Use Of Sacral Neuromodulation Research Articles

Sacral Neuromodulation for Fecal Incontinence and Constipation: Evidence, Programming and Long-term Management

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. 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 (14Hz, 210s), 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. 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.

Comparison of Two Treatment Modalities in Overactive Bladder: A Rapid Overview.

Overactive bladder is a syndrome of urgency with the absence of infection and is usually accompanied by frequency and nocturia. Both sacral neuromodulation (SNM) and intravesical botulinum toxin (BTX) injection are used contentiously in overactive bladder after failure of conservative management. We aimed to provide an updated comparative overview of BTX injection versus SNM in the treatment of overactive bladder. PubMed and Google scholar databases were explored starting from 2016 to 2022 to obtain relevant articles. English studies on adult population were included. Six articles included 648 participants were included in the current overview. Both BTX and SNM are comparable for the treatment of overactive bladder, with no major complications were reported. However, the use of SNM for refractory overactive bladder after failure of BTX was more successful and effective and resulted in patient satisfaction compared to the use of BTX after failure of SNM. Our update provides the latest comparative overview of outcomes of BTX versus SNM in the treatment of overactive bladder.

Comparison of Two Treatment Modalities in Overactive Bladder: a Rapid Overview

Background: Overactive bladder is a syndrome of urgency with the absence of infection and is usually accompanied by frequency and nocturia. Both sacral neuromodulation (SNM) and intravesical botulinum toxin (BTX) injection are used contentiously in overactive bladder after the failure of conservative management. Objective: We aimed to provide an updated comparative overview of botulinum toxin versus sacral neuromodulation in the treatment of overactive bladder. Methods: PubMed and Google scholar databases were explored starting from 2016 to 2022 to obtain relevant articles. English studies on the adult population were included. Results: Six articles included 502 participants were included in the current overview. Both BTX and SNM are comparable for the treatment of overactive bladder, with no major complications were reported. However, the use of SNM for refractory overactive bladder after the failure of BTX was successful and effective and resulted in patient satisfaction compared to the use of BTX after the failure of SNM. Conclusion: Our update provides the latest comparative overview of outcomes of botulinum toxin versus sacral neuromodulation in the treatment of overactive bladder.

The Safety and Efficacy of Sacral Neuromodulation on Refractory Urgency Urinary and Fecal Incontinence in Iraqi Patients

Background: Urinary urgency incontinence is characterized by symptoms of involuntary loss of urine thatpreceded or accompanied by sudden desire to void. Fecal incontinence is defined as involuntary passage ofstool through the anus. It may vary from soiling to complete evacuation. This involuntary loss of feces, flatusor urge incontinence adversely affects quality of life.Objectives: To evaluate the efficacy and safety of sacral neuromodulation on these pathologies.Method: Following a detailed investigation, 21 patients with either urinary incontinence, or both urinaryand fecal, who did not respond to medical and behavioral treatment were offered the sacral neuromodulationtherapy and followed for at least 12 months post implant regarding response and development of complicationif any found.Results: In the period from November 2015 to May 2017. The unit of neurogenic bladder and neuromodulationin surgical subspecialty hospital, medical city complex had implanted 21 Patients with urinary incontinencewere using from (4-17) pads/day (mean of 10.5/day) presacral neuromodulation which were declinedsignificantly to (0-3) pads/day (mean of 2.2/day).From the eighteen patients who presented with fecal incontinence after the implantation of sacralneuromodulation interstim 11 permanent devices only four remained incontinent .and from the nine patientswho presented with erectile dysfunction only two remained impotent.Conclusion: The use of Sacral Neuromodulation in Iraqi patients with Urinary and Fecal Incontinence issafe and effective

Do you really want to deactivate your sacral neuromodulation device during pregnancy? A single center case series

Introduction and hypothesisThe main objective of the study is to assess the efficacy and safety of sacral neuromodulation (SNM) during pregnancy.MethodsWe retrospectively enrolled patients who underwent SNM implantation in our center and subsequently became pregnant. The indication for SNM, timing of device de-activation (if performed), course of pregnancy and urological complications, duration of labor, childbirth term, delivery mode, congenital abnormalities and SNM dysfunctions after delivery were recorded.ResultsFourteen pregnancies were recorded among 11 women undergoing SNM. Indications for device implantation were urinary retention (7 cases) and dysfunctional voiding (4 cases). Two patients carried on two and three pregnancies, respectively, with the device turned off since the first trimester. They both had to return to self-catheterization and developed recurring urinary tract infections. No major urological complications were recorded among the remaining nine women that kept the device on during pregnancy. A cesarean section was performed in four cases for obstetric reasons, and in seven cases it was planned by the urologist and gynecologist to avoid lead damage/displacement. Three pregnancies resulted in a vaginal delivery, and no association with term of delivery or duration of labor was observed. No congenital abnormalities related to SNM or lead displacement are reported, and only one patient required device removal because of significant loss of efficacy after childbirth.ConclusionsThe use of SNM during pregnancy appears to be safe, without morbidity for the fetus. Moreover, risks associated with switching the device off may be greater than benefits and justify maintaining the electrical stimulation throughout pregnancy.

Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres.

The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013. This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5years, complications and requirement for further interventions were recorded. A total of 461 patients (median age 56years, range 24-90years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P=0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P<0.05). The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Sacral Neuromodulation with the InterStim™ System for Intractable Lower Urinary Tract Dysfunctions (SOUNDS): Results of Clinical Effectiveness, Quality of Life, Patient-Reported Outcomes and Safety in a French Multicenter Observational Study

BackgroundReal-world data that support the use of sacral neuromodulation (SNM) for lower urinary tract dysfunctions are of continued interest. ObjectiveTo evaluate the effectiveness, quality of life (QoL), patient-reported outcomes (PROs), and safety of SNM with the InterStim™ system in real life during 1-yr postimplant. Design, setting, and participantsThis is a prospective, multicenter, observational study at 25 representative public and private French sites. Eligible patients received SNM therapy for overactive bladder (OAB) and non-obstructive urinary retention based on local standard of care. Overall, 320 patients were enrolled; 247 received permanent implant or replacement; 204 implanted patients completed second follow-up after mean of 10.0±3.8 mo. Outcome measurements and statistical analysisEffectiveness outcomes were change in voids, leaks, and catheterizations/day. Other outcomes included validated QoL and disease severity scores as well as PROs and adverse event data. Outcomes at follow-ups were compared with baseline using the Wilcoxon signed-rank test. Results and limitationsVoids in urinary frequency (UF) and leaks/day in urinary urge incontinence (UI) patients were significantly reduced after 10 mo in both de novo (mean baseline voids/day UF de novo: 12.7 vs 8.6 after 10 mo; p<0.001; mean baseline leaks/day UI de novo: 4.3 vs 1.1 after 10 mo; p<0.001) and replacement patients (mean baseline voids/day UF replacement: 11.5 vs 7.9 after 10 mo; p<0.001; mean baseline leaks/day UI replacement: 5.4 vs 1.0 after 10 mo; p<0.001). Disease bother, Urinary Symptom Profile score, and Ditrovie questionnaire score were also significantly improved. Revisions postimplant occurred in 20% of patients including in 9% due to permanent explantation during a mean exposure time of 24.3 mo. ConclusionsThrough a real-life study, SOUNDS (Sacral neuromOdUlation with InterStim™ therapy for intractable lower uriNary tract DySfunctions) confirms the clinical effectiveness, safety, and positive effect of SNM on QoL and PROs for the treatment of OAB patients. Patient summaryThese analyses on French patients who received sacral neuromodulation (SNM) for retention or OAB during a 10-mo period showed that SNM improved OAB symptoms, quality of life, and reduced disease bother. Trial registrationClinicalTrials.gov: NCT02186041

523 - Do failure of posterior tibial nerve stimulation precludes to use sacral neuromodulation in patient with overactive bladder?

Purpose To evaluate the outcomes of sacral neuromodulation (SNM) after failure of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with overactive bladder (OAB). Methods A retrospective study was conducted in 3 university hospitals and included all patients with OAB and treated with SNM after TPTNS had been tried between October 2008 and May 2018. The primary endpoint was the proportion of definitive SNM device implantation in patients with 50% objective and/or subjective improvement after a test period (stage 1). The secondary outcomes of interest were changes of the number of diurnal voids and nocturia episodes per 24 hours between the end of TPTNS and the end of stage 1. Results Overall, 28 of the 43 patients included achieved at least 50% objective and/or subjective improvement during stage 1 and underwent an Interstim II implantation (65.1%). The mean daytime frequency decreased significantly from 10.3/day at the end of TPTNS to 7.8 diurnal voids/day at the end of SNM stage 1 (P=0.01). The mean number of nocturia episodes decreased from 2.5/night at the end of TPTNS to 2.1/night at the end of stage 1, but this did not reach statistical significance (P=0.18). There was no other parameter significantly associated with response to SNM. Conclusion SNM might improve OAB symptoms in most patients who experienced no or poor efficacy with TPTNS. History of failed TPTNS should not preclude the use of SNM in OAB patients.

Optimizing Neuromodulation Testing—Who, When, and How?

We review the current literature pertaining to recommendations for selecting appropriate patients and performing a test phase for sacral neuromodulation. Current literature reveals that this therapy can be successfully offered to patients with mild and severe forms of refractory overactive bladder, wet or dry. It can also be offered to elderly patients and patients with concurrent fecal incontinence, even in the setting of a known history of obstetric anal sphincter injury. Patients with non-obstructive urinary retention should be carefully selected with other etiologies ruled out, and an emphasis on those patients with suspected Fowler’s syndrome. We also summarize the recommendations for ideal lead placement and the advantages/disadvantages of a percutaneous nerve evaluation in the office compared to a staged procedure. The use of sacral neuromodulation for bladder dysfunction has evolved over the years. Patient selection and testing technique is an important component in optimizing the success of this therapy.

Do Failure of Posterior Tibial Nerve Stimulation Precludes to Use Sacral Neuromodulation in Patient With Overactive Bladder?

PurposeTo evaluate the outcomes of sacral neuromodulation (SNM) after failure of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with overactive bladder (OAB).MethodsA retrospective study was conducted in 3 university hospitals and included all patients with OAB and treated with SNM after TPTNS had been tried between October 2008 and May 2018. The primary endpoint was the proportion of definitive SNM device implantation in patients with 50% objective and/or subjective improvement after a test period (stage 1). The secondary outcomes of interest were changes of the number of diurnal voids and nocturia episodes per 24 hours between the end of TPTNS and the end of stage 1.ResultsOverall, 28 of the 43 patients included achieved at least 50% objective and/or subjective improvement during stage 1 and underwent an Interstim II implantation (65.1%). The mean daytime frequency decreased significantly from 10.3/day at the end of TPTNS to 7.8 diurnal voids/day at the end of SNM stage 1 (P=0.01). The mean number of nocturia episodes decreased from 2.5/night at the end of TPTNS to 2.1/night at the end of stage 1, but this did not reach statistical significance (P=0.18). There was no other parameter significantly associated with response to SNMConclusionsSNM might improve OAB symptoms in most patients who experienced no or poor efficacy with TPTNS. History of failed TPTNS should not preclude the use of SNM in OAB patients.

Tibial Nerve and Sacral Neuromodulation in the Multiple Sclerosis Patient with Voiding Dysfunction

Storage and voiding dysfunction are highly prevalent in patients with multiple sclerosis (MS). Many MS patients fail behavioral modifications and oral medications. Neuromodulation in the form of posterior tibial nerve stimulation (PTNS) and sacral neuromodulation (SNM) is a potential treatment for this group of patients. We review contemporary and impactful literature regarding neuromodulation in the MS patient with lower urinary tract dysfunction. Large-scale randomized trials regarding the use of neuromodulation in the treatment neurogenic lower urinary tract dysfunction are limited. Despite this, several small prospective studies demonstrate durable responses to neuromodulation in the MS patient. Posterior tibial nerve trials reveal improvements in urodynamic parameters, incontinence episodes, post-void residual volumes, and quality of life metrics. Additionally, SNM in the MS patient results in improvements in daytime and nighttime frequency, urgency symptom, and quality of life. Currently, the frequent need for routine spinal MRI scans precludes the use of SNM. Limited research suggests that some MRI use may be safe, but investigation in this area is ongoing. Tibial and sacral neuromodulation appear safe and offer significant improvements in lower urinary tract symptoms and quality of life in MS patients who have failed oral medications and behavioral modifications. Though randomized controlled trials are limited in this area, neuromodulation offers great promise to this often refractory and complex patient population. Future studies are warranted and necessary to better evaluate the efficacy of these treatment options.

International continence society best practice statement for use of sacral neuromodulation.

Aims Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. Methods Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. Results The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. Conclusions These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.

International Continence Society best practice statement for use of sacral neuromodulation.

Sacral neuromodulation (SNM) is an accepted therapy for a variety of conditions. However, despite over 20 years of experience, it remains a specialized procedure with a number of subtleties. Here we present the recommendations issued from the International Continence Society (ICS) SNM Consensus Panel. Under the auspices of the ICS, eight urologists, three colorectal surgeons and two urogynecologists, covering a wide breadth of geographic and specialty interest representation, met in January 2017 to discuss best practices for neuromodulation. Suggestions for statements were submitted in advance and specific topics were assigned to committee members, who prepared and presented supporting data to the group, at which time each topic was discussed in depth. Best practice statements were formulated based on available data. This document was then circulated to multiple external reviewers after which final edits were made and approved by the group. The present recommendations, based on the most relevant data available in the literature, as well as expert opinion, address a variety of specific and at times problematic issues associated with SNM. These include the use of SNM for a variety of underlying conditions, need for pre-procedural testing, use of staged versus single-stage procedures, screening for success during the trial phase, ideal anesthesia, device implantation, post-procedural management, trouble-shooting loss of device function, and future directions for research. These guidelines undoubtedly constitute a reference document, which will help urologists, gynecologists, and colorectal surgeons optimize their use of SNM for refractory urinary urgency and frequency, UUI, NOR, and FI.

Sacral neuromodulation for pelvic pain and pelvic organ dysfunction: A case series.

The use of neuromodulation is growing and it is an established therapy for conditions such as bladder dysfunction. It is an increasingly used therapy for the management of chronic perineal pain but little research is currently available looking at its efficacy. We present a series of 52 patients who underwent placement of a neuromodulator, the majority of whom suffered from perineal pain, with most placements via the sacral hiatus. Patients were asked to complete a survey recalling their symptoms prior to implantation and describing their symptoms and experience after. The majority had two leads placed via the sacral hiatus. Fifty-two patients had implantation of a permanent neuromodulator and 44 completed at least part of the survey. Forty-eight had leads placed via the sacral hiatus, 29 of whom had these leads only. Forty patients had perineal pain as an indicator and 32 reported that their pain improved; this difference was statistically significant (95% CI: 2.60-4.27, P<0.001). Bladder, bowel and sexual dysfunction were reported by about half the cohort with smaller numbers of improvement for each. Thirty-five patients reported improved quality of life and 32 said they would have the procedure done again. Ten patients had the device removed. We present the largest published case series looking at the use of sacral neuromodulation as a treatment option for pelvic pain and the overall results of our audit are promising for the ongoing use and further development of this modality as a management option.

Impact of Age and Comorbidities on Use of Sacral Neuromodulation

We investigated the influence of patient age on sacral nerve stimulation trial outcomes, device implantation and treatment durability. We analyzed a database of all sacral nerve stimulation procedures performed between 2012 and 2014 at a high volume institution for associations of patient age with sacral nerve stimulation indication, trial stimulation success, device revision and device explantation. In a cohort of 356 patients those with nonobstructive urinary retention and urgency-frequency were younger than patients with urgency urinary incontinence. Trial stimulation success did not differ by age in stage 1 and percutaneous nerve evaluation trials (p = 0.51 and 0.84, respectively). Logistic regression identified greater odds of trial success in females compared to males (OR 2.97, 95% CI 1.32-6.04, p = 0.009) and for urgency urinary incontinence compared to urgency-frequency (OR 3.02, 95% CI 1.39-6.50, p = 0.006). In analyzed patients there were 119 surgical revisions, including battery replacement, and 53 explantations. Age was associated with a decreased risk of revision with 3% lower odds per each additional year of age (OR 0.97, 95% CI 0.95-0.98, p<0.0001). While age did not influence explantation, for each body mass index unit there was a 5% decrease in the odds of explantation (OR 0.95, 95% CI 0.91-0.98). In contrast to previous studies, older patients experienced no difference in the sacral nerve stimulation response in stimulation trials and no difference in the implantation rate. Furthermore, age was modestly protective against device revision. This suggests that age alone should not negatively predict sacral nerve stimulation responses.

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction

ABSTRACTIntroduction: Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States.Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years.Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

Sacral neuromodulation for refractory overactive bladder after prior intravesical onabotulinumtoxinA treatment.

Sacral neuromodulation (SNM) is a well-established treatment modality for refractory overactive bladder (OAB). There is a paucity of evidence examining the use of SNM in patients who have received prior intravesical onabotulinumtoxinA (BTXA) treatment. We aim to review those patients who underwent SNM for refractory OAB following treatment with BTXA. A retrospective review was conducted to identify patients who had undergone prior intradetrusor BTXA for refractory OAB, then subsequent first-stage SNM. Patient demographics, number/dosage of BTXA, voiding diaries, and patient global impression of improvement (PGI-I) scores were recorded. Successful first-stage SNM was defined as subjective patient improvement of greater than 50%. Patient satisfaction and device use at last follow-up was noted. Eighty-three patients were identified having undergone SNM for OAB, of which 36 had prior BTXA treatment and were included in the series. 23/36 (63.9%) of patients had successful first-stage SNM, and underwent insertion of implantable pulse generator, compared to 33/47 (70.2%) in those who had never been treated with BTXA (P = 0.5). Mean PGI-I score was 2.6 (range 1-4). With a mean follow up of 29.1 months (range 12-53), 17/23 (73.9%) were satisfied, and using the device at last follow-up. SNM is a suitable treatment option in those patients who have had prior BTXA treatment for refractory OAB, even in those for whom BTXA proved ineffective. Success rates were within the published range, and comparable to our own results, for SNM in OAB patients without prior BTXA treatment.

Sacral Neuromodulation for the Treatment of Persistent Genital Arousal Disorder

Patients affected with persistent genital arousal disorder report unprovoked, excessive, and unremitting genital arousal unrelated to sexual desire. Those afflicted experience severe physical and psychological distress with significant feelings of shame, guilt, and frustration. Definitive treatment options for this disorder are limited. We present the case of a 32-year-old woman, gravida 1 para 1, with persistent genital arousal disorder after treatment of an uncomplicated urinary tract infection while in a military-deployed environment. After numerous treatment modalities failed, she responded to an implanted sacral neuromodulator. Persistent genital arousal disorder may be the result of upregulated sacral nerve pathways. We report the use of sacral neuromodulation using unique program settings, which may be an effective alternative in the treatment of this distressing disorder.

MP17-10 SACRAL NEUROMODULATION THERAPY IN PATIENTS WITH NEUROLOGIC LOWER URINARY TRACT DYSFUNCTION – SHOULD IT REMAIN AN OFF LABEL INDICATION? ANALYSIS OF 80 CONSECUTIVE CASES

INTRODUCTION AND OBJECTIVES: Although early Sacral Neuromodulation (SNM) trials excluded patients with neurologic lower urinary tract dysfunction (NLUTD), an increasing number of small studies show outcomes in these patients are similar to those without NLUTD. The use of SNM in NLUTD remains off label. The aim of this study was to compare SNM in patients with NLUTD to those without NLUTD and determine clinical factors associated with successful utilization of SNM. METHODS: A retrospective review of patients who underwent SNM between 2011 and 2015 was completed. Patients with a neurologic diagnosis in the electronic chart were identified and placed in the NLUTD cohort. Demographic and clinical characteristics of the NLUTD and non-NLUTD cohort were identified. Rates of progression to stage 2, revision and explant were analyzed. The data were examined using Pearson’s chi-square and Fisher exact tests as appropriate. RESULTS: Out of 412 patients, 80 (19.4%) had NLUTD at time of SNM with a mean age was 54 17 years. 75% of the NLUTD group was female (N1⁄460). The neurogenic diagnoses were: spinal cord injury 28.8% (N1⁄423), multiple sclerosis 23.8% (N1⁄419), Stroke 15% (N1⁄412), cerebral palsy12.5% (N1⁄410), peripheral nervous system disorders 12.5% (N1⁄410) and Parkinson’s disease 7.5% (N1⁄46). The primary indication for SNM was urgency incontinence in 62.5% of the NLUTD group (N1⁄450) and 59.5% in the non-NLUTD group (N1⁄4197). Progression to stage 2 SNM was similar in both groups, 90% in NLUTD versus 87% in non-NLUTD. Revision rates were higher in the NLUTD cohort compared to non-NLTUD, 46% versus 35%, but this trend did not reach statistical significance (p1⁄40.09). There was a statistically significant higher explant rate in the NLUTD group, 33% vs 20% (p1⁄40.0194) and the most common reason for explant in both groups was loss of efficacy. Progression to stage 2, revision rates, and explant rates for each type of neurologic diagnosis did not have any statistically significant difference. CONCLUSIONS: The primary indication for SNM in both NLUTD and non-NLUTD was urgency incontinence. The specific neurologic diagnosis is not predictive of SNM success, revision, or explants rates. However, patients with NLUTD appear more likely to need the device explanted when compared to patients with nonNLUTD.

Physician Use of Sacral Neuromodulation Among Medicare Beneficiaries With Overactive Bladder and Urinary Retention

To identify physician-level factors associated with high rates of sacral neuromodulation testing. We performed a retrospective cohort study using a 20% sample of national Medicare claims to identify physicians who performed sacral neuromodulation procedures between 2005 and 2010. Physician-level rates of device testing were determined based on the number of patients seen for overactive bladder and urinary retention diagnoses in the office in each calendar year. These rates were then used to fit a Poisson model to examine factors associated with high rates of device testing. The number of physicians performing test procedures increased 4-fold from 2005 to 2010. Average rates of test procedures increased from 4.0 to 6.4 procedures per physician per year (P <.001), whereas rates of device implantation remained stable (P = .23). Physicians who had higher rates of device testing were associated with lower rates of device implantation (estimate, -1.76, P <.01). Other predictors of physicians with higher test rates included more recent calendar year, testing done in any setting other than an ambulatory surgery center, gynecology subspecialty, and geographic location in the South and West (all P values <.01). Over time, physicians are testing more patients but are not implanting more devices. Additionally, there is an inverse relationship between rates of device testing and implantation, suggesting opportunities to improve efficiency and resource utilization.