Sacral Neuromodulation Treatment Research Articles

Outcomes of sequential third-line therapies in patients with refractory overactive bladder.

Sacral neuromodulation (SNM) and onabotulinumtoxinA (BoNTA) injection are third-line therapies for overactive bladder (OAB). Although the efficacy of each third-line treatment has been well established in clinical trials, there is far less information about performing one third-line therapy after the other. Our aim is thus to investigate the outcomes of post-SNM BoNTA and post-BoNTA SNM as "second" third-line treatments. We retrospectively reviewed all OAB patients who had both SNM and BoNTA between 2013 and 2022. The primary endpoint was the response rates (>50% improvements) of the second third-line treatments. Secondary endpoints were the proportion of the patients who achieved total dry, the duration of treatments of patients who had significant responses, and risk factors that are associated with treatment response or duration of treatments. A total of 172 patients had two third-line therapies. There were 104 patients who had post-SNM BoNTA and 68 patients who had post-BoNTA SNM. In the post-SNM BoNTA group, 62.5% (65/104) had significant responses after BoNTA treatment. In the post-BoNTA SNM group, 61.8% (44/68) had significant responses after SNM treatment. The proportions of patients who became dry were 21.2% and 23.5%, respectively. In the post-SNM BoNTA group, spinal pathology is associated with a lower probability of a significant response (48.9% vs. 73.7%, p-value = 0.0105). BoNTA or SNM remains a viable option for refractory OAB after patients fail from one another. Spinal pathology is associated with a poorer response of post-SNM BoNTA.

Evaluation of the efficacy of sacral neuromodulation in the treatment of voiding dysfunction after endometriosis surgery

Pelvic surgery for endometriosis is associated with a risk of bladder and digestive sequelae. Sacral neuromodulation (SNM) has been shown to be effective in the treatment of overactive bladder (OAB) and voiding dysfunction (VD). This study aimed to evaluate the efficacy of sacral neuromodulation (SNM) in treating voiding dysfunction (VD) following endometriosis surgery. A retrospective analysis was conducted on data from women who underwent SNM testing for persistent VD after endometriosis surgery. The study included 21patients from a French tertiary referral center. Patient characteristics, lower urinary tract symptoms, urodynamic findings, SNM procedures, and outcomes were assessed. The primary outcome was the success of SNM treatment for VD. After a median follow-up of 55months, 60% of patients achieved successful outcomes, with significant improvements of VD and quality of life. Moreover, more than half of patients who required clean intermittent self-catheterization (CISC) before SNM were able to wean off CISC. Complications such as infections and paraesthesia were observed, but overall, SNM was found to be effective and well tolerated. Age and the interval between endometriosis surgery and SNM testing were associated with treatment success. This study adds to the limited existing literature on SNM for VD after endometriosis surgery and suggests that SNM can be a valuable therapeutic option for these patients. Further research is needed to identify predictive factors and mechanisms underlying the effectiveness of SNM in this context. MRI-compatible and rechargeable devices, has improved the feasibility of SNM for these patients. In conclusion, SNM offers promise as a treatment option for persistent VD after endometriosis surgery, warranting further investigation. LEVEL OF EVIDENCE: 4.

Removal of Sacral Neuromodulation Devices Is an Office Procedure

In some instances, sacral neuromodulation (SNM) devices need to be removed. Traditionally, permanent lead and/or implantable pulse generator (IPG) removals are done in the operating room under sedation. Our objective is to present our experience removing SNM components under local in the office. We performed a retrospective chart review from 2017-2022 of SNM lead and IPG removals performed under local anesthesia in the office by a single surgeon. Patient characteristics, outcomes and complications were reported. From 2017-2022 41 SNM leads with and without IPGs were removed in the office using local anesthesia. 88% were female, mean age 66 ± 15.8 years, and mean BMI 28.6 (19.1-49.4). The most common indications for SNM treatment were urgency incontinence (56%) and non-obstructive urinary retention (24%). 44% (18/41) of SNM device removals were leads removed after failed stage I and 56% (23/41) were leads with IPGs removed most commonly for decreased efficacy (52%). In the latter group, median time to removal was 3.1 (0.3-12.3) years, and 52% (12/23) required a separate medial incision for lead retrieval. 9% (2/23) required fluoroscopy, of which, one was planned secondary to BMI 49.4, and the other needed secondary to excessive scar tissue. No stage I failures required fluoroscopy. 7% (3/41) of leads required cutdown to the sacrum for removal with leads in place between 3.1-3.9 years. All leads were removed completely intact and there were no complications. Removal of SNM devices in the office using local anesthesia is effective, well-tolerated, and safe.

Effectiveness and safety of sacral neuromodulation for neurogenic bladder

ABSTRACT Background The treatment of neurogenic bladder (NB) is a challenge because conventional therapy often fails. Sacral neuromodulation (SNM) is a minimally invasive technique and an unconventional treatment for neurogenic bladder. Its research is still in the exploratory stage. The research on its effectiveness and safety is not clear. Objective To assess the effectiveness and safety of sacral neuromodulation (SNM) for neurogenic bladder (NB). Methods By searching the PubMed databases and Cochrane Library databases, combined with the method of literature tracing, the clinical researches and works on neurogenic bladder and sacral neuromodulation therapy were collected. Two reviewers independently selected and extracted data, (1) determine whether the study meets the inclusion criteria and exclude the literature that meets the exclusion criteria. (2) Researchers’ screening results and data, if there are differences in the results, will be discussed to eliminate the differences. (3) Read the full text of the literature carefully to determine the final literature to be included. (4) The relevant data of 11 independent studies, a total of 291 patients, were systematically reviewed using review manager 5.3 software. Results This research included 11 independent studies with a total of 291 patients. The improvements of main outcomes before and after SNM therapy were significant: incontinence episodes /24 h (WMD −2.52; 95%CI-3.14-1.90; p <0.001), frequency/24 h (WMD-5.96; 95%CI −6.27，-5.66; p <0.001), voiding volume (WMD 116.09 mL; 95%CI 86.68，145.51; p <0.001), cystometric capacity (WMD 129.84 mL; 95%CI 100.53, 159.15; p <0.001), post-void residual volume (WMD-198.00 mL; 95%CI-264.60, −131.40; p <0.001), clean intermittent self-catheterization/24 h (WMD-2.48; 95%CI −2.96, −2.00; p <0.001). Conclusion This systematic review indicated that the sacral neuromodulation treatment for neurogenic bladder was effective and safe.

Sacral neuromodulation treatment for urinary voiding dysfunctions: results of treatment with the largest single-center series in a tertiary referral center in Turkey

Sacral neuromodulation (SNM) is a minimally invasive treatment that modulates spinal reflexes to regulate bladder, urinary sphincter, and pelvic floor and has successfully been used in the treatment of refractory voiding dysfunctions. The aim of this study was to present our experience with SNM in a tertiary referral center with the largest number of patients and review the safety and efficacy of the procedure. A total of 42 patients with refractory lower urinary tract symptoms were included into the study. After an initial test period, patients who showed more than 50% improvement in their symptoms underwent the second stage of SNM. Twelve patients had overactive bladder (OAB), bladder pain syndrome/interstitial cystitis (BPS/IC) and 17 had urinary retention. The clinical success was examined during follow-up by voiding diary, urodynamics, and global response assessment. Between February 2015 and December 2020, a total of 29 patients underwent stages I&II SNM procedures. The mean ages of patients in OAB/BPS group and retention group were 40 (37-57 years) and 35 (27-44 years), respectively. Mean follow-up time was at least 1 year. Overall, 58.5% success rate was observed in OAB, BPS/IC, and urinary retention groups. Global response assessment score in both groups increased significantly (p = 0.001). No statistically significant difference was found between success or failure rates when sex and age were variable parameters (p > 0.05). SNM appears to be an effective and safe treatment option in restoring voiding dysfunctions in patients with refractory idiopathic and neurogenic voiding dysfunctions. Our initial series revealed favorable results; however, further studies with larger series and longer follow-up are needed.

Noninvasive Sacral Neuromodulation in Children and Adolescents: A Case-Control Study of Patients With Chronic Refractory Constipation

ObjectivesIn adult patients with chronic refractory constipation, invasive sacral neuromodulation (SNM) has been applied successfully. There is a need for less invasive solutions while providing comparable therapeutic effects in children and adolescents. We present a prospective, interventional case-control study on the application of noninvasive SNM. Materials and MethodsPatients with chronic constipation refractory to conservative treatment were prospectively included in the study from 2018 to 2021 and randomized to either SNM (SNM group: single current stimulation for 24 h/d, frequency 15 Hz, pulse width 210 μs, intensity 1–10 mA) or conventional treatment (controls: full range of pharmacologic and nonpharmacologic options). Treatment was conducted for 12 weeks. Treatment effects were collected with specialized questionnaires and quality-of-life analysis (KINDLR). Outcome variables were defecation frequency, stool consistency, fecal incontinence (FI) episodes, and abdominal pain. ResultsAnalysis was conducted in 28 patients with SNM and 31 controls (median age 7.0, range 3–16 years). Overall responsiveness to treatment was 86% of the SNM group and 39% of the control group (p < 0.001). All outcome variables were positively influenced by SNM treatment. Defecation frequency improved in 46% of patients with SNM and in 19% of controls (p = 0.026), as did stool consistency in 57% of patients with SNM and in 26% of controls (p = 0.014). Fecal incontinence was significantly reduced in 76% of patients with SNM (n = 16/21 vs 42% of controls [n = 11/26], p = 0.042). Quality of life improved significantly during SNM treatment (71.32 [baseline] vs 85.00 [after 12 weeks], p < 0.001) and confirmed a positive influence of SNM treatment compared with the control group (85.00 [SNM after 12 weeks] vs 79.29 [controls after 12 weeks], p = 0.047). ConclusionsOutcome of noninvasive SNM treatment in patients with chronic refractory constipation is better than conventional treatment.

MP16-07 FRAILTY AS A PREDICTOR OF SACRAL NEUROMODULATION OUTCOMES

You have accessJournal of UrologyCME1 May 2022MP16-07 FRAILTY AS A PREDICTOR OF SACRAL NEUROMODULATION OUTCOMES Colby Souders, Mary Enoh Adakama, Allison Sih, Seth Cohen, Maude Carmel, Jennifer Anger, Karyn Eilber, and Kai Dallas Colby SoudersColby Souders More articles by this author , Mary Enoh AdakamaMary Enoh Adakama More articles by this author , Allison SihAllison Sih More articles by this author , Seth CohenSeth Cohen More articles by this author , Maude CarmelMaude Carmel More articles by this author , Jennifer AngerJennifer Anger More articles by this author , Karyn EilberKaryn Eilber More articles by this author , and Kai DallasKai Dallas More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Geriatric patients with overactive bladder or urge incontinence (UUI) are often medically under-treated. Concerns regarding anticholinergic side effects, polypharmacy, and cost of beta-3 agonists result in limited treatment options. Sacral neuromodulation (SNM) is a minimally invasive and non-pharmacological option. Geriatric patients considered frail may not be offered SMN due to concerns of surgery complications, treatment efficacy, and complexity of device operations. Thus, the purpose of this study is to investigate SNM outcomes in geriatric patients who meet frailty criteria. METHODS: We reviewed California Office of Statewide Health Planning and Development (OSHPD) from 1/1/2012-12/31/2018. Using Current Procedural Terminology (CPT) codes, we identified patients who underwent Stage 1 (CPT:64581) and Stage 2 (CPT:64590) SNM surgery. Treatment was considered successful if a patient proceeded to Stage 2 from Stage 1. Patient age, gender, ethnicity, academic status surgery facility, and payor status were obtained. The SNM patient population was then analyzed using a validated claims-based frailty index (Kim, 2018). Univariate (chi-square/ T-test) and multivariate analysis were performed to assess for associations between variables of interest and completion of Stage 2. RESULTS: We identified 2,400 patients who underwent Stage 1, and 1,132 patients successfully proceeded to Stage 2. Rates of Stage 2 were higher in females compared to males (36.6% vs. 50.5%, p<0.001), those who had surgery at academic medical centers (58.6% vs. 20.8%, p<0.001), and those with a diagnosis of urgency (52.1% vs. 45.3%, p=0.003). These findings remained significant with multivariate analysis. Of the 2,400 patients identified 363 (15.1%) met frailty criteria and 165 (45.5%) underwent Stage 2. For non-frail patients, SNM success rate was 47.5% (p=0.514) (Table 1). There were no significant associations between patient age, ethnicity, payor status, and completion of Stage 2. CONCLUSIONS: Our work demonstrates that frailty had no significant adverse impact on success of SNM treatment. However, female gender, surgery at an academic center, and a diagnosis of UUI were more likely to have treatment success than patients with other indications. This data supports recommendation of SNM to older, frail patients, especially those with UUI. Source of Funding: The Medical Student Training in Aging Research Program and the National Institute on Aging (T35AG026736) © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e277 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Colby Souders More articles by this author Mary Enoh Adakama More articles by this author Allison Sih More articles by this author Seth Cohen More articles by this author Maude Carmel More articles by this author Jennifer Anger More articles by this author Karyn Eilber More articles by this author Kai Dallas More articles by this author Expand All Advertisement PDF DownloadLoading ...

Sacral neuromodulation treatment for urinary voiding dysfunctions: Results of treatment with the largest single-center series in a tertiary referral center in Turkey.

Background/aim: Sacral neuromodulation (SNM) is a minimally invasive treatment that modulates spinal reflexes to regulate bladder, urinary sphincter, and pelvic floor and has successfully been used in the treatment of refractory voiding dysfunctions. The aim of this study was to present our experience with SNM in a tertiary referral center with the largest number of patients and review the safety and efficacy of the procedure. Materials and methods: A total of 42 patients with refractory lower urinary tract symptoms were included into the study. After an initial test period, patients who showed more than 50% improvement in their symptoms underwent the second stage of SNM. Twelve patients had overactive bladder (OAB), bladder pain syndrome/interstitial cystitis (BPS/IC) and 17 had urinary retention. The clinical success was examined during follow-up by voiding diary, urodynamics, and global response assessment. Results: Between February 2015 and December 2020, a total of 29 patients underwent stages I&II SNM procedures. The mean ages of patients in OAB/BPS group and retention group were 40 (37-57 years) and 35 (27-44 years), respectively. Mean follow-up time was at least 1 year. Overall, 58.5% success rate was observed in OAB, BPS/IC, and urinary retention groups. Global response assessment score in both groups increased significantly (p = 0.001). No statistically significant difference was found between success or failure rates when sex and age were variable parameters (p > 0.05). Conclusion: SNM appears to be an effective and safe treatment option in restoring voiding dysfunctions in patients with refractory idiopathic and neurogenic voiding dysfunctions. Our initial series revealed favorable results; however, further studies with larger series and longer follow-up are needed.

Sacral Neuromodulation Improves Abnormal Prefrontal Brain Activity in Patients with Overactive Bladder: A Possible Central Mechanism.

We explored the central pathogenesis of overactive bladder (OAB) and the central mechanism of action of sacral neuromodulation (SNM). We prospectively enrolled patients with OAB who chose SNM and healthy controls (HCs). At baseline, all subjects completed a 72-hour voiding diary, OAB symptom score and prefrontal cortex functional near-infrared spectroscopy scan synchronous urodynamic monitoring. All OAB patients were tested after implantation of the SNM electrode, and both success and failure groups were reevaluated. NIRS_KIT software was used to analyze prefrontal activity (p <0.05 and corrected by false discovery rate). SPSS® 22.0 was used to analyze clinical parameters, and p <0.05 was considered statistically significant. A total of 16 HC and 20 OAB patients were enrolled. SNM treatment was successful in 18 OAB patients and failed in 2. The parameters of the voiding diary, OAB symptom score and urodynamic monitoring of OAB group were significantly improved after SNM treatment in success group, not in the failure group. Compared with HCs, Brodmann's area 9 (left dorsolateral prefrontal cortex [DLPFC]) was significantly deactivated in the preoperative OAB success group and significantly activated after SNM treatment. Before surgery, compared with the success group, the failure group showed significantly deactivated Brodmann's area 9 (left DLPFC). Our study provides novel neuroimaging evidence for the possible central pathogenesis of OAB (ie abnormal deactivation of the left DLPFC) and the possible central mechanism of action of SNM (ie restore activation of the left DLPFC).

Sacral Neuromodulation Treatment for Non-neurogenic Urological Disorders: Experience of a Single Center in Turkey

Sacral Neuromodulation Treatment for Non-neurogenic Urological Disorders: Experience of a Single Center in Turkey

Efficacy and Safety of Sacral Neuromodulation in Treatment of Refractory Overactive Bladder

Background: Overactive bladder syndrome is a urinary disorder that occurs more frequently in women andolder people and is characterized by feeling an urge to urinate (sudden urge to urinate, with the feeling thatyou cannot get to the bathroom in time), doing it many times throughout the day (more than six) or havingepisodes of urinary incontinence (involuntary loss of urine) and nocturia (waking up several times duringthe night to urinate). In addition, other secondary symptoms may also occur, such as headache, dry mouth orblurred vision, among others. It is a problem that has a clear impact on the quality of life of those who sufferit and that can lead them to significantly reduce their social activity and negatively condition their work.Overactive bladder (OAB) is defined as urinary urgency with or without urgency urinary incontinence,nocturia, and/or frequency in the absence of UTI or other obvious pathology. Sacral neuromodulation is anewer surgical therapy for refractory OAB.Aim of Study: Is to assess the sacral neuromodulation (SN) safety and efficacy in refractory overactivebladder patients.Patients and Methods: In the period from November 2015 to May 2017. the unit of neurogenic bladderand neuromodulation in (Gazi Al_Harriry) surgical specialty hospital, medical city complex 27 patient agedfrom (17—55) year old were complaining from refractory overactive bladder. All the 27 patients underwentstage1 &amp; stage2 SNS devices implantation.Results: Patients of urgency incontinence (group1) demonstrated that the number of leak was significantlyreduced (p=0.01) after implantation of SN, (11.6_2.7) leak/day pre&amp; post SN, numbers of pads (6.9 _ 0.8)pad/day pre&amp;post SN. Patients with urgency frequency (group 2), numbers of voids/day pre &amp; post SNimplantation decreased significantly (p=0.01) (14.7 _ 6) voids /day. The voided volume increased significantly(p=0.02) from (136.4 _ 371.8) ml/void. The urgency episodes were decreased significantly (p=0.01) from(6.4 _ 2.1) episode/day. The complications occurred in 5 patients (18.5%). Two patients (7.4%) developedpain after trauma to the back, lead migration, lack of efficacy of device, treated by reprogramming thedevice, one patient (3.7%) get infection at the site of device implantation, SN was removed , there was onefemale patient (3.7%) got pregnancy and devise was deactivated. One patient (3.7%) complaining from painand discomfort at the device site was treated conservatively.Conclusion: Sacral neuromodulation is FDA approved as option for treatment of refractory OAB. There isexpanding of utilizing of SN in the past two decades. According to multiple studies in addition to our studyresults. The sacral neuromodulation is safe and efficacious treatment option for refractory OAB.

Current Position of Sacral Neuromodulation in Treatment of Fecal Incontinence.

Fecal incontinence (FI) is defined as uncontrolled passage of feces or gas for at least 1-month duration in an individual who previously had control. FI is a common and debilitating condition affecting many individuals. Continence depends on complex relationships between anal sphincters, rectal curvatures, rectoanal sensation, rectal compliance, stool consistency, and neurologic function. Factors, such as pregnancy, chronic diarrhea, diabetes mellitus, previous anorectal surgery, urinary incontinence, smoking, obesity, limited physical activity, white race, and neurologic disease, are known to be the risk factors for FI. Conservative/medical management including biofeedback are recognized as the first-line treatment of the FI. Those who are suitable for surgical intervention and who have failed conservative management, sacral nerve stimulation (SNS) has emerged as the treatment of choice in many patients. The surgical technique involves placement of a tined lead with four electrodes through the S3 sacral foramen. The lead is attached to a battery, which acts as a pulse generator, and is placed under the patient's skin in the lower lumbar region. The use of SNS in the treatment of FI has increased over the years and the beneficial effects of this treatment have been substantiated by multiple studies. This review describes SNS as a modality of treatment for FI and its position in the current medical diaspora in patients with FI.

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

This study aimed to evaluate whether patients stratified by age have the same level of benefits after a sacral neuromodulation (SNM) procedure for refractory lower urinary tract dysfunction. This retrospective study comprised 211 patients with refractory lower urinary tract dysfunction who had been treated with SNM and recruited from multiple medical centers across China. Patients were grouped according to age: <40 (n = 58), 40-64 (n = 94), and > 64 (n = 59) years. Data were compared using voiding diaries and subjective scores pre-operatively, post-implantation of a stage I tined lead, and during a short-term follow-up period postimplantation of a stage II implanted pulse generator. In all groups, voiding diary data and subjective scores improved significantly over different periods. Residual urine improved in the 40-64 and > 64-year-old age groups. Quality of life scores improved in the <40-year-old age group. Voiding diary data among age groups varied at baseline; however, average urinary frequency did not differ at the last follow-up. Urgency and sexual life scores differed at baseline and these differences had resolved at the last follow-up. O'Leary-Sant and Pelvic Pain and Urgency/Frequency Symptoms Scale scores did not differ at baseline; however, significant differences were observed at the last follow-up. SNM success is unrelated to age, and age alone should not be considered a limiting factor in SNM. For older patients, an overactive bladder appears a better indication for SNM treatment; however, further studies are required to confirm this finding.

Optimizing sacral neuromodulation for low anterior resection syndrome: learning from our experience.

The aim of this work was to review our institutional series of patients treated with sacral neuromodulation (SNM) for low anterior resection syndrome (LARS) and evaluate possible factors associated with therapeutic success. Twenty-five patients were treated with SNM for LARS between 2008 and 2019. SNM was performed as per our institutional protocol. Patients were evaluated with Wexner and LARS scores before and after SNM treatment. A visual analogue scale (1-10) was used to evaluate overall patient satisfaction with SNM. There were significant differences between the mean LARS score values before (37.82) and after (29) SNM therapy (P<0.004). The mean Wexner score was higher (16.24) before SNM treatment than afterwards (11.13) (P<0.004). There was a direct relationship between the height of anastomosis and LARS score (P=0.035): there were big changes in LARS scoring (pre-/post-SNM therapy) in patients with higher anastomoses, and vice versa. Patients who received radiotherapy scored lower in mean satisfaction (6.38) than patients without previous radiotherapy (8.22) (P=0.008). There was an important positive association between Wexner score and patient satisfaction (P=0.001): relevant changes in Wexner scoring after SNM therapy were associated with high patient satisfaction, and vice versa. Our study showed a relationship between changes in Wexner and LARS scores before and after SNM and overall patient satisfaction with SNM therapy. These findings also suggest patients with previous radiotherapy may have worse results with SNM (based on lower overall satisfaction), and that higher anastomoses have a greater impact on the post-SNM LARS score.

Neural pathway of bellows response during SNM treatment revisited: Conclusive evidence for direct efferent motor response.

In sacral neuromodulation (SNM) patients, it is thought the bellows response elicited upon sacral spinal nerve stimulation is reflex-mediated. Therefore the mechanism of action of SNM is considered to be at the spinal or supraspinal level. These ideas need to be challenged. To identify the neural pathway of the bellows response upon sacral spinal nerve stimulation. Single tertiary center, prospective study (December 2017-June 2019) including 29 patients with overactive bladder refractory to first-line treatment. Recording of the pelvic floor muscle response (PFMR) using a camcorder and electromyography (EMG) (intravaginal probe and concentric needles) upon increasing stimulation during lead or implantable pulse generator placement. The lowest stimulation intensity needed to elicit a visual PFMR and electrical PFMR was determined. Electrical PFMRs were subdivided according to their latency. the association between visual and electrical PFMRs. Statistical analyses were performed using the weighted kappa coefficient. Three different electrical PFMRs could be identified by surface and needle EMG, corresponding with a direct efferent motor response (R1), oligosynaptic (R2), and polysynaptic (R3) afferent reflex response. Only the R1 electrical PFMR was perfectly associated with the visual PFMR (κ = 0.900). The visual PFMRs upon sacral spinal nerve stimulation are direct efferent motor responses. A reopening of the discussion on the mechanism of action of SNM is possibly justified.

Outcomes of sacral neuromodulation for chronic pelvic pain: a Finnish national multicenter study.

The aim of this study was to report the outcomes of sacral neuromodulation (SNM) in chronic pelvic pain (CPP) patients in the Finnish national cohort. This was a register-based retrospective study, involving all the centers that provide SNM treatment in Finland. The data of all patients treated with SNM for CPP were gathered from Oulu-, Turku-, Tampere- and Helsinki University Hospitals, as well as Jyväskylä and Seinäjoki Central Hospitals. All patients who had been tested for SNM implantation prior to April 2017 were included in the study. A total of 51 patients were selected for SNM treatment due to CPP from 2004 until 2017. The mean follow-up time was 13.8months (SD 22.9months). A total of 28 patients (57%) advanced from testing to permanent stimulator implantation. There were 21 patients (41%) who had a working modulator implanted at the end of follow-up. Patients with endometriosis-related pain had a significantly higher permanent implantation rate than the overall implantation rate (88% vs. 57%; p = 0.01). The endometriosis patients also had a higher overall success rate by the end of the follow-up (75% vs. 41%;p = 0.026) CONCLUSIONS: SNM may be a viable treatment option for patients with CPP due to endometriosis. Further research on SNM treatment for endometriosis patients with refractory CPP is needed.

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

PurposeIntradetrusor onabotulinum toxin A (BTXA) and sacral neuromodulation (SNM) are effective third-line therapies for overactive bladder (OAB). We aimed to measure the outcomes of BTXA for treatment of OAB refractory to initial SNM and identify patient characteristics associated with these outcomes.MethodsThis retrospective cohort study included patients who failed to respond to initial SNM treatment for OAB and subsequently received BTXA at a single provider’s clinic between January 2013 and December 2016. Treatment successes were defined as patients willing to continue BTXA or who found symptom relief whereas treatment failures discontinued BTXA due to adverse effects or lack of symptom relief. Symptoms and patient-reported outcomes on validated questionnaires were compared before the initial BTXA trial to 2 months after the last BTXA treatment. The SNM failure BTXA groups were also compared to BTXA SNM naïve groups.ResultsOf 18 patients who received BTXA after failed SNM treatment, 7 (39%) achieved treatment success. Successfully treated patients demonstrated decreased urinary frequency from a median 11 voids/day pre-BTXA to 8 voids/day with BTXA (P=0.042). Patients whose treatment failed reported increased complaints of a weak urinary stream (P=0.03) and higher frequency of straining to urinate (P=0.016) than the successful treatment group pre-BTXA. Compared to BTXA patients without prior SNM, the odds of failing BTXA after initial SNM were 3.6 times higher (P=0.016).ConclusionsBTXA appears effective for OAB refractory to SNM, although the success rate is lower compared to BTXA patients without SNM exposure.

Nursing Care of the Patient With Neurogenic Bladder After Kidney Transplantation: A Case Report

ObjectiveUrologic complications are among the most common complications after kidney transplantation. These complications are urinary retention, hematuria, hemorrhage, urinary leakage, vesicoureteral reflux, pyelonephritis, and nephrolithiasis. Although neurogenic bladder is one of the indications for kidney transplantation, it is not considered in the literature to be an expected complication after transplantation. In this case, we discuss the nursing care of a patient who underwent kidney transplantation from a living donor and developed neurogenic bladder. Case reportA 60-year-old woman underwent kidney transplantation from a living donor, and neurogenic bladder developed in the patient 1 year after kidney transplantation. Clear intermittent catheterization treatment was administered for the kidney transplant recipient with neurogenic bladder. Clear intermittent catheterization treatment was stopped in the patient who had frequent urinary tract infections and, alternatively, sacral neuromodulation treatment was administered to the patient. ConclusionsThe nursing care of a patient with neurogenic bladder after kidney transplantation aims to prevent excessive bladder distension, infection, stone formation, vesicoureteral reflux, renal failure, urinary tract damage, and incontinence, and to ensure regular and complete discharge of the bladder. The most common treatment modalities for these objectives are permanent or intermittent catheterization, sacral neuromodulation, and medical therapy. In the care of the patient with neurogenic bladder after kidney transplantation, nurses should provide appropriate care related to treatment options and bladder training, plan urination schedules of the patient, and monitor for possible complications.

Effect of Early Sacral Neuromodulation on Bladder Function in a Rat Model of Incomplete Spinal Cord Injury Due to Focal Contusion

Incomplete spinal cord injury (SCI) accounts for two-thirds of all SCIs in clinical practice. Preclinical research on the effect of sacral neuromodulation (SNM) on bladder function, however, has been focused only on animal models of complete SCI. We aimed to evaluate the effect of early SNM on bladder responses in a rat model of incomplete SCI. Altogether, 21 female Sprague-Dawley rats were equally assigned to control (CTR), SCI + sham stimulation (SHAM), and SCI + SNM (SNM) groups. In the SHAM and SNM groups, incomplete SCI was created by producing a moderate contusion with an NYU-MASCIS impactor at the T9-T10 level of the spine, with needle electrodes implanted bilaterally into the S2 or S3 sacral foramen. Only SNM group underwent electrical stimulation for 28 days, beginning on day 7 after SCI. Cystometry was performed 35 days after SCI. Although the interval between voiding contractions was significantly longer in the SHAM group than the CTR group (25.5 ± 1.4 vs. 12.5 ± 1.7 min; p < 0.05), there were no significant differences between the SNM group (16.5 ± 1.5 min) and the CTR group. Maximum voiding contraction pressure did not differ among the groups. The SNM group had a significantly lower frequency (3.5 ± 0.5 vs. 14.6 ± 2.0; p < 0.05) and maximum pressure (11.4 ± 6.2 vs. 21.3 ± 1.8 cmH2 O; p < 0.05) of nonvoiding contractions than the SHAM group. Our results provide experimental evidence that early SNM treatment may prevent or diminish bladder dysfunctions (e.g., detrusor overactivity, abnormal micturition reflex) in a clinical condition of incomplete SCI.

Real World Performance of Sacral Neuromodulation and OnabotulinumtoxinA for Overactive Bladder: Focus on Safety and Cost.

We aimed to determine the real world safety and cost of third line overactive bladder therapies, including onabotulinumtoxinA and sacral neuromodulation. We performed an all-inclusive, population based cohort study of third line therapies of overactive bladder (sacral neuromodulation or onabotulinumtoxinA) using the statewide surgical data captured in the New York Statewide Planning and Research Cooperative System. The main outcome measures were 30-day safety events, and 1 and 3-year health care utilization costs. Propensity score matching was done to control for confounding factors and comparative analyses of safety events were also performed. Our cohort included 2,680 patients, of whom 1,328 underwent sacral neuromodulation and 1,352 received onabotulinumtoxinA from January 1, 2013 through December 31, 2016. Average ± SD age was 61.7 ± 16.3 years and 82.7% of the patients were female. Sacral neuromodulation implantation led to re-intervention in 15.8% of cases within 1 year and in 26.1% at 3 years. In this comparative analysis patients who received onabotulinumtoxinA therapy were at higher risk for urinary tract infection, hematuria, urinary retention and an emergency room visit compared to those treated with sacral neuromodulation. The overall cost of onabotulinumtoxinA was lower than the cost of the sacral neuromodulation device (cost at 1 year $2,896 vs $15,343 and at 3 years $3,454 vs $16,189, each p <0.01). Sacral neuromodulation implantation was more expensive than onabotulinumtoxinA injection. However, patients who underwent sacral neuromodulation had a lower complication rate than patients treated with onabotulinumtoxinA. A quality improvement collective database must be created to track information on onabotulinumtoxinA and sacral neuromodulation treatment. This would help generate better performance and comparative data for patient and physician decision making.