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PubMed2004

Improvement in depression and health-related quality of life after sacral nerve stimulation therapy for treatment of voiding dysfunction.

OBJECTIVES: To assess depression and health-related quality of life (HRQOL) in 89 people with refractory urge incontinence, nonobstructive urinary retention, or urgency frequency enrolled at 13 U.S. study centers. The subjects were part of a large international, multicenter, randomized clinical trial on the safety and efficacy of sacral nerve stimulation for the treatment of refractory voiding dysfunction. METHODS: The Beck Depression Index and the Medical Outcomes Study Short-Form 36 were used to assess depression and HRQOL at baseline and at two follow-up visits. RESULTS: Detectable levels of depression and reduced quality of life were noted at baseline. Subjects implanted with the stimulation device reported significant improvements in both HRQOL and depression at 3 months after implant that were maintained for the 6-month study period. Subjects assigned to the delayed implant group showed a slight worsening of HRQOL and depression from baseline to 3 months that continued through the 6-month visit. CONCLUSIONS: The results demonstrated the serious impact that unresolved voiding symptoms have on the physical, social, and psychological dimensions of quality of life. Treating refractory voiding dysfunction with sacral nerve stimulation resulted in improvement in both depression and HRQOL.

Adult↗
PubMed2005

Sacral neuromodulation: long-term experience of one center.

OBJECTIVES: To perform a retrospective analysis of the long-term results of our experience with neuromodulation. Our center has been involved in the early studies leading to approval of the NeuroStim system of neuromodulation for the treatment of patients presenting with refractory lower urinary symptoms of urgency/frequency with or without incontinence and chronic urinary retention. METHODS: A total of 52 patients have undergone implantation at our center since 1990 using very rigid criteria, including temporary percutaneous nerve evaluation for up to 7 days and a requirement of 50% improvement before consideration for implantation. Patients were followed up closely and a telephone questionnaire was conducted for those patients not seen in the previous 6 months. Of the 52 patients, 11 were not available for evaluation. Of the 41 remaining patients, 22 had urgency/frequency syndrome, 6 had urgency incontinence, 9 had urinary retention, and 4 had interstitial cystitis with intractable pelvic pain. RESULTS: Of the 41 patients, 5 required explantation. These 5 patients were offered reimplantation but declined. Of the 22 patients in the urgency/frequency group, 10 (45%) had persistent improvement. In the urgency incontinence group, 3 of the 6 patients required explantation, and 1 (17%) reported improvement in the frequency of incontinence episodes. Of the 9 patients in the chronic urinary retention group, 7 (78%) had improvement. CONCLUSIONS: The long-term (up to 13 years) results of neuromodulation in patients presenting with urgency/frequency with and without urge incontinence and urinary retention were reviewed. The long-term results in the first two groups were not maintained over time. The patients with chronic urinary retention, although a small sample, fared better.

Adolescent↗
PubMed2005

Bacterial contamination of test stimulation leads during percutaneous nerve stimulation.

OBJECTIVES: To analyze the bacterial contamination of conventional percutaneous nerve stimulation (PNE) leads. Sacral neuromodulation has become an important tool for the treatment of urgency and chronic retention. Patients likely to benefit from this type of therapy are identified by PNE testing before implantation of the definitive system. Recently, a new system was introduced, using a self-blocking electrode that remains in place for both PNE testing and final implantation. PNE testing warrants an extracorporeal stimulator. Thus, using the same electrode for both external stimulation and definitive implantation may carry a significant risk of infection. METHODS: Bilateral PNE testing was performed in 11 consecutive patients (8 women and 3 men, mean age 41.6 years) for either urgency (n = 7) or chronic retention (n = 4). Electrodes were placed under aseptic conditions and stimulated for 3 days. At the end of each test, the electrodes were removed and evaluated microbiologically. RESULTS: In 5 of the 11 patients (9 of 22 leads), significant bacterial growth was detected: Staphylococcus epidermidis in 5, Escherichia coli in 3, and Enterococcus faecalis in 1. However, no patient showed signs of inflammation at the electrode insertion sites. CONCLUSIONS: Bacterial growth was found in 45.5% of the patients after conventional PNE testing under aseptic conditions. Therefore, the new electrodes may well carry an elevated risk of infection. Infection of the implant can lead to major surgical revision or even explantation. Thus, additional studies of the infection risk of this new electrode are warranted before its general use can be recommended.

Bacteria↗
PubMed2005

Sacral neuromodulation for intractable urge incontinence: are there factors associated with cure?

OBJECTIVES: To determine the variables that affect the cure rate in patients with urge incontinence treated with sacral neuromodulation. METHODS: This prospective analysis of patients with refractory urinary urge incontinence who underwent placement of a neuromodulator lead and generator was undertaken between October 2000 and December 2003. Quantitative assessment of the severity of their urinary leakage was assessed by preoperative and postoperative 3-day bladder diaries documenting leakage episodes, number of pads used per day, and a 24-hour pad weight assessment. Cure was defined as no daily leakage episodes after permanent implantation. Subjective outcome was assessed using the Incontinence Impact Questionnaire. Two-sample independent t tests, two-way chi-square tests, and tests of two proportions were performed when appropriate, with P < 0.05 considered significant. RESULTS: The mean postimplantation follow-up was 29 months, and the average age was 60 years (range 29 to 83). The cure rate was associated with age, with individuals younger than 55 years having a statistically significant greater cure rate (65% versus 37% for older individuals; P < 0.05). Having three or more chronic conditions was associated with a lower cure rate in both younger and older individuals. Patients with a neurologic condition also had a lower cure rate, but no specific neurologic condition was associated. CONCLUSIONS: Age older than 55 years and more than three chronic conditions were independent factors associated with a lower cure rate in patients implanted with a sacral neuromodulator for refractory urge incontinence. A neurologic condition may be associated with a decrease in the cure rate.

Adult↗
PubMed2006

Pudendal nerve branch injury during radical perineal prostatectomy.

We report the first case of direct surgical injury to a pudendal nerve branch during radical perineal prostatectomy. A 65-year-old patient presented with typical symptoms of a pudendal nerve lesion after radical perineal prostatectomy. As the patient did not respond to conservative treatment, surgical exploration and exeresis of the injured sensory branch of the pudendal nerve was necessary, resulting in pain improvement. Urologic surgeons should be aware of the typical symptoms after iatrogenic injury to the pudendal nerve or its branches. Early diagnosis and neurosurgical intervention are important to obtain a more favorable outcome.

Aged↗
PubMed2006

Evaluation and management of malfunctioning sacral neuromodulator.

OBJECTIVES: To describe a strategy for revising the malfunctioning InterStim device and to provide an algorithm for evaluation and management. METHODS: We retrospectively reviewed 82 patients who had undergone InterStim placement. Ten patients (eight women and two men) experienced complications and subsequently underwent revision of their device between October 2001 and October 2003. Five patients had originally received a permanent implant after a successful percutaneous test stimulation trial, and five had undergone a test stimulation using the tined lead. Indications for revision included gradual onset of recurrent voiding dysfunction (n = 2), lead migration (n = 5), generator malfunction (n = 1), generator site pain and infection (n = 1), and genital/rectal pain with stimulation (sensory discomfort; n = 1). RESULTS: Of the 10 patients who underwent revision, 7 experienced complete resolution of their problem. Eight patients had lead site changes and two had generator replacements. No intraoperative or postoperative complications occurred in the revision cases. CONCLUSIONS: In our experience, 70% of patients who undergo revision of the malfunctioning InterStim can expect success. In this study, no difference in success appeared to be related to the original cause of malfunction. In the management of malfunctioning sacral neuromodulators, we recommend an attempt at revision before permanent explantation.

Algorithms↗
PubMed2006

Complications and troubleshooting of two-stage sacral neuromodulation therapy: a single-institution experience.

OBJECTIVES: With the increasing use of sacral neuromodulation therapy, urologists are faced with postimplantation challenges. The purpose of this study was to identify these events and their causes and management in our large single-institution experience. METHODS: From July 2002 to September 2004, all patients who underwent sacral neuromodulation therapy for refractory bladder conditions were identified. Their medical records were retrospectively evaluated for history, operative intervention, and programming visits. Events after implantation of the implantable pulse generator (IPG) unit were noted. The evaluation, troubleshooting, management, and resolution of events at the last follow-up visit were extracted. RESULTS: A total of 214 patients underwent sacral neuromodulation therapy at our institution. The mean patient age was 53.5 +/- 15.4 years. Of the 214 patients, 161 underwent IPG implantation during a mean follow-up period of 16 months (range 5 to 30). The second-stage explantation and revision rate was 10.5% and 16.1%, respectively. The indications for explantation were infection (8 of 17) and failure to maintain a response (9 of 17). Revisions were done for decreases in response with abnormal (12 of 26) or normal (5 of 26) impedance measurements, IPG site discomfort (4 of 26), draining sinus at the IPG site (4 of 26), and lead migration (1 of 26). Equalization of impedance measurements was the most commonly observed impedance abnormality. These were managed by drying fluid from the connection in 4 patients and lead change in the rest. CONCLUSIONS: After IPG implantation, a decline in response may occur. Although some were explanted, most were revised, with most of the revisions functional on follow-up. Familiarity with impedance evaluation and development of algorithms for postimplant management are essential for troubleshooting and maintenance of the device.

Electric Stimulation Therapy↗
PubMed2006

Ultrasound imaging of sacral reflexes.

OBJECTIVES: To investigate the reliability of examination of the guarding reflex of the pelvic floor by dynamic perineal ultrasonography in children with bladder dysfunction and in controls. METHODS: A total of 40 patients with nonneurogenic bladder/sphincter dyssynergia, 40 with spina bifida, and 40 controls underwent a dynamic ultrasound examination of the pelvic floor while coughing and while being tapped on the abdominal wall. The reflex action of the puborectal muscle in females, and the combined action of the puborectal muscle and external sphincter muscle in males, were recorded. RESULTS: Of the 40 patients with nonneurogenic bladder/sphincter dyssynergia, 38 had a normal reflex action of the puborectal muscle during the abdominal tap and 36 had a normal reflex action when coughing. Two of these patients had unexplained underactive bladder syndrome and were using clean intermittent catheterization, and two could not be assessed because of hypermobility of the bladder neck when coughing but had a normal reaction during abdominal tapping. Of the 40 patients with spina bifida, none had puborectal activity during coughing and 5 had some puborectal activity during tapping. Of the 40 controls, 39 had normal reflex activity during both coughing and tapping. CONCLUSIONS: The question of whether a child has nonneurogenic or neuropathic bladder/sphincter dysfunction is often difficult to answer on the basis of urodynamic studies alone. Dynamic perineal ultrasound recording of the S2-S4 reflex arches provides reliable additional information and is noninvasive to the patient.

Child, Preschool↗
PubMed2001

The use of neuromodulation for treatment of urinary incontinence.

Urinary incontinence (UI) affects many people in the United States. Although the prevalence of UI increases with age, it should not be considered part of the normal aging process. Medication to relax the bladder and behavioral therapy have been used to treat patients suffering from UI, but they often are unsuccessful or poorly tolerated. Neuromodulation through sacral nerve stimulation is a minimally invasive surgical procedure for treatment of urge incontinence. Neuromodulation is becoming the next logical step at many centers for treating urge incontinence after the failure of more conservative measures.

Electric Stimulation Therapy↗
PubMed2003

Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions.

OBJECTIVE: The purpose of this study was to map the course of the ilioinguinal and iliohypogastric nerves. STUDY DESIGN: The courses of iliohypogastric and ilioinguinal nerves from 11 fresh frozen cadavers were mapped from their lateral emergence on the anterior abdominal wall to their midline termination in reference to fixed bony landmarks. Bivariate fit ellipses were generated for each nerve and compared with sites of standard abdominal surgical incisions. RESULTS: Thirteen iliohypogastric and 16 ilioinguinal nerves were identified and mapped. On average, the proximal end of the ilioinguinal nerve entered the abdominal wall 3.1 cm medial and 3.7 cm inferior to the anterior superior iliac spine, then followed a linear course to terminate 2.7 cm lateral to the midline and 1.7 cm superior to pubic symphysis. The iliohypogastric nerve entered the abdominal wall on average 2.1 cm medial and 0.9 cm inferior to the anterior superior iliac spine, which followed a linear course to terminate 3.7 cm lateral to the midline and 5.2 cm superior to pubic symphysis. CONCLUSION: Abdominal wall surgical sites below the level of the anterior superior iliac spine have the potential for ilioinguinal or iliohypogastric injury.

Abdominal Wall↗
PubMed1996

Lumbosacral plexopathy after gynecologic surgery: case report and review of the literature.

Very unusual lumbosacral plexopathy, symptoms appearing after an uncomplicated abdominal hysterectomy prompted a review of the literature. The patient's symptoms spanned the somatic and autonomic systems and ranged from T-11 to S-4; a cause that would explain these is perplexing. Pelvic neuroanatomy and plexopathy symptoms are presented. Etiologies of neurologic symptoms are discussed and preventive strategies are explored.

Adult↗
PubMed2000

A ganglion cyst causing lumbar radiculopathy in a baseball pitcher: a case report.

This report describes a case of a professional baseball pitcher who developed acute left lumbar radicular symptoms after a baseball game and was subsequently sidelined for the rest of the season. Physical examination revealed depressed reflexes in the left posterior tibialis and left medial hamstring muscles, mild weakness in the left extensor hallucis longus, and positive dural tension signs. Magnetic resonance imaging demonstrated an ovoid mass at the L4-L5 level, causing compression of the dura. Surgical resection of the mass resulted in resolution of his symptoms. Pathology revealed that the mass was a ganglion cyst. A ganglion cyst is a rare cause of lumbar radiculopathy and should be considered in the differential diagnosis if a patient with lumbar radiculopathy fails to respond to conservative treatment.

Adult↗
PubMed1976

Sexual function after major resections of the sacrum with bilateral or unilateral sacrifice of sacral nerves.

The sexual function of nine patients with severance of sacral nerves bilaterally (five patients) or unilaterally (four patients), performed during operations for radical extirpation of tumors of the sacrum or its vicinity, was studied. Sexual histories were obtained and sensibility tests were performed. In four of the five male patients an attempt was made to collect electromyographic recordings from the external urethral and anal sphincters during ejaculation. Bilateral loss of S3 to S5 nerves in two women seemed not to affect their sexual function. Bilateral loss of S2 to S5 nerves in one man was compatible with gratifying sexual intercourse, the stimulation for erection being purely psychogenic, and "ejaculation" of a dripping nature. Unilateral loss of all sacral nerves did not impair previously normal sexual function, although the penises and vulvae of these patients were anesthetic on one side. The sensibility of the penis seemed to be subserved by the second sacral nerve. The myoelectric activity of the striated urethral and anal sphincters during ejaculation recorded in one patient with unilateral total loss of sacral nerves was normal bilaterally considering the duration of, and intervals between, the clonic contractions.

Adult↗
PubMed1979

Surgical treatment of endometriosis in the infertile female: a modified approach.

Two groups of infertile women underwent conservative surgery for endometriosis, group I (107 patients) prior to 1970 and group II (138 patients) after 1970. To determine whether modifications to the surgical approach after 1970 further increased the likelihood of conception, postoperative pregnancy rates were examined. The data suggest that postoperative pregnancy rates can be improved by (1) removal rather than "repair" of diseased adnexa if the involvement is unilateral and (2) leaving diseased areas undisturbed where excision or cauterization may predispose to the development of postoperative ovarian and/or tubal adhesions. The current surgical technique (used for group II) is described in detail.

Adnexa Uteri↗
PubMedDate not supplied

Lumbosacral nerve root avulsion.

Lumbosacral nerve root avulsion is a rare clinical entity. Since the first description in 1955, only 35 cases have been reported. It is often associated with pelvic fractures and may be missed in the initial clinical examination as these patients usually present with multiple injuries. We present three such cases with clinical and radiological findings. These patients were involved in road traffic accidents. Two had fractures of the sacroiliac joint with diastasis of the symphysis pubis (Tile type C 1.2) and one had fractures of the public rami (Tile type B 2.1). All three had various degrees of sensory and motor deficit of the lower limbs. Lumbar myelogram shows characteristic pseudomeningoceles in the affected lumboscral region. Magnetic resonance (MR) imaging provides an additional non-invasive modality to diagnose this condition.

Accidents, Traffic↗
PubMed1997

Does calcitonin gene-related peptide act as a chemoattractant for rat gubernacular cells?

Calcitonin gene-related peptide (CGRP) receptors are located in the cremaster muscle of the gubernaculum of rats, and causes gubernacular contraction in vitro, suggesting that CGRP plays an important role in testicular descent. It has been postulated that CGRP released from the genitofemoral nerve acts as a "chemoattractant" for gubernacular migration to the scrotum. The aim of this study is to investigate whether the gubernacular cells of rats exhibit a chemotactic response to CGRP in vitro. Chemotaxis of gubernacular cells from Sprague-Dawley rats (1 to 6 days old) was measured using blind-well chambers. The migration of cells, which passed from the upper to the lower compartment through a polycarbonate filter, were counted using microscopy. The lower compartment included 10(-11), 10(-10), 10(-9), and 10(-8) M CGRP or phosphate buffered saline (PBS) as control. The chemotactic index (CI) was defined as the ratio of migration toward CGRP versus PBS as control. There was no significant migration even at varying CGRP concentrations. Isolated rat gubernacular cells therefore did not exhibit a chemotactic response to CGRP and the role CGRP plays in testicular descent still remains unclear. This result does not exclude the possibility that the gubernaculum responds to CGRP as a whole organ rather than as individual cells.

Animals↗