The Impact of Fluoroscopy During Percutaneous Nerve Evaluation on Subsequent Implantation of a Sacral Neuromodulator Among Women With Pelvic Floor Disorders: A Randomized, Noninferiority Trial

Supplemental Lidocaine Patches Prior to Percutaneous Nerve Evaluation, a Randomized Trial

IMPORTANCE

Improving patient comfort during percutaneous nerve evaluation (PNE), a trial procedure for sacral neuromodulation, is essential.

OBJECTIVE

The aim of the study was to determine whether the use of a lidocaine patch (LP) prior to PNE procedure improves the pain associated with PNE.

STUDY DESIGN

This double-masked, randomized controlled trial compared a 4% LP to placebo patch (PP) immediately prior to PNE. Female patients ≥18 years of age were included if they were undergoing an office PNE, performed bilaterally and without fluoroscopy, for any indication. Either a lidocaine or placebo patch was placed over the sacrum 30 minutes prior to PNE. Additional local anesthesia with 2% lidocaine without epinephrine was administered per surgeon discretion. All patients received some volume of injectable lidocaine with their procedures. Secondary outcomes included volume of injectable lidocaine used, progression to a permanent implant, amplitude of perineal sensation, and patient satisfaction.

RESULTS

Thirty-nine women were enrolled, with 20 receiving LP and 19 patients receiving PP. Lower 100-mm visual analog scale pain score was seen in the LP group (45 ± 17 with LP vs 61 ± 21 with PP, P = 0.018). This difference was statistically and clinically significantly different between groups. The total injectable lidocaine, patient satisfaction, and progression to permanent implant were similar between groups.

CONCLUSIONS

Patients experienced clinically and statistically significantly less pain at the time of PNE with a preprocedural LP when compared to placebo, despite similar use of local anesthetic. Satisfaction rates were high among all patients.

Baiona's Consensus Statement for Fecal Incontinence. Spanish Association of Coloproctology

Faecal incontinence (FI) is a major health problem, both for individuals and for health systems. It is obvious that, for all these reasons, there is widespread concern for healing it or, at least, reducing as far as possible its numerous undesirable effects, in addition to the high costs it entails. There are different criteria for the diagnostic tests to be carried out and the same applies to the most appropriate treatment, among the numerous options that have proliferated in recent years, not always based on rigorous scientific evidence. For this reason, the Spanish Association of Coloproctology (AECP) proposed to draw up a consensus to serve as a guide for all health professionals interested in the problem, aware, however, that the therapeutic decision must be taken on an individual basis: patient characteristics/experience of the care team. For its development it was adopted the Nominal Group Technique methodology. The Levels of Evidence and Grades of Recommendation were established according to the criteria of the Oxford Centre for Evidence-Based Medicine. In addition, expert recommendations were added briefly to each of the items analysed.

Prospective, multicenter study to evaluate performance and safety of a re-engineered temporary lead for InterStim™ therapy evaluation

AIMS

The basic evaluation or percutaneous nerve evaluation (PNE) is a method to assess pre-implantation therapeutic response in patients considering sacral neuromodulation for the treatment of refractory overactive bladder. A new PNE lead with a more robust design and greater distensibility designed to reduce the possibility of lead migration has recently been introduced to the market. The aim of this prospective, multicenter, global, postmarket study was to evaluate the clinical performance and safety of the new InterStim PNE lead with the foramen needle.

METHODS

Patients with overactive bladder were enrolled in this study. The primary objective of this study was to determine the proportion of subjects who demonstrated motor or sensory response(s) during lead placement using the InterStim PNE lead. Additional measures included the Patient Global Impression of Improvement (PGI-I), patient satisfaction at the end of therapy evaluation, and change in bladder symptoms from baseline to the end of therapy evaluation (1-week follow-up visit).

RESULTS

One-hundred and ten subjects met the inclusion and exclusion criteria and underwent a lead implant procedure. Of those, 108 had a successful procedure and 107 completed the 1-week follow-up visit. Ninety-nine percent of subjects (109/110) had a motor or sensory response during needle placement (95% confidence interval [CI]: 95%-100%) and 97% of subjects (107/110) had a motor or sensory response during lead placement (95% CI: 92%-99%). The majority of subjects (88%, 95/108) reported their bladder condition was better at the follow-up visit compared to before the PNE implant procedure, as reported in PGI-I. Subjects reported being satisfied with how the therapy impacted their voiding symptoms (82%, 88/108) and that they would recommend this therapy (87%, 94/108) to other patients. Symptom improvement was demonstrated with urinary urge incontinence subjects having an average of 4.2 ± 3.4 urinary incontinence episodes/day at baseline and 2.2 ± 2.5 at follow-up, and urinary frequency subjects having an average of 12.5 ± 4.4 voids/day at baseline and 10.5 ± 4.3 voids/day at follow-up. Lead removal was deemed to be easy and safe by the implanting physician, with a total of three adverse device effects in 3/110 subjects. No event was categorized as serious and all were resolved without sequelae.

CONCLUSIONS

The updated InterStim PNE lead with a more robust design and greater distensibility designed to reduce migration was shown to have a high rate of motor or sensory response during lead placement. Furthermore, subjects reported high rates of global improvements and amelioration of symptoms, and the lead was easy to remove with minimal morbidity.

Neuromodulation

Sacral neuromodulation (SNM) has been available in the United States for more than 20 years and is a guideline-recommended therapy by both the American Urological Association and the American Society of Colon and Rectal Surgeons, with proven long-term success for urinary urgency incontinence, urinary urgency frequency, nonobstructive urinary retention, and fecal incontinence. Initially the therapy involved a more invasive surgical approach that included a large cut down over the sacrum. This article reviews recent advancements in SNM therapy including updates in best practices for implant technique, technological innovations, and the new clinical literature relevant to contemporary practice.