Removal of sacral neuromodulation quadripolar tined-lead using a straight stylet: description of a surgical technique

Background Up to 7.5% of tined-lead removals in patients having sacral neuromodulation (SNM) therapy are associated with a lead breakage. It is still unclear what adverse effects can be caused by unretrieved fragments. The aim of our study was to describe the lead removal technique we have been using for the last 2 years in our centre. Methods We retrospectively enrolled patients who had lead removal between January 2018 and January 2020 using our standardized technique. The novelty of the technique is in the use of the straight stylet, which is available in the quadripolar tined-lead kit. The stylet gives the electrode greater stiffness, reducing interactions with surrounding tissues and probability of damage or breakage during removal. Results In 59 patients (42 women, mean age 57.2 years [range 40–79 years]) the lead was removed using our standardized technique. In 44 of 59 patients, the tined-lead was removed within 2 months from the SNM-test, due to lack of beneficial effects. In 15 patients the electrode was removed because of failure of definitive implantation. Meantime from definitive implantable pulse generator (IPG) implantation to lead removal was 67.9 months. We recorded only 1 case of lead-breakage during removal: a female patient with a non-tined lead fixed on sacral bone, placed 18 years previously using an open technique. Conclusions Lead breakage during removal is not uncommon and adverse effects of retained fragments may occur. Our technique has been safely used for the last 2 years in our centre, with no episodes of lead breakage or retained fragments, except for one non-tined electrode.

Sacral Nerve Stimulation Lead Migration through the Sciatic Foramen, Successfully Repositioned

Introduction: SNS (Sacral Nerve Stimulation) has become an established minimally invasive procedure for urinary and faecal incontinence. Minor complications related to the procedure are common; include pain, infection or migration. We present a case of a tined lead migration through the sciatic foramen. Case Report: A 72-year-old woman with faecal incontinence, who did not respond to dietary of medical treatment, underwent a sacral nerve stimulation test. Under fluoroscopic vision a tined lead was placed in S3 foramen, with an adequate motor and sensory response. In the 7th postoperative day, she reported no improvement and she referred sensory response in the thigh and leg. Radiography showed migration of the electrode through the sciatic foramen. The repositioning of the same electrode was possible with a gentle traction of the lead. Correct placement of the lead was confirmed radiologically, and the patient showed motor and sensory response in the anal area. The patient improved Wexner score from 18/20 to 4/20. Conclusion: Migration of the tined lead should be considered if loss of response in found. Repositioning of the same lead is possible in selected patients, without the need of removal of the device.

Current Position of Sacral Neuromodulation in Treatment of Fecal Incontinence

Fecal incontinence (FI) is defined as uncontrolled passage of feces or gas for at least 1-month duration in an individual who previously had control. FI is a common and debilitating condition affecting many individuals. Continence depends on complex relationships between anal sphincters, rectal curvatures, rectoanal sensation, rectal compliance, stool consistency, and neurologic function. Factors, such as pregnancy, chronic diarrhea, diabetes mellitus, previous anorectal surgery, urinary incontinence, smoking, obesity, limited physical activity, white race, and neurologic disease, are known to be the risk factors for FI. Conservative/medical management including biofeedback are recognized as the first-line treatment of the FI. Those who are suitable for surgical intervention and who have failed conservative management, sacral nerve stimulation (SNS) has emerged as the treatment of choice in many patients. The surgical technique involves placement of a tined lead with four electrodes through the S3 sacral foramen. The lead is attached to a battery, which acts as a pulse generator, and is placed under the patient's skin in the lower lumbar region. The use of SNS in the treatment of FI has increased over the years and the beneficial effects of this treatment have been substantiated by multiple studies. This review describes SNS as a modality of treatment for FI and its position in the current medical diaspora in patients with FI.