Sacral neuromodulation lead removal, a novel technique. More than 50,000 patients have undergone sacral neuromodulation placement for the treatment of lower urinary tract symptoms. Occurrence of explantation ranges anywhere from 6 to 24.6 percent within an average of 18 to 44 months after placement. Extraction of time leads may be secondary to infection, pain, lead migration, lack of efficacy, or device malfunction. Lead being placed upon the lead during extraction may cause fracture of the lead resulting in retained fragments. The amount of morbidity and mortality of retained fragments or more invasive removal procedures such as a sacral cut down is unknown. Potential health complications include pain, infection, lead migration, MRI complications, and viscous perforation. Cardiologists often use a locking stylet to aid in the removal of pacemaker leads where complete removal is necessary and the formation of scar tissue makes intact removal difficult. Certain lead locking devices can fit inside the hollow lumen of the lead and once deployed releases a braided mesh which expands along the length of the lead increasing the integrity of the lead and allowing the physician to apply a steady traction during removal. We will now describe a novel and safe sacral lead extraction technique using a lead extraction device. Our patient is a 39-year-old G3P3 African-American female with a history of refractory OAB, chronic pelvic pain, and new onset low back pain. She desired complete removal of her sacral neuromodulation system after consultation with her neurosurgeon who recommended a lumbar MRI. The procedure began by identifying the prior IPG pocket. The skin overlying the area was infiltrated with quarter percent marcaine. A scalpel was used to make an incision over the existing scar. The subcutaneous tissue was then taken down with electrocautery all the way to the level of the pocket revealing the IPG. The capsule was excised and any adhesions surrounding the IPG were broken up with a Kelly clamp. At this point, the battery was then delivered through the incision and the lead was cut from the battery. Gentle traction on the lead revealed the path of the lead to the sacrum. A counter-incision was then made over the insertion site of the lead. A right angle clamp was used to bring the lead into the field and out of the incision. The lead extracting device was then prepared to be used. This particular device has a one centimeter radiopig tip which allows verification of the tip under fluoroscopy. When deployed, a braided mesh expands within the hollow lumen of the lead. This provides the lead with increased stability under tension along the entire length of the lead. The braided mesh can also be compressed if needed to allow for adjustment or removal of the device by the surgeon. The radiopig tip of the lead extracting device is inserted into the lumen of the tined lead and threaded to the distal end. This is performed under continuous fluoroscopy. The one centimeter radiopig tip of the lead extracting device allows the surgeon the ability to watch advancement of the device under fluoroscopy as is depicted in these sequential images. This allows the surgeon to ensure adequate placement, adjustment, or insertion of the lead extracting device as needed. Once optimal placement is considered adequate, the device is deployed. This is performed by releasing the proximal connector from the crimped core mandrel and sliding the connector off the crimped section. This action expands the wire mesh inside the lead lumen and locks it into place. The device is now deployed. A Kelly clamp is placed on the most distal end of the lead and lead extracting device and used as a source of tension. With gentle traction and a rotating manner, the Kelly is used to remove the lead entirely intact. The removal of the lead can be performed under fluoroscopy to ensure complete removal of the lead. The lead extracting device is useful in improving the integrity of the lead and allowing the appropriate amount of traction to be placed upon the lead for complete and intact removal. This may be helpful in situations where leads have been in place for longer periods of time and have developed more scar tissue surrounding the lead. The lead extracting device helps prevent fragmenting of the lead, decreasing the need for a more invasive procedure, such as a safer cut down or retaining a ghost lead. Adequate data on the rate of lead fracture and morbidity associated with removal or retainment of fractured leads is not currently available. This is an area where the opportunity for research exists. In conclusion, using a lead extracting device during lead removal aids in a safe, minimally invasive, and complete removal of a timed lead.

sacral neuromodulation leads

lower urinary tract symptoms

lead extraction

lead integrity

minimally invasive lead removal