Hypothesis / aims of study
Nocturia is a prevalent condition with impact on quality of life and also on morbidity and mortality. There are different treatments for nocturia. Lifestyle measurements are the first important step that should be initially considered; but there are also some pharmacological options to manage nocturia if conservative measures fail. Depending on the underlying cause: desmopressin, a synthetic ADH analog can be administered or in patients with an overactive bladder or bladder outlet obstruction as an underlying cause of nocturia, drugs like antimuscarinics and α-blockers can be used. Unfortunately, in some cases, patients may not present any improvement after initiation of treatment, or may need to interrupt it because of side effects. Causality of nocturia and nocturnal polyuria may involve the lower urinary tract (reduced bladder capacity due to overactive bladder [OAB] or postvoid residual), the kidneys (aging, reversed circadian rhythm, nephrogenic diabetes insipidus, etc. …), the endocrine system (estrogen or testosterone deficiency, diabetes mellitus, and diabetes insipidus), sleep and neurologic diseases (sleep apnea, restless legs, insomnia and dopamine deprivation), the cardiovascular system (leg edema, heart failure, hypertension, and metabolic syndrome), and intake related disorders (polydipsia, high salt, or protein diet)(1).
The purpose of this study was to systematically review and to evaluate the effect of invasive treatments (such as surgical procedures, implantable devices…) on nocturia and/or nocturnal polyuria.
By doing so we aimed to investigate the options available and the existing knowledge about it when all the conservative treatments have failed.
Study design, materials and methods
A systematic review was carried out by searching Pubmed and Embase articles on nocturia and invasive treatments that were published before April 2022. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidance and registered the details of the systematic review in PROSPERO.
Pubmed search, abstract selection and full text reviewing was aided by Silvi® (Silvi.AI, Copenhagen, Denmark), an artificial intelligence aided meta-analysis online platform.
Keywords of the literature search can be found in Figure 1.
We searched for invasive procedure related to the treatment of obesity, cardiac failure, veinous insufficiency, obstructive sleep apnea and Parkinson’s disease.
Procedures related to uro-gynecology have voluntarily been not included in the research, owing the fact that there is already sufficient knowledge about invasive treatments such as sacral neuromodulation, botulinum toxin, prolapse surgery or intermittent self-catheterization and nocturia.
We included all observational and trial studies evaluating the effect of invasive procedure (surgical procedure, implantable device) on patients with nocturia and/or nocturnal polyuria.
Studies were excluded if they were reviews of mechanisms or clinical overview, if they addressed pediatric population and/or lifestyle advices or medical treatments. Commentary and review articles were also not included.
Results
Searches identified 572 articles. After title and abstract screening,151 articles were retrieved among which 22 were selected for the review (see flowchart in Figure 1).
The selected reports concerned: invasive treatment of obstructive sleep apnea (n = 16) deep brain stimulation (n = 5), bariatric surgery (n = 1).
No study related to cardiac surgery or invasive treatment of venous insufficiency met the inclusion criteria.
Of the 22 papers included, 3 were randomized-controlled trials (RCT) (among which, one was a cross-over study), 5 were non-RCT and 14 were observational studies (majority of self-controlled case series (SCCS).
In RCTs there was no significant reduction in nocturia between the intervention group and the control group.
From the 3 RCT, only one found a statistically significant decrease of the systolic blood pressure that can explain a decrease in nocturia, when using Continuous Positive Airways Pressure (CPAP) and best supportive care (BSC) versus BSC alone (138,0 +/- 18,2 vs. 137,5 +/- 15,6; p=0,04)
4 non-RCTs showed statistically significant improvement of nocturia, out of which 2 were based on non-validated questionnaires, and 2 validated questionnaires (DanPSS and NMSquest).
9 SCCS found a significant improvement of nocturia after invasive treatment; based on validated questionnaires.
Only one study evaluating uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea syndrome (OSAS) has been included.
4 observational studies on CPAP have found a statistically significant improvement of nocturnal urine production on frequency volume chart or polysomnography.
One study evaluating the effect of bariatric surgery (sleeve gastrectomy and Roux-en-Y gastric bypass) on lower urinary tract symptoms showed an improvement of the IPSS total score (6,6+/-6,4 vs. 5,6 +/-6,2; p <0,001) and a reduction in nocturia episodes evaluated thanks to the question 7 of the IPSS questionnaire (1,9 +/- 1,2 vs. 1,1 +/- 0,9; p=0,014).
Informations related to the studies included, outcomes and statistic informations are summarized in the table attached (Figure 2).
Interpretation of results
The findings are limited by the small size of the datasets. Comparison between studies on the same topic was restricted due to algorithms and datasets heterogeneity.
There is some evidence that CPAP, and implantable devices such as mandibular advancement devices, are effective treatment options for nocturia in patients with obstructive sleep apnea syndrome. Few articles have addressed the topic nocturia in patients undergoing deep brain stimulation for Parkinson disease or sleeve gastrectomy and Roux-en-Y gastric bypass tor the treatment of obesity.
No data has been found on the effect on nocturia of surgery for veinous insufficiency.