Third‐Line Overactive Bladder Treatments: Cost–Benefit Analysis in an Australian Public Hospital

INTRODUCTION AND OBJECTIVES: To review the efficacy and cost-effectiveness of third-line overactive bladder (OAB) managements, including percutaneous tibial nerve stimulation (PTNS), intravesical botulinum toxin A (Botox) and sacral neuromodulation (SNM) in the urology department of a tertiary public hospital. MATERIALS AND METHODS: A prospective review was performed to determine the therapeutic outcomes of PTNS, Botox and SNM from 2019 to 2023. Costings data were obtained from the government healthcare portal to determine the overall cost and cost effectiveness of each treatment. RESULTS: Twenty-Eight patients underwent basic SNM lead insertion trial during the study period, with a response rate of 84%. Twelve patients proceeded to full implant insertion. The cost of SNM insertion is AU$23736. Comparatively, intravesical Botox has a unit cost of AU$2105 per treatment, with 67% efficacy in our patient cohort. PTNS was performed on 27 patients, with observed efficacy of 42%, at a cost of AU$200 per session. Comparing SNM and Botox, it would take 11.3 Botox treatments to generate equivalent cost to SNM. The Medtronic InterStim II Neurostimulator has a median battery life of approximately 6.2 years; if Botox was given 9-monthly during this time it would require 8.3 treatments, with a cost saving of over AU$6000. Each treatment is cost-effective when compared to the economic burden associated with OAB, with Botox being most cost-effective. CONCLUSION: OAB significantly impacts quality of life and has significant financial and economic burdens. Third-line OAB treatments including PTNS, Botox and SNM differ significantly in their cost, efficacy and durability of effect. The availability of SNM in public hospitals has long been limited due to perceived cost ineffectiveness. Our series suggests a high efficacy associated with SNM in a public hospital setting, and cost-effectiveness when compared to the economic burden associated with OAB. Botox remains the most cost-effective option at our institution.