Use of timed alarm device for pediatric daytime urinary incontinence Meta-analysis of comparative studies.

REVIEW Use of timed alarm device for pediatric daytime urinary incontinence Meta-analysis of comparative studies Michael E. Chua1,2,3, Mandy Rickard2, Jin Kyu Kim4, Natasha Brownrigg2, Joana Dos Santos2, Luzelle Kate Aba3, Armando Lorenzo2, Niraj Mistry5 1 Global Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; 2Division of Urology, Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada; 3Institute of Urology, St. Luke’s Medical Center, Quezon City, NCR, Philippines; 4Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; 5 Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada Cite as: Chua ME, Rickard M, Kim JK, et al. Use of timed alarm device for pediatric daytime urinary incontinence: Metaanalysis of comparative studies. Can Urol Assoc J 2023;17(4):129-36. http://dx.doi.org/10.5489/cuaj.8113 Published online December 6, 2022 Appendix available at cuaj.ca ABSTRACT INTRODUCTION: This meta-analysis aimed to determine the comparative effectiveness of timed alarm device-assisted urotherapy vs. standard urotherapy alone in managing pediatric daytime urinary incontinence (pDUI). METHODS: A systematic literature search was performed in December 2021, with an update search in July 2022. Comparative studies assessing the pDUI treatment effectiveness of timed alarm device-assisted urotherapy vs. urotherapy alone were identified and evaluated according to Cochrane collaboration recommendations. The assessed outcome includes pDUI complete response and adherence rates. Relative risk (RR) with 95% confidence intervals (CI) was extrapolated. A random-effects model was used to pool effect estimates. Heterogeneity was assessed with sensitivity and subgroup analysis performed according to study design and comparative group characteristics. GRADE criteria were used to assess evidence certainty. (PROSPERO CRD42022299173). RESULTS: Four studies (three randomized controlled trials [RCTs] and one retrospective cohort) with 635 cases were included. The pooled effect estimates of pDUI complete response showed no differences between intervention groups (RR 1.20, 95% CI 0.81, 1.76). Pooled effect estimates for treatment adherence were generated from two studies, which showed significantly better adherence for the timed-alarm device group (RR 2.97, 95% CI 1.46, 6.06). Significant interstudy heterogeneity was noted; the source is likely from the study design and comparator device characteristics. The quality of evidence was assessed to be of very low certainty. CONCLUSIONS: Based on very low certainty evidence, timed alarm device-assisted urotherapy does not seem to have the advantage of complete treatment response over standard urotherapy alone in managing pDUI; however, a timed-alarm device is likely able to improve urotherapy treatment adherence. INTRODUCTION According to the International Children’s Continence Society (ICCS), daytime urinary incontinence (DUI) is defined as intermittent involuntary urine leakage during the daytime wake period among children aged five years old or older.1 A recent ICCS standardization document for the treatment of DUI recommends that treatment modalities be tailored according to the individual child’s condition.2 Given that the majority (>65%) of the DUI etiology in children is determined to be functional,3 urotherapy is considered the primary intervention after organic and concomitant medical morbidities have been ruled out.2 Specifically, according to some studies, behavioral modification (timed voiding, avoidance of urine holding, and optimizing voiding posture) treated 40–45% of DUI in children.4,5 Timed alarm devices, such as alarm watches, are being suggested to enhance pediatric (p) DUI treatment.2,6 Notably, the suggested mechanism of action for the timed alarm device is timed voiding reminders of school-age children.7 Prior studies have shown the superiority of urotherapy with a timed alarm device over standard urotherapy alone;8,9 however, a recent study has shown no difference in treatment outcomes.10 Due to inconsistent reported evidence, this systematic review and meta-analysis aimed to determine the comparative effectiveness of timed alarm deviceassisted urotherapy vs. standard urotherapy alone in managing DUI among children. CUAJ • april 2023 • Volume 17, Issue 4 © 2023 Canadian Urological Association 129 Chua et al METHODS The meta-analysis protocol was made in consultation with a topic expert and review methodologist, and subsequently registered priori at the PROSPERO registry CRD42022299173. The meta-analysis was conducted according to the Cochrane Collaboration recommendation and reported in compliance with the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) statement.11,12 Identification and evaluation of the literature A comprehensive literature search with no language restriction was carried out initially in December 2021; an update search was conducted in July 2022 to identify published medical literature of human studies on the use of any timed alarm device in the management of pDUI. The databases used were MEDLINE, EMBASE, Scopus, and PubMed, while Googlescholar and Clinicaltrial.gov were searched for grey literature and trial registry for unpublished data. The platform/database-specific search strategies are detailed in the Appendix (available at cuaj.ca). In addition, relevant Cochrane reviews and studies that met our inclusion criteria were cross-referenced for potentially eligible records. This meta-analysis included comparative studies, such as randomized controlled trials (RCTs, prospective and retrospective cohorts) that compare clinical outcomes of the use of timed alarm device-assisted urotherapy vs. standard urotherapy alone or with other non-timed devices in the management of pDUI. Excluded studies were non-comparative trials, reviews, commentaries, non-assessment of clinical outcome response rate, and adult population studies. The primary outcome considered in this meta-analysis was the post-intervention response rate, specifically complete response, which according to ICCS is defined as a 100% reduction in wet days per week.1,2 The secondary outcome assessed was treatment adherence, defined by the individual studies. The retrieved records from the databases were imported into a systematic review software, Covidence app.13 Once duplicate records were removed, unique records were independently evaluated by two of the three reviewers (MR, NM, MEC). Records that either reviewer flagged were retrieved for full-text and were further reviewed to determine whether they met the inclusion criteria. The full-text review was performed independently by two other reviewers (MEC and NB) who were knowledgeable in the principles of critical appraisal. The risk of bias, quality of the design, execution, and data analysis of studies were assessed accord130 CUAJ • april 2023 • Volume 17, Issue 4 ing to Cochrane Collab (...truncated)