Neuromodulation for intractable OAB

Efficacy of Transurethral Vesical Deafferentation with Mid-Urethral Sling Operation for Female Mixed Urinary Incontinence: Preliminary Results

OBJECTIVES

In female patients with mixed urinary incontinence (MUI), a mid-urethral sling operation (MUS) is an effective treatment for stress urinary incontinence (SUI), but urgency urinary incontinence (UUI) frequently persists. We developed a novel transurethral vesical deafferentation procedure and assessed its efficacy in these patients.

METHODS

From December 2009 to December 2012, 41 female patients with MUI were enrolled prospectively. After baseline evaluation including urodynamic study and symptom questionnaires (Overactive Bladder Symptom Score (OABSS) and International Consultation on Incontinence Questionnaire - Overactive Bladder [ICIQ-OAB]), patients in the study group underwent both the deafferentation procedure and MUS, and those in the control group underwent MUS alone. The outcome was assessed 3 months after the operation by subjective assessment of SUI and OABSS.

RESULTS

At 3 months, the treatment response rate of UUI was significantly higher in the study group than in the control group; UUI was improved in 80 and 57.1% of patients, respectively. SUI was cured in most patients. There were no serious complications, such as voiding symptom and urinary retention.

CONCLUSIONS

The transurethral vesical deafferentation procedure combined with MUS is effective for the treatment of MUI. The procedure is simple, safe and efficacious in treating urgency and UUI without affecting voiding function.

Effect of vaginal electrical stimulation on female sexual functions: a randomized study

INTRODUCTION

Female sexual dysfunction (FSD) is a common problem that may be encountered in the interruption of normal sexual functioning in the sexual response cycle. Women with a pelvic floor disorder who scored low on the Female Sexual Function Index (FSFI) showed an improvement in their sexual life following treatment by vaginal electrical stimulation (VES).

AIM

The aim of this trial was to evaluate the effectiveness of VES in women with FSD without a predominant pelvic floor disorder or urinary incontinence.

METHODS

Forty-two women with FSD were randomly allocated to VES and placebo groups. Pelvic floor muscle (PFM) assessment and the FSFI questionnaire were performed at baseline and after the completion of sessions. VES treatment was administered using a vaginal probe. The probe was inserted, and a medium-frequency (50 Hz) alternating current was administered for a duty cycle of 5 seconds on followed by a 5-second rest.

MAIN OUTCOMES MEASURES

Primary outcome measure was the improvement in FSFI score. PFM assessments were performed according to the PERFECT scheme.

RESULTS

Total FSFI scores improved significantly in both the VES group and the control group. Results show that in the VES group, there was an improvement in total score and FSFI domains that improved including arousal, desire, orgasm, and satisfaction. Similarly, control group domains that improved were desire, arousal, and orgasm. But there was no significant increase in satisfaction scores in the placebo group. No significant changes in pain or lubrication domains were seen in either group. Power, endurance, fast contractions, and repetitions were significantly improved in the VES group.

CONCLUSIONS

The lack of significant differences between the placebo and VES groups, except the satisfaction domain, puts into question the effectiveness of electrical stimulation as a monotherapy in treating primary FSD without pelvic floor disorder.

Women's perspective: intra-detrusor botox versus sacral neuromodulation for overactive bladder symptoms after unsuccessful anticholinergic treatment

INTRODUCTION AND HYPOTHESIS

Comprehension of women's perspective and reasons for their choice between intra-detrusor botox (botox) and sacral neuromodulation (SNM) after failed anticholinergic treatment for overactive bladder syndrome (OAB) have not been evaluated and reported in the literature. Our voluntary service evaluation survey aimed to determine reasons behind individual patient choice.

METHODS

All women were counseled in detail regarding the two treatment options available after failed anticholinergic treatment as per the hospital trust policy. Once the decision-making process was completed, they were asked to highlight one or more of the 12 questions within the survey that influenced their decision-making process.

RESULTS

Fifty patients, with a mean age of 61.66 years (range 38-82 years) participated in our voluntary survey. Seventy-four per cent chose Botox and 26% chose SNM. In the botox group 54.05% disliked the thought of a foreign body in the back with SNM; 45.94% quoted shorter waiting times and 43.24% said that the quicker onset of benefit (within 3-5 days) with botox compared with SNM (up to 2 weeks) helped to influence their decision towards botox. In the SNM group 61.53% were averse to the potential need for botox to be repeated at variable intervals; 46.15% chose SNM to avoid the risk of urinary retention associated with botox.

CONCLUSION

The botox group seemed more likely to need quicker results with easy access to the treatment modality, whilst the SNM group seemed keener to focus on a more permanent option with a known interval for the repeat procedure. The difference in patient choice was found to be statistically significant.

Electrical stimulation for urinary incontinence in women: a systematic review

BACKGROUND

Electrical stimulation is commonly recommended to treat urinary incontinence in women. It includes several techniques that can be used to improve stress, urge, and mixed symptoms. However, the magnitude of the alleged benefits is not completely established.

OBJECTIVES

To determine the effects of electrical stimulation in women with symptoms or urodynamic diagnoses of stress, urge, and mixed incontinence.

SEARCH STRATEGY

Our review included articles published between January 1980 and January 2012. We used the search terms ″urinary incontinence″, ″electrical stimulation ″, ″ intravaginal ″, ″ tibial nerve ″ and ″ neuromodulation ″ for studies including female patients.

SELECTION CRITERIA

We evaluated randomized trials that included electrical stimulation in at least one arm of the trial, to treat women with urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the data from the trials, for inclusion or exclusion, and methodological analysis.

MAIN RESULTS

A total of 30 randomized clinical trials were included. Most of the trials involved intravaginal electrical stimulation. Intravaginal electrical stimulation showed effectiveness in treating urge urinary incontinence, but reported contradictory data regarding stress and mixed incontinence. Tibial-nerve stimulation showed promising results in randomized trials with a short follow-up period. Sacral-nerve stimulation yielded interesting results in refractory patients.

CONCLUSIONS

Tibial-nerve and intravaginal stimulation have shown effectiveness in treating urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases. Presently available data provide no support for the use of intravaginal electrical stimulation to treat stress urinary incontinence in women. Further randomized trials are necessary to determine the magnitude of benefits, with long-term follow-up, and the effectiveness of other electrical-stimulation therapies.

Sacral nerve stimulation lead implantation using the O-arm

Background

Sacral neuromodulation operations have usually been performed based on 2D fluoro images. However, sacral nerve stimulation lead implantation may be challenging when the normal anatomy is confused by obesity or congenital anomalies. Thus the surgical navigation and intraoperative imaging methods could be helpful as those same methods have proven to be feasible methods for guiding other surgical operations. Our recent knowledge about the O-arm in trauma pelvic operations encouraged us to evaluate the usefulness of O-arm guided navigation in sacral neuromodulation. Similar navigation would be useful for complex sacral nerve stimulation lead implantations.

Methods

In this preliminary article we report our experience of utilizing the orthopedically optimized O-arm to implant the S3 stimulation electrode in a patient. The 3D O-arm imaging was performed intraoperatively under surgical navigation control. General anesthesia was used. The obtained 3D image dataset was registered automatically into the patient’s anatomy. The stimulation needle was guided and the tined lead electrode was implanted using navigation.

Results

The bony sacral structures were clearly visualized. Due to automatic registration, the navigation was practicable instantly after the O-arm scanning and operation could be performed successfully under navigation control.

Conclusions

To our knowledge, this is the first published tined lead implantation which was guided based on the surgical navigation and intraoperative O-arm images. In this case, the applied method was useful and helped the surgeon to demarcate the region of surgical interest. The method is slightly more invasive than the formal technique but could be an option in anatomically challenging cases and reoperations. However, further evaluation with larger patient series is required before definitive recommendations can be made.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study

AIMS

To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO).

METHODS

Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS).

RESULTS

The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001).

CONCLUSIONS

Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

Outcome of sacral nerve stimulation for fecal incontinence in patients refractory to percutaneous tibial nerve stimulation

BACKGROUND

Percutaneous tibial nerve stimulation and sacral nerve stimulation are both second-line treatments for fecal incontinence, but the comparative efficacy of the 2 therapies is unknown. In our institution, patients with refractory fecal incontinence are generally treated with percutaneous tibial nerve stimulation before being considered for sacral nerve stimulation.

OBJECTIVE

The aim of this study was to assess the outcome associated with this treatment algorithm in order to guide future management strategies.

DESIGN

All patients with fecal incontinence treated over a 3-year period with tibial nerve stimulation before receiving sacral nerve stimulation were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiological data were available for all patients.

SETTINGS

This study was conducted at an academic colorectal unit in a tertiary center.

PATIENTS

Twenty patients (17 female:3 male, median age 55 (33-79) years) were identified to be refractory to percutaneous tibial nerve stimulation.

MAIN OUTCOME MEASURES

Clinical outcome data were collected prospectively before and after treatment, including 1) Cleveland Clinic Florida-Fecal Incontinence scores and 2) number of incontinence episodes per week.

RESULTS

The mean (±SD) pretreatment incontinence score (11.7 ± 3.5) did not differ from the mean incontinence score after 12 sessions of tibial nerve stimulation (10.9 ± 3.6, p = 0.42). All patients were subsequently counseled for sacral nerve stimulation, and 68.4% of them reported a significant therapeutic benefit with an improved incontinence score (7.7 ± 4.1, p = 0.014).

LIMITATIONS

This was a nonrandomized study with a relatively small number of patients

CONCLUSION

Sacral nerve stimulation appears to be an effective treatment for patients who do not gain an adequate therapeutic benefit from percutaneous tibial nerve stimulation and, thus, should be routinely considered for this patient cohort.