Klaus E Matzel1, Emmanuel Chartier-Kastler2,3, Charles H Knowles4, Paul A Lehur5, Arantxa Muñoz-Duyos6, Carlo Ratto7, Mona B Rydningen8, Michael Sørensen9, Philip van Kerrebroeck10, Stefan de Wachter11. 1. Chirurgische Klinik, Universität Erlangen, Germany. 2. Sorbonne Universités, UPMC, Paris, France. 3. Urology Department, Academic Hospital Pitié-Salpêtrière, AP-HP, Paris, France. 4. National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK. 5. Clinique de Chirurgie Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif (IMAD), University Hospital of Nantes, Nantes, France. 6. Department of General Surgery, Hospital Universitari Mutua Terrassa, University of Barcelona, Terrassa, Barcelona, Spain. 7. Proctology Unit, Department of Surgical Sciences, Catholic University, Rome, Italy. 8. Department of Gastroenterological Surgery, University Hospital of North Norway, Tromsö, Norway. 9. Department of Surgical and Medical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark. 10. Pelvic Care Centre Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands. 11. Department of Urology, University Hospital Antwerpen, Antwerpen, Belgium.
Abstract
INTRODUCTION: Sacral neuromodulation (SNM) (sacral nerve stimulation SNS) has become an established therapy for functional disorders of the pelvic organs. Despite its overall success, the therapy fails in a proportion of patients. This may be partially due to inadequate electrode placement with suboptimal coupling of the electrode and nerve. Based on these assumptions the technique of sacral spinal neuromodulation has been redefined. All descriptions relate to the only currently available system licensed for all pelvic indications (Medtronic Interstim® ). METHOD: An international multidisciplinary working party of ten individuals highly experienced in performing SNM convened two meetings (including live operating) to standardize the implant procedure. This report addresses the main steps to optimal electrode lead placement in temporal sequence. RESULTS: Key elements of the electrode placement are radiological marking, the use of a curved stylet, the entry of the electrode into the sacral foramen and its progression through the foramen, its placement guided by a combination of a typical appearance in fluoroscopy and achieving specific motor/sensory responses with stimulation. The report describes quadripolar electrode placement and then either insertion of a connecting percutaneous extension lead or permanent implantation of the programmable device. CONCLUSION: Standardization of electrode placement may ensure close electrode proximity to the target nerve providing a higher likelihood for optimal effect with less energy consumption (better battery longevity), more programming options with more electrode contacts close to the nerve and reduced likelihood of side-effects. The potentially better clinical outcome needs to be demonstrated.
INTRODUCTION: Sacral neuromodulation (SNM) (sacral nerve stimulation SNS) has become an established therapy for functional disorders of the pelvic organs. Despite its overall success, the therapy fails in a proportion of patients. This may be partially due to inadequate electrode placement with suboptimal coupling of the electrode and nerve. Based on these assumptions the technique of sacral spinal neuromodulation has been redefined. All descriptions relate to the only currently available system licensed for all pelvic indications (Medtronic Interstim® ). METHOD: An international multidisciplinary working party of ten individuals highly experienced in performing SNM convened two meetings (including live operating) to standardize the implant procedure. This report addresses the main steps to optimal electrode lead placement in temporal sequence. RESULTS: Key elements of the electrode placement are radiological marking, the use of a curved stylet, the entry of the electrode into the sacral foramen and its progression through the foramen, its placement guided by a combination of a typical appearance in fluoroscopy and achieving specific motor/sensory responses with stimulation. The report describes quadripolar electrode placement and then either insertion of a connecting percutaneous extension lead or permanent implantation of the programmable device. CONCLUSION: Standardization of electrode placement may ensure close electrode proximity to the target nerve providing a higher likelihood for optimal effect with less energy consumption (better battery longevity), more programming options with more electrode contacts close to the nerve and reduced likelihood of side-effects. The potentially better clinical outcome needs to be demonstrated.
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