The purpose of this study is to investigate current trends in third line treatments for Overactive Bladder (OAB) including sacral neuromodulation (NM), percutaneous tibial nerve stimulation (PTNS) and chemodenervation (CD). There is a paucity of data regarding the progression of patients to third line therapy and is reported to be highly variable among providers(1). A more complete knowledge of urologists characteristics associated with usage of these modalities may highlight discrepancies between providers.

Data on third line OAB procedures performed between 2010 and 2016 by urologists were obtained from The American Board of Urology annualized case logs. Non-pediatric urologists applying for initial certification, recertification and female pelvic medicine and reconstructive surgery (FPMRS) were included. CPT codes 64581 (NM), 64561 (NM), 64553 (PTNS), 64566 (PTNS) and 52287 (CD) were queried. Summary statistics characterizing trends in the utilization of these procedures were calculated. Statistical analysis was then performed to identify surgeon characteristics that predicted the number of procedures performed using analysis of variance. Characteristics considered included gender, years in practice, specialty, practice size, practice type, certification type, and practice location.

Usage of third line therapies has increased from 1,822 in 2010 to a peak of 6,143 in 2013. NM cases logged peaked in 2013, the year of FDA approval for CD, and has since been declining. CD procedures increased each year after 2013, until declining in 2016 (Table 1). From 2010 to 2016, 5,499 case logs were submitted with 1,224 urologists logging a total of 26,874 NM and/or CD procedures, while only two urologists logged PTNS cases. Practitioners performed an average of 13.35 NM and 4.22 CD procedures per case log. Women performed more CD procedures than men (5.97 vs. 3.79, p=.001). FMPRS physicians performed significantly more procedures than physicians in all other specialty categories (p<.001). Similarly, urologists submitting cases for FMPRS certification performed more procedures than those submitting for initial certification or recertification (all comparisons p < .001).  The majority of third line OAB therapies are being performed in large urban centers where >1,000,000 patients are served (33.4%, 41.5%, and 35.3% of NM, CD, and total cases) and in private practices (50.8%, 51.2%, and 50.9% of NM, CD, and total cases). Among the eight regions outlined by the American Urological Association, the Southeastern region had the most activity with respect to third line OAB procedures, containing 25.8% of urologists who submitted these cases and 26.4%, 23.6% and 25.8% of NM, CD, and total cases performed respectively. On a per-urologist bases, North Central urologists perform the most NM (16.23 cases/urologist), Northeastern urologists perform the most CD (8.45 cases/urologist), and North Central urologists perform the most total cases (20.69 cases/urologist). ANOVA revealed that region was predictive of variation in the number of NM and total cases performed, but not for the number of CD procedures performed.

Third line therapies have increased considerably in the past 6 years. The rapid increase in number of CD procedures was inverse to the change in the number of NM cases. Comparison of Stage 1 to PNE procedures remained similar throughout time, suggesting little change to practice patterns over the years. PTNS procedures were likely not logged due to only recent insurance coverage or may not have been submitted since it is not required for credentialing. Overall, neuromodulation and chemodenervation are being utilized more commonly by urologists, specifically those FPMRS certified, re-certifying physicians and in specific regions.

Our study summarizes current trends and utilization patterns of tertiary OAB treatments. The results highlight differences in usage between gender, subspecialty, size of practice area, practice setting, certification status, and practice region suggesting the need for additional research as to why certain practitioners are more likely to perform certain procedures. Only 22% of urologists submitting case logs reported the use of one or more of these procedures for this highly prevalent condition. The majority of patients with OAB do not or cannot adhere to medical therapy, and these effective treatments may be underutilized in the large OAB population.

Moskowitz, D., Adelstein, S. A., Lucioni, A., Lee, U. J. & Kobashi, K. C. Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers-Are We Doing Enough? J. Urol. (2017). doi:10.1016/j.juro.2017.09.102