Long-term outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms: 14-year experience at 1 center

Pilot Study of a Novel At-Home Posterior Tibial Nerve System for Overactive Bladder Syndrome

IMPORTANCE

Urgency urinary incontinence and overactive bladder are common conditions. Third-line therapies are often underutilized because of either being too invasive or being burdensome for the patient.

OBJECTIVE

We aimed to determine the efficacy and acceptability of a noninvasive, home-based posterior tibial nerve treatment system for the treatment of overactive bladder syndrome.

STUDY DESIGN

In this pilot study, 10 postmenopausal women with urgency urinary incontinence were given the SoleStim System for home-based posterior tibial nerve stimulation. Symptoms at baseline and completion of the 8-week study were determined by 3-day voiding diary and quality-of-life questionnaire (Overactive Bladder Questionnaire) to assess for reduction in incontinence episodes.

RESULTS

All patients were 100% adherent to the SoleStim System application over the 8-week period and reported statistically significant reductions in the mean number of voids (-16.3%, P = 0.022), urgency episodes (-31.2%, P = 0.02), and urgency urinary incontinence episodes (-31.4%, P = 0.045). Forty percent of participants reported a decrease of ≥50% in their urgency urinary incontinence episodes. SoleStim was scored a value of 1.8 ± 2.0 (mean ± SD) on a 10-point usability scale, indicating that it was highly acceptable from an ease-of-use perspective. No adverse events were reported.

CONCLUSIONS

The SoleStim System improved key overactive bladder (frequency, urgency, and urgency urinary incontinence episodes) and quality-of-life metrics. The results from this pilot study suggest that the SoleStim System may be a safe, effective, and highly acceptable at-home overactive bladder therapy.

Retrospective study of sacral neuromodulator implantations in a French hospital center: Lifespan and hospital costs assessment

PURPOSE

Sacral nerve neuromodulation (SNM) is a safe and effective therapy for the management of fecal and/or urinary incontinence. The generators InterStim™ and InterStim™ II (Medtronic™) are non-rechargeable active implantable medical devices with a limited lifespan. The aims of this study were to assess the generators' median lifespan for all indications and the long-term hospital costs of the therapy.

METHODS

This was a retrospective monocentric study that included 215 patients aged over 18 years who were treated by SNM for fecal incontinence and/or urinary incontinence. Lifespan was considered as the amount of time between definitive implantation and observed battery depletion by the surgeon and was assessed by the Kaplan-Meier method. Costs were assessed according to the activity-based pricing of the French public health care system.

RESULTS

The median observed lifetime of stimulators implanted in our center was 7.29 years and 5.9 years for InterStim™ and InterStim™ II, respectively. The difference observed between the two generations was statistically significant. The modelling of primary implantation and renewal costs allowed us to observe that the decrease in the lifetime of Interstim™ II is associated with an increase in hospital costs over time. The retrospective study design is one limitation and we did not take into consideration stimulation's settings.

CONCLUSIONS

The InterStim™ II lifespan is shorter than the first-generation device. This is associated with an increase of the long-term hospital costs. Additional information about the new neuromodulator will be required to choose the most appropriate IPG for the patient while optimizing the costs.

Sacral neuromodulation remote programming in patients with refractory lower urinary tract dysfunction: China’s experience during the COVID-19 pandemic

Objectives

Sacral neuromodulation is an effective, minimally invasive treatment for refractory lower urinary tract dysfunction. However, regular postoperative programming is crucial for the maintenance of the curative effects of electronic sacral stimulator devices. The outbreak of coronavirus disease 2019 (COVID-19) limited the ability of practitioners to perform traditional face-to-face programming of these stimulators. Therefore, this study aimed to evaluate the application of remote programming technology for sacral neuromodulation during the COVID-19 pandemic in China.

Materials and methods

We retrospectively collected data including baseline and programming information of all patients with lower urinary tract dysfunction who underwent sacral neuromodulation remote programming in China after the outbreak of COVID-19 (i.e., December 2019). The patients also completed a self-designed telephone questionnaire on the subject.

Results

A total of 51 patients from 16 centers were included. They underwent 180 total remote programming visits, and 118, 2, 25, and 54 voltage, current, pulse width, and frequency adjustments, respectively, were performed. Additionally, remote switching on and off was performed 8 times; impedance test, 54 times; and stimulation contact replacement, 25 times. The demand for remote programming was the highest during the first 6 months of sacral neuromodulation (average, 2.39 times per person). In total, 36 out of the 51 patients completed the questionnaire survey. Of these, all indicated that they chose remote programming to minimize unnecessary travel because they had been affected by COVID-19. The questionnaire also showed that remote programming could reduce the number of patient visits to the hospital, save time, reduce financial costs, and would be easy for patients to master. All surveyed patients indicated that they were satisfied with remote programming and were willing to recommend it to other patients.

Conclusion

Remote programming for sacral neuromodulation is feasible, effective, safe, and highly recommended by patients with refractory lower urinary tract dysfunction. Remote programming technology has great development and application potential in the post-pandemic era.

[Therapeutic value of neuromodulation in women]

BACKGROUND

Neuromodulative treatment for the treatment of overactive bladder has been used in clinical practice since its introduction in the early 1980s.

OBJECTIVES

Description and update of the various neuromodulative techniques (tibial nerve stimulation, sacral and pudendal neuromodulation), presentation of their effectiveness and safety, and evaluation of their evidence for clinical practice.

MATERIALS AND METHODS

Literature search in PubMed and Embase, inclusion of studies according to the following criteria: evidence level, timeliness, length of follow-up and number of female patients according to the author's preference.

RESULTS

The efficacy and safety of both percutaneous tibial nerve stimulation (PTNS) and sacral neuromodulation (SNM) has been proven by studies with an evidence level of 1. Long-term data of up to 20 years are available for SNM, while long-term data for PTNS are limited. Permanent implants for tibial nerve stimulation are promising new developments. Pudendal neuromodulation (PNM) is suitable for more complex indications but is surgically more challenging.

CONCLUSIONS

Both PTNS and SNM are suitable for broad application in clinical practice. PTNS can be offered as an alternative to pharmacotherapy, while SNM provides the most convincing clinical data of all neuromodulative therapies.

Bullseye Technique to Optimize S3 Foramen Access: Applying a Trusted Endourology Technique to Pelvic Medicine

BACKGROUND

Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement.

OBJECTIVE

This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM.

METHODS/MATERIAL

Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen.

RESULTS

The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation.

CONCLUSION

The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices.

Comparison of Two Treatment Modalities in Overactive Bladder: A Rapid Overview

Background

Overactive bladder is a syndrome of urgency with the absence of infection and is usually accompanied by frequency and nocturia. Both sacral neuromodulation (SNM) and intravesical botulinum toxin (BTX) injection are used contentiously in overactive bladder after failure of conservative management.

Objective

We aimed to provide an updated comparative overview of BTX injection versus SNM in the treatment of overactive bladder.

Methods

PubMed and Google scholar databases were explored starting from 2016 to 2022 to obtain relevant articles. English studies on adult population were included.

Results

Six articles included 648 participants were included in the current overview. Both BTX and SNM are comparable for the treatment of overactive bladder, with no major complications were reported. However, the use of SNM for refractory overactive bladder after failure of BTX was more successful and effective and resulted in patient satisfaction compared to the use of BTX after failure of SNM.

Conclusion

Our update provides the latest comparative overview of outcomes of BTX versus SNM in the treatment of overactive bladder.

Intermediate-term results of a prospective, multicenter study on remote programming sacral neuromodulation for refractory overactive bladder

Background

To evaluate the efficacy and safety of a novel remote programming sacral neuromodulation (SNM) system (BetterStim system) in the treatment of patients with refractory overactive bladder (OAB) for 3 years.

Methods

A total of 8 centers in China enrolled 84 patients with OAB. Following test stimulation 70 patients underwent implantation using BetterStim. All patients returned for follow-up at 3 and 6 months postoperatively. After that, the visits were conducted by telephone. Outcomes of voiding diaries, the overactive bladder symptom score (OABSS), questionnaires regarding OAB-related quality of life (OAB-qol), and adverse events (AEs) were evaluated at each visit. The clinical therapeutic success was defined as ≥50% improvement from baseline in any of the voiding diary variables or average voids/day return to normal voiding (<8 voids/day). The analysis is a modified Completers analysis.

Results

At the 36-month follow-up, the success rate was 79% for overall OAB symptoms, 69% for urge urinary incontinence (UUI) and 42% for urgency frequency (UF). The average number of voids/day decreased from 29.2±14.9 at baseline to 17.6±11.2 at 3 years, the average volume/void increased from 94.7±54.2 to 151.4±80.8 mL, the urgency reduced from 3.0±1.4 to 1.8±1.7 (all P<0.001). For patients with urge incontinence, mean leaking episodes/day decreased from 8.1±7.6 at baseline to 2.1±3.5 at three years (P<0.05). The devices were explanted in 8 (11.4%) patients. There were no remote programming-related AEs or device-related serious AEs that occurred.

Conclusions

The Intermediate-term results demonstrated that BetterStim SNM system with remote programming is safe and effective for patients with refractory OAB.

Removal of sacral neuromodulation quadripolar tined-lead using a straight stylet: description of a surgical technique

Background

Up to 7.5% of tined-lead removals in patients having sacral neuromodulation (SNM) therapy are associated with a lead breakage. It is still unclear what adverse effects can be caused by unretrieved fragments. The aim of our study was to describe the lead removal technique we have been using for the last 2 years in our centre.

Methods

We retrospectively enrolled patients who had lead removal between January 2018 and January 2020 using our standardized technique. The novelty of the technique is in the use of the straight stylet, which is available in the quadripolar tined-lead kit. The stylet gives the electrode greater stiffness, reducing interactions with surrounding tissues and probability of damage or breakage during removal.

Results

In 59 patients (42 women, mean age 57.2 years [range 40–79 years]) the lead was removed using our standardized technique. In 44 of 59 patients, the tined-lead was removed within 2 months from the SNM-test, due to lack of beneficial effects. In 15 patients the electrode was removed because of failure of definitive implantation. Meantime from definitive implantable pulse generator (IPG) implantation to lead removal was 67.9 months. We recorded only 1 case of lead-breakage during removal: a female patient with a non-tined lead fixed on sacral bone, placed 18 years previously using an open technique.

Conclusions

Lead breakage during removal is not uncommon and adverse effects of retained fragments may occur. Our technique has been safely used for the last 2 years in our centre, with no episodes of lead breakage or retained fragments, except for one non-tined electrode.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-020-02403-6.

Fowler's Syndrome-The Cause of Urinary Retention in Young Women, Often Forgotten, but Significant and Challenging to Treat

Urinary retention in young women is a relatively rare clinical problem and is often underdiagnosed. In particular, functional causes of urinary retention pose a diagnostic challenge. One of them is Fowler’s syndrome, which is associated with impaired urethral relaxation. Fowler’s syndrome is characterized by a large bladder capacity, reduced sensation, increased maximal urethral closure pressure, and detrusor underactivity. Several hypotheses have arisen to explain the cause of urethral relaxation disorders: hormonal changes characteristic of Polycystic Ovary Syndrome (PCOS), causing abnormal stabilization of the muscle membrane, primary failure of relaxation of the striated muscle of the urethra sphincter, and increased urethral afferent activity, inhibiting the bladder afferent signals from reaching the brain by potentiating a spinal mechanism of urinary continence. Currently, sacral neuromodulation is the only intervention that can restore an atypical voiding pattern in women with Fowler’s syndrome. The therapeutic effectiveness exceeds 70%, although the revision rate is relatively high, exceeding 50%. Well-designed, long-term prospective studies comparing sacral neuromodulation (SNM) with other therapies such as pelvic floor muscle physiotherapy are warranted to offer the best patient-tailored treatment.

Long-term Outcomes of Sacral Nerve Stimulation in Pelvic Floor Dysfunctions

Purpose

The aim of this study was to analyze the long-term outcomes of sacral nerve stimulation (SNS) in both idiopathic and neurogenic pelvic floor disorders in patients treated at a referral center.

Methods

This retrospective observational study analyzed the records of 106 patients tested at our department from December 1999 to January 2017. The efficacy variables evaluated were the Global Response Assessment (range, 0%–100%) and, according to the clinical indication, other specific variables such International Consultation on Incontinence QuestionnaireShort Form, number of catheterizations or pads/day, and the numerical pain scale. The safety variables analyzed were complications (pain, migration, infection), reinterventions and explants. Patients’ quality of life (QoL) and satisfaction with the procedure were evaluated through telephone interviews.

Results

The clinical indications were overactive bladder (OAB) (n=36), urinary retention (UR) (n=37), bladder pain syndrome/interstitial cystitis (BPS/IC) (n=19), fecal incontinence (FI) (n=8), and double incontinence (DI) (n=6). The implant rates according to the clinical indication were as follows: OAB, 55.6%; UR, 56.8%; BPS/IC, 63.15%; FI, 87.5%; and DI, 66.7%. Clinical and/or statistically significant improvements in all efficacy variables were observed. Loss of therapeutic effect at 75 months of follow-up was observed in 34% of patients. Device-related pain appeared in 25 patients (39%); in 20 patients, it was resolved by reprogramming and 5 patients required device removal. An overall improvement in QoL and high levels of satisfaction with the procedure were observed. More than 90% of patients would recommend SNS to a friend or relative.

Conclusions

SNS is a minimally invasive procedure that offers a real alternative to patients with refractory pelvic floor dysfunction. Its safety profile is very favorable and it provides a long-lasting improvement in symptoms and QoL.

Evaluation of progression from first to second stage sacral neuromodulation and unplanned device removal

OBJECTIVE

Sacral neuromodulation (SNM) is an advanced treatment option for patients with refractory overactive bladder (OAB) symptoms, urinary retention, and bowel disorders; it is usually performed in 2 separate procedures. This study aims to determine a cohort's progression rate from stage 1 to 2 and predict factors for progression and unplanned device removal or revision.

MATERIAL AND METHODS

A retrospective review was conducted in patients who underwent SNM at a single institution between June 2012 and May 2019. Progression rates from stage 1 to 2, patient characteristics, and indications for unplanned SNM removal or revision were recorded. Chi-square, Mann-Whitney U, and Fisher's exact tests were used for data analysis.

RESULTS

A total of 128 patients underwent SNM for 1 or more of the following diagnoses: OAB (n=103), urinary retention (n=15), neurogenic bladder dysfunction (n=4), fecal incontinence (n=2), and constipation (n=4). The progression rate to stage 2 was 92.2% (118/128). Patients who failed to progress to stage 2 had additional diagnoses other than OAB, such as urinary retention or bowel disorders (p=0.007). Fifteen patients (12.7%) required SNM removal or revision within 4 years of surgery. Among these patients, the body mass index was significantly lower (p=0.036).

CONCLUSION

Most patients (92.2%) progressed to stage 2. Patients with only OAB symptoms had a higher progression rate to stage 2. Single full-stage procedures may be considered in select patients to reduce morbidity, time, and costs.

Long-term outcomes of sacral neuromodulation for lower urinary tract dysfunction: A 23-year experience

AIMS

To evaluate the long-term outcomes of sacral neuromodulation (SNM), and patient characteristics that may predict long-term success or complications.

METHODS

A single-center retrospective cohort study was performed of all patients who underwent SNM testing and implantation. Outcome results, resolution of symptoms, and device removal were reported. Multivariable logistic regression was used to identify predictors of success. Cox proportional hazards model was used to identify predictors for device removal.

RESULTS

Four hundred and thrity four patients underwent SNM test phase of which 241 (median age 48.0 years, 91.7% [221/241] female) had device implantation and were followed up for median [range] time of 4.0 (3 months-20.5 years) years. Multivariable logistic regression showed that male gender (odds ratio: 0.314; 95% confidence interval: 0.164-0.601, p = .0005) was independently associated with decreased peripheral nerve evaluation success. At final follow-up for patients who originally had device implantation, median (interquartile range) percent of symptoms resolution of all patients was 60.0% (0%-90%) and 69.3% (167/241) had SNM successful outcomes. Cox proportional hazards model showed no difference for time to SNM device removal with respect to patient age, gender, or diagnosis. 69.3% (167/241) patients had at least 1 surgical re-intervention. The most common reason at first surgical re-intervention was lead change only (26.3%, 44/167).

CONCLUSION

SNM is a minimally invasive procedure with good long-term success rates. There is a high revision rate but overall, SNM has a good safety profile and excellent long-term outcomes.

Medium-term outcomes of sacral neuromodulation in patients with refractory overactive bladder: A retrospective single-institution study

Background

Sacral neuromodulation (SNM) is a minimally invasive fully reversible therapy that was approved in 1997 for overactive bladder syndrome (OAB) refractory to behavior modification and pharmacotherapy. Despite being in use for over two decades, the data on medium to long-term safety and efficacy of SNM in OAB is limited. We investigated the medium-term efficacy and safety of SNM along with the predictive factors for its success in patients with refractory OAB.

Methods

A retrospective consecutive case series of 66 patients undergoing SNM for refractory OAB between July 2009 and July 2018. All patients underwent a test period followed by permanent implantation, if there was > = 50% improvement in any symptom. The primary outcome was “success” defined as > = 50% improvement in any clinical parameter based on the subjective assessment of patient’s response. The secondary outcomes were number of pads used in 24 hours, post-operative complications and re-operation rates.

Results

66 females with an average age of 62.7 years were included. 55/66 patients (83.3%) had a successful test phase and underwent permanent implantation. After a median follow-up of 32 months, SNM was successful in 41/55 (74.5%) patients. Mean number of pads used in 24 hours decreased significantly from 3.5 preoperatively to 1.2 at last follow-up (p<0.001). 8/55 (14.5%) patients reported complications of pain, lead migration, wound dehiscence and device malfunction. 10/55 (18.2%) patients underwent revision surgeries after a median duration of 21.9 months. Device was explanted in 15/55 (27.3%) patients after a median duration of 24 months. No significant predictor for success was identified.

Conclusions

The success rate of SNM is 75% with a complication rate of 14.5% after a median follow-up of ~3 years. This study suggests medium-term efficacy and safety but a high re-operation rate of SNM in patients with refractory OAB.

Sacral Neuromodulation: Determining Predictors of Success

OBJECTIVE

To determine predictors of success for sacral neuromodulation in women with overactive bladder, urinary retention, and fecal incontinence.

METHODS

A retrospective chart review was performed on women who underwent a staged sacral neuromodulation implantation between 2007 and 2018. Clinical and procedural characteristics were recorded. Presence of intraoperative motor responses in either all 4 or <4 electrodes were used to group women. Endpoints included completion of stage II implant, tined lead revision, and patient-reported success.

RESULTS

In 198 women with a mean age of 62.9 years (SD+/- 14.7), completion of stage II implant occurred in 92.4% of women, and 83.3% of these women reported success at the first postoperative visit. Continued success at 6 months was reported in 70.3%. Lead revision was noted in 23.0%. Age >65 years (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.06-0.8) and prior onabotulinumtoxinA (onaBoNT-A) (OR = 0.2, 95% CI = 0.06-0.9) were negative predictors for completion of stage II implant on multivariable analysis. Also, prior pelvic floor physical therapy was a significant negative predictor of postoperative patient-reported success on multivariable analysis (OR = 0.25, 95% CI = 0.1-0.6). There were no differences seen in women who had motor responses with either all 4 electrodes or <4 electrodes in any endpoint (P > .05).

CONCLUSION

Patient age >65 and history of prior onaBoNT-A were associated with failure to complete stage II implant. Women with prior pelvic floor physical therapy were less likely to report success after sacral neuromodulation. Motor responses in <4 electrodes during lead testing did not impact patient-reported success.

The history of sacral neuromodulation in Canada

Sacral neuromodulation (SNM) has been used for the past 30 years, with significant improvements in the implantation technique and technology over the last several years. Canadian centers were involved with this technique from the very beginning by participating in several multicenter clinical trials and engaging in basic and clinical research. Presently, six Canadian centers continue to have SNM implantation programs.

Analysis of the Correlation Between the Clinical Effect of Sacral Neuromodulation and Patient Age: A Retrospective Multicenter Study in China

OBJECTIVES

This study aimed to evaluate whether patients stratified by age have the same level of benefits after a sacral neuromodulation (SNM) procedure for refractory lower urinary tract dysfunction.

MATERIALS AND METHODS

This retrospective study comprised 211 patients with refractory lower urinary tract dysfunction who had been treated with SNM and recruited from multiple medical centers across China. Patients were grouped according to age: <40 (n = 58), 40-64 (n = 94), and > 64 (n = 59) years. Data were compared using voiding diaries and subjective scores pre-operatively, post-implantation of a stage I tined lead, and during a short-term follow-up period postimplantation of a stage II implanted pulse generator.

RESULTS

In all groups, voiding diary data and subjective scores improved significantly over different periods. Residual urine improved in the 40-64 and > 64-year-old age groups. Quality of life scores improved in the <40-year-old age group. Voiding diary data among age groups varied at baseline; however, average urinary frequency did not differ at the last follow-up. Urgency and sexual life scores differed at baseline and these differences had resolved at the last follow-up. O'Leary-Sant and Pelvic Pain and Urgency/Frequency Symptoms Scale scores did not differ at baseline; however, significant differences were observed at the last follow-up.

CONCLUSIONS

SNM success is unrelated to age, and age alone should not be considered a limiting factor in SNM. For older patients, an overactive bladder appears a better indication for SNM treatment; however, further studies are required to confirm this finding.

Outcomes of Intradetrusor Onabotulinum Toxin A Therapy in Overactive Bladder Refractory to Sacral Neuromodulation

Purpose

Intradetrusor onabotulinum toxin A (BTXA) and sacral neuromodulation (SNM) are effective third-line therapies for overactive bladder (OAB). We aimed to measure the outcomes of BTXA for treatment of OAB refractory to initial SNM and identify patient characteristics associated with these outcomes.

Methods

This retrospective cohort study included patients who failed to respond to initial SNM treatment for OAB and subsequently received BTXA at a single provider’s clinic between January 2013 and December 2016. Treatment successes were defined as patients willing to continue BTXA or who found symptom relief whereas treatment failures discontinued BTXA due to adverse effects or lack of symptom relief. Symptoms and patient-reported outcomes on validated questionnaires were compared before the initial BTXA trial to 2 months after the last BTXA treatment. The SNM failure BTXA groups were also compared to BTXA SNM naïve groups.

Results

Of 18 patients who received BTXA after failed SNM treatment, 7 (39%) achieved treatment success. Successfully treated patients demonstrated decreased urinary frequency from a median 11 voids/day pre-BTXA to 8 voids/day with BTXA (P=0.042). Patients whose treatment failed reported increased complaints of a weak urinary stream (P=0.03) and higher frequency of straining to urinate (P=0.016) than the successful treatment group pre-BTXA. Compared to BTXA patients without prior SNM, the odds of failing BTXA after initial SNM were 3.6 times higher (P=0.016).

Conclusions

BTXA appears effective for OAB refractory to SNM, although the success rate is lower compared to BTXA patients without SNM exposure.

Neuromodulation - a therapeutic option for refractory overactive bladder. A recent literature review

Overactive bladder (OAB) affects approximately 17% of the population. The treatment of this clinical condition is challenging, especially when conservative therapy is not effective. There are limited options for the treatment of recurrent OAB. Neuromodulation has taken a significant place in the therapy of recalcitrant lower urinary tract dysfunctions over the past 20 years. The aim of this study was to review the literature evaluating the different forms of neuromodulation in various urological clinical conditions and to show the future prospects of this treatment method. Further studies are necessary to determine the effectiveness of neuromodulation and to identify the prognostic factors of therapeutic success. This could be helpful in the selection of patients who will be most likely to respond positively to the treatment.

What uro-gynecologists should know about sacral neuromodulation (SNM) for the treatment of refractory overactive bladder

PURPOSE

To inform uro-gynecologists about the current standards and latest developments of sacral neuromodulation (SNM) in women with overactive bladder (OAB).

METHODS

Literature search in the PubMed database for articles published between 1988 and 2019 on SNM for OAB in women.

RESULTS

In total, 361 articles were identified and 51 articles retrieved for the review. SNM shows an objective success rate of 70-80%, OAB cure rate of 17-47% and a subjective satisfaction rate of 80-90%. These benefits have to be weighed against an adverse event rate of approx. 40%. SNM is significantly more successful than switching to another antimuscarinic after failed antimuscarinic drug therapy. Efficacy of SNM is slightly lower compared to bladder wall injections with 200 U botulinum toxin in the first months but efficacy of both treatments appears to be similar after 24 months. MRI examinations of patients with a sacral neurostimulator should only be performed after radiologist consultation. Sacral neurostimulators in patients with another pacemaker system should only be implanted after interdisciplinary consultation. The sacral neuromodulator should be turned off during pregnancy and delivery. SNM for OAB in patients with concomitant female sexual dysfunction or fecal incontinence seems to be beneficial.

CONCLUSIONS

SNM is a successful and recommended second-line treatment of OAB. Sacral neurostimulators should preferably be implanted in SNM-centers because complications and the frequency of revisions are significantly reduced with increasing experience of the surgeon.

Application of Internet+-based Tsinghua PINS Remote Tech to improve sacral neuromodulation programming procedure

OBJECTIVE

To explore the feasibility and safety of the Tsinghua PINS Remote Tech to facilitate sacral neuromodulation programming procedure.

METHOD

For 22 patients who had previously participated in the phase III clinical trial for treating overactive bladder with the Tsinghua PINS sacral neuromodulation system during several Hospital, PINS Remote Tech was applied to perform postoperative parameter adjustment in order to evaluate the safety and reliability of this new technique. Telephone surveys on Remote Tech-related questionnaires were also conducted.

RESULTS

17/22 patients underwent 26 parameter adjustments, average adjustment frequency was 1.53 times per person; the average adjustment time was 23.4 ± 5.1 min (15-32 min). The total effective rate of the Remote control was 14/17 (82.3%). 7/17 (41.1%) patients' symptoms recurrence due to not knowing how to handle patient controller, these patients were instructed on how to use it correctly through Remote Tech even without reprogramming it. Other 10 patients received reprogramming. There was no discomfort during and after parameter adjustment. The questionnaire survey showed that the remote technology saved patients' time and lowered financial costs, significantly improved patient satisfaction. All patients expressed their willingness to recommend it to other patients.

CONCLUSION

The PINS Remote Tech can significantly reduce the financial cost and provide a remote reprogram control service that is as safe and reliable as outpatient program control.

Neuromodulation for Pelvic and Urogenital Pain

Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.

Troubleshooting Interstim Sacral Neuromodulation Generators to Recover Function

Purpose of Review

Sacral neuromodulation (SNM) is being used to treat lower urinary tract symptoms (LUTS) with growing popularity among clinicians in multiple specialties. As this therapy becomes more common in the USA and Europe, urologists will encounter more patients implanted with SNM generators.

Recent Findings

Over time, it has recently been understood that up to 53% will develop pain at the implant site as reported by Groen et al. (J Urol 186:954, 2011) and 3–38% will lose effective stimulation as reported by Al-zahrani et al. (J Urol 185:981, 2011) and White et al. (Urology 73:731, 2009). There is a paucity of troubleshooting methodology in the literature, apart from revision surgery, to salvage the SNM generator. In fact, it has been suggested that one contemporary series’ failure rate is lower than some historic series because of the ability to reprogram devices as reported by Siegel et al. (J Urol 199:229, 2018). Standard algorithms for such reprogramming efforts are lacking in the literature and may salvage some patients otherwise destined for surgical revision or addition of multimodal therapy to achieve acceptable symptom control.

Summary

It is possible to troubleshoot and thereby salvage many SNM generators, saving patients from surgical revision in many cases and increasing the number of patients with persistent benefit from SNM. The algorithms presented in this manuscript represent a systematic strategy for reprogramming and troubleshooting SNM generators.

Application of an individualized and reassemblable 3D printing navigation template for accurate puncture during sacral neuromodulation

OBJECTIVE

To evaluate the feasibility and safety of an individualized and reassemblable three-dimensional (3D) printing navigation template for making accurate punctures during sacral neuromodulation (SNM).

METHODS

From July 2016 to July 2017, 24 patients undergoing SNM were enrolled. Conventional X-ray guidance was used in the control group, which included 14 patients, while the 3D printing template was used in the experimental group, which included 10 patients. The number of punctures, the average puncture time, the exposure to X-ray, the adjustment time during the operation and the testing of the SNM device, the infection and haemorrhage rate, and the implantable pulse generator (IPG) implantation rates were compared between the two groups.

RESULTS

In total, 24 patients successfully underwent stage I. When comparing the control group and the experimental group, the number of punctures were 9.6 ± 7.7 and 1.5 ± 0.7, respectively; the average puncture times were 35.4 ± 14.6 and 4.1 ± 2.2 min, respectively; and the X-ray exposure levels were 8.37 ± 4.83 mAs and 2.34 ± 0.54 mAs, respectively. No postoperative complications were reported in either group. The IPG implantation rates were not different between the two groups.

CONCLUSION

The 3D printing template for SNM can help us to perform accurate and quick punctures into the target sacral foramina, reduce X-ray exposure, and shorten the operation time. For patients with obesity, sacral variation, sacral bone fractures or losses and for patients who are unable to tolerate the prone position during operation, use of the 3D printing template is recommended.

International Continence Society best practice statement for use of sacral neuromodulation

AIMS

Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel.

METHODS

Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group.

RESULTS

The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research.

CONCLUSIONS

These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.

The role of the neurometer CPT/C in sacral neuromodulation

Objective

The aim of the current research project was to study the role of the Neurometer^® as a tool to predict responders to sacral neuromodulation therapy (SNM).

Material and methods

This was a prospective, open study in male and female patients, aged 18 and over with voiding dysfunction [non-obstructive retention and/or frequency/ urgency syndrome]. The first group underwent a screening test to evaluate percutaneous nerve functions (PNE) and to determine whether they are candidates for SNM with the InterStim^®. Prior to PNE testing, all patients were evaluated with the pain tolerance test (PTT) using the electro-diagnostic Neurometer^® CPT/C device. An InterStim^® implant was placed in patients who were responders to PNE testing underwent. On the other hand, non-responders underwent a staged implant placement. The second group consisted of patients who already had InterStim^® implanted for voiding dysfunction. During the routine office follow-up, the patients implanted with Interstim^® underwent a PTT using the Neurometer^® CPT/C device. All the testing using the Neurometer CPT/C was performed on the day of the PNE for the first group, and the day of the routine follow-up visit for the second group. All of the results for the Neurometer^® testing were kept blinded from the PNE results, and those of the outcome of the follow-up visit. The study received approval by the Research Ethics Board of the University Health Network (No. 14-8196).

Results

We recruited a total of 123 patients. The results presented here include 110 patients who completed the study, 48 of whom were in the first group, and 62 in the second group. The statistical analysis used was as follows: Group 1: Simple linear regression analysis and the linear discriminate analysis were preformed. It was found that for patients without the InterStim^® implant with a combined CPT/CPD of 800 and above, the Neurometer^® could predict the test screening results with an accuracy of 71%. Group 2: Same analysis and tests were conducted for patients with the InterStim^® implant, and the results showed that if the patient had a combined CPT/CPD of 600 and above, the Neurometer^® could predict the patients satisfaction or dissatisfaction with an accuracy of 72%.

Conclusion

Neurometer^® may play a role in predicting test trial positive responders and patient satisfaction after the placement of InterStim^® implant.

Electrical neuromodulation in the management of lower urinary tract dysfunction: evidence, experience and future prospects

Lower urinary tract dysfunction (LUTD) is common and causes a spectrum of morbidity and decreased quality of life (QoL) for patients. LUTD can range from urinary retention to urge incontinence, and includes a variety of syndromes, with the most common and widely recognized being overactive bladder (OAB). The classic treatments of LUTD and OAB comprise different strategies including behavioral therapies, medications and minimally invasive or invasive surgical procedures. Generally, once patients have tried behavioral modifications and oral medical therapy, and have not experienced adequate relief of their symptoms, the next step is to consider minimally invasive therapies. In the last two decades since FDA approval, sacral nerve stimulation (SNS) has become an accepted intervention, with increasing use and evidence of effectiveness for LUTD, specifically OAB and non-obstructive urinary retention. SNS has shown both objective and subjective improvement in voiding symptoms in several randomized controlled trials (RCTs) when compared to sham or standard medical therapy. The main limitations for more extensive use include relatively high cost, implantation of a device and possibly reoperation secondary to adverse events (AE). Percutaneous tibial nerve stimulation (PTNS) is a less invasive, less direct and less expensive method for neuromodulation, which has also shown effectiveness in several randomized and non-randomized trials, including comparable improvement rates to anticholinergics in OAB management. However, the efficacy of PTNS is only maintained for a short period after the stimulation is delivered. This technique has a much lower rate of AE compared to SNS, but with the inconvenience of weekly visits for stimulation, although implantable devices are on the horizon. In this article we review the mechanism of action, indications, effectiveness and complications related to SNS and PTNS therapy for LUTD.

Prospective randomized study evaluating ultrasound versus fluoroscopy guided sacral InterStim® lead placement: A pilot study

OBJECTIVE

To investigate the use of intraoperative ultrasound during stage I InterStim® sacral lead placement.

METHODS

A total of 40 patients were randomly assigned to undergo InterStim® lead placement utilizing fluoroscopy or ultrasound guidance. Patients were blinded for the duration of the study. The surgeon and staff were blinded until after induction of anesthesia. Patients met criteria for refractory overactive bladder, fecal incontinence, or both. The ICIQ-OABqol, OABSS, and FIQL validated questionnaires were used pre- and post-operatively. Primary endpoint was total fluoroscopy time. Secondary endpoints were total radiation exposure and total number of foramen needle skin punctures.

RESULTS

Forty patients were enrolled, twenty in the ultrasound and twenty in the fluoroscopy only arm. Mean age was 60 (SD = 14.4) and mean BMI 32 (SD = 7.2). Twenty-seven patients (67.5%) had urinary symptoms, four (10%) fecal incontinence, and nine (22.5%) had mixed symptoms. Radiation exposure time was reduced by 70.5 s (P = 0.002), radiation exposure was decreased by 42.3 mGy (P = 0.017), and the number of needle skin punctures decreased by 3.6 (P = 0.035) with use of ultrasound. Mean OR time in minutes was 55.5 in ultrasound and 58.2 in fluoroscopy group (P = 0.53). There were no statistically significant differences in questionnaire scores between groups.

CONCLUSION

Ultrasound guided placement of foramen needle during Stage I sacral neuromodulation results in reduction of radiation exposure to the patient, surgeon, and operating room staff. Further studies are necessary to determine the learning curve and efficacy of this technique.

Radiographic Position of the Electrode as a Predictor of the Outcome of InterStim Therapy

Purpose

Sacral neuromodulation (SNM) therapy is indicated for some refractory urological conditions. The electrode lead position in sacral x-rays during routine follow-up may predict the outcome of SNM therapy. To determine whether the radiographic position of the electrode in the sacral foramen predicted the long-term outcome of SNM therapy.

Methods

This was a retrospective study of patients who underwent InterStim SNM at Toronto Western Hospital by 2 surgeons from July 2013 to March 2014. The position of electrodes in relation to the sacral bone was assessed on follow-up sacral x-rays. In the lateral view, we determined the location of the radio-opaque marker of the electrode relative to the inner surface of the sacrum (P3, D3, P2, D2, P1, D1, P0, and D0). In the anteroposterior view, the angle between a line through the spinous process shadow and the electrode was measured (0°–30°, 30°–60°, 60°–90°, >90°, or medial). Dissatisfied patients were defined as those who did not improve based on a voiding diary or those who needed salvage treatment after SNM. The primary endpoint was to determine whether the electrode lead position on sacral x-rays predicted the outcome of SNM therapy.

Results

A total of 69 patients (61 female and 8 male patients) were included, with a median age of 55 years. Forty-two of the patients (60.9%) had refractory overactive bladder, 21 (30.4%) suffered from chronic urinary retention, and 6 (8.7%) had lower urinary tract symptoms and chronic pelvic pain syndrome. The univariate analysis did not show any correlation between SNM response and the electrode position or angle. Dummy regression analysis using response to implantation as the dependent outcome variable did not show any significance for any of the predictors.

Conclusions

Our study did not show a correlation between the long-term response to SNM and the electrode position on follow-up sacral x-rays. In this study, electrode lead position in sacral x-ray at follow-up was not correlated with the outcome of SNM therapy.

Long-Term Functional Outcomes of S3 Sacral Neuromodulation for the Treatment of Idiopathic Overactive Bladder

OBJECTIVES

To assess the long-term functional outcomes of sacral neuromodulation (SNM) in the treatment of refractory idiopathic overactive bladder (IOAB) and to determine predictive factors for success.

MATERIALS AND METHODS

To obtain long-term data, all consecutive patients suffering from IOAB and treated by SNM at a single tertiary care center between December 1996 and December 2004 were included. Data regarding patient demographics, past medical, and surgical history, bladder diary, complications as well as device revision and removal rates were collected. Success was defined as an improvement ≥ 50% of any clinical parameter.

RESULTS

Overall, 34 patients, with a median age of 57.8 years (IQR 44.8-65.7) were included. Immediately after definitive implantation, 2 (6%) patients were lost to follow-up. After a median follow-up of 9.7 years (IQR 4.7-12.0), SNM was considered successful in 20 (63%) patients. Mean amount of protections used per 24 hours significantly decreased (4.1 preoperatively vs. 1.8 at the last follow-up visit, p = 0.02). Devices were removed in 2 (6%) patients due to pain and lack of efficacy. Twenty-two revision surgeries were performed in 15 (47%) patients. First revision surgery occurred after a mean of 6.2 years (± 3.1). Revision surgeries were mainly performed for end of battery life/device dysfunction (n = 18, 82%). No significant predictor for success was identified.

CONCLUSIONS

With a median follow-up time of 9.7 years, this retrospective SNM study reports a 63% efficacy rate (≥ 50% improvement) for the treatment of refractory IOAB. Moreover, it is a well-tolerated and minimally invasive therapy.

Overactive bladder treatment: application of methylene blue to improve the injection technique of onabotulinum toxin A

OBJECTIVE

The aim of this study was to test the addition of methylene blue (MB) to onabotulinum toxin A (BTX-A) solution in overactive bladder (OAB) treatment, as a means of facilitating observation of the injection site and assessing the distribution of the drug under the bladder mucosa during injection. Pharmacological interactions between BTX-A and MB were also evaluated.

MATERIALS AND METHODS

The study was conducted between December 2014 and April 2016 on 30 patients: six males and 24 females (median age 57.7, range 23-80 years) diagnosed with OAB, who qualified for intravesical BTX-A injection. Each received 100 IU of BTX-A (Botox^®; Allergan), dissolved in 9.5 ml of 0.9% NaCl with the addition of 0.5 ml of MB. Cystoscopy with submucosal injection of the solution was performed systematically, including the bladder triangle. For pharmacological evaluation, quantitative determination of MB was performed on a capillary electrophoresis system with diode array detection.

RESULTS

In the course of 600 injections, the addition of MB facilitated the observation of the procedure; the exact distribution of the solution could not be observed in only 43 injections in seven patients. The range of distribution of the drug varied from 1 to 2.5 cm. Pharmacological evaluation based on visual observations and experiments showed that pharmaceutical interactions do not occur between MB and this commercially available formulation of BTX-A.

CONCLUSIONS

Applying a coloured solution of BTX-A significantly facilitates observation of the procedure and assessment of drug distribution. There are no pharmaceutical interactions between MB and BTX-A.

The underactive bladder: diagnosis and surgical treatment options

The underactive bladder (UAB)/detrusor underactivity (DU) is a relatively common condition. It is difficult to diagnose and can be difficult to manage. The aim of this review is to provide a review of the diagnosis and different surgical treatment options for UAB/DU. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, UAB, DU, TURP, reduction cystoplasty, bladder diverticulectomy and sacral neuromodulation (SNM). Search results were assessed for their overall relevance to this review. Definitions, general overview and management options were extracted from the relevant medical literature. DU affects up to 45% of men and women >70 years of age. The symptoms of DU overlap significantly with overactive bladder (OAB) and bladder outlet obstruction (BOO). Urodynamic findings include low voiding pressure combined with slow intermittent flow and incomplete bladder emptying. Non-operative management for DU is acceptable; only 1 in 6 male patients may need a TURP and acute urinary retention (AUR) is rare. TURP for DU is feasible and is associated with good short and medium term outcomes, but over time, there is a return to baseline symptoms. Bladder diverticulectomy can also improve DU, but there is a paucity of guidelines on patient selection. SNM provides excellent outcomes for DU, but patient selection is important.

Sacral neuromodulation for detrusor hyperactivity with impaired contractility

INTRODUCTION

Detrusor hyperactivity with impaired contractility (DHIC) is a challenging condition to manage. Sacral neuromodulation (SNM) is a proven treatment modality for both the individual aspects of DHIC. To date, data reporting the outcome of SNM for DHIC are lacking.

MATERIALS AND METHODS

Consecutive patients undergoing SNM for DHIC were followed prospectively, from April 2013 to October 2016. Patient demographics, bladder diaries, subjective response rates, ICIQ-OAB, and PGI-I scores were recorded. Success was defined as greater than 50% improvement in storage symptoms and a 50% improvement in voided volume or reduction of post-void residual volumes.

RESULTS

Twenty patients underwent stage 1 trial of SNM for DHIC. Median age was 68.5, IQR (54.25-76.25). Thirteen (65%) patients were female. A total of 14/20 (70%) of patients had a significant treatment response, 9/20 had a response to both elements of DHIC, 4/20 patients had a response to the detrusor overactivity (DO) alone, and 1/20 had a response to the voiding component alone. A total of 12/20 (60%) patients proceeded to insertion of an IPG. At mean follow-up of 17 months, IQR (1.5-35), 11/12 (91.7%) of patients are still using the SNM for DHIC. Median PGI score is 2, IQR (2-4). SNM for DHIC resulted in statistically significant improvements in voided volume (P = 0.016), PVR (P = 0.0296), ICIQ-OAB score (P < 0.0001), and ICIQ-OAB bother score (P = 0.016) CONCLUSION: This is the first study we know of to report the results of SNM for DHIC. SNM is associated with satisfactory success rates, treating both the detrusor hyperactivity, and impaired contractility components of this condition.

Long-term outcome of sacral neuromodulation in patients with idiopathic nonobstructive urinary retention: Single-center experience

OBJECTIVE

The objective of this study was to determine the safety and efficacy of sacral neuromodulation (SNM) in patients with idiopathic nonobstructive urinary retention.

MATERIALS AND METHODS

We retrospectively reviewed the files of patients who underwent staged neuromodulation for idiopathic nonobstructive urinary retention from 2004 to 2016 at our hospital. Patients who had a 50% improvement in symptoms after 1 week of stage 1 procedure were qualified for permanent device implantation. Patient data were assessed on efficacy and need for intermittent self-catheterization, complications, and operative revision rates.

RESULTS

Twenty-seven female patients who underwent SNM therapy were analyzed. The mean age of the patients was 32.5 ± 10.8 years. The mean duration of urinary retention was 3.2 ± 1.7 years. All patients were doing intermittent self-catheterization, but few were able to void <100 ml. Twenty-four (88.8%) of the 27 patients demonstrated a >50% improvement in symptoms and underwent permanent device placement. At a median follow-up of 5.7 ± 3.2 years, 20 (83.3%) of the 24 patients demonstrated sustained improvement rates of >50%. Seventeen (70.83%) of 24 patients could void spontaneously with a mean residual urine of 28.1 ± 24.4 ml (P < 0.001). Three (12.5%) were voiding with significant mean decreasing number of catheterizations from 5.6 ± 2.4 to 1.4 ± 2.1 (P < 0.001). Four (16.6%) had their device explanted. Ten (41.6%) of the 24 patients underwent surgical revision. Most of the adverse events were managed by device reprograming.

CONCLUSION

SNM is a highly effective and safe procedure in this subset of the female population with idiopathic refractory nonobstructive urinary retention.

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction

INTRODUCTION

Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

Bladder response to acute sacral neuromodulation while treating rats in different phases of complete spinal cord injury: a preliminary study

Background:

Compared to conventional therapies, sacral neuromodulation (SNM) may offer an alternative, non-destructive treatment for SCI patients with bladder dysfunction. Understanding bladder response to SNM treatment for SCI in different phases may yield new insights for innovative use of this promising technique.

Materials and Methods:

Female Sprague-Dawley rats were used in this study to examine the effects of acute SNM on bladder reflex in complete SCI rats. All rats were anesthetized and set up for continuous saline infusion. Acute SNM treatment was implemented for about 6 hours for each rat. Cystometric parameters, including time between contractions, contraction duration, bladder peak pressure, and number of uninhibited contractions, were analyzed and compared within rats before and after SNM treatment.

Results:

For the spinally transected rats during early phase (less than two weeks post spinalization), the time between contractions and contraction duration both increased after SNM treatments, yet the increased amplitude was about or less than 20%. For the spinally transected rats with a longer days survival (about two to four weeks post spinalization), the time between contractions and contraction duration substantially increased after SNM treatment and the changes for their average values were more than 90%. For the spinally transected rats with a much longer days survival (more than five weeks post spinalization), the time between contractions and contraction duration increased after SNM treatments, yet the magnitude of changes were less than 30%.

Conclusion:

The present study suggested that the significant effectiveness of SNM for complete SCI played its role after the spinal shock phase and prior to the development of detrusor overactivity. It indicated that the time point of SNM treatment is necessary to be paid attention.

Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration

AIM: To investigate the nature and severity of AE related to sacral neurostimulation (SNS).

METHODS: Based on Pubmed and Embase searches, we identified published trials and case series of SNS for fecal incontinence (FI) and extracted data on adverse events, requiring an active intervention. Those problems were operationally defined as infection, device removal explant or need for lead and/or generator replacement. In addition, we analyzed the Manufacturer and User Device Experience registry of the Federal Drug Administration for the months of August - October of 2015. Events were included if the report specifically mentioned gastrointestinal (GI), bowel and FI as indication and if the narrative did not focus on bladder symptoms. The classification, reporter, the date of the recorded complaint, time between initial implant and report, the type of AE, steps taken and outcome were extracted from the report. In cases of device removal or replacement, we looked for confirmatory comments by healthcare providers or the manufacturer.

RESULTS: Published studies reported adverse events and reoperation rates for 1954 patients, followed for 27 (1-117) mo. Reoperation rates were 18.6% (14.2-23.9) with device explants accounting for 10.0% (7.8-12.7) of secondary surgeries; rates of device replacement or explant or pocket site and electrode revisions increased with longer follow up. During the period examined, the FDA received 1684 reports of AE related to SNS with FI or GI listed as indication. A total of 652 reports met the inclusion criteria, with 52.7% specifically listing FI. Lack or loss of benefit (48.9%), pain or dysesthesia (27.8%) and complication at the generator implantation site (8.7%) were most commonly listed. Complaints led to secondary surgeries in 29.7% of the AE. Reoperations were performed to explant (38.2%) or replace (46.5%) the device or a lead, or revise the generator pocket (14.6%). Conservative management changes mostly involved changes in stimulation parameters (44.5%), which successfully addressed concerns in 35.2% of cases that included information about treatment results.

CONCLUSION: With reoperation rates around 20%, physicians need to fully disclose the high likelihood of complications and secondary interventions and exhaust non-invasive treatments, including transcutaneous stimulation paradigms.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients

AIMS

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM).

METHODS

Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ² , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression.

RESULTS

Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46).

CONCLUSIONS

In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the management of adult non-neurogenic overactive bladder

Due to the myriad of treatment options available and the potential increase in the number of patients afflicted with overactive bladder (OAB) who will require treatment, the Female Urology Special Advisory Group (FUSAG) of the Urological Society of Australia and New Zealand (USANZ), in conjunction with the Urogynaecological Society of Australasia (UGSA), see the need to move forward and set up management guidelines for physicians who may encounter or have a special interest in the treatment of this condition. These guidelines, by utilising and recommending evidence-based data, will hopefully assist in the diagnosis, clinical assessment, and optimisation of treatment efficacy. They are divided into three sections: Diagnosis and Clinical Assessment, Conservative Management, and Surgical Management. These guidelines will also bring Australia and New Zealand in line with other regions of the world where guidelines have been established, such as the American Urological Association, European Association of Urology, International Consultation on Incontinence, and the National Institute for Health and Care Excellence guidelines of the UK.

Underactive Bladder: Clinical Features, Urodynamic Parameters, and Treatment

Purpose:

Underactive bladder is a complex clinical condition that remains poorly understood due to limited literature. This study aimed to determine its prevalence among patients with voiding dysfunction, presenting symptoms, risk factors, urodynamic findings, and ongoing treatment.

Methods:

A retrospective chart review of consecutive urodynamic studies performed on voiding dysfunction between 2012 and 2014 was conducted to identify patients with detrusor underactivity. Detrusor underactivity was defined by a bladder contractility index of less than 100. Charts and urodynamic tracings were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken. Descriptive statistics were utilized to analyze the data.

Results:

The prevalence of detrusor underactivity in this study was 23% (79 of 343). Average age of the patients was 59.2 years (range, 19–90 years). Women represented 68.4% (54 of 79) of the patients. The most common reported symptoms were urinary urgency (63.3%), weak stream (61.0%), straining (57.0%), nocturia (48.1%), and urinary frequency (46.8%). Prior pelvic surgery and prior back surgery were noted in 40.5% and 19.0% of the patients, respectively. The most common management was intermittent self-catheterization in 54.4%, followed by observation/conservative treatment in 25.3% and sacral neuromodulation in 12.7%.

Conclusions:

Although underactive bladder is a common condition, its precise diagnosis and treatment remain a challenge. Its symptoms significantly overlap with those of other bladder disorders, and hence, urodynamic evaluation is particularly useful in identifying patients with impaired detrusor contractility. This will help prevent mismanagement of patients with surgery or medical therapy, as that may worsen their condition. Much work needs to be done to better understand this condition and establish optimal management of patients.

CT evaluation of acupuncture needles inserted into sacral foramina

OBJECTIVE

To use CT scanning to evaluate the precision with which acupuncture needles can be inserted into sacral foramina to establish sacral nerve modulation by electroacupuncture.

METHODS

The subjects were five adult women (mean age 71.6 years). These five cases were divided into two groups. In the first three subjects (group A) the intention was to insert acupuncture needles in the S3 and S4 foramina; in the remaining two subjects (group B) the intention was to insert acupuncture needles in the S2 and S3 foramina.

RESULTS

CT scanning showed that in subject 1 of group A, the acupuncture needle intended for insertion in S3 was actually in the S4 foramen, and the acupuncture needle intended for insertion in S4 was actually distal to the sacral body. In subjects 2 and 3, the acupuncture needles were inserted accurately in the S3 and S4 foramina. In the three subjects who had acupuncture needles inserted in the S4 foramen, the tip of the acupuncture needle was an average distance of 6.0 mm from the rectum. The acupuncture needles inserted in subjects 4 and 5 of group B were inserted accurately into the S2 and S3 foramina.

CONCLUSIONS

Inserting acupuncture needles into the sacral foramina of S2 and S3 at an angle of about 60° has the potential to be used for sacral nerve modulation by repeated electroacupuncture stimulation. Needling may be less accurate in subjects with higher body mass index. Because of the potential risk of perforating the rectum with the needle, this technique must be used by specialists only.

TRIAL REGISTRATION NUMBER

2013-026.