Neuromodulation is becoming a practical alternative for more patients
Clinical trials could lead to new, individualized ways to use neuromodulation.
Neuromodulation is going mainstream. What was once a quiet corner of urology with occasional minor advances in sacral nerve stimulation is exploding with MRI-compatible devices, implantable posterior tibial nerve stimulation, transcutaneous spinal or tibial nerve stimulation, options for neurogenic bladder and, recently, exploration of direct brain stimulation for improved bladder health.
“We have better biologic understanding of the mechanics of neuromodulation, devices that are MRI compatible and more data in a wider range of patients than ever before,” said Rose Khavari, MD, professor of urology at Houston Methodist Institute for Academic Medicine and Weill Cornell Medical College. “There have been modifications in the technology that have expanded indications for patients beyond overactive bladder. We have new devices that should be coming on the market in the near future and a new spectrum developing on the research side.”
Dr. Khavari will deliver a state-of-the-art lecture on "Neuromodulation: What’s New and What’s Coming?" 3:50-4:05 p.m. today in the Stars at Night Ballroom. The next step could be closed loop systems to regulate bladder health and function, much as implanted pacemakers regulate cardiac function.
“We’re not there yet,” Dr. Khavari said, “but we are moving toward the path of individualizing neuromodulation at the sacral level to activate neurostimulation only as needed and not all the time.”
The next step is to move beyond the bladder, sacral nerve and spinal cord to the brain. The advent of functional neuroimaging, functional MRI, is revealing regions that contribute to bladder control and loss of control in overactive bladder, multiple sclerosis, pelvic pain syndromes and interstitial cystitis.
“There are multiple clinical trials around the world utilizing noninvasive brain stimulation, either direct current stimulation or magnetic stimulation, to modulate these regions and restore functional connectivity,” Dr. Khavari said. “We hope restoration of that functional neural network could lead to improvement in bladder function.”
Some centers are recruiting for trials involving noninvasive brain stimulation in interstitial cystitis pain syndrome. Dr. Khavari’s center has active trials using individualized transcranial magnetic stimulation for overactive bladder in multiple sclerosis and for idiopathic overactive bladder.
“Brain stimulation has become an option to explore over the past two or three years, and is opening up a new and exciting avenue for neuromodulation beyond just the bladder and the sacral/peripheral nerves,” she said. “Shifting care more centrally toward the brain to improve bladder health is a shifting paradigm.”
Rapidly advancing technologies are making neuromodulation a practical alternative for more and more patients, Dr. Khavari said, giving urologists a growing menu of new treatment options. Recently approved implantable devices poised to enter the market will further expand practice-changing treatment options.
“The big picture is realizing there are clinical trials around the country recruiting for novel, individualized therapies,” she added. “Urologists who have patients who might be interested can find trials on clinicaltrials.gov and refer patients to trial centers. We may have a whole new shift in the ways we do neuromodulation in the next few years.”
