Sacral neuromodulation is a well-known and effective treatment option for urge incontinence and voiding dysfunction. In this video, we present our techniques to optimize treatment efficacy while minimizing postoperative complications. Our experience has identified three key components to enhance patient outcomes. Efficient insertion of the localizing needle, optimizing patient response during testing, and minimizing postoperative complications. Implantation of the sacral tined lead is performed under local analgesia with conscious sedation. By expediting needle placement through correct patient positioning and the use of fluoroscopy to identify sacral landmarks, procedure length and patient discomfort are minimized. Proper setup of the operative bed with padding at the hips, as seen here, serves to flatten the sacrum, enhancing the localizing needle's approach to the sacroforamen. It is also important to assemble the bed in such a manner as to allow unrestricted access underneath the sacral region for the fluoroscopic C arm. Once the patient has been positioned on the operative bed, the buttocks are retracted laterally with tape so that anal bellows can be visualized. The use of fluoroscopy enables quick determination of the medial edges of the sacroforamen, as shown here. This border is then marked for reference during localizing needle placement. Lateral fluoroscopy now allows the surgeon to identify the best angle of approach to the foramen, which we highlight here. The optimal points for localizing needle insertion are then marked. Following administration of local analgesia, efficient insertion of the localizing needles is now accomplished. An important step in optimizing testing response is to balance the prevention of patient discomfort with the need for easy and coherent arousal of the patient during stimulation of the localizing needle so that felt sensations may be reported. The use of conscious sedation while avoiding midazolam, which may result in patient confusion, along with effective communication between the surgeon, patient, and anesthesia team can ensure an efficient testing experience as demonstrated here. Okay, where are you feeling that? Tell me where, baby. Vagina. Vagina. Very good. Once the patient reports a comfortable vaginal sensation, careful movements under fluoroscopic guidance of the localizing needle within the foramen allow sensory testing along the entire length of the tined sacral lead electrode region. This ensures that subsequent tined lead deployment is more likely to be parallel and in close proximity to the dorsal root. We have found it helpful to evaluate the amplitude required for the patient to report stimulation using the localizing needle prior to insertion of the tined lead. Low amplitude confirms close proximity to the targeted nerve and may increase the patient's success during the testing period. Good. Are you still feeling it vaginally? Still. Yes, ma'am. And it's comfortable? Comfortable. What's our amplitude? Four. Okay. The most commonly encountered complications of sacral neuromodulation therapy are pain associated with device position, tined lead migration, and postoperative infection. Several strategies can be employed to reduce the risk of these complications, including paying careful attention to the site chosen for generator implantation, minimizing trauma during placement of the sacral tined lead, and antimicrobial prophylaxis with barrier dressings during the testing period. In order to reduce postoperative pain related to the location of the implantable generator, we examine the patient in a sitting position just prior to surgery. A tissue marking pen is used to identify potential operative sites bilaterally for generator implantation, paying careful attention to avoid areas prone to discomfort from clothing or sitting. When creating the generator subcutaneous pocket, we place the pocket on the ipsilateral side as the sacral tined lead. Not crossing the sacral midline helps to lessen the potential for excessive traction on the lead, thereby reducing the risk of lead migration with falls or sudden movements. Furthermore, we create the pocket at a depth of approximately two centimeters in order to minimize potential irritation associated with the generator. It is important during the sacral tined lead placement to pay careful attention to minimizing tissue injury. We limit the depth of insertion of the dilating trocar to minimize tissue trauma in and around the sacral foramen. This further allows the sacral tined lead to follow a more natural path as it is placed adjacent to the nerve. Once the sacral tined lead has been successfully placed and tunneled to the subcutaneous pocket, the incision sites are copiously irrigated with an antibiotic-containing solution and a two-layer closure is performed. Tachyderm and sterile gauze dressings are then applied as a barrier and will remain in place until the patient undergoes placement of the generator or removal of the lead. The patient is further placed on oral antibiotic prophylaxis for the duration of the testing period. Implementation of these components during sacral tined lead placement will enhance patient outcomes through increased testing success and decreased postoperative complications.

sacral neuromodulation

urge incontinence

voiding dysfunction

needle insertion

postoperative complications