Prosthetic Surgery in Urology by Asif Muneer Ian Pearce & David Ralph

Author:Asif Muneer, Ian Pearce & David Ralph
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Keywords

Sacral nerve stimulationNeuromodulationUrinary incontinenceUrinary retentionBladder pain syndromeNeurogenic bladder

Introduction

A wide range of electrical stimulation techniques have been used in attempts to influence lower urinary tract function; the history of these efforts dates back to the late 19th century [1]. Electrical stimulation can be used to alter LUT function through a variety of mechanisms. These include direct stimulation of smooth or striated muscle, inhibition of pain pathways and modulation of reflex activity [2]. External stimulation, using transcutaneous and transvaginal systems, have been widely incorporated into clinical practice but the use of implanted devices has been more limited until recent years. The Brindley sacral anterior root stimulation device was developed to drive bladder contractions in patients with complete spinal cord injuries but has no role in other patient groups [3]. In contrast, sacral nerve stimulation (SNS) using the InterStim® (Medtronic, Inc.) implanted neuromodulation system is used in several different patient groups and the device has now been used in tens of thousands of patients.

The introduction of SNS as an effective therapy for LUT dysfunction followed the pioneering work of Tanagho and Schmidt [4]. Following the initial development work, multicentre, prospective controlled clinical trials were carried out and provided an evidence base which has led to the incorporation of SNS into clinical guidelines and pathways. For example, the National Institute for Health and Care Excellence, (NICE), has placed SNS in their management algorithm for female urinary incontinence [5]. Although there is strong evidence to support the use of SNS in patients with LUT dysfunction, there are important issues that have yet to be satisfactorily addressed. These include the imperfect methodology for selecting patients for treatment with a minority of patients who receive implants failing to maintain long-term clinical benefit. Questions also remain regarding the cost-effectiveness of the treatment, the equipment is expensive and there are additional surgical costs from the test procedure and surgical implantation. In addition approximately one third of patients undergo re-operation for complications. This chapter examines the theoretical basis for neuromodulation using the InterStim system, the procedures involved, the benefits of treatment, its potential risks and questions about cost-effectiveness.

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