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PubMed2002

Predictive factors for sacral neuromodulation in chronic lower urinary tract dysfunction.

OBJECTIVES: To investigate data from 211 patients who underwent a trial stimulation (percutaneous nerve evaluation [PNE]) to determine the clinical parameters that can enhance the prediction of PNE success. The advantageous effect of sacral neuromodulation depends on the accurate identification of suitable candidates during the preimplantation PNE. METHODS: A total of 211 patients (161 women and 50 men), with refractory urge incontinence, urgency-frequency syndrome, and urinary retention, underwent a PNE. Patient data (demographics, medical history, urologic investigations, and diagnosis) were collected. The PNE results were evaluated from a voiding diary and patient history. More than 50% improvement of voiding parameters was considered a successful PNE, and those patients were selected for implantation. Logistic regression analysis was performed. The factors tested for predicting the test result were sex, patient age, diagnosis, previous surgery, neurogenic bladder dysfunction, duration of complaints, and previous treatments. RESULTS: The PNEs were positive in 85 patients (40.3%) and negative in 105 patients (49.8%). In 18 patients (8.5%), the test electrode had migrated; 3 more patients were not assessable and were also excluded. Missing data on the variable "duration of complaints" reduced the number of patients in the analyses from 190 to 174 patients. CONCLUSIONS: Intervertebral disk prolapse, duration of complaints, neurogenic bladder dysfunction, and urge incontinence were found to be significant predictive factors. However, a PNE remains necessary to evaluate a patient's chance of implant success objectively.

Adult↗
PubMed1997

Modulation of feline bladder and distal urethral responses to dorsal sacral root stimulation by intrathecal administration of a kappa 1-opioid agonist.

OBJECTIVES: We examined bladder and distal urethral responses to sacral dorsal root (SDR) electrostimulation with simultaneous intrathecal administration of a kappa 1-opiate agonist. METHODS: Experiments were conducted on 14 spinally intact and 6 chronic spinally transected decerebrated mongrel cats. In the chronically spinalized cats, midthoracic complete spinal cord transection was performed 6 to 8 weeks before the electrostimulation experiments. Sympathetic denervation was carried out by cutting the sympathetic chain and the hypogastric nerve bilaterally. Proximal ends of the cut S1-3DR were stimulated, and bladder pressure and urethral perfusion pressure changes were recorded before and after drug administration. RESULTS: The S2DR electrostimulation in spinally intact cats produced the best vesical contraction, but with dyssynergic urethral response. The magnitude and the pattern of the response changed with the different stimulation parameters. U-50,488H, a selective kappa 1-opiate receptor agonist, decreased significantly the bladder and the urethral responses to S2DR stimulation in spinally intact but not in chronic spinally transected cats. Nor-BNI, a kappa antagonist, reversed these responses in spinally intact cats. CONCLUSIONS: Our results showed that it is feasible to produce bladder contraction with SDR stimulation and suggest that kappa 1 receptors may have a role in bladder and distal urethral reflexes at the suprasacral level.

Animals↗
PubMed1995

Nitric oxide control of lower genitourinary tract functions: a review.

It is apparent that evolving concepts of the regulatory basis for functions in the pelvis must take into account the role exerted by nitric oxide. A recently characterized messenger molecule, nitric oxide has been associated with numerous physiologic processes. Intense investigations of this molecule have extended its importance to several genitourinary functions. Penile erection, micturition, peristalsis of the male excurrent duct system, contractile properties of the prostate, and lumbosacral spinal cord neurotransmission are all functions that may transpire under some degree of control by nitric oxide. Impotence, urinary obstruction, or ejaculatory problems, in turn, may represent alterations of nitric oxide production or action. The strategic manipulation of nitric oxide or its mechanism of action, possibly by pharmacologic means, may restore or produce desired functional effects. These possibilities, therefore, suggest that the advancing knowledge of nitric oxide in the genitourinary tract may be of enormous clinical value in the future.

Humans↗
PubMed2004

Sacral spinal nerve stimulation for faecal incontinence: multicentre study.

BACKGROUND: In patients with faecal incontinence in whom conservative treatment fails, options are limited for those with a functionally deficient but morphologically intact sphincter. We investigated the effect of sacral nerve stimulation on continence and quality of life. METHODS: In this multicentre prospective trial, 37 patients underwent a test stimulation period, followed by implantation of a neurostimulator for chronic stimulation in 34. Effect on continence was assessed by daily bowel-habit diaries over a 3-week period and on quality of life by the disease-specific American Society of Colon and Rectal Surgeons (ASCRS) questionnaire and the standard short form health survey questionnaire (SF-36). Every patient served as his or her own control. FINDINGS: Frequency of incontinent episodes per week fell (mean 16.4 vs 3.1 and 2.0 at 12 and 24 months; p<0.0001) for both urge and passive incontinence during median follow-up of 23.9 months. Mean number of days per week with incontinent episodes also declined (4.5 vs 1.4 and 1.2 at 12 and 24 months, p<0.0001), as did staining (5.6 vs 2.4 at 12 months; p<0.0001) and pad use (5.9 vs 3.7 at 12 months; p<0.0001). Ability to postpone defecation was enhanced (at 12 months, p<0.0001), and ability to completely empty the bowel was slightly raised during follow-up (at 12 months, p=0.4122). Quality of life improved in all four ASCRS scales (p<0.0001) and in seven of eight SF-36 scales, though only social functioning was significantly improved (p=0.0002). INTERPRETATION: Sacral nerve stimulation greatly improves continence and quality of life in selected patients with morphologically intact or repaired sphincter complex offering a treatment for patients in whom treatment options are limited.

Adult↗
PubMed1976

Herpes zoster with dysfunction of bladder and anus.

Herpes zoster may give rise to dysfunction of bladder and anus. Mucosal lesions have been reported, and 7 cases are described with retention, loss of sensation, or incontinence. Sacral shingles is associated with sensory loss and flaccid detrusor paralysis. Lumbar shingles may cause retention, and zoster at higher levels can also damage the spinal cord. Recovery is usually complete. The implication for schemes of bladder innervation is discussed.

Aged↗
PubMed1978

Effect of myo-inositol on peripheral-nerve function in diabetes.

myo-Inositol, 500 mg twice a day, given to seven diabetic patients for two weeks, increased the amplitude of the evoked action potentials of the median, sural, and popliteal nerves by an average of 76%, 160%, and 40%, respectively. There was no significant change in the conduction velocities of these nerves, myo-Inositol may be valuable in the treatment of diabetic neuropathy.

Aged↗
PubMed1998

Buerger's disease with intestinal involvement.

Here I describe three cases of intestinal Buerger's disease and review previously reported cases. All patients had involvement of the extremities and clinical manifestations of Buerger's disease. Occlusive changes in intestinal arteries also occurred, in both the presence and absence of abdominal symptoms. Intestinal Buerger's disease may be asymptomatic, acute, or chronic, and treatment varies according to the type of disease.

Adult↗
PubMed1998

Buerger's disease at the 'San Juan De Dios' Hospital, Santa Fe De Bogota, Colombia.

OBJECTIVES: To know the clinical characteristics in the presentation of Buerger's disease in San Juan de Dios Hospital, Bogota, Colombia, between 1986 and 1996, and compare them with a previous series from the same Hospital and another reported in international literature; To determine the changes in the form of appearance of the disease. METHODS: We reviewed the clinical information of 22 patients with diagnosis of Buerger's disease, observed between 1986 and 1993, and we added the information of the clinical histories of eight other patients with equal diagnosis, observed between 1994 and 1996 in our Unit. RESULTS: We observed 30 patients: 28 men (93%) and two women (7%), with a ratio M:F of 14:1, with an average age of 39+10 years (range from 18 to 52 years). Sixty percent were younger than 40 years and only the 10% were older than 50 years. The most frequent reasons for consultation were: pain in rest in the affected extremity, gangrene and ulceration in more than 50%. Raynaud's phenomenon in 30%, and the related surgical history in 40%. The pedal pulse was the most compromised followed by popliteal, poster or tibial and femoral. We did not observe the presence of thrombophlebitis. Eighty percent showed compromise of more than one extremity. All of them were active smokers. Three patients showed IgG anticardiolipine antibodies at high level. CONCLUSIONS: The clinical characteristics are similar to those reported, we find also a reduction of the disease diagnosis. It calls to our attention that no thrombophlebitis was found in the present series and the less compromise of the upper extremities with a frequent femoral compromise. All this points toward a change in the natural history of the disease.

Adolescent↗
PubMed1998

The change in concept and surgical treatment on Buerger's disease--personal experience and review.

Buerger's disease was originally described by Leo Buerger in 1908 as thromboangitis obliterance and has been considered as one of the most intractable vasculitis syndromes in our country. This lesion is popularly seen in male young generation with a background history of heavy smoking. Buerger's disease in Japan has been frequently seen in our practice; however, it is noted that there have been certain definitive changes in relation to number of patients, clinical manifestation as well as course of treatment in particular in surgical treatment. Firstly, the number of patients who visited at outpatient clinic as well as to admit hospital has been sharply declined. Secondly, the number of surgical treatments of Buerger's disease have also decreased. The sympathectomy, mainly lumbal sympathectomy, which was maintained at about 15 to 20% of the number of patients admitted, was virtually abolished from the practice and mainly converted to the medical and pharmacological treatment by prostaglandin. The reliability of pharmacological sympathectomy is one of the other reasons which contributed to the shift of treatment. It is also our impression that the severity of the disease itself has been changed, in other words, we do not frequently see very severely ill patients. As far as surgery is concerned the important modality in the treatment for the advanced lesion of Buerger's disease is mainly confined in small arteries with multisegmental occlusion. As a consequence, the surgical reconstructive procedures are technically difficult and long term patency rate is considered to be low. As far as our experience is concerned, it is noted that the number of bypass surgery was most frequently seen at below trifurcation segment of knee joint; in other words, peripheral, distal type bypass was the most popular, followed by above knee segment. The reconstructive surgery at femoral region was least frequently seen. On the other hand, the patency rate of bypass graft was higher in the proximal segment in comparison to the distal segment. Although the number of arterial reconstructive procedures has been definitively declined, as was seen in sympathectomy surgery. It is difficult to predict accurately what kind of factors are affecting or contributing to the change in concept in Buerger's disease as well as the course of treatment, it is suggested that the environmental factors may playing a major role for the modification of disease process.

Amputation, Surgical↗
PubMedDate not supplied

[Effect of sacral roots block in the prostatic structure of the rat].

OBJECTIVE: To validate a simplified model of neural manipulation of the lower urinary tract of the rat, by means of alcoholic blockade of sacral roots. MATERIAL AND METHODS: Twenty Sprague-Dawle rats (aged 3 months) underwent alcohol sacral root blockade under total anesthesia with previous needle placement monitoring (electrostimulation). After 28-30 days, ipsilateral ventral prostatic lobe (VL) was obtained. Macroscopic and light microscopy (LM) studies were performed (computerized image analysis). Results were compared with 20 LV from non manipulated rats. RESULTS: A slight non significant decrease of LV weight in the blockade group was notice. LM study showed a reduced epithelial height after manipulation. Gland compartment mean proportions were: control group: 28.1% (epithelial), 29.8% (stromal), y 70.2% (glandular -lumen plus epithelium-); study group: 30.5% (not significant), 37.4% y 62.3% (both p < 0.05) respectively. Epithelium area did not suffer any variation. A reduced vascular overall count was noted in the study group. Ipsilateral diffusion of blockade solution was shown in 9 rats (45%), and bilateral in 11 (55%). CONCLUSIONS: Alcoholic sacral root blockade produces an atrophy of the glandular component (due to luminal shrinkage, without epithelial change). No differences were found after the macroscopic study. This study could not reproduce the changes produced after standard surgical denervation, therefore we cannot recommend this method to be used in future models.

Animals↗
PubMedDate not supplied

[Peripheral nerve evaluation:indications, technique and results].

INTRODUCTION: Sacral nerve neuromodulation is a new treatment modality for patients with chronic voiding dysfunction (CVD). The aim of this treatment is to restore the disbalanced micturition reflexes by electrical stimulation ot the sacral roots. Peripheral Nerve Evaluation (PNE) is the first step needed to determine wether sacral nerve stimulation for the control of lower urinary tract dysfunction is appropriate for a given patient, yielding accurate information about the location, integrity and function of sacral nerves, and motor and sensorial responses to electrical stimulation. PATIENTS AND METHOD: 43 PNE in 28 patients (13 man and 15 women) were performed between january 2000 and november 2001 (mean age 56.3 years old, 22-76). Every patient have been diagnosed of CVD: 13 Urinary Urge Incontinence (UUI). 5 Urgency-Frequency Syndrome (UFS), 7 Dysfunctional Voiding (DV) and 3 Mixed Syndromes (1 patient UFS + DV and two patients with UUI + DV). RESULTS: Every acute stimulation showed positive sensory and motor responses. There was premature lead migration in 8 PNE (18.6%), preventing an appropriate evaluation of the temporal stimulation. 35 PNE were evaluated after a 6.5 days period (3-15) of electrical stimulation. There were no significative complications, and PNE was well tolerated. Good clinical results (> 50% reduction in symptoms) were observed in 7/13 patients with UUI (53.8%), 2/5 patients with UFS (40%), 1/7 patients with DV (14.2%) and 1/3 patients with mixed syndromes (UUI + DV) (33.3%). 11 of 28 patients with CVD (39.2%) have been selected as candidates for permanent implantation. CONCLUSION: Actually, PNE is the first step needed to determine wether sacral nerve stimulation for the control of lower urinary tract dysfunction is appropriate for a given patient. With PNE we can select properly adequate candidates for permanent implantation. It is an easy and well tolerated technique, and can be performed in any medical center in an outpatient basis.

Adult↗
PubMedDate not supplied

[Sacral root neuromodulation. Experience in our site: 1998-2003, concerning 18 definite neuromodulation implants].

OBJECTIVE: Sacral root neuromodulation is an effective technique for the treatment of Chronic Micturition Dysfunction (CMD) refractory to conventional therapy. New indications such as chronic pelvic pain and interstitial cystitis are currently making their way within the urologic setting. Several groups of gastric surgeons are now choosing this technique for the management of rectal diseases (constipation, sphincter dysfunction). This paper contributes our experience in the treatment of patients with CMD and the comparative results at one year from implant in all patients. MATERIAL AND METHODS: From December 1998 through July 2003, 18 neuromodulation definite implants were performed. The main indication was CMD in 62.5% patients. Follow up of patients was done at one month and three months, and every six months thereafter. Follow up is conducted through a micturition diary and QoL questionnaire. Electrode implant in the first 16 patients was achieved by open surgery. The next 2 patients had the electrode placed by a percutaneous technique using the "Tined Lead" kit. RESULTS: Results at one year after implant were compared in all patients. The total number of neuromodulation implants placed was 18, 14 (77.7%) of which were women and 4 (22.3%) men. Mean age was 52.56 years. Implant indication was CMD in 72.2% patients, mixed incontinence (urinary and faecal) in 22.1%, and interstitial cystic disease in 5.5%. Symptoms improvement at one year from implant, as determined by a micturition diary and QoL questionnaire was 76.4%. Clinical improvement was greater in patients with urgency symptoms than in patients with predominance of voiding symptoms.

Adult↗
PubMed2002

Alterations of cortical electrical activity in patients with sacral neuromodulator.

OBJECTIVES: Sacral neuromodulation represents chronic stimulation of the sacral (S3) nerve. So far, the mode of action and neuro-anatomical basis is unclear. Sacral reflex mechanisms as well as pontine or cortical centers of modulation have been postulated. Our aim was to evaluate possible alterations in electroencephalogram (EEG) activity as an indicator of a supraspinally mediated mechanism of sacral neuromodulation. MATERIALS AND METHODS: We analyzed serial EEGs (apparatus: Kölner Vitaport System) using electrodes placed at Fz, Cz, Cz' and Pz in 10 patients. Subsequently, the sacral (S3) nerve was stimulated by means of an impulse generator (Medtronic, Interstim 3023) using an on-off paradigm with a 1.5s "on" interval followed by a 10s stimulation break. Raw data were analyzed using both Matlab 4.0 software and a specially developed averaging routine. RESULTS: All patients demonstrated a cortical potential complex following sacral root stimulation with an early electronegative component at 50 ms with a mean amplitude of 23 microV followed by a late potential component with a mean latency of 253 ms and a mean amplitude of 5 microV, both with a maximum at Cz, corresponding to the post-central gyrus. This finding occurred irrespective of patient's reports of actually feeling the neuromodulator being switched on and off. CONCLUSION: In neuromodulation responders, both short and long latency cortical potentials can be reproduced with a maximum at the sensory cortical area. Although these potentials are similar to cognitively mediated "event-related potentials", they are clearly distinct from any subjective sensory or even painful response since several patients of this series have not been able to feel any neuromodulator action. Therefore, this pilot study indicates a supraspinally mediated site of modulation, most probably in sensory cortex areas.

Adult↗
PubMed2003

New percutaneous technique of sacral nerve stimulation has high initial success rate: preliminary results.

OBJECTIVE: We report on the new technique of sacral nerve stimulation in the treatment of voiding dysfunction. This new technique is characterized by percutaneous approach to the sacral nerves resulting in minimally invasiveness of the procedure and the ability to have patient awake during the electrode placement. METHODS: Since December 1999, we prospectively evaluated patients who underwent this novel percutaneous technique approach. Thirty-two patients (10 male, 22 female, mean age 43 years) were included and no complications were reported. Average follow-up time was 11 months (range 2-25 months). Main elements of the new technique are also described. The needle is inserted into the sacral foramen to a desired location (usually S3) and metal stylet is then inserted through the needle. With metal stylet only in the foramen, two dilators are successively inserted and the chronic lead is placed through the plastic dilator. Only a very small skin incision is necessary to allow the anchor fixation. RESULTS: Out of the 32 patients who underwent the percutaneous lead placement, 22 received the neurostimulator (IPG). Out of the remaining 10 patients, 4 are still in screening and 6 had unsuccessful results (<50% improvement) and therefore did not undergo the second stage (neurostimulator placement). From the 22 implanted patients, 20 reported 90% improvement in their primary voiding symptoms, 1 had an improvement between 50 and 70% and 1 patient was explanted due to IPG damage following magnetic resonance imaging. There were total of four lead displacements, two occurred where the silicone anchoring was used and the other two occurred when no anchoring was done. CONCLUSION: Success rate of this technique in selecting patients for the permanent implant is significantly higher than currently reported in the literature. Very beneficial clinical outcome of the implanted patients confirms better patient selection with no complications. Our experience with this technique shows the feasibility of percutaneous lead placement with major advantages such as: (1) use of local anesthesia and possibility to test sensitive responses during implant, (2) the possibility for more accurate patient selection by using the definitive lead for a longer test period before proceeding with the neurostimulator (IPG) implant. The presented percutaneous technique requiring fascial lead fixation represents a safe and effective method of Sacral Neuromodulation Therapy.

Adult↗
PubMed2001

The effect of lumbar sympathectomy on increased tactile sensitivity in spinal nerve ligated rats.

The aim of this study was to investigate the reason for the contradictory results following surgical sympathectomy on increased tactile sensitivity in spinal nerve ligated rats. For this purpose, firstly the results of L5 spinal nerve ligation alone and both L5 and L6 (L5/6) spinal nerve ligation were compared in Sprague-Dawley rats. Secondly, the difference in tactile sensitivity between the plantar surface (the middle glabrous area on the foot pads of the hind paw) and on the toe (the proximal half of the third and fourth toe of the hind paw) after the spinal nerve injury was studied. Third, we divided the L5 spinal nerve ligated rats into two groups, (i.e. low and high threshold groups) based on the degree of tactile sensitivity and investigated the effect of surgical lumbar sympathectomy (L2-L5) on tactile sensitivity in both the plantar and toe areas. The results show that the tactile sensitivities of L5 spinal nerve ligated rats and L5/6 spinal nerve ligated rats were not different. However, tactile sensitivities of the plantar surface were less than those of toe area suggesting that the response from toe is a better indicator of neuropathic pain. Surgical sympathectomy reduced the response from only the toe area and only in the low threshold group. These results suggest that the reason for the contradictory results of surgical sympathectomy in spinal nerve ligation models is, at least in part, the difference in the degree of mechanical allodynia in each study.

Animals↗
PubMed2002

Effects of electroacupuncture on the mechanical allodynia in the rat model of neuropathic pain.

The analgesic effects of acupuncture on the mechanical allodynia in the rat model of neuropathic pain have not yet been studied. The aim of the present study is: first, to determine if electroacupuncture (EA) or morphine attenuates the mechanical allodynia; and secondly, to examine if the EA effect may be mediated by endogenous opioids. To produce neuropathic pain, the right superior caudal trunk was resected between the S3 and S4 spinal nerves. Twenty-one days after the neuropathic surgery, low frequency EA stimulation (2 Hz, 0.3 ms, 0.07 mA) delivered to Houxi (S13) for 30 min relieved significantly the signs of mechanical allodynia. Intraperitoneal (i.p.) morphine (0.5 or 1.5 mg/kg) also relieved the signs of mechanical allodynia in a dose-dependent manner. In addition, the antiallodynic effect of Houxi EA was blocked by pretreatment with naloxone (2 mg/kg, i.p.). However, combined application of EA and morphine did not show an obvious synergistic effect. These results suggest that low frequency EA or morphine can relieve the mechanical allodynia signs and the EA effect can be mediated by endogenous opioid systems.

Animals↗