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Mancini V, Damaser MS, Chermansky C, Ochoa CD, Hashim H, Przydacz M, Hervé F, Martino L, Abrams P. Can we improve techniques and patients' selection for nerve stimulation suitable for lower urinary tract dysfunctions? ICI-RS 2023. Neurourol Urodyn 2024; 43:1420-1430. [PMID: 38048061 DOI: 10.1002/nau.25346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 12/05/2023]
Abstract
AIMS Lower urinary tract dysfunctions (LUTD) are very common and, importantly, affect patients' quality of life (QoL). LUTD can range from urinary retention to urgency incontinence and includes a variety of symptoms. Nerve stimulation (NS) is an accepted widespread treatment with documented success for LUTD and is used widely. The aim of this review is to report the results of the discussion about how to improve the outcomes of NS for LUTD treatment. METHODS During its 2023 meeting in Bristol, the International Consultation on Incontinence Research Society discussed a literature review, and there was an expert consensus discussion focused on the emerging awareness of NS suitable for LUTD. RESULTS The consensus discussed how to improve techniques and patients' selection in NS, and high-priority research questions were identified. CONCLUSIONS Technique improvement, device programming, and patient selection are the goals of the current approach to NS. The conditional nerve stimulation with minimally invasive wireless systems and tailored algorithms hold promise for improving NS for LUTD, particularly for patients with neurogenic bladder who represent the new extended population to be treated.
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Affiliation(s)
- Vito Mancini
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Margot S Damaser
- Department of Biomedical Engineering, Lerner Research Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, and Advanced Platform Technology Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | | - Carolina D Ochoa
- Bristol Urological Institute, North Bristol Trust, University of Bristol, Bristol, UK
| | - Hashim Hashim
- Bristol Urological Institute, North Bristol Trust, University of Bristol, Bristol, UK
| | - Mikolaj Przydacz
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - François Hervé
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| | - Leonardo Martino
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Paul Abrams
- Bristol Urological Institute, University of Bristol, Bristol, UK
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Lee JH, Jang TM, Shin JW, Lim BH, Rajaram K, Han WB, Ko GJ, Yang SM, Han S, Kim DJ, Kang H, Lim JH, Lee KS, Park E, Hwang SW. Wireless, Fully Implantable and Expandable Electronic System for Bidirectional Electrical Neuromodulation of the Urinary Bladder. ACS NANO 2023; 17:8511-8520. [PMID: 37070621 DOI: 10.1021/acsnano.3c00755] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Current standard clinical options for patients with detrusor underactivity (DUA) or underactive bladder─the inability to release urine naturally─include the use of medications, voiding techniques, and intermittent catheterization, for which the patient inserts a tube directly into the urethra to eliminate urine. Although those are life-saving techniques, there are still unfavorable side effects, including urinary tract infection (UTI), urethritis, irritation, and discomfort. Here, we report a wireless, fully implantable, and expandable electronic complex that enables elaborate management of abnormal bladder function via seamless integrations with the urinary bladder. Such electronics can not only record multiple physiological parameters simultaneously but also provide direct electrical stimulation based on a feedback control system. Uniform distribution of multiple stimulation electrodes via mesh-type geometry realizes low-impedance characteristics, which improves voiding/urination efficiency at the desired times. In vivo evaluations using live, free-moving animal models demonstrate system-level functionality.
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Affiliation(s)
- Joong Hoon Lee
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Tae-Min Jang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Jeong-Woong Shin
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Bong Hee Lim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Kaveti Rajaram
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Won Bae Han
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Gwan-Jin Ko
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Seung Min Yang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Sungkeun Han
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Dong-Je Kim
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Heeseok Kang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Jun Hyeon Lim
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
| | - Kyu-Sung Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Eunkyoung Park
- Department of Biomedical Engineering, Soonchunhyang University, Asan 31538, Republic of Korea
| | - Suk-Won Hwang
- KU-KIST Graduate School of Converging Science and Technology, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), Seoul 02792, Republic of Korea
- Department of Integrative Energy Engineering, Korea University, Seoul 02841, Republic of Korea
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A New Electrode Design for Direct Bladder Wall Stimulation: A Pilot Minipig Study with Chronic Testing. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12031149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
(1) Aims: To test a newly designed helical-wire hook electrode implanted in the bladder wall to induce contraction and promote voiding. (2) Methods: In three minipigs with a created lesion of the sacral spinal cord, four electrodes were implanted in the bladder wall, ventral to the trigone. Stimulation tests were conducted initially in conscious pigs, and later after general anesthesia. (3) Results: Electrical stimulation in the conscious animals on postoperative days 4 and 7 at 40 Hz was limited to 10 mA, because of abdominal, leg, and anal contractions with animal discomfort; bladder contractions were not induced. Electrical stimulation on postoperative days 9 and 28 at 60 mA under anesthesia induced sustained vesical wall contractions with bladder pressure variations, but without voiding. Simultaneous abdominal contractions occurred, with strong leg and anal contractions. Subsequent stimulation with a single set of electrodes or at 20 Hz induced less vesical pressure response. At autopsy, the electrodes had not migrated, and extraction forces were high, at 7.9 ± 0.9 Newtons (n = 12). (4) Conclusions: Our 28-day study has confirmed the utility of the new electrode design, preventing migration from the bladder wall and making it suitable for long-term electrode implants.
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Yan D, Bruns TM, Wu Y, Zimmerman LL, Stephan C, Cameron AP, Yoon E, Seymour JP. Ultracompliant Carbon Nanotube Direct Bladder Device. Adv Healthc Mater 2019; 8:e1900477. [PMID: 31556241 PMCID: PMC6893921 DOI: 10.1002/adhm.201900477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/08/2019] [Indexed: 12/20/2022]
Abstract
The bladder, stomach, intestines, heart, and lungs all move dynamically to achieve their purpose. A long-term implantable device that can attach onto an organ, sense its movement, and deliver current to modify the organ function would be useful in many therapeutic applications. The bladder, for example, can suffer from incomplete contractions that result in urinary retention with patients requiring catheterization. Those affected may benefit from a combination of a strain sensor and electrical stimulator to better control bladder emptying. The materials and design of such a device made from thin layer carbon nanotube (CNT) and Ecoflex 00-50 are described and demonstrate its function with in vivo feline bladders. During bench-top characterization, the resistive and capacitive sensors exhibit stability throughout 5000 stretching cycles under physiology conditions. In vivo measurements with piezoresistive devices show a high correlation between sensor resistance and volume. Stimulation driven from platinum-silicone composite electrodes successfully induce bladder contraction. A method for reliable connection and packaging of medical grade wire to the CNT device is also presented. This work is an important step toward the translation of low-durometer elastomers, stretchable CNT percolation, and platinum-silicone composite, which are ideal for large-strain bioelectric applications to sense or modulate dynamic organ states.
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Affiliation(s)
- Dongxiao Yan
- Department of Electrical and Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Tim M. Bruns
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Yuting Wu
- Department of Electrical and Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Lauren L. Zimmerman
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Chris Stephan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Biointerfaces Institute, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Anne P. Cameron
- Department of Urology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Euisik Yoon
- Department of Electrical and Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Center for Nanomedicine, Institute for Basic Science (IBS), Seoul, 03722, Korea
- Graduate Program of Nano Biomedical Engineering (Nano BME), Yonsei-IBS Institute, Yonsei University, Seoul, 03722, Korea
| | - John P. Seymour
- Department of Electrical and Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
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Peh WYX, Raczkowska MN, Teh Y, Alam M, Thakor NV, Yen SC. Closed-loop stimulation of the pelvic nerve for optimal micturition. J Neural Eng 2018; 15:066009. [PMID: 30181427 DOI: 10.1088/1741-2552/aadee9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Neural stimulation to restore bladder function has traditionally relied on open-loop approaches that used pre-set parameters, which do not adapt to suboptimal outcomes. The goal of this study was to examine the effectiveness of a novel closed-loop stimulation paradigm for improving micturition or bladder voiding. APPROACH We compared the voiding efficiency obtained with this closed-loop framework against open-loop stimulation paradigms in anesthetized rats. The bladder pressures that preceded voiding, and the minimum current amplitudes for stimulating the pelvic nerves to evoke bladder contractions, were first calibrated for each animal. An automated closed-loop system was used to initiate voiding upon bladder fullness, adapt the stimulation current by using real-time bladder pressure changes to classify voiding outcomes, and halt stimulation when the bladder had been emptied or when the safe stimulation limit was reached. MAIN RESULTS In vivo testing demonstrated that the closed-loop system achieved high voiding efficiency or VE (75.7% ± 3.07%, mean ± standard error of the mean) and outperformed open-loop systems with either conserved number of stimulation epochs (63.2% ± 4.90% VE) or conserved charge injected (32.0% ± 1.70% VE). Post-hoc analyses suggest that the classification algorithm can be further improved with data from additional closed-loop experiments. SIGNIFICANCE This novel approach may be applied to an implantable device for treating underactive bladder (<60% VE), especially in cases where under- or over-stimulation of the nerve is a concern.
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Affiliation(s)
- Wendy Yen Xian Peh
- Singapore Institute for Neurotechnology, National University of Singapore, 28 Medical Drive, #05-02, Singapore 117456, Singapore
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Inskip JA, Ramer LM, Ramer MS, Krassioukov AV. Autonomic assessment of animals with spinal cord injury: tools, techniques and translation. Spinal Cord 2008; 47:2-35. [DOI: 10.1038/sc.2008.61] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Wang CC, Huang CC, Liou JS, Ciou YJ, Huang IY, Li CP, Lee YC, Wu WJ. A Mini-Invasive Long-Term Bladder Urine Pressure Measurement ASIC and System. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2008; 2:44-49. [PMID: 23852632 DOI: 10.1109/tbcas.2008.921601] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A mini-invasive system for long-term bladder urine pressure measurement system is presented. Not only is the design cost reduced, but also the reliability is enhanced by using a 1-atm canceling sensing instrumentation amplifier (IA). Because the urine pressure inside the bladder does not vary drastically, both the sleeping and working modes are required in order to save the battery power for long-term observation. The IA amplifies the signal sensed by the pressure sensor, which is then fed into the following analog-to-digital converter. Owing to the intrinsic 1-atm pressure existing inside the bladder, the IA must be able to cancel such a pressure from the signal picked up by the pressure sensor to keep the required linearity and the resolution for pressure measurement of the bladder urine. The pressure range of the proposed system is found out to be 14.7~19.7 Psi, which covers the range of all of the known unusual bladder syndromes or complications.
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Gaunt RA, Prochazka A. Control of urinary bladder function with devices: successes and failures. PROGRESS IN BRAIN RESEARCH 2006; 152:163-94. [PMID: 16198700 DOI: 10.1016/s0079-6123(05)52011-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of urinary tract dysfunction is crucial for the health and well-being of people with spinal cord injury. Devices, specifically catheters, play an important role in the daily regime of bladder management for most people with spinal cord injury. However, the high incidence of complications associated with the use of catheters, and the fact that the spinal segments involved in lower urinary tract control remain intact in most cord-injured people, continue to motivate research into devices that could harness the nervous system to provide greater control over lower urinary tract function. Mechanical devices discussed in this review include catheters, artificial urethral sphincters, urethral stents and intraurethral pumps. Additionally, many attempts to restore control of the lower urinary tract with electrical stimulation have been made. Stimulation sites have included: inside the bladder, bladder wall, thigh, pelvic floor, dorsal penile nerve, pelvic nerve, tibial nerve, sacral roots, sacral nerves and spinal cord. Catheters and sacral root stimulators are two techniques whose efficacy is well established. Some approaches have proven less successful and others are still in the development stage. Modifications to sacral root stimulation including posterior root stimulation, anodal blockade and high-frequency blockade as well as new techniques including intraspinal microstimulation, urethral afferent stimulation and injectable microstimulators are also discussed. No single device has yet restored the control and function of the lower urinary tract to the pre-injury state, but new techniques are bringing this possibility closer to reality.
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Affiliation(s)
- Robert A Gaunt
- Department of Biomedical Engineering and Center for Neuroscience, University of Alberta, 507 HMRC, Edmonton, AB T6G 2S2, Canada
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Middleton JW, Keast JR. Artificial autonomic reflexes: using functional electrical stimulation to mimic bladder reflexes after injury or disease. Auton Neurosci 2004; 113:3-15. [PMID: 15296790 DOI: 10.1016/j.autneu.2004.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Accepted: 04/28/2004] [Indexed: 12/30/2022]
Abstract
Autonomic reflexes controlling bladder storage (continence) and emptying (micturition) involve spinal and supraspinal nerve pathways, with complex mechanisms coordinating smooth muscle activity of the lower urinary tract with voluntary muscle activity of the external urethral sphincter (EUS). These reflexes can be severely disrupted by various diseases and by neurotrauma, particularly spinal cord injury (SCI). Functional electrical stimulation (FES) refers to a group of techniques that involve application of low levels of electrical current to artificially induce or modify nerve activation or muscle contraction, in order to restore function, improve health or rectify physiological dysfunction. Various types of FES have been developed specifically for improving bladder function and while successful for many urological patients, still require substantial refinement for use after spinal cord injury. Improved knowledge of the neural circuitry and physiology of human bladder reflexes, and the mechanisms by which various types of FES alter spinal outflow, is urgently required. Following spinal cord injury, physical and chemical changes occur within peripheral, spinal and supraspinal components of bladder reflex circuitry. Better understanding of this plasticity may determine the most suitable methods of FES at particular times after injury, or may lead to new FES approaches that exploit this remodeling or perhaps even influence the plasticity. Advances in studies of the neuroanatomy, neurophysiology and plasticity of lumbosacral nerve circuits will provide many further opportunities to improve FES approaches, and will provide "artificial autonomic reflexes" that much more closely resemble the original, healthy neuronal regulatory mechanisms.
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Walter JS, Wheeler JS, Cai W, King WW, Wurster RD. Evaluation of a suture electrode for direct bladder stimulation in a lower motor neuron lesioned animal model. IEEE TRANSACTIONS ON REHABILITATION ENGINEERING : A PUBLICATION OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY 1999; 7:159-66. [PMID: 10391586 DOI: 10.1109/86.769406] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The purpose of this study was to evaluate a "suture" type electrode for direct bladder stimulation in an animal model of a lower motor neuron lesion. During an initial surgery, five male cats were instrumented under anesthesia using multistranded, 316 LVM, stainless-steel, wire electrodes implanted on the bladder wall serosa above the trigone area. Electrodes were constructed with a needle attached to the end that was removed after suturing the electrode in place. Additional instrumentation included urinary bladder catheters (tubes) for pressure recording and filling, and hook type electrodes for leg and pelvic floor electromyography recording. Chronic bladder filling and stimulation studies were conducted in tethered animals three to four weeks following surgery. To test these electrodes in a spinal cord injury model, a lower motor neuron lesion was performed including the sacral cord and complete nerve roots at L6 and below. These animals were evaluated during weeks 3 and 10 after injury. Direct bladder stimulation induced active contractions and voiding both before and after spinal cord injury. Effective stimulation parameters consisted of 40 pulses per s, 300 micros to 1 ms pulse duration, a stimulation period from 3 to 4 s, and a stimulation current from 10 to 40 mA. Fluoroscopy revealed an open membranous urethra during stimulation and following stimulation. A small diameter penile urethra was observed to limit flow. Postmortem evaluation of the suture electrode revealed no abnormalities such as corrosion, migration into the bladder lumen or displacement. These findings indicate that suture electrodes are suitable and effective for short-term implantation in the lower motor neuron animal model.
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Affiliation(s)
- J S Walter
- Rehabilitation R&D Center, VA Hines Hospital, Research Service (151), IL 60141, USA
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