Comparison of long-term outcome of sacral nerve stimulation for constipation and faecal incontinence with focus on explantation rate, additional visits, and patient satisfaction

[Invasive neurostimulation in neuro-urology: state of the art]

Modulation or stimulation of the nerves supplying the lower urinary tract is a possible treatment option for dysfunction of the lower urinary tract, pelvic floor and rectum if conservative or minimally invasive treatment approaches fail. This overview shows the possibilities and limitations of sacral neuromodulation, sacral deafferentation with sacral anterior root stimulation and conus deafferentation.Sacral neuromodulation (SNM) is a procedure for the treatment of refractory pelvic floor dysfunction of various origins (idiopathic, neurogenic or post-operative), such as overactive bladder, non-obstructive retention and faecal incontinence. A particular advantage of SNM is the possibility of prior test stimulation with a high prognostic value. The procedure is minimally invasive, reversible and associated with relatively low morbidity rates.Following the introduction of MRI-compatible SNM systems, there has been renewed interest in the treatment of neurogenic bladder dysfunction. A recent meta-analysis reports similar success rates as in the idiopathic patient population.Sacral deafferentation with implantation of a sacral anterior root stimulator (SARS/SDAF) is an excellent therapeutic option for patients with spinal cord injury, which can significantly improve the quality of life of those affected and, in addition to treating neurogenic lower urinary tract dysfunction, can also have a positive effect on neurogenic bowel dysfunction, neurogenic sexual dysfunction or autonomic dysreflexia. If conservative or minimally invasive treatment fails, it is crucial for the success of this procedure to consider SDAF/SARS at an early stage in order to avoid irreversible organic damage.Conus deafferentation (KDAF) is a less invasive surgical treatment option for patients with spinal cord injury for whom sacral deafferentation would be indicated but who would not benefit from the simultaneous implantation of a sacral anterior root stimulator. In principle, these patients also have the option of being subsequently treated with an extradural implant and thus utilising the advantages of anterior root stimulation. Indications for KDAF are autonomic dysreflexia, therapy-refractory detrusor overactivity, recurrent urinary tract infections, urinary incontinence and spasticity triggered by detrusor overactivity. With KDAF, we have a safe and efficient procedure with great potential for improving the spectrum of paraplegiological and neuro-urological treatment.

Technical and functional outcome after sacral neuromodulation using the "H" technique

BACKGROUND

Sacral neuromodulation (SNM) is a widely accepted treatment for pelvic floor disorders, including constipation and fecal incontinence (FI). In 2017, a standardized electrode placement method, the H technique, was introduced to minimize failure rates and improve clinical outcomes. We aimed to investigate the technical feasibility and functional outcome of the procedure.

METHODS

In this prospective study, we evaluated the first 50 patients who underwent SNM according to the H technique between 2017 and 2020 at a tertiary care hospital. Patient demographic and clinical data were collected, and the impact of various factors on patients' postoperative quality of life (QoL) was assessed after a follow-up of 40 months. Functional outcome was monitored prospectively using a standardized questionnaire.

RESULTS

Of 50 patients, 36 (72%) reported greater than 50% symptom relief and received a permanent implant (95% CI: 58.3-82.5). We observed 75% success in relieving FI (95% CI: 58.9-86.3) and 64% in constipation (95% CI: 38.8-83.7). Complication occurred in five (10%) patients. Preoperative vs. postoperative physical and psychological QoL, Vaizey score, and obstructed defecation syndrome (ODS) scores revealed significant improvements (all p < 0.01). Male gender was significantly associated with postoperative complications (p = 0.035).

CONCLUSION

We provide evidence for the technical feasibility and efficacy of the SNM implantation using the H technique. The medium-term results are promising for patients with FI and constipation. Male patients and those with a BMI > 25 are more prone to perioperative complications.

[Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management]

BACKGROUND

Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence.

METHODS AND RESULTS

A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable.

CONCLUSION

Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.

Current Overview on Clinical Management of Chronic Constipation

Constipation is one of the major gastrointestinal disorders diagnosed in clinical practice in Western countries. Almost 20% of population suffer from this disorder, which means constipation is a substantial utilization of healthcare. Pathophysiology of constipation is complex and multifactorial, where aspects like disturbance in colonic transit, genetic predisposition, lifestyle habits, psychological distress, and many others need to be taken into consideration. Diagnosis of constipation is troublesome and requires thorough accurate examination. A nonpharmacological approach, education of the patient about the importance of lifestyle changes like diet and sport activity state, are the first line of therapy. In case of ineffective treatment, pharmacological treatments such as laxatives, secretagogues, serotonergic agonists, and many other medications should be induced. If pharmacologic treatment fails, the definitive solution for constipation might be surgical approach. Commonness of this disorder, costs of medical care and decrease in quality life cause constipation is a serious issue for many specialists. The aim of this review is to present current knowledge of chronic constipation and management of this disorder.