Oral medications, onabotulinumtoxinA injections and transcutaneous tibial nerve stimulation (TTNS) were recommended by the AUA/SUFU guidelines as non or minimally invasive treatments for patients with neurogenic detrusor overactivity (NDO) without treatment hierarchy.To compare and rank the effectiveness and safety of oral medications, three doses of onabotulinumtoxinA and TTNS on improving urodynamic outcomes in patient reported outcomes and safety outcomes in patients with NDO.

We searched PubMed, EMBASE, MEDLINE, Cochrane library, Medicine and clinicaltrials.gov, from their inception to October 2022 and included randomized controlled studies on the drug, onabotulinumtoxinA and TTNS for the treatment of patients with NDO. Outcomes included urodynamic parameters, voiding diary, quality of life (Qol) changes, adverse event rate and post void residual (PVR).For all the data extraction results, pairwise meta-analysis was first applied to explore the differences between various interventions and the control group. Network meta-analysis (NMA) was conducted based on a frequentist framework using random-effects models by Stata software (Version 15.0)

A total of 26 articles and 2938 patients were included in the statistics.Network meta-analysis results indicated that onabotulinumtoxinA 100U, 200U and 300U were effective in improving the urodynamic outcomes of the patients compared to the control group. Pharmacological treatments antimuscarinics and β3-adrenoceptor-agonists were also good but less effective overall than onabotulinumtoxinA. Compared to the control group, onabotulinumtoxinA 100U was effective in relieving the patient's symptoms during the urinary storage period while improving their quality of life (Frequency: MD: -1.70, 95%CI: -1.87 to -1.59; Urgency Urinary Incontinence: MD: -2.70, 95%CI: -5.34 to -0.06; I-QoL: MD:30.50, 95%CI: 3.52 to 57.48). Safty outcomes suggested that TTNS and α-blocker had a better safety profile, with no statistical difference in their AE rates and PVR changes compared to the placebo group. In contrast, all doses of onabotulinumtoxinA had a higher complication rate, and patients treated with onabotulinumtoxinA 200 U and 300 U were more likely to develop urinary retention.

Regarding efficacy, all interventions except TTNS and α-blockers were statistically different for the placebo group. The urodynamic outcome and patient reported outcome suggested that onabotulinumtoxinA injection (urodynamic outcome: onabotulinumtoxinA 200U, mean SCURA:87.4; patient reported outcome: onabotulinumtoxinA 100U, mean SCURA: 89.8) was the most effective treatment, and the safety outcome suggested that TTNS (mean SCURA:83.3) was the safest. Cluster analysis found that antimuscarinics and β3-adrenoceptor-agonists possessed good efficacy and safety.

OnabotulinumtoxinA injection is probably the most effective way to treat patients with NDO, with increasing efficacy but decreasing safety as the dose rises. The efficacy of α-blockers and TTNS was not statistically different from the placebo group. Antimuscarinics and β3-adrenoceptor-agonists have good efficacy and safety.

Continence 7S1 (2023) 100952
DOI: 10.1016/j.cont.2023.100952