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Desprez C, Leroi AM, Gourcerol G. Gastric and sacral electrical stimulation for motility disorders-A clinical perspective. Neurogastroenterol Motil 2024:e14884. [PMID: 39099155 DOI: 10.1111/nmo.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/04/2024] [Accepted: 07/21/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Electrical stimulation of the gut has been investigated in recent decades with a view to treating various gastro-intestinal motility disorders including, among others, gastric electrical stimulation to relieve nausea and vomiting associated with gastroparesis and sacral neuromodulation to treat fecal incontinence and/or constipation. Although their symptomatic efficacy has been ascertained by randomized controlled trials, their mechanisms of action are not fully understood. PURPOSE This review summarizes the past year's literature on the mechanisms of action of gut electrical stimulation therapies, including their impact on the gut-brain axis.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
| | - Anne-Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
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Huang Y, Peng F. Micro/nanomotors for neuromodulation. NANOSCALE 2024; 16:11019-11027. [PMID: 38804105 DOI: 10.1039/d4nr00008k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Micro-nanomotors (MNMs) are micro/nanoscale intelligent devices with vast potential in the fields of drug delivery, precision medicine, biosensing, and environmental remediation. Their primary advantage lies in their ability to convert various forms of external energy (such as magnetic, ultrasonic, and light energy) into their own propulsive force. Additionally, MNMs offer high controllability and modifiability, enabling them to navigate in the microscopic world. Importantly, recent research has harnessed the unique advantages of MNMs to synergize their capabilities in neuromodulation. This mini-review presents the significant progress and pioneering achievements in the use of MNMs for neuromodulation, with the aim of inspiring readers to explore the broader biomedical applications of these MNMs. Through continuous innovation and diligent exploration, MNMs show promise to have a profound impact on the field of biomedicine.
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Affiliation(s)
- Yulin Huang
- School of Materials Science and Engineering, Sun Yat-Sen University, Guangzhou 510275, China.
| | - Fei Peng
- School of Materials Science and Engineering, Sun Yat-Sen University, Guangzhou 510275, China.
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Meng L, Yan Z, Wang X, Zhang Y, Zhu Z, Zhu W, Ling Q, Sun X, Gu Y, Lv J, Li Y. Preliminary analysis of stimulation parameters for sacral neuromodulation in different indications: a multicenter retrospective cohort study from China. Int J Surg 2024; 110:3536-3542. [PMID: 38445489 PMCID: PMC11175814 DOI: 10.1097/js9.0000000000001302] [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: 12/20/2023] [Accepted: 02/23/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Sacral neuromodulation (SNM) is an effective approach for treating lower urinary tract dysfunction (LUTD), and stimulation programming is essential for successful treatment. However, research on SNM programming for various indications is limited. Thus, the authors aimed to determine whether there were differences in the stimulation parameters for different SNM indications and the appropriate programming recommendations. MATERIALS AND METHODS Clinical data were retrospectively collected from patients with LUTD who underwent SNM and completed internal pulse generator implantation. The parameters with the highest patient satisfaction or the most symptom improvement during the test period were considered optimal and used to set the programming after internal pulse generator implantation. RESULTS After screening, 282 patients were enrolled and categorized into four groups based on the following indications: refractory overactive bladder (OAB) ( n =61), neurogenic lower urinary tract dysfunction (nLUTD) ( n =162), interstitial cystitis/painful bladder syndrome (IC/BPS) ( n =24), and idiopathic nonobstructive urinary retention (NOUR) ( n =35). When analyzing the optimal stimulus parameters, disparities in the stimulation amplitude and pulse frequency were noted among the four groups. The stimulation amplitude in the nLUTD group was higher than that in the idiopathic NOUR group ( P =0.013). Differences in pulse frequency were observed between the refractory OAB and nLUTD groups ( P <0.001) and between the refractory OAB and idiopathic NOUR groups ( P =0.001). No differences in the electrode configuration or pulse width settings existed among the four groups. CONCLUSIONS The stimulation parameters for SNM varied among the different indications. For the initial programming of stage I, most patients are recommended to start with stimulation amplitudes below 2 V, although patients with nLUTD may benefit from higher amplitudes. A standard pulse width of 210 μs is recommended for all patients. However, for individuals experiencing nLUTD or idiopathic NOUR, the pulse frequency can begin above the standard 14 Hz but not exceed 50 Hz.
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Affiliation(s)
- Lingfeng Meng
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Zehao Yan
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Xinhao Wang
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Yaoguang Zhang
- Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Zhikai Zhu
- Center for Big Data, National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Wen Zhu
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou
| | - Qing Ling
- Department of Urology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan
| | - Xiaoke Sun
- Department of Urology, Honghui Hospital, Xi’an Jiaotong University, Xi’an
| | - Yinjun Gu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine
| | - Jianwei Lv
- Department of Urology, Gongli Hospital of Shanghai Pudong New Area, Shanghai
| | - Yan Li
- Department of Urology, Qilu Hospital of Shandong University, Jinan, People’s Republic of China
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Goudelocke C, Jungbauer Nikolas LM, Bittner KC, Offutt SJ, Miller AE, Slopsema JP. Sensing in Sacral Neuromodulation: A Feasibility Study in Subjects With Urinary Incontinence and Retention. Neuromodulation 2024; 27:392-398. [PMID: 37589643 DOI: 10.1016/j.neurom.2023.07.002] [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: 03/30/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Sacral neuromodulation (SNM) therapy standard of care relies on visual-motor responses and patient-reported sensory responses in deciding optimized lead placement and programming. Automatic detection of stimulation responses could offer a simple, consistent indicator for optimizing SNM. The purpose of this study was to measure and characterize sacral evoked responses (SERs) resulting from sacral nerve stimulation using a commercial, tined SNM lead. MATERIALS AND METHODS A custom external research system with stimulation and sensing hardware was connected to the percutaneous extension of an implanted lead during a staged (tined lead) evaluation for SNM. The system collected SER recordings across a range of prespecified stimulation settings (electrode configuration combinations for bipolar stimulation and bipolar sensing) during intraoperative and postoperative sessions in 21 subjects with overactive bladder (OAB) and nonobstructive urinary retention (NOUR). Motor and sensory thresholds were collected during the same sessions. RESULTS SERs were detected in all 21 subjects. SER morphology (number of peaks, magnitude, and timing) varied across electrode configurations within and across subjects. Among subjects and electrode configurations tested, recordings contained SERs at motor threshold and/or sensory threshold in 75% to 80% of subjects. CONCLUSIONS This study confirmed that implanted SNM leads can be used to directly record SERs elicited by stimulation in subjects with OAB and NOUR. SERs were readily detectable at typical SNM stimulation settings and procedural time points. Using these SERs as possible objective measures of SNM response has the capability to automate patient-specific SNM therapy, potentially providing consistent lead placement, programming, and/or closed-loop therapy.
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Affiliation(s)
- Colin Goudelocke
- Department of Urology, Ochsner Medical Center, New Orleans, LA, USA
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Hokanson JA, Langdale CL, Grill WM. Pathways and parameters of sacral neuromodulation in rats. Am J Physiol Renal Physiol 2023; 325:F757-F769. [PMID: 37795537 PMCID: PMC10874681 DOI: 10.1152/ajprenal.00123.2023] [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: 05/10/2023] [Revised: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 10/06/2023] Open
Abstract
The stimulation paradigm for sacral neuromodulation has remained largely unchanged since its inception. We sought to determine, in rats, whether stimulation-induced increases in bladder capacity correlated with the proportion of sensory pudendal (PudS) neurons at each stimulated location (L6, S1). If supported, this finding could guide the choice of stimulation side (left/right) and level (S2, S3, S4) in humans. Unexpectedly, we observed that acute stimulation at clinically relevant (low) amplitudes [1-1.5 × motor threshold (Tm)], did not increase bladder capacity, regardless of stimulus location (L6 or S1). More importantly for the ability to test our hypothesis, there was little anatomic variation, and S1 infrequently contributed nerve fibers to the PudS nerve. During mapping studies we noticed that large increases in PudS nerve activation occurred at amplitudes exceeding 2Tm. Thus, additional cystometric studies were conducted, this time with stimulation of the L6-S1 trunk, to examine further the relationship between stimulation amplitude and cystometric parameters. Stimulation at 1Tm to 6Tm evoked increases in bladder capacity and decreases in voiding efficiency that mirrored those produced by PudS nerve stimulation. Many animal studies involving electrical stimulation of nerves of the lower urinary tract use stimulation amplitudes that exceed those used clinically (∼1Tm). Our results confirm that high amplitudes generate immediate changes in cystometric parameters; however, the relationship to low-amplitude chronic stimulation in humans remains unclear. Additional studies are needed to understand changes that occur with chronic stimulation, how these changes relate to therapeutic outcomes, and the contribution of specific nerve fibers to these changes.NEW & NOTEWORTHY Acute low-amplitude electrical stimulation of sacral nerve (sacral neuromodulation) did not increase bladder capacity in anesthetized CD, obese-prone, or obese-resistant rats. Increasing stimulation amplitude correlated with increases in bladder capacity and pudendal sensory nerve recruitment. It is unclear how the high-amplitude acute stimulation that is commonly used in animal experiments to generate immediate effects compares mechanistically to the chronic low-amplitude stimulation used clinically.
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Affiliation(s)
- James A Hokanson
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States
- Joint Department of Biomedical Engineering, Medical College of Wisconsin, Marquette University, Milwaukee, Wisconsin, United States
| | - Christopher L Langdale
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States
| | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States
- Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina, United States
- Department of Neurobiology, Duke University, Durham, North Carolina, United States
- Department of Neurosurgery, Duke University, Durham, North Carolina, United States
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Daikh A, Reymond F, Lombardo D, Thuillier C, Bedouch P, Faucheron JL. Retrospective study of sacral neuromodulator implantations in a French hospital center: Lifespan and hospital costs assessment. Int J Colorectal Dis 2023; 38:273. [PMID: 38015254 DOI: 10.1007/s00384-023-04569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Assia Daikh
- Department of Pharmacy, Grenoble Alpes University Hospital, F-38000, Grenoble, France.
| | - Fabienne Reymond
- Department of Pharmacy, Grenoble Alpes University Hospital, F-38000, Grenoble, France
| | - Dorothée Lombardo
- Department of Pharmacy, Grenoble Alpes University Hospital, F-38000, Grenoble, France
| | - Caroline Thuillier
- Department of Urology, Grenoble Alpes University Hospital, F-38000, Grenoble, France
| | - Pierrick Bedouch
- Department of Pharmacy, Grenoble Alpes University Hospital, F-38000, Grenoble, France
- Faculty of Pharmacy, University Grenoble Alpes, F-38000, Grenoble, France
- TIMC-IMAG UMR5525, CNRS, University Grenoble Alpes, F-38041, Grenoble, France
| | - Jean-Luc Faucheron
- TIMC-IMAG UMR5525, CNRS, University Grenoble Alpes, F-38041, Grenoble, France
- Colorectal Surgery Unit, Department of Visceral Surgery and Acute Care Surgery, Grenoble Alpes University Hospital, F-38000, Grenoble, France
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Coolen RL, Frings D, van Asselt E, Scheepe JR, Blok BFM. Transcutaneous Electrical Stimulation of the Abdomen, Ear, and Tibial Nerve Modulates Bladder Contraction in a Rat Detrusor Overactivity Model: A Pilot Study. Int Neurourol J 2023; 27:167-173. [PMID: 37798883 PMCID: PMC10556428 DOI: 10.5213/inj.2346144.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/17/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE The global prevalence of overactive bladder (OAB) is estimated at 11.8%. Despite existing treatment options such as sacral neuromodulation, a substantial number of patients remain untreated. One potential alternative is noninvasive transcutaneous electrical stimulation. This form of stimulation does not necessitate the implantation of an electrode, thereby eliminating the need for highly skilled surgeons, expensive implantable devices, or regular hospital visits. We hypothesized that alternative neural pathways can impact bladder contraction. METHODS In this pilot study, we conducted transcutaneous electrical stimulation of the abdominal wall (T6-L1), the ear (vagus nerve), and the ankle (tibial nerve) of 3 anesthetized female Sprague-Dawley rats. Stimulation was administered within a range of 20 Hz to 20 kHz, and its impact on intravesical pressure was measured. We focused on 3 primary outcomes related to intravesical pressure: (1) the pressure change from the onset of a contraction to its peak, (2) the average duration of contraction, and (3) the number of contractions within a specified timeframe. These measurements were taken while the bladder was filled with either saline or acetic acid (serving as a model for OAB). RESULTS Transcutaneous stimulation of the abdominal wall, ear, and ankle at a frequency of 20 Hz decreased the number of bladder contractions during infusion with acetic acid. As revealed by a comparison of various stimulation frequencies of the tibial nerve during bladder infusion with acetic acid, the duration of contraction was significantly shorter during stimulation at 1 kHz and 3 kHz relative to stimulation at 20 Hz (P = 0.025 and P = 0.044, respectively). CONCLUSION The application of transcutaneous electrical stimulation to the abdominal wall, ear, and tibial nerve could provide less invasive and more cost-effective treatment options for OAB relative to percutaneous tibial nerve stimulation and sacral neuromodulation. A follow-up study involving a larger sample size is recommended.
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Affiliation(s)
- Rosa L. Coolen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dennis Frings
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Els van Asselt
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jeroen R. Scheepe
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bertil F. M. Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
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Bittorf B, Matzel K. [Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management]. Zentralbl Chir 2023; 148:228-236. [PMID: 37267977 DOI: 10.1055/a-2063-3630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Over the last two decades, sacral neuromodulation (SNM) has established its role in the treatment of functional pelvic organ-/pelvic floor disorders. Even though the mode of action is not fully understood, SNM has become the preferred surgical treatment of fecal incontinence. METHODS AND RESULTS A literature search was carried out on programming sacral neuromodulation and long-term outcomes in treating fecal incontinence and constipation.Sacral neuromodulation was found to be successful in the long term. Over the years, the spectrum of indications has expanded, and now includes patients presenting with anal sphincter lesions. The use of SNM for low anterior resection syndrome (LARS) is currently under clinical investigation. Findings of SNM for constipation are less convincing. In several randomised crossover studies, no success was demonstrated, even though it is possible that subgroups may benefit from the treatment. Currently the application cannot be recommended in general.The pulse generator programming sets the electrode configuration, amplitude, pulse frequency and pulse width. Usually pulse frequency and pulse width follow a default setting (14 Hz, 210 s), while electrode configuration and stimulation amplitude are adjusted individually to the patient need and perception of stimulation.Despite low infection rates and few electrode-/pulse generator dysfunctions, up to 65% of patients require surgical reintervention during long term follow-up - in 50% of cases because of battery depletion, which is an expected event. At least one reprogramming is necessary in about 75% of the patients during the course of the treatment, mostly because of changes in effectiveness, but rarely because of pain. Regular follow-up visits appear to be advisable. CONCLUSION Sacral neuromodulation can be considered to be a safe and effective long-term therapy of fecal incontinence. To optimise the therapeutic effect, a structured follow-up regime is advisable.
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Affiliation(s)
- Birgit Bittorf
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Klaus Matzel
- Chirurgische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
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Ibáñez-Vera AJ, Mondéjar-Ros RM, Franco-Bernal V, Molina-Torres G, Diaz-Mohedo E. Efficacy of Posterior Tibial Nerve Stimulation in the Treatment of Fecal Incontinence: A Systematic Review. J Clin Med 2022; 11:jcm11175191. [PMID: 36079119 PMCID: PMC9457187 DOI: 10.3390/jcm11175191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
Fecal incontinence is a condition that carries high social stigmatization and a determining factor in the quality of life of the person who suffers from it. Its etiology is multifactorial and treatment includes surgical and conservative measures, including stimulation of the posterior tibial nerve. The aim of this review is to determine whether posterior tibial nerve stimulation (PTNS) is more effective than other treatments in reducing episodes of fecal incontinence in adults. A systematic review of randomized clinical trials that analyzed different approaches and comparisons with other treatments in adults without neurological or metabolic diseases was carried out, analyzing, fundamentally, the reduction of episodes of fecal incontinence. In general, a reduction in fecal incontinence episodes is observed in the experimental groups compared with the control groups, although these differences are not significant in most studies. The results regarding the effectiveness of PTNS in reducing episodes of fecal incontinence compared to other treatments are not entirely conclusive, although benefits are observed regarding the stimulation of sacral roots. More well-designed studies with a long-term follow-up of the results are needed so that the recommendation of this treatment can be generalized.
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Affiliation(s)
| | | | - Vanessa Franco-Bernal
- Physiotherapy of Pelvic Floor, Campus Teatinos, University of Malaga, 29071 Malaga, Spain
| | - Guadalupe Molina-Torres
- Department of Nursing Science, Physiotherapy and Medicine, University of Almeria, 04120 Almería, Spain
- Correspondence: ; Tel.: +34-950-214601
| | - Esther Diaz-Mohedo
- Department of Physiotherapy, Faculty of Health Sciences, Campus Teatinos, University of Malaga, 29071 Malaga, Spain
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Desprez C, Grange A, Gourcerol G, Deperrois A, Garçonnet O, Leroux C, Mosni G, Poux L, Breemeersch J, Goblot C, Kepka S, Ruillon J, Vannier M, Bridoux V, Leroi AM. Is sacral nerve modulation reprogramming effective after permanent implantation for faecal incontinence? Colorectal Dis 2022; 24:754-763. [PMID: 35133694 DOI: 10.1111/codi.16083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/12/2021] [Accepted: 12/28/2021] [Indexed: 02/08/2023]
Abstract
AIM Sacral nerve modulation (SNM) is recommended as a first-line surgical therapy for patients with faecal incontinence (FI). During patient follow-up, it is recommended that stimulation settings be reprogrammed to optimize patient outcomes. The aim of the present study was to evaluate the efficacy of stimulator reprogramming in patients with an implanted SNM device to treat FI. METHOD The data from patients who received a permanent SNM implant in a single centre from January 2008 to December 2019 were retrospectively analysed. Symptoms that occurred after implantation, the stimulator settings of the SNM device and changes made at each follow-up visit were noted. The efficacy of reprogramming was determined by assessing patient satisfaction. RESULTS Of the 117 patients (male/female 4/113; mean age 59.5 ± 11.8 years) with a SNM implant for FI, 84 (72%) had at least one symptom requiring reprogramming of the stimulator, most often during the first year after implantation (p = 0.05). The most frequently reported symptoms were loss of efficacy (68.5%; p = 1 × 10-3 ) and pain (20.5%; p = 1 × 10-3 ). Reprogramming was effective 53% of the time when treating loss of efficacy and 76% of the time when treating pain. When the stimulation parameters were reprogrammed at least four consecutive times to correct a symptom, the reprogramming was less effective in treating the symptom (p = 0.02). CONCLUSION Regular follow-up of patients with SNM device implants associated with reprogramming of stimulation parameters to improve the treatment of reported symptoms would optimize the efficacy of SNM.
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Affiliation(s)
| | | | - Guillaume Gourcerol
- Department of Digestive Physiology and CIC-CRB 1404, UNIROUEN, Inserm U1073, CHU Rouen, Normandie University, Rouen, France
| | | | | | | | | | | | | | | | | | | | - Margot Vannier
- Department of Biostatistics, Rouen University Hospital, Rouen, France
| | - Valérie Bridoux
- Department of Digestive Surgery, UNIROUEN, Inserm U1073, CHU Rouen, Normandie University, Rouen, France
| | - Anne-Marie Leroi
- Department of Digestive Physiology and CIC-CRB 1404, UNIROUEN, Inserm U1073, CHU Rouen, Normandie University, Rouen, France
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Tilborghs S, Van de Borne S, Vaganée D, De Win G, De Wachter S. The Influence of Electrode Configuration Changes on the Sensory and Motor Response During (Re)Programming in Sacral Neuromodulation. Neuromodulation 2021; 25:1173-1179. [PMID: 35088741 DOI: 10.1016/j.neurom.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study aimed to assess the neurophysiological basis behind troubleshooting in sacral neuromodulation (SNM). Close follow-up of SNM patients with program parameter optimization has proven to be paramount by restoring clinical efficacy and avoiding surgical revision. MATERIALS AND METHODS A total of 34 successful SNM patients (28 overactive bladder wet, six nonobstructive urinary retention) with an implantable pulse generator were included. All possible bipolar and monopolar electrode settings were tested at sensory threshold (ST) to evaluate sensory (mapped on a perineal grid with 1 cm2 coordinates) and motor (peak-to-peak amplitude and latency of muscle action potential) responses of the pelvic floor. Pelvic floor muscle electromyography was recorded using a multiple array probe, placed intravaginally. Parametric tests were used for paired data: repeated-measures ANOVA or t-test. A nonparametric test was used for paired data: Friedman ANOVA or Wilcoxon signed rank (WSR) test; p < 0.05 was considered statistically significant. If significant, ANOVA was followed by Dunn-Bonferroni post hoc analysis. RESULTS Monopolar configurations showed significantly lower STs-1.38 ± 0.73 V vs 1.76 ± 0.89 V (paired t-test: p < 0.0001)-and presented with significantly higher peak-to-peak amplitudes-115.67 ± 79.03 μV vs 90.77 ± 80.55 μV (WSR: p = 0.005)-than bipolar configurations. When polarity was swapped, configurations with the cathode distal to the anode showed significantly lower STs, 1.73 ± 0.91 V vs 1.85 ± 0.87 V (paired t-test: p = 0.003), and mean peak-to-peak amplitudes, 81.32 ± 72.82 μV vs 100.21 ± 90.22 μV (WSR: p = 0.0001). Cathodal changes resulted in more changes in sensory responses than anodal changes (χ2 test: p = 0.044). In cathodal changes only, peak-to-peak amplitudes were significantly higher when the distance between electrodes was maximally spread (WSR: p = 0.046). CONCLUSIONS From a neurophysiological point of view, monopolar configurations stimulated more motor nerve fibers at lower STs, therefore providing more therapeutic efficiency. Swapping polarity or changing the position of the cathode led to different sensory and motor responses, serving as potential reprogramming options.
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Affiliation(s)
- Sam Tilborghs
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Antwerp, Belgium
| | - Sigrid Van de Borne
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Antwerp, Belgium
| | - Donald Vaganée
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Antwerp, Belgium
| | - Gunter De Win
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Antwerp, Belgium
| | - Stefan De Wachter
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Anatomy, University of Antwerp, Antwerp, Belgium.
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Dudding TC, Lehur PA, Sørensen M, Engelberg S, Bertapelle MP, Chartier-Kastler E, Everaert K, Van Kerrebroeck P, Knowles CH, Lundby L, Matzel KE, Muñoz-Duyos A, Rydningen MB, de Wachter S. Reprogramming Sacral Neuromodulation for Sub-Optimal Outcomes: Evidence and Recommendations for Clinical Practice. Neuromodulation 2021; 24:1247-1257. [PMID: 34264542 PMCID: PMC9291141 DOI: 10.1111/ner.13494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 06/07/2021] [Indexed: 12/11/2022]
Abstract
Objectives In some patients treated for urinary or fecal incontinence with sacral neuromodulation (SNM) persistence of symptoms, a reduction in efficacy or adverse effects of stimulation can occur. In such situations, further programming of the SNM device can help resolve problems. Infrequently hardware failure is detected. This article aims to provide practical guidance to solve sub‐optimal outcomes (troubleshooting) occurring in the course of SNM therapy. Materials and Methods A systematic literature review was performed. Collective clinical experience from an expert multidisciplinary group was used to form opinion where evidence was lacking. Results Circumstances in which reprogramming is required are described. Actions to undertake include changes of electrode configuration, stimulation amplitude, pulse frequency, and pulse width. Guidance in case of loss of efficacy and adverse effects of stimulation, developed by a group of European experts, is presented. In addition, various hardware failure scenarios and their management are described. Conclusions Reprogramming aims to further improve patient symptoms or ensure a comfortable delivery of the therapy. Initial changes of electrode configuration and adjustment of stimulation parameters can be performed at home to avoid unnecessary hospital visits. A logical and stepwise approach to reprogramming can improve the outcome of therapy and restore patient satisfaction.
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Affiliation(s)
- Thomas C Dudding
- Pelvic Floor Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul A Lehur
- Coloproctology Unit, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Michael Sørensen
- Department of Surgical and Medical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark
| | | | - Maria Paola Bertapelle
- Neurourology Maria Adelaide Hospital, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | | | - Karel Everaert
- Department of Urology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Philip Van Kerrebroeck
- Pelvic Care Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London & Barts Health NHS Trust, London, UK
| | - Lilli Lundby
- Pelvic Floor Unit, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus E Matzel
- Chirurgische Klinik, Sektion Koloproktologie, Universität Erlangen, Erlangen, Germany
| | - Arantxa Muñoz-Duyos
- Coloproctology Unit, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Spain
| | - Mona B Rydningen
- Norwegian National Advisory Unit on Incontinence and Pelvic Floor Health, University Hospital of North Norway, Tromso, Norway
| | - Stefan de Wachter
- Department of Urology, Faculty of Health Sciences, University Hospital Antwerpen, University Antwerpen, Edegem, Belgium
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