[Sacral neuromodulation for bladder voiding dysfunction: Experience at a French university center]. / Neuromodulation sacrée pour trouble de la vidange vésicale : expérience d'un centre universitaire français.

OBJECTIVE: To report the experience of a university hospital center with sacral neuromodulation for patients with bladder voiding disorders. MATERIAL AND METHODS: All patients who underwent sacral neuromodulation between 1998 and 2022 for bladder voiding disorders were included. Medical records were analyzed retrospectively, and population, efficacy and follow-up data were collected. RESULTS: A total of 134 patients underwent test implantation and 122 patients were analyzed. 68 patients (56%) were implanted with a definitive neuromodulation device. Mean age was 43±16 years and BMI 25.5±5.4kg/m2. 74% were women. Bladder voiding disorder was due to sphincter hypertonia in 51% of cases, with associated bladder hypocontractility in 29%. The spontaneous micturition rate after implantation increased from 34% to 92%. Implantation results appeared to be better in patients with sphincter hypertonia, whether or not associated with bladder hypocontractility. The benefit was most often present with a frequency of 5Hz (54.4%). Side-effects were present in 52% of cases at 5 years, and in 85% of cases were pain in relation to the implanted devices. They resolved under medical treatment or after revision of the device (27% of cases at 5 years). CONCLUSION: SNM is effective in micturition recovery, but has side effects. Urodynamic mechanism and etiology may provide clues for modulating NMS box settings and determining predictive factors for NMS success. Data from other centers are needed to identify reliable predictive factors.

Biofeedback therapy for children: What is the maximum number of sessions we should offer?

BACKGROUND: Biofeedback therapy is an effective but resource intensive treatment for pediatric dysfunctional voiding. Based on our center's experience, we evaluated the rate of clinical improvement from biofeedback in order to identify the maximum number of sessions to offer patients. METHODS: We reviewed 490 pediatric patients who underwent at least 6 sessions of biofeedback from 2013 to 2021. At each session, patients and their parents documented their urinary symptoms (urgency, frequency, pain, and difficulties with stream), incontinence, medications, and stool pattern. This longitudinal data was abstracted, and the log odds of urinary symptoms or incontinence was modelled with number of sessions as a predictor using generalized estimating equations and robust standard errors in SAS v9.4. Gender and bowel dysfunction were included as interactions terms. A logistic regression using absence of urinary symptoms at last biofeedback session as a dependent variable was done to further explore differences between genders. RESULTS: Patients were predominantly female (324/490, 66%) with a mean age of 8.9 years (SD 3.3 years). Most common symptoms at presentation were urinary urgency (389/490, 79%) and urinary incontinence (413/490, 84%). Medication use was common at the time of the first session (191/490, 39%) with males more likely to be on alpha-blockers (54/166 vs 1/324, p < 0.001) and females more likely to be on antibiotic prophylaxis (68/324 vs 2/166, p < 0.001). The probability of having urinary symptoms or incontinence decreased up to session 11 (9 months from initial visit). There was slower rate of improvement after session 8 (3 months). Controlling for age, symptoms, and medication use at initial visit, male patients were less likely to report symptom resolution at the time of the last session (OR 0.55, 95% CI 0.33, 0.89). The nadir for reporting symptoms occurred by session 22 for male patients, compared to session 10 for female patients. CONCLUSIONS: Clinical improvement from biofeedback for pediatric patients with dysfunctional voiding may take up to 9 months of therapy, but most cases that improve do so by 3 months. The effect of gender on biofeedback efficacy requires further study, but males may have slower response to biofeedback. Our data provides guidance on when maximum benefit from biofeedback can be expected before considering re-evaluation or other therapies for lower urinary tract symptoms.

Maintenance biofeedback therapy for dysfunctional voiding: Does every child need it?

OBJECTIVES: The aim of the present study is to analyze the long-term clinical outcomes in children who were treated with biofeedback therapy (BF) for dysfunctional voiding (DV) and to determine the need for maintenance of BF due to clinical relapse. METHODS: Files of children with DV who underwent BF between 2013 and 2020 were retrospectively reviewed. Patients with neurological or anatomical problems were excluded. A total of 64 patients (52 girls, 12 boys) with a mean age of 8.89 ± 2.48 years who completed the initial BF sessions were included in the study. The demographic and clinical data, dysfunctional voiding symptom scores (DVSS), and uroflowmetry parameters were recorded before and after the initial BF sessions. Clinical success was regarded as the cessation of electromyography activity as well as concurrent resolution of lower urinary tract symptoms and improvement in uroflowmetry parameters. After the initial BF sessions, children who had initial success showed DV relapse at any time during follow-up received the maintenance BF sessions. Therefore, the patients with successful initial BF were divided into two groups: the group that needed maintenance BF, and the group which required no maintenance BF. RESULTS: Clinical success was achieved in 48 (75.0%) of 64 children following a median of 6 sessions (range 2-8). At the follow-up, 10 (20.8%) out of 48 patients showed symptom relapse at a median of 8 months (range 2-24 months). After a median of 3.5 maintenance BF sessions (range 1-6), clinical success was observed in all patients. Both groups showed a significant DVSS decrease after initial BF, however, those who needed maintenance had significantly higher DVSS (6.80 ± 2.53 vs. 3.61 ± 1.12, p < 0.001). At admission, DVSS <17.5 (odds ratio [OR]: 4.31, p = 0.025) and post-voiding residual volume as a percentage of estimated bladder capacity for age <28.9 (OR: 5.00, p = 0.009) were found as the predictive factors for initial BF success. The need for maintenance BF was 2.56-fold higher with a DVSS above 5.5 after initial BF sessions. CONCLUSIONS: Our results show that despite a clinical success rate of 75% after the initial BF, relapse can be seen within 2 years in approximately 20% of the patients. Nevertheless, maintenance of BF may provide clinical success in all patients. Relatively higher DVSS after initial BF can be used as a predictor of the need for maintenance BF.

The effect of duration between sessions on biofeedback treatment in children with dysfunctional voiding.

OBJECTIVE: Biofeedback is an effective treatment in children with standard urotherapy-resistant dysfunctional voiding (DV). However, the duration of the session intervals is not standardized. We aimed to compare the effectiveness of daily and weekly sessions of biofeedback treatments. METHODS: The data of children who received biofeedback due to DV between March 2018 and May 2019 were retrospectively evaluated. The children were divided into two groups, one with daily and the other with weekly sessions. The voiding patterns in uroflowmetry (UF), maximum flow rate (Qmax), electromyography activity, postvoid residual volume (PVR), the ratio of voided volume to expected bladder capacity (EBC) (%), and Dysfunctional Voiding and Incontinence Scoring System (DVISS) were compared between the two groups. RESULTS: A total of 45 children (39 girls [86.6%] and 6 boys [13.3%]) were included in the study. The daily group consisted of 27 (60%) children and the weekly group of 18 (40%). Qmax, PVR, number of abnormal UF patterns, voiding volume/EBC, and DVISS scores were similar between the two groups before treatment. Voiding parameters improved statistically significantly in both groups following biofeedback, but there was no difference between the two groups. A statistical difference was found between the results of DVISS after treatment (P = .03). CONCLUSION: Both types of biofeedback treatment (daily and weekly) are effective methods that improve voiding parameters and DVISS values in children with DV. Therefore, the duration between sessions can be determined according to the suitability of the patient and the biofeedback unit.

Thoracolumbar epidural stimulation effects on bladder and bowel function in uninjured and chronic transected anesthetized rats.

Pre-clinical studies have shown that spinal cord epidural stimulation (scES) at the level of pelvic and pudendal nerve inputs/outputs (L5-S1) alters storage and/or emptying functions of both the bladder and bowel. The current mapping experiments were conducted to investigate scES efficacy at the level of hypogastric nerve inputs/outputs (T13-L2) in male and female rats under urethane anesthesia. As found with L5-S1 scES, T13-L2 scES at select frequencies and intensities of stimulation produced an increase in inter-contraction interval (ICI) in non-injured female rats but a short-latency void in chronic T9 transected rats, as well as reduced rectal activity in all groups. However, the detrusor pressure during the lengthened ICI (i.e., urinary hold) remained at a low pressure and was not elevated as seen with L5-S1 scES, an effect that's critical for translation to the clinic as high fill pressures can damage the kidneys. Furthermore, T13-L2 scES was shown to stimulate voiding post-transection by increasing bladder activity while also directly inhibiting the external urethral sphincter, a pattern necessary to overcome detrusor-sphincter dyssynergia. Additionally, select scES parameters at T13-L2 also increased distal colon activity in all groups. Together, the current findings suggest that optimization of scES for bladder and bowel will likely require multiple electrode cohorts at different locations that target circuitries coordinating sympathetic, parasympathetic and somatic outputs.

The effect of biofeedback treatment for children with non-neurogenic voiding dysfunction: A systematic review and meta-analysis.

BACKGROUND: Children's non-neurogenic voiding dysfunction (NVD) is a syndrome characterized by lower urinary tract symptoms (LUTs) because of the inability to relax the external sphincter. Patients with NVD always suffer from urinary tract infections (UTI), incontinence, constipation. The aim of this study is to assess the efficacy of biofeedback treatment for children's NVD. METHODS: PubMed, Embase, Cochrane library database were searched for all relevant studies. Two independent reviewers decided whether to include the study, conducted quality evaluation, and extracted article data. A random-effects model was used to calculate overall effect sizes. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. And sensitivity analysis was subsequently performed. RESULTS: Fifteen studies and 1274 patients were included in the systemic review, seven RCTs and 539 patients were included in meta-analysis. Meta-analysis showed efficacy of biofeedback treatment in following aspects, (1) relieving UTI (RR: 1.71, 95% CI: 1.11 to 2.64), (2) reducing PVR (MD: 9.51, 95% CI: 2.03 to 16.98), (3) increasing maximum urine flow rate (MD: 4.28, 95% CI: 2.14 to 6.42) and average urine flow rate (MD: 1.49, 95% CI: 0.53 to 2.46), (4) relieving constipation (RR: 1.59, 95% CI: 1.12 to 2.26)，(5) improving abnormal voiding pattern (RR: 1.75, 95% CI: 1.30 to 2.36) and abnormal EMG during voiding (RR: 1.55, 95% CI: 1.25 to 1.91). The improvement of UTI symptoms, maximum urine flow rate and average urine flow rate took a longer time (12 months). In terms of daytime incontinence (RR: 1.20, 95% CI [0.96, 1.50], p = 0.11), nighttime incontinence (RR: 1.20, 95% CI [0.62, 2.32], p = 0.58), no significant difference was found between biofeedback treatment and standard urotherapy. The qualitative analysis showed that biofeedback treatment was beneficial for NVD. CONCLUSION: Compared with standard urotherapy, biofeedback treatment is effective for some symptoms, such as UTI and constipation, and can improve some uroflowmetric parameters, such as PVR. Biofeedback treatment seems to have a better long-term effect.

Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding.

Dysfunctional voiding (DV), a voiding dysfunction due to hyperactivity of the external urethral sphincter or pelvic floor muscles leading involuntary intermittent contractions during voiding, is not uncommon in neurologically normal women with lower urinary tract symptoms (LUTS). We aimed to investigate the therapeutic efficacy of biofeedback pelvic floor muscle training (PFMT) in female patients with DV and to identify the therapeutic efficacy. Thirty-one patients diagnosed with DV. All participates completed the 3-month biofeedback PFMT program, which was conducted by one experienced physiotherapist. At 3 months after treatment, the assessment of treatment outcomes included global response assessment (GRA), and the changes of clinical symptoms, quality of life index, and uroflowmetry parameters. 25 (80.6%) patients had successful outcomes (GRA ≥ 2), and clinical symptoms and quality of life index significantly improved after PFMT. Additionally, uroflowmetry parameters including maximum flow rate, voided volume, voiding efficiency, total bladder capacity, voiding time, and time to maximum flow rate significantly improved after PFMT treatment. Patients with the history of recurrent urinary tract infection in recent 1 year were found to have unsatisfied therapeutic outcomes. In conclusion, biofeedback PFMT is effective in female patients with DV with significant improvements in clinical symptoms, quality of life, and uroflowmetry parameters. The history of urinary tract infection in recent 1 year is a negative predictor of successful outcome.

First Report of Magnetic Resonance Imaging in Patients with Implanted InterStim Twin (model 7427T) Sacral Nerve Stimulator.

PURPOSE: To detect possible effects of magnetic resonance imaging (MRI) scans on the function of an InterStim Twin sacral nerve stimulation (SNS) device and on patient's health. There is no authorization for MRI scans in InterStim Twin SNS at all. MATERIAL AND METHODS: 10 patients with Interstim Twin sacral nerve stimulator implants underwent a singular MRI scan. Before the MRI was performed, the SNS device function was evaluated and the device was deactivated be the implanting urologist. A continuous monitoring took place during MRI procedure. Micturition-time chart pre- and post MRI procedures were conducted. After the MRI session was completed, the implanted device was examined once more and reactivated, function then was evaluated. RESULTS: A total of 10 patients required MRI examinations in 8 different body regions. No patient reported pain or discomfort during and after the MRI scan. After reactivation of the InterStim Twin device following the MRI, impedances and stimulation amplitude, micturition frequency, urgency, and incontinence episodes remained stable. No significant differences between pre- and post MRI were found (p>0.05). CONCLUSION: This is the first report of patients successfully undergoing a MRI scan despite a previously implanted Interstim Twin sacral nerve stimulator. No negative effect of SNS function or negative side effects for the patients were observed.

Linac-based SBRT as a feasible salvage option for local recurrences in previously irradiated prostate cancer.

BACKGROUND AND OBJECTIVE: The optimal management of prostate cancer (PC) recurrences after definitive or postoperative radiotherapy (RT) is still controversial. The aim of the present retrospective study was to report the preliminary clinical results and toxicity of a mono-institutional series of patients re-irradiated with linac-based SBRT in recurrent prostate cancer. METHODS: Inclusion criteria were previous definitive or adjuvant/salvage RT, evidence of biochemical recurrence and radiological detection of local relapse (Magnetic Resonance Imaging or PSMA/choline-Positron Emission Tomography), and IPSS <10. Toxicity was assessed according to Common Terminology Criteria for Adverse Events v4.0. RESULTS: Between 12/2014 and 12/2019, 24 patients with median age 75 years (65-89) underwent re-RT for PC recurrence. Median follow-up was 21 months (2-68). The recurrences occurred in 13 cases within the prostate and in 11 cases within the prostate bed. All patients were treated with SBRT to a median total dose of 30 Gy (25-36 Gy) in 5-6 fractions, and simultaneous androgen deprivation therapy was administered in 4 patients. Acute toxicity was G1 in 8.3% and G2 in 12.5% for genitourinary (GU), no acute gastrointestinal (GI) toxicity occurred. Concerning late side effects, 19.7% of patients were found to have ≥G2 GU toxicity, including one G3 urethral stenosis. Only one case of G1 late GI toxicity occurred and no ≥G2. The 2­year overall survival was 95%. The 1­ and 2­year biochemical relapse-free survival (BRFS) and progression-free survival (PFS) rates were 80 and 54.9%, respectively. CONCLUSION: Despite of the heterogeneity of the sample, linac-based SBRT as a salvage treatment in previously irradiated locally recurrent PC patients seems to be a safe and feasible treatment option. Long-term data are pending.

Assessment and Management of Urinary Dysfunction in 187 Patients with Parkinson's Disease.

BACKGROUND: Urinary dysfunction is common in Parkinson's disease (PD) patients and management options are limited. OBJECTIVE: This study aimed to explore the management of urinary dysfunction by researching the special needs of PD patients. METHODS: PD patients with urinary dysfunction who underwent urodynamic testing were recruited from a single center from October 2013 to February 2019. The urinary symptoms, International Prostate Symptom Score and Hoehn-Yahr scale were evaluated. Management was made at the urologists' discretion with follow-up after three weeks. Urinary symptoms, urodynamics and the management of urinary dysfunction were analyzed. RESULTS: A total of 187 patients with a median age of 66.2 and Hoehn-Yahr scale soccer of 2 were enrolled. Irritative symptoms were more common than obstructive symptoms, while obstructive symptoms were more common in male than female patients, except for incomplete voiding. There were 51% cases of detrusor overactivity, followed by 33% with bladder outlet obstruction, 13% had normal function, 12% had detrusor underactivity, 9% had stress incontinence, 7% had increased bladder sensation and 4% had an acontractile bladder. Tolterodine and tamsulosin were the most common therapeutic agents, respectively prescribed to 38.5% and 27.3% of the patients. Other treatments included catheterization, botulinum toxin A bladder wall injection, transurethral resection of the prostate and urethral dilatation. Urinary symptoms were improved significantly in 74.5% of the patients (p < 0.001), including 27 patients treated with tamsulosin only and 54 patients with tolterodine only. CONCLUSIONS: Urinary symptoms and urodynamics were highly variable in PD patients, indicating that most patients may benefit from personalized management.

Linac-based stereotactic body radiation therapy for low and intermediate-risk prostate cancer : Long-term results and factors predictive for outcome and toxicity.

INTRODUCTION: Stereotactic body radiation therapy (SBRT) is considered an effective and safe treatment in patients with low- and intermediate-risk prostate cancer (PC). However, due to a lack of long-term follow-up and late toxicity data, this treatment is not universally accepted. The present study aimed to evaluate outcome and early and late toxicity in a cohort of patients with low- and intermediate-risk PC treated prospectively with linear accelerator (linac)-based SBRT. PATIENTS AND METHODS: Patients with low- or intermediate-risk (NCCN criteria) PC were included. All patients received linac-based SBRT to 35 Gy in 5 fractions delivered on alternate days. Endpoints were toxicity, biochemical relapse-free survival (BRFS), metastatic progression-free survival (mPFS), and overall survival (OS). RESULTS: From 2012 to 2018, 178 patients were treated. Median baseline prostate-specific antigen (iPSA) was 6.37 ng/ml (range 1.78-20). Previous transurethral resection of the prostate (TURP) was present in 23 (12.9%) patients. Median follow-up was 58.9 months (range 9.7-89.9). BRFS rates at 1, 3, and 5 years were 98.3 (95% confidence interval, CI, 94.7-99.4%), 94.4 (95%CI 89.4-97), and 91.6% (95%CI 85.4-95.2), respectively. In univariate analysis, performance status (PS), iPSA, and nadir PSA (nPSA) were correlated with BRFS. In multivariable analysis iPSA and nPSA remained significant. BRFS rates at 5 years were 94.9% (95%CI 86.8-98) for International Society of Urological Pathology (ISUP) grade group 1, 93.2% (95%CI 80.5-97.7) for ISUP group 2, and 74.8% (95%CI 47.1-89.5) for ISUP group 3. At 1, 3, and 5 years, mPFS rates were 98.8 (95%CI 95.5-99.7), 96.2 (95%CI 91.9-98.3), and 92.9% (95%CI 87.2-96.2), respectively; OS rates were 100, 97.2 (95%CI 92.9-98.9), and 95.1% (95%CI 90-97.6), respectively. One (0.56%) case of grade 3 acute genitourinary (GU), one case of acute gastrointestinal (GI), and one case of grade 3 late GU toxicity were observed. GI toxicity positively correlated with prostate volume. CONCLUSION: At long-term follow-up, linac-based SBRT continues to be a valid option for the management localized PC. Biochemical control remains high at 5 years, albeit with some concerns regarding the optimal schedule for unfavorable intermediate-risk PC. Considering the excellent prognosis, patient selection is crucial for prevention of severe late toxicity.

Rehabilitation strategies for low anterior resection syndrome. A systematic review.

OBJECTIVE: To summarize the evidence in the literature about rehabilitative treatments that reduce low anterior resection syndrome (LARS) symptoms in patients who underwent surgery for colorectal cancer. METHODS: We have search in PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health and Scopus databases. Studies selected were limited to those including only patient undergone low rectal resection with sphincter preservation and with pre-post assessment with a LARS score. Five articles fit the criteria. RESULTS: The percutaneous tibial nerve stimulation demonstrated moderate results and sacral nerve stimulation was found to be the best treatment with greater symptom improvement. Only one study considered sexual and urinary problems in the outcomes assessment. CONCLUSIONS: In clinical practice patients should evaluate with the LARS and other score for evaluation of urinary and sexual problems. Future research must be implemented with higher quality studies to identify the least invasive and most effective treatment/s.

Brain activation patterns of female multiple sclerosis patients with voiding dysfunction.

AIMS: We compared brain activation patterns between female multiple sclerosis (MS) patients with voiding dysfunction (VD) and those without. We aim to expand current knowledge of supraspinal correlates of voiding initiation within a cohort of female MS patients with and without VD. MATERIALS AND METHODS: Twenty-eight ambulatory female MS patients with stable disease and lower urinary tract dysfunction were recruited for this study. Subjects were divided into group 1, without VD (n = 14), and group 2, with VD (n = 14), defined as postvoid residual urine of ≥40% of maximum cystometric capacity or need for self-catheterization. We recorded brain activity via functional magnetic resonance imaging (fMRI) with simultaneous urodynamic testing. Average fMRI activation maps (the Student t test) were created for both groups, and areas of significant activation were identified (P < .05). A priori regions of interest (ROIs), identified by prior meta-analysis to be involved in voiding, were selected. RESULTS: Group-averaged blood-oxygen level-dependent (BOLD) activation maps demonstrated significant differences between groups 1 and 2 during initiation of voiding with group 2 showing significantly lower levels of activation in all ROIs except for the left cerebellum and right cingulate gyrus. Interestingly, group 2 displayed negative BOLD signals, while group 1 displayed positive signals in the right and left pontine micturition center, right periaqueductal gray, left thalamus, and left cingulate gyrus. The activation map of group 1 was similar to healthy controls. CONCLUSIONS: Our results support the hypothesis that distinct supraspinal activation patterns exist between female MS patients with VD and those without.

A Review of Functional Electrical Stimulation Treatment in Spinal Cord Injury.

Functional electrical stimulation (FES) has been widely adopted to elicit muscle contraction in rehabilitation training after spinal cord injury (SCI). Conventional FES modalities include stimulations coupled with rowing, cycling, assisted walking and other derivatives. In this review, we studied thirteen clinical reports from the past 5 years and evaluated the effects of various FES aided rehabilitation plans on the functional recovery after SCI, highlighting upper and lower extremity strength, cardiopulmonary function, and balder control. We further explored potential mechanisms of FES using the Hebbian theory and lumbar locomotor central pattern generators. Overall, FES can be used to improve respiration, circulation, hand strength, mobility, and metabolism after SCI.

Does biofeedback therapy improve quality of life in children with lower urinary tract dysfunction: parents' perspective.

INTRODUCTION: Lower urinary tract dysfunction (LUTD) is a situation that often disrupts the quality of life (QoL) of both the child and the family with daytime and nighttime incontinence. Although the first-line treatment option for children with LUTD is standard urotherapy, biofeedback therapy can be performed in children in which standard urotherapy failed. OBJECTIVE: We studied the biofeedback success in children with LUTD according to parents' expressions. METHODS: We retrospectively analyzed our hospital records of children who were diagnosed with LUTD between 2005 and 2017. In total, 281 patients, refractory to standard urotherapy were included into the study and directed to biofeedback treatment. Their parents completed the dysfunctional voiding symptom scores (DVSS) before and after biofeedback therapy. RESULTS: At the end of the six-month follow-up period, all voiding disorders and voiding patterns were evaluated. According to DVSS, QoL tools before biofeedback treatment 48 (17%) parents appraised that LUTD caused no effect in their children's daily life, 104 (37.8%) expressed little effect, 89 (31%) moderate effect, and 40 (14.2%) serious effect. And, 120 (43%) parents expressed no effect, 95 (34%) little effect, 51 (18%) moderate effect, and 15 (5%) serious effect (P = 0.001) after biofeedback therapy. Biofeedback therapy affected positively the daily life of LUTD's family. The less serious the effect of LUTD on these children's family, the more success rate of biofeedback therapy. The effect of biofeedback therapy was less successful in moderated and serious affected families. CONCLUSIONS: Biofeedback treatment is a non-invasive and effective treatment modality for improving the QoL for LUTD families who were less suffered from LUTD.

Techniques for optimizing lead placement during sacral neuromodulation.

We present a video describing technical considerations for optimizing lead placement for sacral neuromodulation. A 56-year-old female presented with urinary urgency incontinence refractory to behavioral modification, physical therapy, and oral pharmacotherapy. An Interstim device had been placed 3 years prior by another provider, but the patient did not find it beneficial and had uncomfortable stimulation despite reprogramming. After counseling, she opted for device revision. The S3 foramen is identified using fluoroscopy in anterior-posterior and lateral views; a needle is advanced through the cephalad and medial aspect of the foramen and tested for bellows and toe responses. After the directional guide is placed, the introducer is advanced until it is midway through the bony table. The lead, with a curved stylet, is advanced for repeat testing prior to deployment. It should have a cephalad-to-caudad appearance and curve laterally. Motor responses are tested and optimally should be < 2 V with all electrodes. The lead is then advanced fully, deployed, and retested. The patient's daytime frequency improved to 6 per day from 11 per day at baseline; her urgency incontinence and the uncomfortable stimulation resolved. Optimization of lead placement for sacral neuromodulation is crucial for improving clinical results.

Impact of transcutaneous interferential electrical stimulation for management of primary bladder neck dysfunction in children.

INTRODUCTION: Several studies have revealed that electrical stimulation is an effective modality for treatment of lower urinary tract (LUT) dysfunction via raising the capacity or compliance of the bladder or maybe by pelvic floor relaxation and reducing detrusor pressure as well. OBJECTIVE: This study aimed to assess the efficacy of transcutaneous interferential (IF) electrical stimulation on LUT symptoms as well as urine flow parameters in children with primary bladder neck dysfunction (PBND). STUDY DESIGN: We reviewed the charts of all children with persistent LUT symptoms who underwent IF electrical stimulation between 2010 and 2017. Twenty-three neurologically and anatomically normal children (mean age: 7.7 years, range: 5-13) with LUT symptoms were included in this study. Children had different LUT symptoms such as hesitancy, straining, urinary incontinence and constipation with no sufficient response to medical treatment (α -blocker) for at least 6 months. IF electrical stimulation was performed for 15 sessions, two times per week. All children were symptomatic and had abnormal urine flow pattern with an electromyographic (EMG) lag time of more than 6 s on uroflowmetry with EMG. A voiding chart, uroflowmetry with EMG and kidney and bladder ultrasounds were performed before and after the treatment for all children. Maximum and average urine flow rates, EMG lag time and postvoid residual volume were analyzed. In addition, alpha blocker therapy was continued during IF therapy. RESULTS: Mean maximum and average urine flow rates improved from 14.1 to 7.6-19.7 ml/s and 9.5 ml/s, respectively, while mean EMG lag time decreased from 11.7 to 5.2 s after the treatment (all P < 0.05). Also postvoid residual volume decreased significantly from 35.6 to 7.6 ml at the end of treatment courses. DISCUSSION: Pelvic floor EMG lag time, a documented parameter on uroflowmetry with EMG, defined as the time from the start of pelvic floor relaxation during a volitional voiding effort (the first stage of normal voiding) to the start of urine flow. Results showed that IF therapy decreased pelvic floor EMG lag time in children with PBND. In addition, increase in mean maximum and average urine flow rates in our patients indicated that pelvic IF therapy and behavioral modification improved voiding dysfunction in most of the patients and probably decreased bladder neck activity during voiding. Future studies with larger sample size are needed to support this finding. CONCLUSION: IF therapy appears safe, effective and reproducible in improvement of PBND in children.

Can we improve our management of dysfunctional voiding in children and adults: International Consultation on Incontinence Research Society; ICI-RS2018?

AIMS: Dysfunctional voiding (DV) remains a poorly understood and a poorly managed problem, both in children and adults. The Think Tank (TT) discussed how to improve the management of DV in these two different age groups and in transitional care. METHODS: During the 2018 International Consultation on Incontinence Research Society held in Bristol, a multidisciplinary TT on DV was created. The presentations and subsequent discussion, leading to research recommendations intended to improve the management of DV in children and adults are summarized. RESULTS: To improve the management of DV in children and adults, the TT panel proposed: (1) to conduct reliable prevalence studies of DV; (2) to perform longitudinal studies to prospectively test the sequence hypothesis by answering the following questions: (a) Which, if any children show a progression from overactive bladder or voiding postponement to DV?; (b) Which children develop each disorder without precursors?; and (c) Is there a continuation of DV from childhood to adulthood, or are adult cases new-onset presentations?; (3) to obtain detailed information regarding psychopathology to understand which comorbid psychological disorders prevail and at which rate, in those suffering DV; (4) to develop and validate diagnostic tools specifically for DV; (5) to better establish urodynamic correlates of DV specific for different age groups; and (6) to generate prospective long-term data regarding the efficacy of different treatment options and management strategies. CONCLUSIONS: The future research recommendations of this TT may improve our management of DV in children and adults.

Implantable Electronic Stimulation Devices from Head to Sacrum: Imaging Features and Functions.

Electronic stimulation devices are implanted in various locations in the body to decrease pain, modulate nerve function, or stimulate various end organs. The authors describe these devices using a craniocaudal approach, first describing deep brain stimulation (DBS) devices and ending with sacral nerve stimulation (SNS) devices. The radiology-relevant background information for each device and its imaging appearance are also described. These devices have a common design theme and include the following components: (a) a pulse generator that houses the battery and control electronics, (b) an insulated lead or wire that conveys signals to the last component, which is (c) an electrode that contacts the end organ and senses and/or acts on the end organ. DBS electrodes are inserted into various deep gray nuclei, most commonly to treat the symptoms of movement disorders. Occipital, trigeminal, and spinal nerve stimulation devices are used as second-line therapy to control craniofacial or back pain. For cardiac devices, the authors describe two newer devices, the subcutaneous implantable cardioverter defibrillator and the leadless pacemaker, both of which avoid complications related to having leads threaded through the venous system. Diaphragmatic stimulation devices stimulate the phrenic nerve to restore diaphragmatic movement. Gastric electrical stimulation devices act on various parts of the stomach for the treatment of gastroparesis or obesity. Finally, SNS devices are used to modulate urinary and defecatory functions. Common complications diagnosed at imaging include infection, hematoma, lead migration, and lead breakage. Understanding the components, normal function, and normal imaging appearance of each device allows the radiologist to identify complications. ©RSNA, 2019.