Sacral neuromodulation for neurological disease-induced lower urinary tract symptoms in Saudi Arabia: a single-centre experience.

OBJECTIVE: To evaluate the effectiveness of sacral neuromodulation therapy (SNM) for lower urinary tract symptoms (LUTS) caused by neurological diseases. METHODS: This prospective cohort study enrolled patients that developed LUTS secondary to neurological disorders. All patients underwent staged SNM. A 5-day voiding diary was used to evaluate their response to the stage 1 procedure. Implantation of the full system during the stage 2 procedure was undertaken in patients that had ≥50% improvement on their voiding diary. RESULTS: Twenty-one patients were included in the study with the following neurological aetiologies: diabetes mellitus (n = 2), myelitis (n = 3), multiple sclerosis (n = 5), spinal cord injury (n = 10) and cerebrovascular accident (n = 1). Fifteen patients underwent the stage 1 procedure successfully; their mean age was 47.5 years and the mean follow-up was 29 months. SNM resulted in significantly increased voided volume/void/day, decreased leaking episodes/day, decreased postvoiding residual/day and decreased number of clean intermittent catheterization/day compared with baseline. Five patients were highly satisfied, nine were moderately satisfied and one patient was not satisfied with the therapy. CONCLUSION: SNM was an effective therapy for LUTS caused by neurological disease and there was a high rate of patient satisfaction.

Effect of COVID-19-related lockdown on functional urology practice and patient care in Gulf Cooperation Council region.

BACKGROUND: This survey was designed and conducted during the lockdown period to assess its effect on urology practice dealing with patients with voiding dysfunction and their care in the Gulf Cooperation Council (GCC) region. METHODS: An online survey was sent across to urologists managing patients with voiding dysfunction in countries of the GCC region through various social media platforms. All valid responses were tabulated and analyzed. RESULTS: A total of 202 responses were received. Higher proportion of urologists in private sector (98.2%) were treating patients in comparison to those in public or governmental hospitals (82.7%); (P = 0.007). Telemedicine was used by 72% of the respondents. Telephone calls were preferred With regard to perception of risk while examining patients, 65% of the respondents felt that their risk was equal to other specialties. Their preferred prevention strategy would be pre-operative screening. Financial impact affected only 10% claimed major catastrophic effect. There was a significant difference between private and public government urology services provided, with a higher proportion of patients seen, operations performed, fees charged for telemedicine, and financial effect in the private sector with P = 0.012, P = 0.037, P = 0.004, and P = 0.001, respectively. CONCLUSION: Our survey showed that majority of urologists in the GCC region were seeing patients during COVID-19 lockdown. Emergency services were prioritized. A large proportion of urologists had switched over to telephonic communication. Most of the responding urologists were uncertain about when and how to resume surgical procedures upon easing of the COVID-19-related restrictions.

Multicenter Study for the Effect of COVID-19 Lockdown on Patients With Sacral Neuromodulation Implants.

INTRODUCTION: The massive spread of COVID-19 affected many aspects of medical and surgical services. Many patients with sacral neuromodulation (SNM) devices needed integrated follow-up and close communication regarding the programming of the device. In this study, we aimed to explore the effect of COVID-19 lockdown on patients with SNM devices. MATERIALS AND METHODS: This was a multicenter study designed and conducted in four centers performing SNM (Toronto Western Hospital, Toronto, Canada; King Abdulaziz University Hospital, Jeddah, Saudi Arabia; Al-Amiri Hospital, Kuwait City, Kuwait; and Austin and Western Health, University of Melbourne, Australia). An online questionnaire was created through Google Forms and circulated among patients with SNM devices in all four mentioned centers. The questionnaire was sent to patients during the forced lockdown period in each country. RESULTS: A total of 162 responses were received by September 2020. Data showed that most patients had their device implanted before the lockdown period (92.5%, 150/162). Most patients did not experience any contact difficulties (91.9%, 149/162). When patients were requested for their preference of programming, 89.5% (145/162) preferred remote programming. Correlation analysis did not show any significant relation between patient diagnosis and COVID-19-related difficulties or preferences. CONCLUSION: The difficulties with access to care experienced during the pandemic and the patient's expressed willingness to participate in virtual care should provide impetus for manufacturers of SNM devices to move forward with developing remote programming capabilities.

Sacral neuromodulation implanted patients: Patient concerns during the COVID-19 pandemic and practical modifications.

OBJECTIVE: To study the effect of the COVID-19 pandemic on sacral neuromodulation (SNM) implanted patients and examine patient concerns. METHODOLOGY: A web-based survey was sent to all SNM patients, including those with implants and who had a cancelled operation because of the pandemic. The survey consisted of 15 questions in Arabic language, which sought to evaluate outcomes, as well as patient concerns and preferences during the COVID-19 pandemic. RESULTS: A total of 66 patients were contacted, and of which, 62 replied. Most of the patients (n = 51; 82.3%) had the device implanted, and 11 (17.7%) patients had a postponed operation secondary to the pandemic. There were 20 males and 42 females. The mean age was 34 years ± SD 16.5 (9-62 years). Indications for sacral neuromodulation therapy were refractory overactive bladder OAB 35 (56.5%), retention 17 (27.4%), OAB + retention 3 (4.8%). When questioning the effect of the lockdown on patients, most reported no effect (43.5%), while 14.5% had some programming difficulties. The patients preferred telephone calls for device emergencies and clinic follow-up with 88.7% and 98.4%, respectively. Most patients had no concerns regarding their Interstim device during the pandemic and found it manageable; 8.1% had insurance concerns due to the economic changes. CONCLUSION: Patients with implanted SNM for lower urinary tract symptoms were mainly concerned with device programming. Telemedicine is a great solution for continuous care in this group.

Sacral Neuromodulation for Lower Urinary Tract Symptoms: Effect of Therapy on Saudi Patient Sexual Function.

BACKGROUND: Sacral neuromodulation (SNM) is FDA-approved therapy for lower urinary tract and bowel dysfunction. It is newly introduced therapy in Saudi Arabia. AIM: To evaluate the effect of SNM therapy in both male and female Saudi patient's sexual function. METHODS: A prospective cohort study was conducted for all patients who underwent SNM implantation from January 2016 till January 2020 at a single center in Jeddah, Saudi Arabia. Sexual function was assessed before and after treatment using International Index of Erectile Function (IIEF-5) for men and the Female Sexual Function Index (FSFI) for women. MAIN OUTCOME MEASURES: Sexual function score changes from the baseline was reported. Correlation analysis was studied between IIEF-5 to assess erectile dysfunction and FSFI assessing desire, arousal, orgasm, pain and sexual satisfaction and other collected data including patient's age, functional diagnosis and post void residual (PVR). RESULTS: The study included 13 total patients (8 female, 5 male) with mean age 47y (33-60). Diagnosis included non-obstructive urine retention (5), refractory overactive bladder (3), combined retention + over active bladder (OAB) (1), pelvic pain syndrome (3) and impotence in 1 patient. All male patients showed significant improvement in their IIEF-5 score from mean pre op 7.8 ±5.7 to post op sore of 19.8±2.3 with significant p value p=0.003. Female patients showed significant improvement in their FSFI total score from baseline of 18.313±7.4 to post-operative mean FSFI score 26.7±1.8 with p value = 0.013. Domains od FSFI which showed significant improvement were desire, arousal, orgasm and sexual satisfaction with p value =0.002, p=00.1,0.012, and p=0.015. Age, functional diagnosis and PVR did not show significant correlation with IIEF-5 and FSFI score. CONCLUSION: Our results suggest that SNM might improve male and female sexual dysfunction regardless of patient's age and diagnosis. Banakhar MA, Younos A. Sacral neuromodulation for lower urinary tract symptoms: effect of therapy on Saudi patient sexual function. Sex Med 2021;9:100388.

Spinal cord injury patients: Effect of urinary intervention therapy type on quality of life, questionnaire-based study.

OBJECTIVE: The objective of the study is to assess the quality of life (QoL) with or without surgical intervention in patients with spinal cord injury (SCI) with neurogenic bladder. MATERIAL AND METHODS: A prospective study was conducted on SCI patients with neurogenic bladder. The questionnaires used to assess the QoL were the 36-Item Short-Form Health Survey questionnaire (SF-36), the Incontinence questionnaire [Urogenital Distress Inventory (UDI-6)], the International Index of Erectile Function (IIEF-5), and the Female Sexual Function Index (FSFI). Patients were categorized into two groups: the first group consisted of patients who underwent a surgical procedure and the second group included patients managed by a conservative treatment option: clean intermittent bladder catheterization. RESULTS: Total of 29 patients included in the study, 13 patients underwent urinary diversion (mean age: 45.84±16.41 years) and 16 patients had a conservative treatment (mean age: 47.61±13.90 years). The SF-36 questionnaire evaluation revealed that the bodily pain component was significantly lower in patients who underwent urinary diversion (p=0.009), whereas vitality (p=0.045) and social functioning (p=0.005) components were significantly lower in patients who underwent any type of urinary surgical procedure. The incontinence questionnaire (UDI-6) revealed significantly lower scores in patients who underwent urinary diversion (17.84±5.2) than patients who underwent a conservative treatment (47.05±5.8; p=0.001). CONCLUSION: Urinary surgical intervention improved the QoL in SCI patients with neurogenic bladder as per the UDI-6 scores. However, contrasting results of the SF-36 assessment warrant its further validation by conducting studies with a larger sample size.

Radiographic Position of the Electrode as a Predictor of the Outcome of InterStim Therapy.

PURPOSE: Sacral neuromodulation (SNM) therapy is indicated for some refractory urological conditions. The electrode lead position in sacral x-rays during routine follow-up may predict the outcome of SNM therapy. To determine whether the radiographic position of the electrode in the sacral foramen predicted the long-term outcome of SNM therapy. METHODS: This was a retrospective study of patients who underwent InterStim SNM at Toronto Western Hospital by 2 surgeons from July 2013 to March 2014. The position of electrodes in relation to the sacral bone was assessed on follow-up sacral x-rays. In the lateral view, we determined the location of the radio-opaque marker of the electrode relative to the inner surface of the sacrum (P3, D3, P2, D2, P1, D1, P0, and D0). In the anteroposterior view, the angle between a line through the spinous process shadow and the electrode was measured (0°-30°, 30°-60°, 60°-90°, >90°, or medial). Dissatisfied patients were defined as those who did not improve based on a voiding diary or those who needed salvage treatment after SNM. The primary endpoint was to determine whether the electrode lead position on sacral x-rays predicted the outcome of SNM therapy. RESULTS: A total of 69 patients (61 female and 8 male patients) were included, with a median age of 55 years. Forty-two of the patients (60.9%) had refractory overactive bladder, 21 (30.4%) suffered from chronic urinary retention, and 6 (8.7%) had lower urinary tract symptoms and chronic pelvic pain syndrome. The univariate analysis did not show any correlation between SNM response and the electrode position or angle. Dummy regression analysis using response to implantation as the dependent outcome variable did not show any significance for any of the predictors. CONCLUSIONS: Our study did not show a correlation between the long-term response to SNM and the electrode position on follow-up sacral x-rays. In this study, electrode lead position in sacral x-ray at follow-up was not correlated with the outcome of SNM therapy.

Sacral neuromodulation and refractory overactive bladder: an emerging tool for an old problem.

Overactive bladder (OAB) syndrome negatively affects the daily life of many people. Conservative treatments, such as antimuscarinics, do not always lead to sufficient improvement of the complaints and are often associated with considerable side effects resulting in treatment failure. In the case of failure or intolerable side effects, sacral neuromodulation (SNM) and botulinum toxin intravesical injections are minimally invasive and reversible alternatives. Currently, both SNM and botulinum toxin injection have FDA approval for use in OAB patients. This mini-review attempts to provide an update on SNM as a second-line management of adults with refractory OAB, based on the available clinical evidence concerning the efficacy and safety.