1
|
Possover M. Minimally Invasive Two-passage Electrical Genital Nerve Stimulation: A Human Cadaver Study of a New Technique. J Minim Invasive Gynecol 2023; 30:480-485. [PMID: 36924880 DOI: 10.1016/j.jmig.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/16/2023] [Accepted: 02/06/2023] [Indexed: 03/17/2023]
Abstract
STUDY OBJECTIVE To present and evaluate the feasibility of a new technique of lead-electrode stimulation to the genital nerves using a 2-step, double-passage retropubic/retrograde approach. DESIGN Prospective observational study. INTERVENTIONS The procedure was initiated in the retropubic passage by placing the electrode from below through a paravulvar/testicular small incision toward the urogenital diaphragm, guided through the retropubic space along the backside of the pubic bone. Through a second passage along the frontside of the pubic bone, the lead-electrode was placed finally at the genital nerves. SETTING Department of Anatomy, University Bern, Bern, Switzerland PARTICIPANTS: The study was performed in 5 cadavers (bilaterally) and tested by 10 obstetrics and gynecology surgeons. MEASUREMENTS AND MAIN RESULTS Positions and courses of the lead electrode in relation to the dorsal nerve of the clitoris/penis were evaluated by dissection of the genitals and showed an optimal parallel course of the lead electrodes to the dorsal nerve from the perforation of the urogenital diaphragm to the crura of the clitoris, with area of the dorsal nerve of the clitoris/penis to the electrode never exceeding 2 mm. Participant surgeons self-evaluated reproducibility and difficulty of the procedure by using a score from 1 to 10 (1, easy/safe; 10, extremely difficult/dangerous). Both reproducibility and difficulty achieved a score of 1 by all participants. CONCLUSIONS The double-passage genital nerve stimulation procedure is a new peripheral nerve stimulation technique that had a high self-evaluated rate of ease and reproducibility for surgeon participants.
Collapse
Affiliation(s)
- Marc Possover
- Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany; Department of Obstetrics and Gynecology, Aarhus University, Aarhus, Denmark; Department of Obstetrics and Gynecology, Xi'An Jiaotong University (Dr. Possover), Xi'An Shaanxi, China.
| |
Collapse
|
2
|
Zillioux J, Slopnick EA, Vasavada SP. Third-line therapy for overactive bladder in the elderly: Nuances and considerations. Neurourol Urodyn 2022; 41:1967-1974. [PMID: 35645033 PMCID: PMC9796112 DOI: 10.1002/nau.24965] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Overactive bladder (OAB) disproportionally affects older adults in both incidence and severity. OAB pharmacotherapy is often problematic in the elderly due to polypharmacy, adverse side effect profiles and contraindications in the setting of multiple comorbidities, and concerns regarding the risk of incident dementia with anticholinergic use. The burden of OAB in older patients coupled with concerns surrounding pharmacotherapy options should motivate optimization of nonpharmacologic therapies in this population. At the same time, several aspects of aging may impact treatment efficacy and decision-making. This narrative review critically summarizes current evidence regarding third-line OAB therapy use in the elderly and discusses nuances and treatment considerations specific to the population. METHODS We performed an extensive, nonsystematic evidence assessment of available literature via PubMed on onabotulinumtoxinA (BTX-A), sacral neuromodulation, and percutaneous tibial nerve stimulation (PTNS) for OAB, with a focus on study in elderly and frail populations. RESULTS While limited, available studies show all three third-line therapies are efficacious in older populations and there is no data to support one option over another. BTX-A likely has a higher risk of urinary tract infection and retention in older compared to younger populations, especially in the frail elderly. PTNS incurs the lowest risk, although adherence is poor, largely due to logistical burdens. CONCLUSION Advanced age and frailty should not preclude third-line therapy for refractory OAB, as available data support their efficacy and safety in these populations. Ultimately, treatment choices should be individualized and involve shared decision-making.
Collapse
Affiliation(s)
- Jacqueline Zillioux
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| | - Emily A. Slopnick
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| | - Sandip P. Vasavada
- Department of UrologyGlickman Urological and Kidney Institute, Cleveland ClinicClevelandOhioUSA
| |
Collapse
|
3
|
Statewide Success of Staged Sacral Neuromodulation for the Treatment of Urinary Complaints in California (2005-2011). Female Pelvic Med Reconstr Surg 2021; 26:437-442. [PMID: 30059438 DOI: 10.1097/spv.0000000000000605] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Sacral neuromodulation (SNS) is approved by the Food and Drug Administration as a third-line treatment for refractory overactive bladder, idiopathic urinary retention, and fecal incontinence. Prior to implantation of an implantable pulse generator, all patients undergo a trial phase to ensure symptom improvement. The published success rates of progression from the test phase to permanent implant vary widely (range, 24% to >90%). We sought to characterize success rates using a statewide registry. METHODS Using nonpublic data, we identified SNS procedures using the California Office of Statewide Planning and Development ambulatory surgery database from 2005 to 2011. A successful trial was defined as receiving a stage 2 generator implantation after trial lead placement. Multivariable logistic regression was performed to identify factors associated with staged success. RESULTS During the study period, 1396 patients underwent a staged SNS procedure, with 962 (69%) subsequently undergoing generator placement. Successful trial rates were 72% for overactive bladder wet, 69% for urgency/frequency, 68% for interstitial cystitis, 67% for neurogenic bladder, and 57% for urinary retention. On multivariate logistic regression, only male sex (odds ratio, 0.51) and urinary retention [odds ratio, 0.54) were significantly associated with lower odds of success, whereas age, race/ethnicity, medical insurance, and placement at an academic or high-volume institution had no association. CONCLUSIONS The "real world" success rates for staged SNS implantation in California are less than those observed by some academic centers of excellence but better than previously reported for Medicare beneficiaries. Successful trial rates for interstitial cystitis and neurogenic voiding dysfunction are similar to refractory overactive bladder.
Collapse
|
4
|
Greenberg DR, Sohlberg EM, Zhang CA, Santini VE, Comiter CV, Enemchukwu EA. Sacral Nerve Stimulation in Parkinson's Disease Patients With Overactive Bladder Symptoms. Urology 2020; 144:99-105. [PMID: 32681915 DOI: 10.1016/j.urology.2020.06.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess the efficacy, safety, and outcomes of sacral nerve stimulation (SNS) for Parkinson's disease (PD) patients with overactive bladder symptoms. METHODS We retrospectively reviewed PD patients who underwent Stage I SNS. Demographics, urodynamic data, and baseline voiding function were analyzed. Efficacy and safety of treatment were determined by rate of progression to Stage II, explantation, and surgical revision. Long-term outcomes were assessed using voiding diaries and/or clinic notes. RESULTS Sixty percent (9/15) experienced ≥50% improvement in urinary parameters and proceeded to Stage II. There was no significant difference in age, body mass index, comorbidities, PD disease duration, or levodopa equivalent daily dose between successful and nonsuccessful Stage I patients. However, 100% of female patients experienced Stage I success compared to 44% of male PD patients (P = .04). Individuals with >12-month follow-up experienced an average reduction of 6 voids/day. No patients required revision or explantation of their device at latest clinic follow-up (22.2 ± 7.8 months). Higher maximal urethral closure pressures, detrusor pressure at maximum flow rate (PdetQmax), post-void residual volume, and mean bladder outlet obstruction index were observed in the Stage I trial failures. CONCLUSION At our institution, PD patients have a similar rate of progression to Stage II compared to the general population. SNS is an effective therapy that should be considered among the treatment options for PD patients with overactive bladder symptoms. Urodynamic parameters associated with obstruction may be predictive of SNS failure in PD patients and may help guide patient selection, however further studies are needed.
Collapse
Affiliation(s)
- Daniel R Greenberg
- Stanford University School of Medicine, Department of Urology, Stanford, CA.
| | - Ericka M Sohlberg
- Stanford University School of Medicine, Department of Urology, Stanford, CA
| | - Chiyuan A Zhang
- Stanford University School of Medicine, Department of Urology, Stanford, CA
| | - Veronica E Santini
- Stanford University School of Medicine, Department of Neurology and Neurological Sciences, Stanford, CA
| | - Craig V Comiter
- Stanford University School of Medicine, Department of Urology, Stanford, CA
| | - Ekene A Enemchukwu
- Stanford University School of Medicine, Department of Urology, Stanford, CA
| |
Collapse
|
5
|
Gupta A, Kinman C, Hobson DTG, Meriwether KV, Gaskins JT, Uddin MN, Stewart JR, Francis SL. The Impact of Fluoroscopy During Percutaneous Nerve Evaluation on Subsequent Implantation of a Sacral Neuromodulator Among Women With Pelvic Floor Disorders: A Randomized, Noninferiority Trial. Neuromodulation 2020; 23:1164-1171. [PMID: 32367666 DOI: 10.1111/ner.13164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/07/2020] [Accepted: 04/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether percutaneous nerve evaluation (PNE) without fluoroscopy is inferior to fluoroscopy use in women undergoing trials of sacral neuromodulation (SNM) for pelvic floor disorders (PFDs). MATERIALS AND METHODS In an unblinded noninferiority trial, women undergoing PNE were randomized to fluoroscopy or no fluoroscopy. The primary outcome was "success" and defined as implantation of the permanent SNM device within three months of PNE. At an expected 40% success and a 30% noninferiority threshold, 33 participants in each group were needed for 80% power (α = 0.05). Univariate analyses and a logistic regression model adjusting for univariate variables associated with the primary outcome were performed. RESULTS From April 2016 to December 2018, 74 participants underwent PNE of which 36 underwent PNE with fluoroscopy and 38 without. The fluoroscopy group had less baseline mean daily voids compared to the no fluoroscopy group (10.79 ± 6.48 vs. 16.21 ± 10.05, p = 0.01). PNE performed without fluoroscopy had similar success (18/38, 47.4%) compared to fluoroscopy (21/36, 58.3%), meeting our noninferiority definition (difference 10.9%, 90% CI -8% to 30%, p = 0.049). In a logistic regression model adjusting for age, Charlson comorbidity index, stage of prolapse, and number of baseline voids per day, trial success was still similar between the two groups (adjOR 1.82, 95% CI 0.52 to 6.94, p = 0.36). CONCLUSIONS PNE performed without fluoroscopy is noninferior to PNE with fluoroscopy use for the outcome of SNM device implantation within three months among women undergoing therapy for PFDs.
Collapse
Affiliation(s)
- Ankita Gupta
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Casey Kinman
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Baylor Scott & White Medical Center, Irving, TX, USA
| | - Deslyn T G Hobson
- Department of Obstetrics & Gynecology, Wayne State University, Detroit, MI, USA
| | - Kate V Meriwether
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Jeremy T Gaskins
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, KY, USA
| | - Md Nazir Uddin
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, KY, USA
| | - J Ryan Stewart
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Sean L Francis
- Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| |
Collapse
|
6
|
Greenberg DR, Syan R, Young‐Lin N, Comiter CV, Enemchukwu E. Outcomes of Sacral Nerve Stimulation for Treatment of Refractory Overactive Bladder Among Octogenarians. Neuromodulation 2019; 22:738-744. [DOI: 10.1111/ner.12981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Raveen Syan
- Department of UrologyStanford University School of Medicine Stanford CA USA
| | - Nichole Young‐Lin
- Department of Obstetrics and GynecologyStanford University School of Medicine Stanford CA USA
| | - Craig V. Comiter
- Department of UrologyStanford University School of Medicine Stanford CA USA
| | - Ekene Enemchukwu
- Department of UrologyStanford University School of Medicine Stanford CA USA
| |
Collapse
|
7
|
Moskowitz D, Adelstein SA, Lucioni A, Lee UJ, Kobashi KC. Use of Third Line Therapy for Overactive Bladder in a Practice with Multiple Subspecialty Providers-Are We Doing Enough? J Urol 2017; 199:779-784. [PMID: 28965782 DOI: 10.1016/j.juro.2017.09.102] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Overactive bladder impacts more than 15% of the adult population. Compliance with medical treatment is low due to inadequate symptom control or intolerable side effects. Although third line therapies have improved the treatment of overactive bladder, many patients do not receive optimal treatment. We hypothesized that third line treatment use is higher among female pelvic medicine and reconstructive surgery urologists, and we examined its use at our tertiary referral center. MATERIALS AND METHODS The electronic medical record was queried for patients with overactive bladder seen in 1 year. The number of visits associated with an overactive bladder prescription and the number of patients who received third line therapy were determined and subcategorized by department. Female pelvic medicine and reconstructive surgery providers were considered separately. RESULTS A total of 5,445 patients (8,994 visits) were seen for overactive bladder. Of all patients seen for overactive bladder 3.5% received third line therapy compared with 10.0% and 14.1% of those seen by urology providers and female pelvic medicine and reconstructive surgery providers, respectively. CONCLUSIONS The use of third line therapy was reported to be less than 5%. This rate is higher at our institution, which is likely due to multiple female pelvic medicine and reconstructive surgery providers. We also apply an algorithm that facilitates patient education on available options should first and second line treatments fail. Given the limited compliance with medical treatment for overactive bladder, we are likely missing a segment of the patient population who would benefit from third line treatment. Our data demonstrate an opportunity for urologists to improve the quality of overactive bladder treatment and subsequently improve patient quality of life.
Collapse
Affiliation(s)
- Dena Moskowitz
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington.
| | - Sarah A Adelstein
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Alvaro Lucioni
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| | - Kathleen C Kobashi
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, Washington
| |
Collapse
|
8
|
Bielefeldt K. Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration. World J Gastrointest Pharmacol Ther 2016; 7:294-305. [PMID: 27158546 PMCID: PMC4848253 DOI: 10.4292/wjgpt.v7.i2.294] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/23/2016] [Accepted: 03/16/2016] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
9
|
Noblett KL, Dmochowski RR, Vasavada SP, Garner AM, Liu S, Pietzsch JB. Cost profiles and budget impact of rechargeable versus non-rechargeable sacral neuromodulation devices in the treatment of overactive bladder syndrome. Neurourol Urodyn 2016; 36:727-733. [DOI: 10.1002/nau.23008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/04/2016] [Indexed: 11/07/2022]
Affiliation(s)
| | | | | | | | - Shan Liu
- Wing Tech, Inc.; Menlo Park California
- University of Washington; Seattle Washington
| | | |
Collapse
|