Abdominal Versus Standard Placement of the Sacral Nerve Stimulator Implantable Pulse Generator.

OBJECTIVES: To determine patient factors prompting anterior abdominal wall placement of the sacral nerve stimulator implantable pulse generator and investigate revision and infection rates for buttock (standard) and abdominal placement. METHODS: We retrospectively reviewed records of consecutive sacral nerve stimulation procedures by a single surgeon from 2012 to 2017 at a single institution. RESULTS: 75 patients underwent sacral nerve stimulation--60 with standard and 15 with abdominally placed implantable pulse generators. The mean age and body mass index of the standard group was higher than that of the abdominal group and the majority was female. A greater proportion of patients in the abdominal group had a neurological diagnosis and was wheelchair-dependent. Overall, a total of 20 patients underwent 38 revision surgeries. The indications for revision surgery were pain, loss of efficacy, or lead migration. The standard group accounted for more revisions than the abdominal group (34vs 4 cases, P = .048), with no revisions due to pain in the abdominal group. The infection rate (2% vs 13%, P = .10), average time from implantation to revision, and operative duration were not statistically different between groups. CONCLUSION: In a subset of patients who were wheelchair-dependent or lacked gluteal fat, placement of the implantable pulse generator in the anterior abdominal wall resulted in no revisions due to pain. Operative duration and infection rates were similar between abdominal and standard placement. Abdominal placement with extended length leads could be considered as a primary or revision option in these select patients.

Reprogramming requirements after sacral nerve stimulator implantation: correlation with preoperative indication.

PURPOSE: Recent publications support sacral nerve stimulator implantation in patients with interstitial cystitis. To our knowledge the reprogramming requirements for all patients following stimulator implantation has not been described and it is unknown whether the number of sessions required vary by pre-implantation diagnosis. We determined overall reprogramming requirements following nerve stimulator implantation and whether requirements vary based on preoperative indication. MATERIALS AND METHODS: After obtaining institutional review board approval we retrospectively reviewed the records of all patients who underwent sacral nerve stimulator implantation at our institution between June 2002 and October 2004. The preoperative indication and number of reprogramming sessions during the initial test period (stage 1) and following permanent implantation (stage 2) were compared. RESULTS: The 17 patients proceeding to stage 2 with a minimum 12-month followup during the study period were included. Mean age was 43 years (range 26 to 78) and all patients except 1 were female. Patients were separated by diagnosis for evaluation purposes, including urgency/frequency/incontinence in 8, urinary retention in 2 and interstitial cystitis in 7. The average number of reprogramming sessions during stage 1 was 0.9, 3.5 and 2.3 for urgency/frequency/incontinence, urinary retention and interstitial cystitis, respectively. The average number of reprogramming sessions after stage 2 was 2.8, 3.0 and 6.9 at 12-month followup for urgency/frequency/incontinence, urinary retention and interstitial cystitis, respectively. No patient had the stimulator removed for reprogramming failure. CONCLUSIONS: Patients in urinary retention appear to require more frequent reprogramming during stage 1, while patients with interstitial cystitis require more sessions after stage 2 implantation.

Stress incontinence: alternatives to surgery.

Although surgery is commonly performed to alleviate or cure stress incontinence, there are non-surgical options that might well be explored and tried before a woman undergoes surgery, for which many are poor candidates. The least drastic treatments are behavioral therapies, chiefly pelvic floor muscle training (Kegel exercises), alone or with biofeedback. This method is effective but has the drawback of poor patient compliance. Another therapy, almost noninvasive, is electrical stimulation via needle or surface electrodes of the pudendal nerve and the pelvic plexus in order to treat detrusor instability. Some studies show good results for many patients; and there is no need for long-term compliance. Medical management has included hormone replacement therapy and alpha-adrenergic agonists, but questionable results and intolerable risks have shifted this mode to serotonin-norepinephrine reuptake inhibitors, which have CNS action. Finally, there are urethral occlusive devices, which have poor acceptance owing to side effects and difficulty of use, and vaginal pessaries, theoretically attractive but inexplicably poor performers in the marketplace.