Cost-utility of implantable tibial neuromodulation (Revi) versus conservative therapy for urgency urinary incontinence in adults: a US payer perspective

AIMS: Implantable tibial nerve neuromodulation (ITNM) represents a minimally invasive intervention for urgency urinary incontinence (UUI). This study evaluated the 3-year cost-utility of ITNM with an external wearable battery (Revi System) versus conservative treatments (behavioral ± pharmacotherapy) from a US payer perspective. MATERIALS AND METHODS: 20,000 Monte Carlo simulations. Health states captured responder and non-responder status with permitted transitions, rescue interventions (onabotulinumtoxinA, sacral neuromodulation, percutaneous tibial nerve stimulation), and downstream event modules (falls, urinary tract infection, incontinence-associated dermatitis, depression, cognitive decline/dementia, and nursing-home entry). Costs and quality-adjusted life-years (QALYs) were discounted at 3% annually and expressed in 2025 US dollars. Parameter uncertainty was assessed using probabilistic sensitivity analysis (PSA; 20,000 simulations) and tornado analysis. RESULTS: ITNM was both more effective and less costly than behavioral ± pharmacotherapy. Mean 3-year costs were $39,308 versus $43,737 (ΔCost = -$4,428), with mean QALYs of 2.188 and 1.940, respectively (ΔQALY = +0.249). The incremental cost-effectiveness ratio was -$17,818/QALY (dominant). Incremental net monetary benefit at $40,000/QALY was $14,369, with 100% probability of cost-effectiveness across thresholds from $20,000-$150,000/QALY. Key value drivers were responder utility and fall-related parameters. LIMITATIONS: The analysis adopts a US payer perspective with direct medical costs only. Some event risks were applied from population-level sources and may not fully capture patient-level heterogeneity. The 3-year base-case horizon may miss longer-term durability effects, though extended-horizon scenarios support consistent findings. CONCLUSIONS: Over 3 years, ITNM with an external wearable battery improves quality-adjusted survival and lowers overall payer costs compared with conservative therapies for UUI, supporting its inclusion as a value-consistent minimally invasive therapy.