Sacral neuromodulation for faecal incontinence - 10 years' experience at a Scottish tertiary centre

Infection Reducing Strategies in Sacroneuromodulation: A Systematic Review

OBJECTIVES

To determine the effect of infection-reducing strategies on postoperative complications for adult patients receiving sacroneuromodulation (SNM).

METHODS

A systematic search of PubMed, Web of Science, Embase, Ovid, various EBSCOHost databases, and ClinicalTrials.gov was initially performed on December 21, 2023, and updated on March 25, 2024. Studies with patients receiving SNM for any indication were included if they reported specific infection-reducing intervention(s) as well as at least one outcome(s) of interest (infection, device explant, or surgery-related complications). Abstracts and potentially relevant full-text manuscripts were double screened. The percentage of reported infections from each study was extracted and studies were categorized by interventions. Meta-analysis and meta-regression were used to characterize the impact of different interventions across studies. Time to infection and colonization results were extracted when available. The quality of studies was assessed using Grading of Recommendations Assessment, Development, and Evaluation criteria (GRADE).

RESULTS

Of 6172 abstracts screened, 16 studies met the inclusion criteria. An additional study that met inclusion criteria but was published after the search was included based on editorial recommendation. Study sizes ranged from 23 to 1930 participants, with 5679 participants across all included studies. Most studies were retrospective, and overall, the evidence was low in quality. There was a wide range of infection rates after SNM (0%-22.2%). Fifteen studies reported preoperative antibiotics (commonly cefazolin, cefoxitin, vancomycin, gentamicin). Six studies reported antibiotics administered before and up to 7 days after surgery. Eight studies reported the use of specific irrigation solution at the time of SNM placement. One study reported on the use of an antimicrobial pouch at the time of SNM. Eleven studies reported on specific skin preparation solutions (chlorhexidine (CHG), iodine-based, or both). One study reported explant rate without specifically reporting the rate of infection. No difference in infection was clearly identified on pooled analysis between different skin preparation solutions (CHG based, iodine based, or both) or between major classes of preoperative antibiotics. In addition, no difference in the pooled infection rate was found between studies reporting pre- and postoperative antibiotics or irrigation solution compared to those that did specify these interventions. Time to infection was assessed with eight studies reporting time to infection < 3 months, three studies reporting time to infection > 3 months, and five studies did not specify the time to infection.

CONCLUSION

There was significant heterogeneity among included studies regarding specific antibiotic or infection-reducing interventions. We recommend surgeons use antibiotics based on availability, regional antibiotic resistance, and patient colonization factors until higher level evidence is available.

TRIAL REGISTRATION

PROSPERO (CRD42024498513).

Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome

PURPOSE

Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up.

METHODS

A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS.

RESULTS

Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings.

CONCLUSIONS

SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.

Sacral nerve modulation for faecal incontinence: influence of age on outcomes and complications. A multicentre study

AIM

Faecal incontinence is frequent in the elderly. Little is currently known about the efficacy of sacral nerve modulation (SNM) in the elderly. The present study aimed to assess the impact of age on the outcome of SNM and on the surgical revision and explantation rates by comparing the results of a large data set of patients.

METHOD

Prospectively collected data from patients who underwent an implant procedure between January 2010 and December 2015 in seven French centres were retrospectively evaluated. In total, 352 patients [321 women; median age (range): 63 (24-86) years] were included. Clinically favourable and unfavourable outcomes, and surgical revision and explantation rates, were compared according to the age of the patients.

RESULTS

A similar outcome was observed when comparing patients < 70 years and ≥ 70 years (a favourable outcome in 79.2% and 76.2%, respectively, P = 0.89). The probability of a successful treatment as a function of time was similar for the two age groups (< 70 years and ≥ 70 years, P = 0.54). The explantation and revision rates were not influenced by age (explantation rate: 17% in patients < 70 years vs 14% in patients ≥ 70 years, P = 0.89; and revision rate: 42% in patients < 70 years vs 40% in patients ≥ 70 years, P = 0.89). The probability of explantation as a function of time was similar for the two age groups (P = 0.82). The limitations of this study were its retrospective status, the rate of loss at follow-up and different durations of patient follow-up.

CONCLUSIONS

Our results suggest that patients ≥ 70 years suffering from faecal incontinence benefit from SNM with a similar risk as a younger population.

Can incontinence be cured? A systematic review of cure rates

BACKGROUND

Incontinence constitutes a major health problem affecting millions of people worldwide. The present study aims to assess cure rates from treating urinary (UI) or fecal incontinence (FI) and the number of people who may remain dependent on containment strategies.

METHODS

Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, and PEDro were searched from January 2005 to June 2015. Supplementary searches included conference abstracts and trials registers (2013-2015). Included studies had patients ≥ 18 years with UI or FI, reported treatment cure or success rates, had ≥ 50 patients treated with any intervention recognized in international guideline algorithms, a follow-up ≥ 3 months, and were published from 2005 onwards. Title and abstract screening, full paper screening, data extraction and risk-of-bias assessment were performed independently by two reviewers. Disagreements were resolved through discussion or referral to a third reviewer where necessary. A narrative summary of included studies is presented.

RESULTS

Most evidence was found for UI: Surgical interventions for stress UI showed a median cure rate of 82.3% (interquartile range (IQR), 72-89.5%); people with urgency UI were mostly treated using medications (median cure rate for antimuscarinics = 49%; IQR, 35.6-58%). Pelvic floor muscle training and bulking agents showed lower cure rates for UI. Sacral neuromodulation for FI had a median cure rate of 38.6% (IQR, 35.6-40.6%).

CONCLUSIONS

Many individuals were not cured and hence may continue to rely on containment. No studies were found assessing success of containment strategies. There was a lack of data in the disabled and in those with neurological diseases, in the elderly and those with cognitive impairment. Surgical interventions were effective for stress UI. Other interventions for UI and FI showed lower cure rates. Many individuals are likely to be reliant on containment strategies.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42015023763 .