Effects of Noninvasive or Minimally Invasive Neuromodulation Techniques on Neurogenic Lower Urinary Tract Dysfunction After Spinal Cord Injury: A Network Meta-analysis.

Objective: To assess the available evidence of noninvasive or minimally invasive neuromodulation therapies in improving urodynamic outcomes, voiding diaries, and quality of life in patients with neurogenic lower urinary tract dysfunction (NLUTD) after spinal cord injury (SCI).

Data sources: A comprehensive search of 10 databases from inception until August 30, 2023, was conducted.

Study selection: Randomized controlled trials (RCTs) assessing the effects of conventional treatment (CT) and CT combined with sham stimulation, transcranial magnetic stimulation (TMS), sacral nerve magnetic stimulation (SNMS), TMS+SNMS, sacral pulsed electromagnetic field therapy (SPEMFT), sacral transcutaneous electrical nerve stimulation (STENS), sacral dermatomal transcutaneous electrical nerve stimulation, bladder & STENS, transcutaneous tibial nerve stimulation (TTNS), transcutaneous electrical acupoint stimulation, pelvic floor electrical stimulation, or pelvic floor biofeedback therapy on postvoid residual volume (PVR), maximum cystometric capacity (MCC), number of voids per 24 hours (V24), mean urine volume per micturition, (MUV), maximum urinary flow rate (Qmax), maximum detrusor pressure (MDP), maximum voiding volume, number of leakages per 24 hours (L24), lower urinary tract symptoms score, and SCI-quality of life (SCI-QoL) score in patients with NLUTD after SCI were included.

Data extraction: Two researchers independently extracted data on study characteristics and outcomes following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The Cochrane risk of bias tool (2.0) was used to assess the quality of RCTs.

Data synthesis: Fifty-two RCTs with 2884 participants were included. CT+TMS was able to remarkably decrease PVR (mean difference [MD], -132.14; 95% confidence interval [CI], -230.97 to -33.31) and increase MUV (MD, 147.79; 95% CI, 64.51-231.06). CT+SNMS ranked high in improving V24 (MD, 2.76; 95% CI, 1.26-4.25) and reducing L24 (MD, -2.73; 95% CI, -4.46 to -1.01); CT+TMS+SNMS maximized the reduction of SCI-QoL scores (MD, -1.52; 95% CI, -2.97 to -0.25) and ranked second in both reducing PVR and improving MCC; CT+SPEMFT had a significant advantage in improving MCC (MD, 83.31; 95% CI, 39.73-126.88) and increasing Qmax (MD, 5.91; 95% CI, 2.99-8.84). Improvement in MDP was highly ranked by CT+TTNS (MD, 9.46; 95% CI, 2.15-16.76).

Conclusions: CT combined with magnetic stimulation therapy provided more benefits than its combination with electrical stimulation. TMS+SNMS seemed to be a promising noninvasive neuromodulation technique in managing NLUTD after SCI. High-quality RCTs should be conducted in the future to validate these findings.