Predicting success using response after lead implantation with sacral neuromodulation for urgency incontinence

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Abstract
Importance: Many women report inadequate symptom control after sacral neuromodulation (SNM), despite 50% reduction in urgency incontinence episodes (UUIE) after test stimulation.Objective: To determine the ideal percent UUIE reduction after test stimulation that predicts 24‐month success.Study Design: Using data from a multicenter SNM trial, we constructed receiver operating characteristic curves to identify an ideal threshold of percent UUIE reduction after test stimulation. We defined 24‐month success as Patient Global Impression of Improvement of “very much better” to “better.” We compared predictive accuracy of two models predicting success: (1) percent UUIE reduction alone and (2) with baseline characteristics.Results: Of 149 women (median [IQR] baseline daily UUIE 4.7 [3.7, 6.0]), the ideal threshold for 24‐month success was 72% (95% confidence interval 64,76%) UUIE reduction with accuracy 0.54 (0.42, 0.66), sensitivity 0.71 (0.56, 0.86) and specificity 0.27 (0.05, 0.55). The accuracy of the 50% reduction threshold was 0.60 (0.49, 0.71), sensitivity 0.95 (0.88, 1.0) and specificity 0.04 (0.0, 0.12). Percent reduction in UUIE was not better than chance in predicting 24‐month success (concordance index [c‐index] 0.47 [0.46, 0.62]); adding age, body mass index, diabetes mellitus and visual or hearing impairment the c‐index was 0.68 (0.61, 0.78).Conclusions: Among women who received an internal pulse generator (IPG) due to ≥50% UUIE reduction after test stimulation, we found no ideal threshold that better predicted 24‐month success. Percent reduction in UUIE after test stimulation poorly predicts 24‐month success with or without clinical factors. Given this, re‐evaluating how we determine who should receive an IPG is needed.

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