There were a lot of patients who didn't want to have a device placed since they couldn't have MRIs, so it was really an impediment for a lot of patients. It makes it much easier if you don't have to think about that. MRI is a very common diagnostic test for all kinds of medical conditions, so it's a big issue if you can't do MRI. That really opened things up for a lot of patients.

Number 2 is the longer battery life of the sacral neuromodulation devices. That has changed how often you need to change the batteries, and that's a big advance as far as programming. I've been doing this a long time, and it's interesting. The old batteries weren't as good, so we put the devices on a cycling mode. They would turn off at night, or they wouldn't be continuously stimulating to save battery life. The thought was that works just as well. As time went on, we then thought continuous stimulation works. I don't know that I ever saw a study on it, but that just became our practice. We were using continuous stimulation. Now, with the advent of tibial stimulation and the new sacral nerve modulation devices, we're going back full circle to intermittent stimulation. It'd be interesting, if you combine intermittent stimulation with these 10-year or 15-year batteries; we'll see where that goes. That's an interesting phenomenon at least with the programming aspect of things.

Urology Times: What are some of the main barriers to broader adoption of sacral neuromodulation, whether it be patient, procedural, or reimbursement related?

Trockman: The more it's used, and the more patients hear about it and hear other people who've had it, they get a little more accepting of it. A lot of them don't want procedures at all, but I think it's becoming more accepted. Most of these devices do require the patient to be able to manipulate the device using the controllers, or put on a wearable device, so it has to be an appropriate patient who can at least manage that, or have someone that can help them with it. That’s one barrier. Insurance [is another]; with these new devices, it takes a while for them to cover them.

But the devices are very low risk with a low level of morbidity, so you don't have a lot to lose for these patients, many of whom are at their wits’ end. The results are probably going to be even better as we go forward and as we move the use of the device earlier in the pathway, because we're going to have less of the very end-stage patients, and they're going to respond better. Even with our end-stage patients, at least 60% were getting a nice response, which, in a very difficult patient population, is impressive. [It's] very helpful to these patients that were struggling. As it becomes more accepted and we get more of these options where we can individualize for the patients, we'll see more neuromodulations done.

Urology Times: What are some of the most promising future directions in sacral neuromodulation, including advancements in device technology or patient selection strategies?

Trockman: It's going to be choosing between the different options for the patients. It's not going to be a one-size-fits-all. Some patients may want one option or another. We're focusing on sacral neuromodulation, but also there's tibial neuromodulation, and there are various forms of that that also play into it for patients who are interested in neuromodulation. I think sacral neuromodulation is still the gold standard as far as effectiveness, at least in my experience. But on a step-wise basis, the tibial stimulation is also an option. There's even a wearable device for the tibial stimulation that's completely non-invasive. That's a nice option for patients as well as they go with something in a stepwise manner, from the least invasive to more invasive to see what helps them. We want to work with our patients and figure out what's best. Again, all these things need to get approved by insurance, and we need to get more experience with them. So, time will tell where all these new devices fit into our treatment algorithm.

Urology Times: Is there anything else that you wanted to add?

Trockman: We have a lot of choices now, which is nice. It's a good and bad thing, though, because you're not going to be experienced at everything. [Just] like in benign prostatic hyperplasia, there are a lot of MISTs [minimally invasive surgical therapies], and you can't do them all. You have to pick 1 or 2 in the different categories and say, "These are what I'm going to use in my practice." It looks like it's going that way with neuromodulation. Doctors are probably going to have something that they do for tibial and then 1 or 2 options for sacral. We’ll just have to roll with that until something proves itself to be head and shoulders above everything else.