Sacral Nerve Root Stimulation Research Articles

Acute Autonomic Nervous System Response to Direct Sacral Nerve Root Stimulation in Lower Urinary Tract Dysfunction: A New Approach to Understand the Mechanism of Action of Sacral Nerve Modulation.

Our goal was to assess acute autonomic nervous system (ANS) response to direct sacral nerve root (SNR) stimulation in the context of lower urinary tract dysfunction. In this retrospective monocentric study, patients undergoing 2-stage sacral nerve modulation for overactive bladder, nonobstructive urinary retention, or chronic bladder pain syndrome between March 2022 and June 2023 were analyzed. A standardized stimulation protocol was applied during the lead implantation, each of the 4 contact points being sequentially stimulated at the amplitude required to elicit anal motor response. Stimulations were labeled as StimA, StimB, StimC, and StimD, ordered by ascending order of minimum amplitude required for anal motor response. Heart rate variability parameters were collected using PhysioDoloris Monitor, and computed through the time-domain (standard deviation of normal-to-normal intervals [SDNN], root mean square of successive differences), the frequency-domain (low frequency, high frequency) and the graphical (Analgesia Nociception Index [ANI]) methods. Fifty patients were analyzed, including 35 females. Twelve patients had an underlying neurological disease. Efficacy was deemed achieved in 54% of patients. SDNN variability significantly increased during StimA to StimC, while maximum SDNN significantly increased only during StimA. ANI variability significantly increased during all 4 stimulations, while maximum ANI significantly increased only during StimA. Direct stimulation of SNR is responsible for a significant increase in ANS and relative parasympathetic nervous system activity, with a greater effect observed when the stimulation was delivered closer to the SNR. These results shed light on potential mechanisms underlying sacral nerve modulation, particularly regarding the treatment of ANS dysregulation in lower urinary tract dysfunction.

Efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na on neurogenic bladder after spinal cord injury: preliminary short-term results.

Neurogenic bladder (NGB) is a serious complication after spinal cord injury (SCI), a destructive neurological disease. This study focused on exploring the efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na in treating NGB after SCI. One hundred patients with NGB after SCI were studied, and intermittent clean catheterization was performed with a water intake program, and patients were grouped into four groups by the random number table method: general treatment group, Tui-na group, magnetic stimulation group, and combined treatment group. A series of relevant factors (voiding diary, urodynamics, and quality of life scores) and clinical efficacy of patients in the four groups before and after treatment were observed. The magnetic stimulation of sacral nerve roots alone, Tui-na alone, and the combination of both were all effective in improving bladder function and quality of life in patients with NGB after SCI, including improvements in voiding frequency, single urine output, maximum urine output, residual urine output, bladder volume and quality of life scores in patients with NGB after SCI. The efficacy of the magnetic stimulation of sacral nerve roots combined with Tui-na was better than that of the magnetic stimulation of sacral nerve roots alone and the Tui-na alone. This research demonstrates that the magnetic stimulation of sacral nerve roots combined with Tui-na treatment could effectively improve the urinary system and the quality of life of patients with NGB after SCI, which is worthy of clinical promotion and application.

V12-02 SACRAL NEUROMODULATOR OPTIMAL LEAD PLACEMENT TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V12-02 SACRAL NEUROMODULATOR OPTIMAL LEAD PLACEMENT TECHNIQUE Sabrina Stair, Una Lee, and Alvaro Lucioni Sabrina StairSabrina Stair More articles by this author , Una LeeUna Lee More articles by this author , and Alvaro LucioniAlvaro Lucioni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sacral neuromodulation is an FDA approved treatment for overactive bladder. Efficacy depends on correct lead placement. The optimal lead placement technique uses real-time fluorosocpy to place the the sacral neurostimulator lead into the most superior and medial aspect of the S3 foramen. Here, we seek to provide guidance on using the optimal lead placement technique. METHODS: Using a recent sacral neurostimulator implant as an example case, we outline the critical steps and key teaching points for sacral neurostimulator implant. RESULTS: Optimal lead placement technique is demonstrated within the video. The patient is positioned in swimmer's position. Real time fluoroscopy is used to identify the most medial aspect of the sacral foramina, and then to guide the entry point of the introducer needle such that it is parallel to the bone seam. This lead placement maximizes stimulation of S3 sacral nerve roots while minimizing stimulation of S2 and S4 nerve roots. In an ideally placed lead, bellows response occurs before toe response. The lead is tested prior to full implant. CONCLUSIONS: Correct patient positioning and knowledge of target anatomy is key the optimal lead placement technique. Optimal lead placement technique uses real time imaging to place lead precisely, leading to improved clinical outcomes. This also increases the efficiency of lead placement, leading to faster operative times and increased cost-savings. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1065 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sabrina Stair More articles by this author Una Lee More articles by this author Alvaro Lucioni More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical effect of repetitive functional magnetic stimulation of sacral nerve roots on urinary retention after spinal cord injury

Urinary retention is a serious complication of spinal cord injury. This study examined whether repetitive functional magnetic stimulation (rFMS) applied over the sacral nerve root affected bladder function or mood in patients with urinary retention after spinal cord injury. This single-center, case-control study included 32 patients with detrusor flaccid neurogenic bladder after spinal cord injury, who were randomly assigned to rFMS (n = 11), electroacupuncture pudinal nerve stimulation (EAPNS; n = 11), and control groups (n = 10). All groups received routine bladder function training. The S3 sacral nerve was stimulated at a frequency of 5 Hz, once per day for 4 consecutive weeks in the rFMS group. Electroacupuncture stimulation of the pudendal nerve was performed once daily for 4 weeks in the EAPNS group. The control group received bladder function retraining alone. After the 4-week treatment, there were significant improvements in all three groups (P < 0.05). Primary bladder sensation, maximum bladder volume, maximum bladder pressure, and residual urine were significantly higher in the rFMS group than in the other two groups (P < 0.05). Primary bladder sensation, maximum bladder volume, residual urine, and urinary leukocyte count were significantly different between the EAPNS and control groups (P < 0.05). The rFMS group had significantly lower scores in the self-rated anxiety scale and self-rated depression scale compared with those of the other two groups. The quality of life score significantly increased in all three groups. rFMS is conducive to the recovery of neurogenic function in patients with urinary retention. This study provides a scientific basis for the clinical application and promotion of rFMS.

Defecation induced by stimulation of sacral S2 spinal root in cats.

The aim of this study was to determine whether stimulation of sacral spinal nerve roots can induce defecation in cats. In anesthetized cats, bipolar hook electrodes were placed on the S1-S3 dorsal and/or ventral roots. Stimulus pulses (1-50 Hz, 0.2 ms) were applied to an individual S1-S3 root to induce proximal/distal colon contractions and defecation. Balloon catheters were inserted into the proximal and distal colon to measure contraction pressure. Glass marbles were inserted into the rectum to demonstrate defecation by videotaping the elimination of marbles. Stimulation of the S2 ventral root at 7 Hz induced significantly (P < 0.05) larger contractions (32 ± 9 cmH2O) in both proximal and distal colon than stimulation of the S1 or S3 ventral root. Intermittent (5 times) stimulation (1 min on and 1 min off) of both dorsal and ventral S2 roots at 7 Hz produced reproducible colon contractions without fatigue, whereas continuous stimulation of 5-min duration caused significant fatigue in colon contractions. Stimulation (7 Hz) of both dorsal and ventral S2 roots together successfully induced defecation that eliminated 1 or 2 marbles from the rectum. This study indicates the possibility to develop a novel neuromodulation device to restore defecation function after spinal cord injury using a minimally invasive surgical approach to insert a lead electrode via the sacral foramen to stimulate a sacral spinal root.NEW & NOTEWORTHY This study in cats determined the optimal stimulation parameters and the spinal segment for sacral spinal root stimulation to induce colon contraction. The results have significant implications for design of a novel neuromodulation device to restore defecation function after spinal cord injury (SCI) and for optimizing sacral neuromodulation parameters to treat non-SCI people with chronic constipation.

Sacral nerve stimulating on intestinal mucosal immune barrier function of rats with acute complete spinal cord injury

Objective: To study the effects of sacral nerve root stimulation on intestinal mucosal immune barrier function in rat with acute complete spinal cord injury(SCI). Methods: Fifty-six Wistar rats were divided into Sham group(SG n=8), control group(CG 24 、 48、 72 h,n=8), and experimental group(EG 24、 48、 72 h,n=8). In CG and EG, according to Fehlings'method,we transected the spinal cord by the aneurysm clip and implanted electrodes into the third sacral foramina on the right side.We stimulated in intensity 4 V,the frequency of 15 Hz,and the pulse of 210 μs.The stimulation period was 2 hours,with 10 minutes stimulation and 10 minutes rest intermittently,twice a day at 8:00-10:00 am and 6:00-8:00 pm. The intestinal morphology was observed under light microscope and electron microscope. The protein expression levels of A20,NOD2,and CD68 by Western blot . Results: ① SCI caused impaired intestinal epithelial barrier function. The intestinal mucosa appeared different degree of damage in CG group; cell-cell connections between intestinal epithelial cells were destroyed; The escherichia coli and other antigen translocated through the injured epithelial cell , M cells, and the leakage to the lamina propria of intestinal villi, which were improved in EG after stimulation.② The expression of A20 in EG was increased ,which had statistical differences between CG or SG(P＜0.01); the expression ofA20 in CG was decreased, which had statistical differences between SG(P＜0.01).The expression of NOD2 in CG was increased, which had statistical differences between SG(24 h,72 h P＜0.05; 48 h P＜0.01);The expression of NOD2 in EG (48 h ,72 h)was decreased, which had statistical differences between CG(48 h P＜0.01,72 h P＜0.05). The expression of NOD2 in EG had no statistical differences between SG. The expression of CD68 in CG was increased,which had statistical differences between SG or EG(P＜0.01).The expression of CD68 in EG was increased in 24 h and 48 h groups ,which had statistical differences between SG(P＜0.01),but had no statistical differences in 72 h group. Conclusion: Sacral nerve root 3 electrostimulation can rehabilitate the peristalsis of intestine,decrease bacterial amount,reduce inflammatory response, enhance endogenous protection, protect the intestinal mucosal immune barrier function.

Blood perfusion changes during sacral nerve root stimulation versus surface gluteus electrical stimulation on in seated spinal cord injury

ABSTRACTThe objective of this article is to examine dynamic changes of ischial blood perfusion during sacral nerve root stimulation against surface functional electrical stimulation (FES). Fourteen adults with suprasacral spinal cord injury (SCI) were recruited. The gluteal maximus was activated by surface FES or stimulating sacral nerve roots by functional magnetic stimulation (FMS) or a sacral anterior root stimulator implant (SARS). Ischial skin index of hemoglobin (IHB) and oxygenation (IOX) was measured.Skin blood perfusion was significantly higher during FMS than the baseline (IHB 1.05 ± 0.21 before vs.1.08 ± 0.02 during stimulation, p = 0.03; IOX 0.18 ± 0.21 before vs. 0.46 ± 0.30, p = 0.01 during stimulation). Similarly, when using the SARS implant, we also observed blood perfusion significantly increased (IHB 1.01 ± 0.02 before vs.1.07 ± 0.02 during stimulation, p = 0.003; IOX 0.79 ± 0.81 before vs. 2.2 ± 1.21 during stimulation, p = 0.036). Among four participants who completed both the FMS and FES studies, the magnitude of increase in both parameters was significantly higher during FMS. This study demonstrates sacral nerve root stimulation confer better benefit on blood perfusion than applying traditional FES in SCI population.

Extracorporeal Stimulation of Sacral Nerve Roots for Observation of Pelvic Autonomic Nerve Integrity: Description of a Novel Methodological Setup.

Neurophysiologic monitoring can improve autonomic nerve sparing during critical phases of rectal cancer surgery. To develop a system for extracorporeal stimulation of sacral nerve roots. Dedicated software controlled a ten-electrode stimulation array by switching between different electrode configurations and current levels. A built-in impedance and current level measurement assessed the effectiveness of current injection. Intra-anal surface electromyography (sEMG) informed on targeting the sacral nerve roots. All tests were performed on five pig specimens. During switching between electrode configurations, the system delivered 100% of the set current (25mA, 30Hz, 200μs cathodic pulses) in 93% of 250 stimulation trains across all specimens. The impedance measured between single stimulation array contacts and corresponding anodes across all electrode configurations and specimens equaled 3.7±2.5kΩ. The intra-anal sEMG recorded a signal amplitude increase as previously observed in the literature. When the stimulation amplitude was tested in the range from 1 to 21mA using the interconnected contacts of the stimulation array and the intra-anal anode, the impedance remained below 250Ω and the system delivered 100% of the set current in all cases. Intra-anal sEMG showed an amplitude increase for current levels exceeding 6mA. The system delivered stable electric current, which was proved by built-in impedance and current level measurements. Intra-anal sEMG confirmed the ability to target the branches of the autonomous nervous system originating from the sacral nerve roots. Stimulation outside of the operative field during rectal cancer surgery is feasible and may improve the practicality of pelvic intraoperative neuromonitoring.

AB314. SPR-41 Localization of neuromuscular nicotinic receptors in the functionally reinnervated canine bladder after prolonged decentralization

ObjectiveWe previously found that intravenous succinylcholine, a depolarizing neuromuscular nicotinic receptors blocker, prevents bladder contractions induced by new neuronal pathways established by nerve transfer in decentralized dogs. We studied the detrusor pressure response in vivo and contractile response of bladder smooth muscle strips in vitro from sham, decentralized and reinnervated animals to localize the neuromuscular nicotinic receptors involved.MethodsThree groups of female mongrel hound dogs were used: sham (N=4), 12-month decentralized (N=3) and 6-month reinnervated (N=3). Decentralization was created by bilateral transection of all spinal roots caudal to L7, including the dorsal roots of L7 and the hypogastric nerves. Reinnervation was created by bilateral transfer of the obturator nerve to anterior vesical branches of the pelvic nerve. Two-way ANOVAs and Sidak post-hoc tests were used to determine group differences.ResultsIn reinnervated dogs, blockade of neuromuscular nicotinic receptor with intravenous injections of the competitive antagonist atracurium besylate significantly reduced the increase in detrusor pressure induced by electrical stimulation of the transferred obturator nerve (L1 or L2). Atracurium did not block the increase in pressure induced by stimulation of sacral nerve roots in sham-operated controls. In vitro, neither the competitive neuromuscular nicotinic receptor antagonist d-tubocurarine nor the ganglionic antagonist hexamethonium inhibited electric field stimulation (EFS)-induced contractions of reinnervated or sham-operated control bladder strips. No contractile response was elicited in the presence of 1 µM tetrodotoxin (TTX) across groups. Similarly, EFS-evoked contractions were strongly reduced by 10 µM alpha, beta-methylene ATP (α,β-mATP) and 1 µM atropine in all groups relative to the vehicle (water).ConclusionsIn vivo blockade of nerve-evoked bladder pressure by atracurium in the reinnervated, but not sham operated controls, suggests that neuromuscular nicotinic receptors become involved in bladder contractions induced by the new neuronal pathway. Because d-tubocurarine did not block in vitro contractions induced by EFS in the reinnervated bladders, the neuromuscular nicotinic receptors involved in the new neuronal pathway must not be located in the bladder muscle or intramural ganglia and therefore, are likely in preganglionic neurons. TTX blockade validates that EFS-induced contractions at all frequencies were nerve-evoked. Both muscarinic and purinergic components contributed similarly to neurotransmission based on response to blockade of nerve evoked muscle strip contractions with a combination of atropine and α,β-mATP.Funding Source(s)NIH-NINDS NS070267

Pressure Changes Under the Ischial Tuberosities During Gluteal Neuromuscular Stimulation in Spinal Cord Injury: A Comparison of Sacral Nerve Root Stimulation With Surface Functional Electrical Stimulation

ObjectiveTo compare the magnitude of interface pressure changes during gluteal maximus contraction by stimulating sacral nerve roots with surface electrical stimulations in patients with spinal cord injuries (SCIs). DesignPilot interventional study. SettingSpinal injury research laboratory. ParticipantsAdults (N=18) with suprasacral complete SCI. InterventionsSacral nerve root stimulation (SNRS) via a functional magnetic stimulator (FMS) or a sacral anterior root stimulator (SARS) implant; and surface functional electrical stimulation (FES). Main Outcome MeasuresInterface pressure under the ischial tuberosity (IT) defined as peak pressure, gradient at peak pressure, and average pressure. ResultsWith optimal FMS, a 29% average reduction of IT peak pressure was achieved during FMS (mean ± SD: 160.1±24.3mmHg at rest vs 114.7±18.0mmHg during FMS, t5=6.3, P=.002). A 30% average reduction of peak pressure during stimulation via an SARS implant (143.2±31.7mmHg at rest vs 98.5±21.5mmHg during SARS, t5=4.4, P=.007) and a 22% average decrease of IT peak pressure during FES stimulation (153.7±34.8mmHg at rest vs 120.5±26.1mmHg during FES, t5=5.3, P=.003) were obtained. In 4 participants who completed both the FMS and FES studies, the percentage of peak pressure reduction with FMS was slightly greater than with FES (mean difference, 7.8%; 95% confidence interval, 1.6%–14.0; P=.04). ConclusionsSNRS or surface FES can induce sufficient gluteus maximus contraction and significantly reduce ischial pressure. SNRS via an SARS implant may be more convenient and efficient for frequently activating the gluteus maximus.

Can Electrical Stimulation Therapy Be Helpful for Patients With Chronic Constipation Refractory to Biofeedback Therapy?

Adequate pelvic floor retraining by biofeedback therapy improves symptoms in more than 70% of patients with functional defecatory disorders.1 If symptoms persist in spite of an adequate trial of biofeedback therapy, anorectal tests and colonic transit should be reevaluated.2 After reassessment of these tests, adequate treatments can be applied according to results of the tests. In patients with refractory pelvic floor dysfunction, suppositories such as anal application of nitric oxide cream or enemas rather than oral laxatives alone should be considered.2 If therapeutic effect is unsatisfactory in patients with refractory pelvic floor dysfunction after retrial of biofeedback therapy with suppositories or enemas, other treatment options are limited. One possible treatment option in these patients is neuromodulation therapy involving modulation of the extrinsic neural control of the pelvic floor through the sacral nerve root stimulation or direct stimulation of the organ, such as the anal canal.3 Early reports showed that anal canal electrical stimulation was associated with improving symptoms of constipation as well as reducing rectal sensory thresholds in patients with rectal hyposensitivity.4,5 In the issue of this journal, Jung et al6 reported 5-year clinical experience of electrical stimulation therapy in patients with chronic functional constipation refractory to biofeedback therapy. According to their research, 59.2% (87/147) of patients refractory to biofeedback therapy improved after anal canal electrical stimulation. The 147 patients consisted of 88 patients that were refractory to biofeedback therapy without rectal hyposensitivity and 59 that had rectal hyposensitivity. Interestingly, the response rate was higher in patients without rectal hyposensitivity than in those with rectal hyposensitivity. The reason is unclear why patients without rectal hyposensitivity showed a higher response rate. Rectal hyposensitivity was first described in 1951,7 and is defined as diminished sensation of the rectum to all kinds of stimuli.3 In 1993, Gladman et al8 reported 23% of patients with intractable constipation, 10% of patients with fecal incontinence and 27% of patients with incontinence associated with constipation had rectal hyposensivity. It is not clear whether rectal hyposensitivity is one of the causes for constipation and fecal incontinence or is a manifestation of these disorders. Several studies show that normalizaton of rectal hyposensitivity using a variety of interventions such as biofeedback therapy, neuromodulation, or surgery was associated with clinical improvement.9-11 However, there is no established treatment for constipation associated with rectal hyposensitivity. In the issue of this journal, Jung et al6 showed that clinical symptoms and some rectal sensory parameters improved after anal canal electrical stimulation in 51% of patients with constipation and rectal hyposensitivity refractory to biofeedback therapy. Anal canal electrical stimulation technique is relatively simple, less invasive than sacral nerve stimulation, and can be widely used in clinical practice. However, there are several limitations in this study.4 This is a single center, retrospective study, which cannot provide a proven conclusion. Further well designed prospective studies that include strict criteria of patient inclusion, timing of analysis for efficacy, establishment of standard procedure protocol and long-term results are needed to identify patients who will most likely benefit from anal canal electrical stimulation. In conclusion, electrical stimulation therapy can be helpful in some patients with functional constipation refractory to biofeedback therapy. However, further studies are needed to elucidate mechanism of electrical stimulation therapy for improving symptoms in patients without rectal hyposensitivity, and to clarify predictive factors associated with beneficial effects.

290 THE SKELETAL NEUROMUSCULAR JUNCTION NICOTINIC RECEPTOR ANTAGONIST SUCCINYL CHOLINE BLOCKS BLADDER CONTRACTIONS INDUCED BY FUNCTIONAL ELECTRICAL STIMULATION OF A NEW NEURONAL PATHWAY CREATED BY REINNERVATION WITH GENITOFEMORAL TO PELVIC NERVE TRANSFER

You have accessJournal of UrologyBladder and Urethra: Anatomy, Physiology and Pharmacology (I)1 Apr 2013290 THE SKELETAL NEUROMUSCULAR JUNCTION NICOTINIC RECEPTOR ANTAGONIST SUCCINYL CHOLINE BLOCKS BLADDER CONTRACTIONS INDUCED BY FUNCTIONAL ELECTRICAL STIMULATION OF A NEW NEURONAL PATHWAY CREATED BY REINNERVATION WITH GENITOFEMORAL TO PELVIC NERVE TRANSFER Michael Ruggieri, Sandra Gomez, Alan Braverman, Vicky Massicotte, and Mary Barbe Michael RuggieriMichael Ruggieri Philadelphia, PA More articles by this author , Sandra GomezSandra Gomez Philadelphia, PA More articles by this author , Alan BravermanAlan Braverman Philadelphia, PA More articles by this author , Vicky MassicotteVicky Massicotte Philadelphia, PA More articles by this author , and Mary BarbeMary Barbe Philadelphia, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1674AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Following bladder denervation by transection of sacral spinal cord roots, genitofemoral nerve (GFN) transfer to vesical branches of pelvic nerve (PN) reinnervates the canine bladder because functional electrical stimulation of the transferred GFN induces bladder contraction. The new pathway reinnervates both intramural bladder ganglia as well as detrusor smooth muscle cells directly which are not normally innervated by parasympathetic spinal cord neurons. This study investigates whether the reinnervated neuronal pathway mediates contraction by the same neurotransmitter and receptor mechanisms as the original pathway. METHODS After bladder, urethral sphincter and anal sphincter denervation in 4 female canines, GFN were transferred bilaterally to PN and implanted with nerve cuff electrodes interfaced with radiofrequency micro-stimulators (RFMS). The effect of GFN stimulation on bladder pressure was determined before and after neuromuscular blockade with succinyl choline (SC) 3-6 months after reinnervation. The effects of SC on bladder contractions induced by intraoperative electrical stimulation of sacral spinal nerve roots was determined in 1 normal control and by stimulation of vesical branches of the pelvic nerve in 3 sham operated controls. RESULTS RFMS functional electrical stimulation of the GFN induced bladder contractions in 7 of 8 transferred nerves causing pressure increases of 11.2±4.1 cm H2O that were completely blocked with succinyl choline. Stimulation of the sacral nerve roots in the normal control induced bladder, urethral sphincter and anal sphincter pressure. The urethral and anal sphincter pressures were completely blocked with succinyl choline but the bladder pressure increases induced by sacral root stimulation in the normal control or pelvic nerve stimulation in the sham operate controls were not affected (13.5±3.3 vs 11.4±3.1 cm H2O). CONCLUSIONS This study demonstrates plasticity in the nicotinic receptors involved in nerve evoked bladder contractions induced by bladder reinnervation. GF to PN transfer results in the emergence of succinyl choline sensitive nicotinic receptors in this pathway that normally mediate cholinergic contractions at the neuromuscular junction of skeletal but not smooth muscle. These new nicotinic receptors may mediate contractions of the reinnervated bladder at the intramural ganglia cells or the newly reinnervated smooth muscle cells. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e118 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Ruggieri Philadelphia, PA More articles by this author Sandra Gomez Philadelphia, PA More articles by this author Alan Braverman Philadelphia, PA More articles by this author Vicky Massicotte Philadelphia, PA More articles by this author Mary Barbe Philadelphia, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Sacral Nerve Stimulation Through the Sacral Hiatus

Sacral nerve stimulation through the retrograde approach has been used for peroneal or irritable bowel syndrome through the retrograde approach. However, several reasons, lead could not be advanced down ward. In this case, anterograde sacral nerve stimulation through the sacral hiatus could be used. The aim of this report is to present of technique of sacral nerve root stimulation through the sacral hiatus approach.

Association Between Stimulation Parameters and Loss of Efficacy of Selective Sacral Nerve Root Stimulation

This study sought to determine the association between stimulation parameters at the time of implantation and loss of efficacy on long-term follow-up. Between 2002 and 2007, 143 patients underwent selective sacral nerve root stimulation at our center as a treatment for voiding dysfunction. Nine patients were explanted because of loss of efficacy. The patients' charts were retrospectively reviewed and compared with those of a well-matched group of 12 positive responders. A t-test was used to determine the differences in voiding parameters and stimulation parameters between both groups (at p < 0.05). The baseline amplitude levels in the loss of efficacy group were significantly higher than those of the control group (2.08 ± 0.35 V vs. 1.27 ± 0.25 V) (p= 0.008). The impedance levels were significantly higher in the loss of efficacy group than the control (1032.4 ± 181 Ω vs. 590 ± 44.6 Ω) (p= 0.025). High stimulation parameters at the time of implantation were associated with loss of efficacy at the long-term follow-up.

Repetitive Lumbosacral Nerve Magnetic Stimulation Improves Bladder Dysfunction Due to Lumbosacral Nerve Injury

Background. Rapid rate magnetic stimulation of human sacral nerve roots can reduce stress incontinence. Objective. To test stimulation for urgency incontinence due to lumbosacral plexopathy. Methods. The authors studied patients with intractable neurogenic urinary dysfunction due to lumbosacral nerve injuries. Eligible patients were randomized to receive either real or sham repetitive lumbosacral magnetic stimulation (rLMS; 15 Hz with a total of 1500 pulses/session) for 10 sessions. Evaluation was performed before starting treatment, immediately after the 5th and 10th treatment session, and 1 month later, using rating scales to score urinary dysfunction and a visual analogue scale (VAS) to assess lower back pain. Posterior tibial nerve F-wave and H-reflexes were tested before and after treatment. Results. Both treatment and control groups were comparable for baseline characters and sphincteric disturbances. The mean number of voids and incontinence per 24 hours was significantly reduced in patients who received rLMS. The improvement was maintained 1 month after the end of treatment. Patients receiving real-rLMS also reported an improvement in VAS ratings. Improvement in F-wave and H-reflex latencies after real stimulation (P = .002 and P = .036, respectively) was found as well. Conclusion. rLMS at 15 Hz may improve urinary dysfunction secondary to lumbosacral nerve injury. Further trials can determine the profile of patients who may benefit and optimal stimulation parameters.

Sacral Nerve Stimulation: A Novel Treatment of Chronic Anal Fissure

The purpose of this pilot study of 5 patients was to test the feasibility of a new treatment approach for chronic anal fissure utilizing minimally invasive sacral nerve stimulation before designing and conducting a larger prospective controlled study. The patients underwent uneventful placement of one temporary 8-electrode Octad lead for sacral nerve root stimulation. Stimulation was conducted for 20 minutes 3 times per day. The lead was removed after 3 weeks of stimulation. The patients experienced an immediate improvement in perineal pain after the initiation of sacral nerve stimulation. The pain relief effect lasted 10 to 12 hours, so stimulation was conducted for short episodes to ensure patient comfort and to extend the battery life of the external neurostimulator. For all patients, the chronic anal fissure healed by the end of the third week of temporary sacral nerve stimulation. There was no recurrence of anal fissure 1 year after treatment in all of the study participants. Sacral nerve stimulation offers an effective alternative treatment option for chronic anal fissure in patients who chose not to pursue more invasive surgical interventions.

New selective endoscopic sacral nerve root stimulation - an advance in the treatment of fecal incontinence

Fecal incontinence (FI) is a major part of illness and physical discomfort in the general population. Since the 1990s, sacral nerve stimulation has been well established in the treatment of neurogenic FI. The precise placement of the electrode is crucial for the success of the procedure. Eighty percent of the patients benefit from permanent treatment, but in 10-20% of the patients tested electrode placement proves impossible due to anatomical variations of the sacral foramina. In this study, we describe the technical requirements and a new method of electrode placement with reference to the anatomical (bone) landmarks in an animal model. With a small endoscope (Verres needle), we accessed the perirectal space to identify the nervous structures. A stimulated sphincter EMG was obtained for the experimental animals and muscle action potential (MAP/M-wave), latency time [ms], and the amplitude of the motor response [μV] were recorded. Electrodes were placed, the animals killed and dissected leaving the pelvic cavity untouched. The specimens were examined in a magnetic resonance scanner and in a multi-slice computed tomography scanner to detect the electrode material and possible surgical complications. After that the specimens were dissected. In all eight cases in the four animals tested, we were able to stimulate the sacral nerve as demonstrated by the EMG findings. No major surgical complications were observed for the procedure. Endoscopic sacral nerve root stimulation is a safe and effective method for delivering stimulation material in the pelvis of the sheep. It is a promising procedure to be tested in humans.

Overview of Evidence for Contemporary Management of Lower Urinary Tract Symptoms Presumed Due to Benign Prostatic Hyperplasia in Males

In the management of patients suffering from lower urinary tract symptoms (LUTS), current therapeutic strategies are watchful waiting, conservative therapy, pharmacologic therapy, and surgery. Pharmacologic therapy should be offered only if conservative management has failed or is inappropriate. It includes 5α-reductase inhibitors (5-ARIs), which are effective in controlling symptoms, shrink prostate volume, and decrease the risk of acute urinary retention and surgery after 12 mo of therapy; α-blockers, which are more effective in controlling LUTS than placebo and the 5-ARIs and are effective also in aborting acute retention; and anticholinergic drugs, which act on storage LUTS. The combination of 5-ARIs and α-blockers is more effective than monotherapy in the long term but also is more expensive and causes more side effects. Anticholinergics should be offered only in combination with an α-blocker to patients with storage LUTS suggestive of overactive bladder who do not have a significantly elevated postvoiding residual urine volume. Surgical interventions should be offered only to men with bothersome or severe symptoms. Standard surgery for voiding symptoms presumed due to secondary bladder outflow obstruction secondary to benign prostatic enlargement includes transurethral resection of the prostate, transurethral vapourisation of the prostate, or holmium laser excision of the prostate. Transurethral incision of the prostate is an alternative for men with a small prostate, and open prostatectomy is an alternative for men with larger prostates. Minimally invasive treatments have been shown to have equivalent efficacy based on the existing evidence. Surgical interventions for recalcitrant storage symptoms include the standard surgical therapies of botulinum toxin, implanted sacral nerve root stimulation, cystoplasty, and, rarely, urinary diversion and implantation of an artificial sphincter to manage stress urinary incontinence.

Randomized Trial of Percutaneous Tibial Nerve Stimulation Versus Extended-Release Tolterodine: Results From the Overactive Bladder Innovative Therapy Trial

The Overactive Bladder Innovative Therapy trial was a randomized, multicenter, controlled study that compared the effectiveness of percutaneous tibial nerve stimulation to extended-release tolterodine. The reduction in overactive bladder symptoms along with global response assessments was evaluated. A total of 100 adults with urinary frequency were randomized 1:1 to 12 weeks of treatment with weekly percutaneous tibial nerve stimulation or to 4 mg daily extended-release tolterodine. Voiding diaries and an overactive bladder questionnaire were completed at baseline and at the end of therapy to compare 24-hour voiding frequency, urinary urge incontinence episodes, voids causing waking, volume voided, urgency episodes and quality of life indices. Global response assessments were completed by subjects and investigators after 12 weeks of therapy. The global response assessment demonstrated that subject assessment of overactive bladder symptoms compared to baseline was statistically significant in the percutaneous tibial nerve stimulation arm with 79.5% reporting cure or improvement compared to 54.8% of subjects on tolterodine (p = 0.01). Assessments by investigators were similar but did not reach statistical significance (p = 0.05). After 12 weeks of therapy objective measures improved similarly in both groups for reductions in urinary frequency, urge urinary incontinence episodes, urge severity and nighttime voids, as well as for improvement in voided volume. There were no serious adverse events or device malfunctions. This multicenter, randomized trial demonstrates that percutaneous tibial nerve stimulation is safe with statistically significant improvements in patient assessment of overactive bladder symptoms, and with objective effectiveness comparable to that of pharmacotherapy. Percutaneous tibial nerve stimulation may be considered a clinically significant alternative therapy for overactive bladder.

Update on neuromodulation for frequency, urgency, retention, and neurogenic voiding dysfunction

Neuromodulation offers a reversible and minimally invasive treatment for patients with urge incontinence, urinary urgency-frequency syndrome, and nonobstructive urinary retention that is refractory to conservative therapy. Despite many advances in the techniques of neuromodulation, the mechanism of neuromodulation of bladder function remains undefined. It seems to involve activation of peripheral afferent nerves and may influence bladder function in part through a supraspinal mechanism. Neuromodulation of bladder function is clinically available via US Food and Drug Administration-approved techniques of sacral nerve root stimulation and posterior tibial nerve stimulation. Sacral neuromodulation has emerged as the preferred treatment for symptoms that are refractory to conservative management. Few predictors of response to sacral neuromodulation have been identified. Alternative, more peripheral forms of neuromodulation for bladder dysfunction such as pudendal and dorsal genital nerve stimulation are being studied.