Real World Performance of Sacral Neuromodulation and OnabotulinumtoxinA for Overactive Bladder: Focus on Safety and Cost

J Urol. 2020 Jan;203(1):179-184. doi: 10.1097/JU.0000000000000462. Epub 2019 Jul 26.


Purpose: We aimed to determine the real world safety and cost of third line overactive bladder therapies, including onabotulinumtoxinA and sacral neuromodulation.

Materials and methods: We performed an all-inclusive, population based cohort study of third line therapies of overactive bladder (sacral neuromodulation or onabotulinumtoxinA) using the statewide surgical data captured in the New York Statewide Planning and Research Cooperative System. The main outcome measures were 30-day safety events, and 1 and 3-year health care utilization costs. Propensity score matching was done to control for confounding factors and comparative analyses of safety events were also performed.

Results: Our cohort included 2,680 patients, of whom 1,328 underwent sacral neuromodulation and 1,352 received onabotulinumtoxinA from January 1, 2013 through December 31, 2016. Average ± SD age was 61.7 ± 16.3 years and 82.7% of the patients were female. Sacral neuromodulation implantation led to re-intervention in 15.8% of cases within 1 year and in 26.1% at 3 years. In this comparative analysis patients who received onabotulinumtoxinA therapy were at higher risk for urinary tract infection, hematuria, urinary retention and an emergency room visit compared to those treated with sacral neuromodulation. The overall cost of onabotulinumtoxinA was lower than the cost of the sacral neuromodulation device (cost at 1 year $2,896 vs $15,343 and at 3 years $3,454 vs $16,189, each p <0.01).

Conclusions: Sacral neuromodulation implantation was more expensive than onabotulinumtoxinA injection. However, patients who underwent sacral neuromodulation had a lower complication rate than patients treated with onabotulinumtoxinA. A quality improvement collective database must be created to track information on onabotulinumtoxinA and sacral neuromodulation treatment. This would help generate better performance and comparative data for patient and physician decision making.

Keywords: health care costs; neuromuscular blocking agents; overactive; risk; transcutaneous electric nerve stimulation; urinary bladder.

MeSH terms

  • Aged
  • Botulinum Toxins, Type A / economics
  • Botulinum Toxins, Type A / therapeutic use*
  • Female
  • Humans
  • Lumbosacral Plexus
  • Male
  • Neuromuscular Agents / economics
  • Neuromuscular Agents / therapeutic use*
  • New York
  • Patient Safety
  • Propensity Score
  • Transcutaneous Electric Nerve Stimulation / economics
  • Transcutaneous Electric Nerve Stimulation / methods*
  • Urinary Bladder, Overactive / economics
  • Urinary Bladder, Overactive / therapy*


  • Neuromuscular Agents
  • Botulinum Toxins, Type A
  • onabotulinum toxin A