Identification of Perioperative Risk Factors for Early Sacral Nerve Stimulator Explantation: A Single-Center Retrospective Cohort Study

Background: Sacral nerve stimulators (SNSs) can be an effective treatment for urinary incontinence. However, with a failure rate of up to 50%, an explantation rate of up to 16%, and a cost of ~USD 10,000 per implant, identification of patients at high risk for explantation is necessary to improve patient satisfaction and reduce the economic burden on the healthcare system. The objective of this retrospective cohort study was to determine predictors of SNS explantation within the first two years of device placement. Methods: The MOVER database was queried for patients with a SNS and at least two years of follow-up (n = 54). Multivariate logistic regression was performed to assess risk factors for explantation. Factor optimization was used to eliminate factors with limited predictive value. Results: The model displayed excellent performance with an AUC of 0.93 (95% CI: 0.78-1.00) and an f1-score of 0.81. Female sex (OR: 3.75; CI: 3.71-3.79), malignancy (OR: 3.14; CI: 3.10-3.18), ASA score (OR: 2.53; CI: 2.50-2.57), peripheral neuropathy (OR: 2.04: CI: 2.01-2.07), alcohol use (OR: 1.98; CI: 1.96-2.01), and length of stay (OR: 1.47; CI: 1.45-1.49) displayed statistically significant increased risk of explantation. Atrial fibrillation (OR: 0.36; CI: 0.35-0.36) and chronic kidney disease (OR: 0.54; CI: 0.53-0.54) were included in the model but conferred decreased risk of explantation. Conclusions: Patient ASA score and a medical history of malignancy, peripheral neuropathy, and alcohol use are possible novel risk factors for SNS explantation.

Changes in the Patient-Reported Outcomes Measurement Information System (PROMIS) scores following sacral neuromodulation for lower urinary tract symptoms

Background

Sacral neuromodulation (SNM) treatment of refractory urinary symptoms is associated with quality of life improvements using disease-specific instruments. There is a paucity of information relating universal health outcomes to effective treatment of urinary symptoms. The objective was to analyze changes in Patient-Reported Outcomes Measurement Information System (PROMIS) item-bank scores following SNM for treating refractory lower urinary tract symptoms (LUTS).

Materials and methods

This is a sub-analysis collected from an institutional review board approved, retrospective chart review evaluating changes between pre- and post-procedure PROMIS scores in subjects undergoing successful SNM implantation for refractory LUTS at a multidisciplinary adult continence clinic. The difference between pre- and post-procedure PROMIS scores was compared via two-sided Wilcoxon signed-rank test, with p <0.05 considered statistically significant.

Results

Of the 29 subjects, most were female (89.66%), Caucasian (68.97%), nonsmokers (89.66%) with public insurance (62.07%). The median age was 63years and body mass index was 33.2kg/m2. Procedure indications included urinary urge incontinence (83%), mixed urinary incontinence (10%), retention (17.24%), and overactive bladder (3%). Pain Interference and Depression scores had a nonsignificant improvement from 64.2 (ranging 58.9-67.5) to 60.75 (ranging 55.2-67.2), p = 0.21, and 55.2 (ranging 51.5-59.9) to 53.4 (ranging 49.5-61.1), p = 0.33, respectively. Median Physical Function scores demonstrated nonsignificant worsening following implantation from 38.0 (ranging 34.7-40.9) to 36.1 (ranging 33.1-40.8) (p = 0.25). Twenty-one subjects (72%) reported an improvement in at least 1 PROMIS item-bank with 6 subjects (21%) reporting no improvement in any of the item-banks.

Conclusions

Treatment of refractory LUTS with SNM resulted in no statistically significant changes in the PROMIS item-banks of Physical Function, Pain Interference, or Depression. Further prospective investigation is necessary to delineate the relationship of the self-reported universal-health outcomes in the treatment of LUTS.

Treatment of the infected sacral nerve stimulator: A scoping review

BACKGROUND

Sacral nerve stimulators (SNSs) are a widely accepted, efficacious surgical option to treat patients who have failed conservative management for overactive bladder, nonobstructive urinary retention, fecal incontinence, or pelvic pain. As with all implanted devices, there are associated risks for surgical site and implant infections. There are currently no clear published data or guidelines regarding treating such infections.

AIMS

We present a scoping review aiming to examine the existing literature on the treatment approaches of infected SNSs.

METHODS

A scoping review was conducted using Preferred Reporting Items for Systematic Review and Meta-Analysis. The search strategy focused on "sacral modulation," and "infection," and "explantation," and conservative management methods such as "antibiotics." A search was conducted on medical databases, and a grey literature search was performed.

RESULTS

Thirty articles were included for data extraction. Articles were published between 2006 and 2022. Outcomes were reported for 7446 patients. Two hundred and seventy-four infection events were reported, giving an overall 3.7% infection rate. Most infection events were treated with explantation, although there is some discussion on the role of conservative management using oral and intravenous antibiotics in the literature. Articles also discussed considerations for future reimplantation after explantation of SNS.

CONCLUSIONS

There are currently no treatment protocols in the literature to help guide whether a patient is suited to conservative or surgical management. There is future scope for developing treatment algorithms to guide clinicians for optimal treatment of infected sacral neuromodulation devices.

Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study

BACKGROUND

Fecal incontinence (FI) is an involuntary passage of fecal matter which can have a significant impact on a patient's quality of life. Many modalities of treatment exist for FI. Sacral nerve stimulation is a well-established treatment for FI. Given the increased need of magnetic resonance imaging (MRI) for diagnostics, the InterStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility. Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used.

AIM

To evaluate the efficacy, outcomes and complications of the MRI-compatible InterStim.

METHODS

Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport, University of Minnesota, Advocate Lutheran General Hospital, and University of Wisconsin-Madison was pooled and analyzed. Patient demographics, clinical features, surgical techniques, complications, and outcomes were analyzed. Strengthening the Reporting of Observational studies in Epidemiology(STROBE) cross-sectional reporting guidelines were used.

RESULTS

Seventy-three patients had the InterStim implanted. The mean age was 63.29 ± 12.2 years. Fifty-seven (78.1%) patients were females and forty-two (57.5%) patients had diabetes. In addition to incontinence, overlapping symptoms included diarrhea (23.3%), fecal urgency (58.9%), and urinary incontinence (28.8%). Fifteen (20.5%) patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement. Thirty-two (43.8%) patients underwent rechargeable InterStim placement. Three (4.1%) patients needed removal of the implant. Migration of the external lead connection was observed in 7 (9.6%) patients after the stage I procedure. The explanation for one patient was due to infection. Seven (9.6%) patients had other complications like nerve pain, hematoma, infection, lead fracture, and bleeding. The mean follow-up was 6.62 ± 3.5 mo. Sixty-eight (93.2%) patients reported significant improvement of symptoms on follow-up evaluation.

CONCLUSION

This study shows promising results with significant symptom improvement, good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI. Further long-term follow-up and future studies with a larger patient population is recommended.

Reprogramming Sacral Neuromodulation for Sub-Optimal Outcomes: Evidence and Recommendations for Clinical Practice

Objectives

In some patients treated for urinary or fecal incontinence with sacral neuromodulation (SNM) persistence of symptoms, a reduction in efficacy or adverse effects of stimulation can occur. In such situations, further programming of the SNM device can help resolve problems. Infrequently hardware failure is detected. This article aims to provide practical guidance to solve sub‐optimal outcomes (troubleshooting) occurring in the course of SNM therapy.

Materials and Methods

A systematic literature review was performed. Collective clinical experience from an expert multidisciplinary group was used to form opinion where evidence was lacking.

Results

Circumstances in which reprogramming is required are described. Actions to undertake include changes of electrode configuration, stimulation amplitude, pulse frequency, and pulse width. Guidance in case of loss of efficacy and adverse effects of stimulation, developed by a group of European experts, is presented. In addition, various hardware failure scenarios and their management are described.

Conclusions

Reprogramming aims to further improve patient symptoms or ensure a comfortable delivery of the therapy. Initial changes of electrode configuration and adjustment of stimulation parameters can be performed at home to avoid unnecessary hospital visits. A logical and stepwise approach to reprogramming can improve the outcome of therapy and restore patient satisfaction.

Removal of sacral neuromodulation quadripolar tined-lead using a straight stylet: description of a surgical technique

Background

Up to 7.5% of tined-lead removals in patients having sacral neuromodulation (SNM) therapy are associated with a lead breakage. It is still unclear what adverse effects can be caused by unretrieved fragments. The aim of our study was to describe the lead removal technique we have been using for the last 2 years in our centre.

Methods

We retrospectively enrolled patients who had lead removal between January 2018 and January 2020 using our standardized technique. The novelty of the technique is in the use of the straight stylet, which is available in the quadripolar tined-lead kit. The stylet gives the electrode greater stiffness, reducing interactions with surrounding tissues and probability of damage or breakage during removal.

Results

In 59 patients (42 women, mean age 57.2 years [range 40–79 years]) the lead was removed using our standardized technique. In 44 of 59 patients, the tined-lead was removed within 2 months from the SNM-test, due to lack of beneficial effects. In 15 patients the electrode was removed because of failure of definitive implantation. Meantime from definitive implantable pulse generator (IPG) implantation to lead removal was 67.9 months. We recorded only 1 case of lead-breakage during removal: a female patient with a non-tined lead fixed on sacral bone, placed 18 years previously using an open technique.

Conclusions

Lead breakage during removal is not uncommon and adverse effects of retained fragments may occur. Our technique has been safely used for the last 2 years in our centre, with no episodes of lead breakage or retained fragments, except for one non-tined electrode.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-020-02403-6.

Electroceuticals in the Gastrointestinal Tract

The field of electroceuticals has attracted considerable attention over the past few decades as a novel therapeutic modality. The gastrointestinal (GI) tract (GIT) holds significant potential as a target for electroceuticals as the intersection of neural, endocrine, and immune systems. We review recent developments in electrical stimulation of various portions of the GIT (including esophagus, stomach, and small and large intestine) and nerves projecting to the GIT and supportive organs. This has been tested with varying degrees of success for several dysmotility, inflammatory, hormonal, and neurologic disorders. We outline a vision for the future of GI electroceuticals, building on advances in mechanistic understanding of GI physiology coupled with novel ingestible technologies. The next wave of electroceutical therapies will be minimally invasive and more targeted than current approaches, making them an indispensable tool in the clinical armamentarium.

Improvements in Self-Reported Depression Following Treatment of Fecal Incontinence with Sacral Neuromodulation

OBJECTIVE

To evaluate changes in self-reported depression after treatment of fecal incontinence (FI) with sacral neuromodulation.

MATERIALS AND METHODS

This is a subanalysis of data collected from March 2016 to October 2017 for an Institutional Review Board-approved retrospective cohort study. Demographic information, medical history, psychiatric comorbidities, and the Patient-Reported Outcomes Measurement Information System item bank t-scores were extracted from the electronic medical record. The differences in t-scores were compared with a two-sided paired t-test, and a p value <0.05 was considered statistically significant.

RESULTS

Of the cohort (n = 24), most were Caucasian (88%), female (92%), nonsmokers (92%). Median age was 63.5 years (interquartile range 57.5-71.0 years) and median body mass index was 27.7 kg/m² (range 18.3-42.9 kg/m² ). A significant decrease in mean depression t-scores occurred after implantation of a sacral neuromodulation device, -4.5 (95% confidence interval [CI]: -8.7, -0.2, p = 0.04). Self-reported pain interference (p = 0.37) and physical function (p = 0.47) scores were similar following implantation. Individuals with comorbid anxiety reported the greatest improvement in depression (-6.5, 95% CI: -11.8, -1.1, p = 0.02).

CONCLUSIONS

Treatment of FI with sacral neuromodulation was associated with improvement in self-reported depression with the greatest improvement in those with anxiety. Further prospective research is needed to corroborate these findings.