Tom Marcelissen

Sacral Neuromodulation as a Treatment for Chronic Pelvic Pain

PURPOSEnChronic pelvic pain syndrome is a debilitating disease which often has a major impact on quality of life. A significant number of patients do not respond to conservative treatment and often no good alternative can be offered except radical surgery. Sacral neuromodulation is a well established therapy for patients with lower urinary tract dysfunction. This therapy has also been suggested to be useful in the treatment of chronic pelvic pain. Although currently no Food and Drug Administration approval exists for this indication, several studies have demonstrated promising results. We provide an overview of the published literature on sacral neuromodulation as a treatment for chronic pelvic pain.nnnMATERIALS AND METHODSnA PubMed® search was performed to identify articles in English from 1990 to February 2010 reporting treatment of pelvic pain with sacral neuromodulation. In addition, the current definitions of pelvic pain syndromes and the mechanisms of action are discussed.nnnRESULTSnA total of 12 relevant articles were identified. Of these articles 10 mainly addressed the efficacy of sacral neuromodulation in patients with interstitial cystitis/bladder pain. The percentage of patients who responded to test stimulation was reported between 51% and 77%. Of the 10 articles 7 reported treatment outcome after implantation. The duration of followup ranged between 5 and 87 months. The mean reduction in pain scores was reported between 40% and 72%. The reoperation rate ranged between 27% and 50% after long-term followup. Two articles included patients with miscellaneous urogenital pain syndromes. The success rates after implantation ranged from 60% to 77% with followup ranging between 19 and 36 months.nnnCONCLUSIONSnCurrently there is insufficient evidence to determine the role of sacral neuromodulation in the treatment of chronic pelvic pain. Larger prospective trials with long-term evaluation are required to determine the ultimate efficacy of this treatment.

Long-Term Results of Sacral Neuromodulation With the Tined Lead Procedure

PURPOSEnWe present long-term followup data on the outcome of sacral neuromodulation using the tined lead procedure.nnnMATERIALS AND METHODSnWe conducted a single center study including all patients who received an implantable neurostimulator between 2002 and 2005 using the tined lead technique. Treatment efficacy was evaluated by comparing the data of a 3-day voiding diary filled out in May 2009 to the data before the onset of sacral neuromodulation treatment (baseline). Clinical success was defined as more than 50% improvement in at least 1 of the relevant voiding diary parameters.nnnRESULTSnA total of 64 patients underwent implantation with an implantable neurostimulator using the tined lead procedure. Mean followup was 53 months (range 35 to 77). Five patients died of causes unrelated to sacral neuromodulation and they were not included in analysis. The implantable neurostimulator was removed from 7 patients and 3 stopped using the neurostimulator. Voiding diary analysis showed that 38 of 59 patients (64%) were successfully treated. There were 21 patients (33%) who underwent a surgical revision due to an adverse event and 1 (1.6%) who underwent lead revision because of suspected lead migration.nnnCONCLUSIONSnSacral neuromodulation with the tined lead procedure is a safe and effective treatment for patients with overactive bladder symptoms or urinary retention.

The Use of Bilateral Sacral Nerve Stimulation in Patients With Loss of Unilateral Treatment Efficacy

PURPOSEnWe evaluated whether bilateral sacral nerve stimulation can be effective to restore treatment efficacy in patients in whom unilateral sacral neuromodulation fails.nnnMATERIALS AND METHODSnPatients in whom unilateral sacral neuromodulation failed were included in analysis. The percutaneous nerve evaluation test was used to evaluate the effect of contralateral and bilateral stimulation. The stimulation electrode was placed in the contralateral S3 foramen and symptoms were self-recorded using a 3-day voiding diary. Clinical success was defined as more than 50% improvement in at least 1 relevant voiding diary parameter vs baseline.nnnRESULTSnThe 15 study patients underwent test stimulation with percutaneous nerve evaluation. In 3 patients lead migration was suspected and, thus, they were not included in analysis. Four of the remaining 12 patients had a successful response to percutaneous nerve evaluation, of whom 3 were eventually implanted with a contralateral lead. After 12 months of treatment 2 of the 3 patients had a successful outcome.nnnCONCLUSIONSnIn this pilot study only a select group of patients appeared to benefit from bilateral stimulation after unilateral therapy failure. Further investigation is needed to determine the predictive factors and cost-effectiveness of this treatment.

Sacral neuromodulation in patients with idiopathic overactive bladder after initial botulinum toxin therapy.

PURPOSEnWe evaluated whether patients with overactive bladder and incontinence who discontinued intravesical botulinum toxin therapy can be successfully treated with sacral neuromodulation.nnnMATERIALS AND METHODSnAll patients who were referred to our center after discontinuation of botulinum toxin-A between 2005 and 2010 were included in this observational study. All patients underwent test stimulation with sacral neuromodulation and were evaluated with voiding diaries. Success was defined as more than 50% improvement in leakage episodes. Successful test stimulation was subsequently followed by a definitive implant. Patient satisfaction with sacral neuromodulation therapy was evaluated 1 year after the definitive implant.nnnRESULTSnA total of 20 patients were included in the study. Of these patients 17xa0(85%) had discontinued botulinum toxin-A because of lack of efficacy and 3xa0had been treated successfully with botulinum toxin-A but requested a more permanent solution. The mean interval between the botulinum toxin-A and the sacral neuromodulation test stimulation was 23 months. In 14 patients (70%) thexa0test stimulation was successful and they received a definitive implant. Of the 14xa0patients 5 even showed a decrease of greater than 90% in leakage episodes. One year after implantation 11 patients (79%) were satisfied with the sacral neuromodulation treatment.nnnCONCLUSIONSnDespite the small sample size, this study indicates that patients who are dissatisfied with or in whom botulinum toxin-A treatment fails can respond successfully to sacral neuromodulation. The success rate of the test stimulation was comparable to that of patients who have never been treated with botulinum toxin-A. The 1-year satisfaction rate was comparable that of patients without a history of botulinum toxin-A treatment.

Is the Screening Method of Sacral Neuromodulation a Prognostic Factor for Long-Term Success?

PURPOSEnWe evaluated whether there is a difference in long-term outcomes between patients screened with percutaneous nerve evaluation and a first stage tined lead procedure. We also evaluated the outcome in patients who only responded to screening with the tined lead procedure after failed initial percutaneous nerve evaluation.nnnMATERIALS AND METHODSnWe evaluated all patients screened for eligibility to receive sacral neuromodulation treatment since the introduction of the tined lead technique in our center in 2002. In May 2009 all implanted patients were asked to maintain a voiding diary to record the effect of sacral neuromodulation on urinary symptoms. Chi-square analysis was used to evaluate differences in the long-term outcomes of the separate screening methods.nnnRESULTSnA total of 92 patients were screened for sacral neuromodulation. Of the 76 patients screened with percutaneous nerve evaluation 35 (46%) met the criteria for permanent implantation. In 11 of the 16 patients (69%) who underwent direct screening with the tined lead procedure permanent stimulators were placed. Of the 41 patients in whom percutaneous nerve evaluation failed and who subsequently underwent screening with tined lead procedure 18 (44%) were implanted with a neurostimulator after a successful response. Statistical analysis showed no difference between screening type and long-term success (p = 0.94).nnnCONCLUSIONSnThe first stage tined lead procedure is a more sensitive screening tool than percutaneous nerve evaluation but long-term success seems to be independent of the screening method. Patients in whom percutaneous nerve evaluation initially failed but who responded to prolonged screening the with tined lead procedure appeared to be as successful as those who directly responded to percutaneous nerve evaluation or the tined lead procedure.

Is on-demand sacral neuromodulation in patients with OAB syndrome a feasible therapy regime?†‡

Sacral neuromodulation (SNM) of the lower urinary tract has proven to be safe and effective in patients with complaints of OAB syndrome who are not responding to conservative therapy. After 5 years of treatment the implanted system is still effective in 56–71% of patients. The loss of effect could be caused by adaptation of the nerve system to prolonged stimulation of the sacral nerves.

The efficacy of botulinum toxin A and sacral neuromodulation in the management of interstitial cystitis (IC)/bladder pain syndrome (BPS), what do we know? ICI-RS 2017 think thank, Bristol

This manuscript aims to address the evidence availale in the literature on the efficacy of Botulinum Toxin A (BoNT‐A) and sacral neuromodulation (SNM) in patients suffering from Interstitial Cystitis (IC)/BPS and propose further research to identify mechanisms of action and establish the clinical efficacy of either therapy.

Do we understand voiding dysfunction in women? Current understanding and future perspectives: ICI-RS 2017

Urinary retention in women is poorly understood, compared to the equivalent condition in men, and was the subject of a dedicated session organized at the International Consultation on Incontinence Research Society (ICI‐RS) in Bristol, United Kingdom, 2017.

What is the exact working mechanism of botulinum toxin A and sacral nerve stimulation in the treatment of overactive bladder/detrusor overactivity? ICI-RS 2017.

Botulinum toxin A (BTX‐A) and sacral nerve stimulation (SNS) are established treatments for overactive bladder (OAB) and are standard of care in refractory cases in international guidelines. Despite long term use over decades their “exact” working mechanisms are not entirely clear. At the ICI‐RS meeting in Bristol in 2017 a think tank was convened to address the question.

What Is New with Sexual Side Effects After Transurethral Male Lower Urinary Tract Symptom Surgery

Transurethral resection of the prostate as well as laser prostatectomy (by either holmium laser enucleation of the prostate or Greenlight laser vaporization) is associated with risks of sexual dysfunction such as antegrade ejaculation and occasionally erectile dysfunction. While ejaculation-sparing variations of these techniques show promising results, larger multicenter studies are needed to confirm promising data. Prostatic urethral lift maintains erectile and ejaculatory function at 5-yr follow-up. The same is true for the 3-yr data on the Rezum system. Recently, Aquablation has shown promising results; however, these 6-mo data need to be confirmed during longer follow-up. An individualized, shared decision-making process based on clinical parameters and patient preference is warranted to select the ideal treatment option for each patient.nnnPATIENT SUMMARYnSexual dysfunction such as loss of ejaculation and, less frequently, erectile dysfunction can occur after transurethral prostate surgery. Ejaculation-sparing modifications as well as minimally invasive alternatives show promising results. An individualized approach is warranted to select the ideal technique for each patient.