Sacral neuromodulation in the treatment of urgency-frequency symptoms: a multicenter study on efficacy and safety

PURPOSE: Neuromodulation of sacral nerves has shown promising results in correcting voiding dysfunction. We report the results of a multicenter trial designed to assess the efficacy of sacral nerve neuromodulation in patients presenting with refractory urinary urgency-frequency. MATERIALS AND METHODS: A total of 51 patients from 12 centers underwent baseline assessment, including a detailed voiding diary, urodynamic evaluation and percutaneous test stimulation of the sacral nerves at S3 and/or S4. All patients enrolled in the study had undergone prior conventional treatment, such as pharmacotherapy, hydrodistention and surgical intervention, which failed. All patients demonstrated a satisfactory response to trial stimulation and were randomly divided into a stimulation group (25 patients) and a control group (26). A sacral nerve stimulation device was implanted after 6 months in the control group. Patients were followed at 1, 3 and 6 months, and at 6-month intervals for up to 2 years after implantation of a neuroprosthetic InterStim* system. dagger The study variables included the number of voids daily, volume voided per void and degree of urgency before void. RESULTS: Compared to the control group, 6-month voiding diary results demonstrated statistically significant improvements (p <0.0001) in the stimulation group with respect to the number voids daily (16.9 +/- 9.7 to 9.3 +/- 5.1), volume per void (118 +/- 74 to 226 +/- 124 ml.) and degree of urgency (rank 2.2 +/- 0.6 to 1.6 +/- 0.9). Patients in the control group showed no significant changes in voiding parameters at 6 months. Significant improvements in favor of the stimulation group were noted in various parameters with respect to water cystometry and quality of life (SF-36). At 6 months after implant, neurostimulators were turned off in the stimulation group and urinary symptoms returned to baseline values. After reactivation of stimulation sustained efficacy was documented at 12 and 24 months. CONCLUSIONS: Neuromodulation of the sacral nerves is an effective, safe therapy that successfully treats significant symptoms of refractory urgency-frequency.     

Long-term effectiveness of sacral nerve stimulation for refractory urge incontinence

OBJECTIVES: To evaluate the long-term efficacy of sacral nerve stimulation for refractory urinary urge incontinence. STUDY DESIGN AND METHODS: Urge incontinent patients qualified for surgical implantation of a neurostimulator system after trial screening with percutaneous test stimulation. Surgical implantation of the InterStim System (Medtronic Inc., Minneapolis, Minn., USA) was performed in cases where a >50% reduction in incontinence symptoms was documented during the 3- to 7-day test stimulation period. The InterStim System consists of an implantable pulse generator, a transforamenally placed quadripolar lead, and an extension that connects these two devices for unilateral stimulation of the S3 or S4 sacral nerve. Efficacy for 96 implanted patients was based on urinary symptom changes as quantified in voiding diaries collected at baseline and annually after surgical implantation. RESULTS: As compared to baseline, the group of 96 implanted patients demonstrated significant reductions in urge incontinent symptoms at an average of 30.8+/-14.8 (range 12-60) months with respect to the number of urge incontinent episodes per day, severity of leaking, and the number of absorbent pads/diapers replaced per day due to incontinence (all p<0.0001, respectively). Gender, pretreatment variables, and age were not found to be relevant factors that affected these results. 11 of the 96 patients underwent device explant due to lack of efficacy, pain or bowel dysfunction. These data were conservatively included in the efficacy results. No permanent injuries associated with the devices or therapy were reported. CONCLUSION: Sacral nerve stimulation is an effective treatment for refractory urge incontinence with sustained long-term benefit through an average of 30.8 months.     

Bilateral caudal epidural neuromodulation for refractory urinary retention: a salvage procedure

PURPOSE: Sacral neuromodulation with InterStim is approved for idiopathic urinary retention with a success rate of approximately 69%. To our knowledge currently no alternatives exist for patients in whom S3 neuromodulation fails. We report a new technique and our experience with bilateral caudal epidural neuromodulation in patients in urinary retention in whom unilateral or bilateral S3 InterStim failed. MATERIALS AND METHODS: Eight patients with multifactorial urinary retention in whom S3 InterStim previously failed underwent retrograde placement of bilateral tined leads into the caudal epidural space for sacral nerve stimulation. Patients with a 50% or greater clinical response underwent stage 2 Synergy-Versitrel implantable pulse generator placement. Patients were evaluated with voiding diaries, the Urinary Distress Inventory Questionnaire short form, quality of life assessment, need for catheterization and post-void residual urine preoperatively, and 6 months after implantation. RESULTS: Five of the 8 patients experienced return of micturition and underwent placement of a permanent implantable pulse generator. At 6-month followup 4 of the 5 patients voided to completion. One patient improved more than 50% and now catheterizes once daily with a post-void residual urine of 200 cc. There was a significant decrease in obstructive symptoms on the Urinary Distress Inventory Questionnaire short form and improved overall quality of life. CONCLUSIONS: To our knowledge this is the first report of the use of bilateral caudal epidural neuromodulation for refractory urinary retention. This therapy can be successful in patients in whom prior InterStim therapy failed.     

Sacral nerve stimulation for treatment of refractory urinary urge incontinence. Sacral Nerve Stimulation Study Group.

PURPOSE: A prospective, randomized study was performed to evaluate sacral nerve stimulation for the treatment of refractory urinary urge incontinence. MATERIALS AND METHODS: Primary outcome variables were obtained from voiding diaries. After baseline evaluation candidates who satisfied inclusion criteria were enrolled into the study. Test stimulation results determined eligibility for randomization into a stimulation (treatment) or delay (control) group. The stimulation group included 34 patients who underwent implantation and were followed for 6 months. The delay group comprised 42 patients who received standard medical therapy for 6 months and then were offered implantation. The stimulation group completed a therapy evaluation test (on versus off) after 6 months. RESULTS: At 6 months the number of daily incontinence episodes, severity of episodes and absorbent pads or diapers replaced daily due to incontinence were significantly reduced in the stimulation compared to the delay group (all p<0.0001). Of the 34 stimulation group patients 16 (47%) were completely dry and an additional 10 (29%) demonstrated a greater than 50% reduction in incontinence episodes 6 months after implantation. Efficacy appeared to be sustained for 18 months. During the therapy evaluation test the group returned to baseline levels of incontinence when stimulation was inactivated. Urodynamic testing confirmed that sacral nerve stimulation did not adversely affect voiding function. Complications included implantable pulse generator site pain in 15.9% of the patients, implant site pain in 19.1% and lead migration in 7.0%. Surgical revision was required in 32.5% of patients with implants to resolve a complication. There were no reports of permanent injury or nerve damage. CONCLUSIONS: Sacral nerve stimulation is safe and effective in treating refractory urinary urge incontinence.     

Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study

PURPOSE: This 5-year, prospective, multicenter trial evaluated the long-term safety and efficacy of sacral neuromodulation in patients with refractory urge incontinence, urgency frequency and retention. MATERIALS AND METHODS: A total of 17 centers worldwide enrolled 163 patients (87% female). Following test stimulation 11 patients declined implantation and 152 underwent implantation using InterStim. Of those treated with implantation 96 (63.2%) had urge incontinence, 25 (16.4%) had urgency frequency and 31 (20.4%) had retention. Voiding diaries were collected annually for 5 years. Clinical success was defined as 50% or greater improvement from baseline in primary voiding diary variable(s). RESULTS: Data for all implanted cases were reported. For patients with urge incontinence mean leaking episodes per day decreased from 9.6 +/- 6.0 to 3.9 +/- 4.0 at 5 years. For patients with urgency frequency mean voids per day decreased from 19.3 +/- 7.0 to 14.8 +/- 7.6, and mean volume voided per void increased from 92.3 +/- 52.8 to 165.2 +/- 147.7 ml. For patients with retention the mean volume per catheterization decreased from 379.9 +/- 183.8 to 109.2 +/- 184.3 ml, and the mean number of catheterizations decreased from 5.3 +/- 2.8 to 1.9 +/- 2.8. All changes were statistically significant (p <0.001). No life threatening or irreversible adverse events occurred. In 102 patients 279 device or therapy related adverse events were observed. At 5 years after implantation 68% of patients with urge incontinence, 56% with urgency frequency and 71% with retention had successful outcomes. CONCLUSIONS: This long-term study demonstrates that InterStim therapy is safe and effective for restoring voiding in appropriately selected cases refractory to other forms of treatment.     

Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study

PURPOSE: The efficacy of sacral neuromodulation for the treatment of symptoms in patients with refractory interstitial cystitis was evaluated. MATERIALS AND METHODS: A total of 25 patients with a mean age of 47 years and refractory interstitial cystitis were prospectively evaluated with a trial of sacral nerve stimulation. Patients who demonstrated 50% improvement in frequency, nocturia, voided volume and average pain qualified for permanent sacral nerve stimulator implantation. Treatment success was measured by voiding diary, report of average pain, and response to the Interstitial Cystitis Symptom Index and Interstitial Cystitis Problem Index. RESULTS: Of the 25 patients 17 qualified for permanent sacral nerve stimulator implantation. At an average of 14 months followup mean daytime frequency and nocturia improved from 17.1 to 8.7 and 4.5 to 1.1, respectively (p <0.01). Mean voided volume increased from 111 to 264 ml. (p <0.01). Report of average pain decreased from 5.8 to 1.6 points on a scale of 0 to 10 (p <0.01). Interstitial Cystitis Symptom and Problem Index scores decreased from 16.5 to 6.8 and 14.5 to 5.4, respectively (p <0.01). Of the 17 patients 16 (94%) with a permanent stimulator demonstrated sustained improvement in all parameters at the last postoperative visit. CONCLUSIONS: Results of this prospective clinical study demonstrate that sacral neuromodulation is a safe and effective treatment for the dysfunctional voiding and pelvic pain in patients with interstitial cystitis who are refractory to other forms of treatment.     

Sacral neuromodulation for the treatment of refractory interstitial cystitis: outcomes based on technique

Patients with refractory interstitial cystitis (IC) underwent testing with sacral nerve modulation via either a traditional percutaneous approach or a staged procedure. Implanted patients were followed with scaled questionnaires and voiding diaries. Twenty-six patients who had a permanent InterStim placed had a reduction in 24-h voids of 51%. More than two-thirds of patients reported a moderate or marked improvement in urinary frequency, urgency, pelvic pain, pelvic pressure, incontinence and overall quality of life. The test to implant rate of a traditional percutaneous procedure was 52%, compared to a staged procedure of 94%. Assessing sensory response at the time of implant reduced the reoperation rate from 43% to 0%. Ninety-six per cent stated they would undergo an implant again and recommend the therapy to a friend. We concluded that sacral nerve modulation can treat refractory IC symptoms. The response to therapy and the reoperation rate are dependent on the technique used to test and implant the device.Abbreviations IC Interstitial cystitis - TENS Transcutaneous electrical nerve stimulation Editorial Comment: The authors nicely describe a very difficult subset of patients with interstitial cystitis. The patients in this paper have failed six prior treatment modalities before undergoing sacral neural modulation. In this small series the response to therapy and reoperation rate was dependent on the technique used to test and implant the device. Sacral neuromodulation using the staged technique does show significant benefit in the treatment of refractory interstitial cystitis.     

Sacral neuromodulation for nonobstructive urinary retention--is success predictable?

PURPOSE: We investigated whether there are factors which can predict successful stage II (permanent) sacral nerve stimulator (InterStim) implantation for patients with nonobstructive urinary retention. MATERIALS AND METHODS: We retrospectively reviewed our sacral neuromodulation database from January 1, 1999 to January 1, 2006. A total of 29 patients were referred to the William Beaumont Hospital Department of Urology for nonobstructive urinary retention. All patients completed a 3-day voiding log followed by test stimulation. Patients underwent test stimulation for a 2-week trial period. Those who experienced 50% improvement in void volume and/or catheterization frequency subsequently underwent permanent implantation. We reviewed patient charts with respect to age, sex, duration of retention, underlying diagnosis for retention and voiding ability. RESULTS: Of the 29 patients 15 were men and 14 were women. Mean patient age was 58.8+/-16 years (range 18 to 82). The mean age of the men in the study was 55.5+/-18 years while the mean age of the women was 62.3+/-14 years. Although all the patients performed intermittent self-catheterization 18 were able to void (more than 50 cc per void). The remaining 11 patients had minimal (50 cc or less) or no ability to void. Of the 18 patients who were able to void 12 (67%) underwent successful permanent implantation. However, voiding improved after test stimulation in only 2 of the 11 patients (18%) who had been unable to void. This difference was statistically significant (p=0.02) and suggests that pre-implantation ability to void can predict success of test stimulation. CONCLUSIONS: Patient ability to void predicts success of first stage test stimulation. Although we would still offer a trial of sacral neuromodulation to those with nonobstructive urinary retention and the inability to void, this study would allow better counseling regarding the likelihood of successful outcome.     

Sakrale Neuromodulation in der Urologie

Sacral nerve modulation (SNM) is an innovative, minimally invasive treatment that uses chronic low-level electrical stimulation of the sacral plexus to recruit residual physiological function of urinary bladder detrusor, pelvic floor muscles, and the anorectal continence structures. Classic indications for sacral neuromodulation in urology are refractory overactive bladder symptoms (urinary urgency ± incontinence) and chronic nonobstructive urinary retention. SNM also offers a therapeutic alternative in refractory chronic pelvic pain syndrome. The exact mechanism of action is still unknown, but it is assumed that electrical stimulation of the sacral nerves leads to neuromodulation as well as clinically beneficial effects in the pelvic floor, the sphincter complex, and the distal colorectum. SNM is a multistep procedure. In a test phase of so-called percutaneous or peripheral nerve evaluation (PNE), the effect of sacral neuromodulation is evaluated over days or weeks during which a bladder diary/pain protocol is kept. The predictive value of PNE is high, while morbidity and surgical trauma are low. The screening phase provided by PNE makes this technique unique and offers an ideal instrument for patient selection. After final implantation of the neurostimulator (InterStim II), the long-term success rate is over 60–90%. At our clinic, 42 patients underwent a PNE procedure between January 2009 and June 2010. Of these, 34 patients had a >50% success rate and had been implanted with the InterStim II device (80.9%). The success rates were 83% for overactive bladder and 89% for chronic retention (mean follow-up 7.8 months). In addition to the surgical procedure, the exact indication and postoperative care are important prerequisites of successful therapy. To date, no information on the number of implanted stimulators in Germany is available. This suggests the need for establishment of a national prospective registry. It would also be appropriate that the experts from the implantation centers form a working group.     

Preliminary results of sacral neuromodulation in 23 children

PURPOSE: Sacral nerve stimulation with InterStim is approved in the United States for use in adults. Limited data on the effectiveness of sacral nerve stimulation in children are available. We report our experience with patients who underwent InterStim placement for the treatment of severe dysfunctional elimination syndrome, which is defined as a constellation of functional urinary and gastrointestinal symptoms in patients without anatomical anomalies or obvious neurological disease, in whom intensive medical and behavioral therapies have failed to improve symptoms. MATERIALS AND METHODS: A total of 23 patients 6 to 15 years old with presenting symptoms of dysfunctional voiding, enuresis, incontinence, urinary tract infections, bladder pain, urinary retention, urgency, frequency, constipation and/or fecal soiling were followed for a mean of 13.3 months after InterStim placement. RESULTS: Of the 19 patients with urinary incontinence 3 (16%) had complete resolution, 13 (68%) had improvement, 2 (11%) were unchanged and 1 (5%) was worse (sign test, p = 0.002). Among the 16 patients with nocturnal enuresis 2 (13%) had resolution, 9 (56%) improved, 4 (25%) were unchanged and 1 (6%) was worse (sign test, p = 0.0063). Of the 15 patients with urinary retention requiring intervention 9 (60%) had improvement and 1 had worsening symptoms (sign test, p = 0.022), while 2 of 6 patients (33%) on intermittent catheterization were able to stop. One patient had development of new incontinence and enuresis. Bladder pain, urgency, frequency and constipation improved in 67% (8 of 12), 75% (12 of 16), 73% (11 of 15) and 80% (12 of 15) of the patients, respectively. Medications required postoperatively decreased by an average of 3 per patient (p < 0.001). The overall patient satisfaction rate was 64%, while that of the caregiver was 67%. Two leads were explanted from the 23 patients. Complications encountered included 1 seroma, 1 episode of skin sensitivity, 2 device failures and 1 lead revision. CONCLUSIONS: Sacral nerve stimulation in children is an option for carefully selected patients who have failed other therapies. Our results show that sacral nerve stimulation was effective in the majority of patients with the dysfunctional elimination syndrome. However, longer followup is needed.     

骶神经刺激治疗膀胱排尿功能障碍

目的：观察骶神经刺激治疗膀胱排尿功能障碍的疗效。方法：采用经皮穿刺刺激骶3神经治疗4例排尿功能障碍患者,其中1例接受永久性神经刺激器植入治疗。通过排尿日记及患者症状评价疗效。结果：3例难治性尿频尿急综合征的患者症状有显著改善,且排尿次数显著减少,平均排尿量增加,尿急程度减轻;另1例膀胱收缩无力患者无效。结论：骶神经刺激可以显著地改善部分患者膀胱排尿功能障碍。     

Sacral neuromodulation in functional urinary retention: an effective way to restore voiding

OBJECTIVE: To determine the long-term efficacy and complications of sacral nerve stimulation as an alternative therapy for functional unobstructive urinary retention, often considered to be psychogenic and effectively treated by clean intermittent catheterization, but for which pelvic floor dysfunction has been recognized as a possible cause. PATIENTS AND METHODS: Twenty patients (17 women and three men, mean age 48 years) with idiopathic, unobstructive functional urinary retention and in whom other forms of therapy had failed, had a pulse generator implanted (Medtronic, Minneapolis, MN, USA) and a sacral nerve implant. Their mean duration of symptoms was 68 months; 13 patients had chronic pelvic and perineal pain associated with their obstructive voiding symptoms. All patients were managed with clean intermittent catheterization and pharmacological therapy (alpha-blockers) before the procedure. All patients had a percutaneous nerve evaluation before the permanent implant, which showed> 50% improvement in their symptoms. All patients were evaluated at 1, 6 12, 18 and 24 months, then yearly thereafter. The results were assessed both subjectively by patient's symptoms and objectively by checking the postvoid residual volume (PVR) and voided volume. RESULTS: Eighteen patients were able to void spontaneously with a mean increase in voided volume from 48 to 198 mL, and a significant decrease in PVR from 315 to 60 mL. Eighteen of the patients had a > or = 50% improvement in their symptoms and said they would recommend the therapy to a friend or relative. Complications occurred in six patients. CONCLUSION: Sacral nerve stimulation is an effective and durable new approach to functional urinary retention, with few associated complications. Test stimulation provides a valuable tool for selecting patients.     

Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: long-term results of a prospective longitudinal study

PURPOSE: Conservative treatment rarely results in a durable cure of patients with urge incontinence and bladder overactivity. Instrumental and surgical procedures often have significant side effects and less than optimal results. We developed a technique of sacral nerve neuromodulation using chronic unilateral electrical stimulation of the S3 sacral nerve to inhibit the micturition reflex to provide effective nondestructive alternative therapy for patients whose condition is refractory to conservative treatment. MATERIALS AND METHODS: Of 85 patients 45 who responded to a test with a temporary electrode underwent implantation of a permanent S3 sacral nerve electrode coupled to a pulse generator. Treatment results were evaluated by urodynamic studies and voiding/incontinence diaries documenting pad use, incontinence episodes, voiding frequency and voided volume. Partial success and cure were defined as 50% to 90% and more than 90% improvement, respectively, in pad use and/or incontinence episodes. RESULTS: Of 45 patients 18 (40%) were cured at an average followup of 47.1 months and 9 (20%) achieved partial success. Median number of pads used and median number of incontinence episodes daily had decreased from 5.4 to 1.2 (p = 0.0001) and 7.1 to 1.3 (p = 0.0001), respectively, 6 months after implantation. Subsequently these results remained almost constant for 5 years. Bladder overactivity disappeared in 19 of the 44 patients (43%). The repeat intervention rate was 37.7% and there was no permanent injury or nerve damage. CONCLUSIONS: Sacral nerve neuromodulation is safe, effective and durable in patients with urge incontinence refractory to conservative treatment.     

Transcutaneous sacral neurostimulation for irritative voiding dysfunction

OBJECTIVE: Patients with irritative voiding dysfunction are often unresponsive to standard clinical treatment. We evaluated the response of such individuals to transcutaneous electrical stimulation of the third sacral nerve. METHODS: 32 patients with refractory irritative voiding dysfunction (31 female and 1 male; mean age 47 years) were recruited to the study. Ambulatory transcutaneous electrical neurostimulation was applied bilaterally to the third sacral dermatomes for 1 week. Symptoms of frequency, nocturia, urgency, and bladder pain were scored by each patient throughout and up to 6 months following treatment. RESULTS: The mean daytime frequency was reduced from 11.3 to 7.96 (p = 0.01). Nocturia episodes were reduced from a mean of 2.6 to 1.8 (p = 0.01). Urgency and bladder pain mean symptom scores were reduced from 5.97 to 4.89 and from 1.48 to 0.64, respectively. After stopping therapy, symptoms returned to pretreatment levels within 2 weeks in 40% of the patients and within 6 months in 100%. Three patients who continued with neurostimulation remained satisfied with this treatment modality at 6 months. CONCLUSIONS: Transcutaneous third sacral nerve stimulation may be an effective and noninvasive ambulatory technique for the treatment of patients with refractory irritative voiding dysfunction. Following an initial response, patients may successfully apply this treatment themselves to ensure long-term relief.     

Unilateral versus bilateral sacral neuromodulation in patients with chronic voiding dysfunction

PURPOSE: Bilateral sacral nerve neuromodulation has been proposed as a more effective treatment for chronic voiding dysfunction. However no comparison with the unilateral approach has been performed. We investigated the possible advantage of bilateral sacral neuromodulation. MATERIALS AND METHODS: In a prospective randomized crossover trial we investigated 33 patients who underwent bilateral implantation of a temporary test lead. Unilateral and bilateral test stimulation was continued for 4 to 6 days in all patients. Patients were randomly assigned to start with bilateral or unilateral stimulation. Between the stimulation episodes a 2-day washout interval was scheduled. Voiding diaries were completed at baseline and during the entire stimulation period. Sacral x-rays were taken to confirm lead positioning or possible migration after implantation and at the end of the test stimulation period. After 10 days the temporary leads were removed and voiding diaries were analyzed. RESULTS: After stimulation sacral x-ray revealed test lead migration in 8 patients, leaving 12 patients with urge incontinence and 13 with voiding difficulty and urinary retention available for review. A statistically significant improvement in voiding parameters was seen during the test stimulation period. However no statistically significant improvement was seen due to bilateral stimulation compared to unilateral stimulation. Two patients with urinary retention only started voiding to completion during bilateral stimulation. CONCLUSIONS: Bilateral is in general not superior to unilateral sacral neuromodulation. However, in some individuals bilateral stimulation may be more effective in relieving symptoms. Therefore, if unilateral percutaneous nerve evaluation fails, a bilateral test should be considered.     

SACRAL ROOT NEUROMODULATION IN IDIOPATHIC NONOBSTRUCTIVE CHRONIC URINARY RETENTION

Purpose

Sacral root neuromodulation is becoming a superior alternative to the standard treatment of idiopathic nonobstructive urinary retention. We report results in 20 successive patients who underwent sacral foramen implantation to restore bladder function.

Materials and Methods

After an initial, thorough baseline assessment 20 patients 19.43 to 55.66 years old with idiopathic nonobstructive urinary retention underwent percutaneous nerve evaluation. Response was assessed by a detailed voiding diary. Responders underwent implantation with an S3 foramen implant, and were followed 1, 3 and 6 months postoperatively, and every 6 months thereafter.

Results

Sacral root neuromodulation restored voiding capability in these patients. Bladders were emptied with minimal post-void residual urine, which decreased from 78.3 to 5.5 to 10.2% of the total voided volume from baseline to postoperative followup. These results were reflected in uroflowmetry and pressure-flow studies, which were almost normal after implantation. Furthermore, the urinary tract infection rate decreased significantly and associated pelvic pain improved substantially. The Beck depression inventory and SF-36 quality of life questionnaire indicated some improvement but reached significance in only 1 item. In addition, cystometrography showed no significant difference after 6 months of implantation compared with baseline values. Complications were minimal and within expectations.

Conclusions

Sacral root neuromodulation is an appealing, successful modality for nonobstructive urinary retention. Only patients who have a good response to percutaneous nerve evaluation are candidates for implantation. The high efficacy in patients who undergo implantation, relative simplicity of the procedure and low complication rate make this a treatment breakthrough in this difficult group.     

热淋清颗粒辅助治疗中重度慢性前列腺炎临床应用分析及体会

目的 探讨热淋清颗粒辅助治疗慢性前列腺炎的临床应用效果.方法 符合美国国立卫生研究院慢性前列腺炎诊断标准,NIH-CPSI疼痛评分≥10分,病程3个月至8年的患者102例,采用随机对照临床观察的研究方法分为两组,每组51例.对照治疗组:用敏感抗生素配合坐浴等物理治疗;热淋清辅助治疗组:在对照治疗的基础上,服用热淋清颗粒8g/次,3次/天,疗程6周.两组患者治疗前后进行NIH-CPSI评分以及前列腺液(EPS)白细胞检查,比较两种治疗的疗效.结果 对照治疗组和热淋清辅助治疗组患者治疗6周后,NIH-CPSI评分、EPS-WBC计数显示比治疗前均有所改善,差异具有统计学意义.热淋清辅助治疗组NIH-CPSI下降更为明显,总有效率为78.0％,对照组有效率57.1％,两组比较差异有统计学意义(x2=4.51,P＜0.05).结论 热淋清颗粒辅助治疗慢性前列腺炎,有较好的临床效用,有助于减轻患者的疼痛,利于提高患者的生活质量,其效果优于单纯西药治疗.     

Canadian experience in sacral neuromodulation

The application of sacral nerve modulation and stimulation has gained wide acceptance asa tool to enhance the control of voiding. The simplicity of the technique has made the therapy appealing for refractory cases of voiding dysfunction. The percutaneous screening test is mandatory for the success of the therapy. Long-term follow-ups have shown efficacy and safety inpatients with voiding dysfunction. Sacral nerve modulation is an effective modality in the treatment of various voiding and storage dysfunction. The tined lead offers a minimally invasive implant procedure. The simplicity of the procedure and the patient's sensory awareness help to ensure best lead placement. Furthermore, local anesthesia instead of general anesthesia allows faster patient recovery and reduces complications. Finally, sacral neuromodulation offers a modality in the management of patients with voiding dysfunction.     

Early versus late treatment of voiding dysfunction with pelvic neuromodulation

Introduction:

Pelvic neuromodulation is an established method of treating voiding dysfunction. Little is known about the pathophysiology associated with voiding dysfunction. Reports have suggested that a delay in treating patients with sacral neuromodulation therapy can impact the success rate of this type of treatment in voiding dysfunction. We examined patient response to pelvic neuromodulation when it was applied early versus late in the postdiagnosis of voiding dysfunction.

Methods:

We conducted a retrospective study of 42 patients (38 women and 4 men) with voiding dysfunction who underwent surgery for implant with the Interstim (Medtronic, Minneapolis, Minn.). Prior to implantation, patients were required to pass a percutaneous nerve evaluation (PNE) over a 1-week period. Patients were observed for 20–48 months postimplantation. All patients recorded their voiding parameters at baseline, after screening and every 6 months thereafter. Twenty patients (in the early group) underwent implant surgery with the neurostimulator 2–4 weeks post-PNE, and 22 patients (the late group) had the device implanted 6–24 months post-PNE owing to local logistical circumstances.

Results:

In the early group, 16 of 20 patients (80%) maintained a good response. In the late group, 13 of 22 (59%) patients showed a good response. Groups were well matched in terms of age, duration of voiding dysfunction and incidence of comorbidity.

Conclusion:

Patients who were delayed more than 6 months in receiving the neurostimulator implant showed a worse response than did patients who had the device implanted soon after PNE. This indicates the possibility of disease progression, which may limit the response to sacral neuromodulation.Sacral neuromodulation (SNM), using permanent foramen S3 electrode, offers an alternative treatment for patients with conditions refractory to conventional measures. SNM has been approved by the US Food and Drug Administration for 3 indications: urge incontinence (UI), urge frequency (UF) and nonobstructive urinary retention. Several reports have been published regarding the efficacy of SNM in the treatment of UI, UF and nonobstructive urinary retention.^1–4SNM is considered a minimally invasive procedure, and when compared with the more drastic procedures to control intractable overactive bladder symptoms, SNM has fewer complications and has provided patients with more durable and consistent bladder control over time.The purpose of the current study is to determine whether a delay in SNM can affect the long-term outcome of treatment in patients with voiding dysfunction.     

Failure of sacral nerve stimulation due to migration of tined lead

PURPOSE: Stimulation of the sacral nerves is a commonly used treatment for frequency, urgency, urge incontinence, retention and other types of voiding dysfunction. Minimally invasive placement of a percutaneous permanent quadripolar tined lead into the sacral foramen has been described. No lead migration has been reported. We report on our experience with lead migration and the subsequent failure of InterStim in a large cohort of patients with a focus on possible diagnostic and salvage techniques. MATERIALS AND METHODS: Between February 2002 and April 2005 tined lead electrodes were implanted in the S3 foramen in 235 patients using the InterStim system. Patients with a good response during the testing phase (greater than 50% improvement) underwent placement of an implantable pulse generator. Position was confirmed by radiographic evaluation intraoperatively. Sacral radiographs were obtained at the first postoperative visit, after IPG placement and whenever there was a change in symptomatic response. RESULTS: There were 5 patients (2.1%) in whom treatment failed after a successful trial of stimulation due to lead migration. This was seen as early as 3 weeks and as late as 8 months. Migration of the lead occurred between first and second stage implantation in 1 of the 5 cases, and occurred after the second stage in 4 of 5. Anterior migration was noted in 4 patients and posterior migration was noted in 1. CONCLUSIONS: Lead migration after placement of the tined lead can occur and thus sacral radiographs should be routinely used. This complication can be easily resolved without significant morbidity to the patient.