Robotic simple cystectomy as a last resort for antibiotic-recalcitrant recurrent urinary tract infections in women.

OBJECTIVE: To report a series of women with antibiotic-recalcitrant recurrent urinary tract infections (rUTI) managed with robotic simple cystectomy and ileal conduit urinary diversion. METHODS: Following Institutional Review Board approval, all female patients who underwent robotic cystectomy for rUTI between 2011 and 2021 were identified from a prospectively-maintained internal database at a tertiary care center. Exclusion criteria included interstitial cystitis, neurogenic bladder, urinary tract neoplasm, or congenital abnormality. Electronic medical records were reviewed by an independent researcher. Patients were also administered the Quality of Life Questionnaire-C30. RESULTS: Twenty-four patients met inclusion criteria. Median age was 75 years (range 53-87). Median rUTI duration was 6 (interquartile range [IQR] 2-10) years. Median urinary tract infections count in the 12-month preceding cystectomy was 5 (IQR 3-9). Infections with multidrug resistant organisms were found in 21 patients (88%). The 30-day postoperative complication rate was 79% (19/24), of which 11% were Clavien-Dindo grade ≥III. The main late complication was parastomal hernia, with 17% requiring repair or revision. At a median of 36 months (range 12-61) post-operatively, the median Quality of Life Questionnaire-C30 global health status score was 50 (range 33-83). CONCLUSION: Cystectomy is a last-resort management option for women with severely symptomatic end-stage bladders in the setting of antibiotic-recalcitrant rUTI. Patients should be counseled thoroughly regarding possible acute and long-term postoperative complications. Select patients, managed in high-volume referral centers, can benefit from robotic simple cystectomy with ileal conduit urinary diversion.

Identifying Patient and Surgical Criteria for Same-Day Discharge After Robotic-Assisted Sacrocolpopexy.

Introduction: To review the postrobotic-assisted sacrocolpopexy (RASC) course of women admitted for 23 hours post-RASC and identify events requiring intensive medical care or potentially leading to deleterious outcome or urgent readmission if that patient had same-day discharge (SDD) instead of observed overnight. Methods: Patients undergoing RASC from January to December 2020 at one institution were identified and relevant data were obtained via retrospective chart review. Patient exclusions: RASC start time after 12:00 PM, concurrent posterior colporrhaphy, rectopexy, or hysterectomy, or conversion to open. Results: Sixty-nine patients (median age 71 years old) met study criteria with majority American Society of Anesthesiologists class 2 (n = 46, 67%) or 3 (n = 22, 32%). Patient characteristics included prior abdominal surgeries (n = 58, 84%), prior hysterectomy/prolapse repair (n = 25, 37%), known allergy to pain medication (n = 25, 36%), and administration of a postoperative antiemetic (n = 37, 54%) or intra-/postoperative keterolac (n = 36, 52%). Median surgery length was 269 minutes. Postoperative events that may have resulted in urgent readmissions if they had SDD were observed in 6% of patients. In the 1st week post-RASC, there were no readmissions. Conclusions: In this limited quality assurance study, patients undergoing RASC experienced no major complications requiring intensive care. Postoperative events were almost entirely nausea and pain, with no readmissions within the 1st week.

Understanding a decade of safety reporting for sacral neuromodulation in the Food and Drug Administration Manufacturer and User Facility Device Experience database.

INTRODUCTION: Over 350 000 sacral neuromodulation (SNM) devices have been implanted since approval by the Food and Drug Administration (FDA) in 1998. SNM technology and clinical applications have evolved, with minimal safety updates after initial trials. We aim to provide an updated overview of real-world SNM safety. These insights will guide informed consent, preoperative counseling, and patient expectation-setting. MATERIALS AND METHODS: The FDA Manufacturer and User Facility Device Experience (MAUDE) database is a repository for medical device safety reports. We performed MAUDE categorical (1/1/98-12/31/10) and keyword (1/1/11-9/30/21) searches for "Interstim." A random sample of 1000 reports was reviewed and categorized by theme. To corroborate our MAUDE database analysis, a legal librarian searched the Public Access to Court Electronic Records (PACER) database, as well as Bloomberg Law's dockets database for all lawsuits related to SNM devices. RESULTS: Our search of the MAUDE database returned 44 122 SNM-related adverse events (AEs). The figure illustrates the prevalence of event categories in the random sample. The largest proportion of reports (25.6%) related to a patient's need for assistance with device use, followed by loss/change of efficacy (19.0%). Interestingly, a fall preceded issue onset in 32% of non-shock pain, 30% of lead/device migration, and 27% of painful shock reports. Our legal search revealed only four lawsuits: one for patient complications after an SNM device was used off-label, one case of transverse myelitis after implant, one for device migration or poor placement, and the fourth claimed the device malfunctioned requiring removal and causing permanent injury. CONCLUSIONS: This review confirms the real-world safety of SNM devices and very low complication rates as seen in the original clinical trials. Our findings indicate that 43.2% (95% confidence interval 40.1%-46.3%) of SNM "complications" are not AEs, per se, but rather reflect a need for improved technical support or more comprehensive informed consent to convey known device limitations to the patient, such as battery life. Similarly, the number of lawsuits is shockingly low for a device that has been in the market for 24 years, reinforcing the safety of the device. Legal cases involving SNM devices seem to relate to inappropriate patient selection-including at least one case in which SNM was used for a non-FDA approved indication-lack of appropriate follow-up, and/or provider inability to assist the patient with utilizing the device after implantation.

Long-term Outcomes and Complications of Trans-vaginal Mesh Removal: A 14-year Experience.

OBJECTIVE: To assess the long-term patient outcomes, including the resolution of symptoms and need for subsequent procedures, after vaginal mesh removals (VMR) we evaluate our 14-year experience with VMR from a tertiary center with three FPMRS-trained surgeons. Although the use of transvaginal mesh (TVM) had decreased significantly before its ban in 2019, surgeons are still treating TVM complications and performing vaginal or open/robotic VMR for mesh-related complications. METHODS: A retrospective review of women undergoing VMR with 6 months minimum follow-up was undertaken. The data abstracted included demographics, provider notes, operative reports, pathology findings, outside medical records, peri-operative information, and reoperations. RESULTS: From 2006 to 2020, 133 patients were identified, and 113 patients met study criteria with at least 6 months follow-up. The most common presenting symptoms were dyspareunia (77%) and pain (71%). The majority of VMR were performed vaginally (84.5%). Vaginal mesh was removed from anterior (60%), posterior (11%), and anterior and posterior (10%) compartments. Two ureteral injuries and one rectal injury were repaired intraoperatively. VMR resulted in resolution of pain in 50% of patients. Some patients had persistent pain (21%) and a few developed de novo pain (4%). More than half of the patients had dyspareunia resolution (52%), but 12% had persistent dyspareunia and 2% developed de novo dyspareunia. CONCLUSION: VMR complexity requires advanced surgical expertise. Most patients undergoing VMR had resolution of their presenting symptoms. However, outcomes for pain, sexual function, continence, and/or prolapse can be unpredictable, resulting in multiple surgeries.

Stress Urinary Incontinence After Urethral Diverticulum Repair Without Concomitant Anti-Incontinence Procedure.

OBJECTIVE: To review the rates of persistent and de novo stress urinary incontinence (SUI) following urethral diverticulum (UD) repairs performed without concomitant SUI surgical procedures. METHODS: Following IRB approval, charts of women who underwent UD excision by three FPMRS surgeons were reviewed. Data collected from the electronic medical record included demographic information, preoperative symptoms and evaluation (validated questionnaires [UDI-6, QoL]), imaging studies, operative details, post-operative symptoms, and subsequent surgical interventions. Excluded were women with <6 months follow-up or concomitant pubovaginal sling placement. SUI was diagnosed by patient report, and UD was confirmed by preoperative magnetic resonance imaging or voiding cystourethrogram. The primary outcome was defined as the rate of SUI following UD repair. Secondary outcomes included resolution of pre-operative SUI, rate of self-reported secondary SUI, and SUI surgical intervention post-UD repair. RESULTS: From 2003-2018, 61 of 67 women met study criteria. SUI pre-UD repair was reported in 31 of 61 (51%). During UD repair, 3 patients underwent Martius flap interposition. Post-UD repair, 18/61 (30%) reported SUI. Persistent SUI was present in 14 of 31 (45%), and de novo SUI occurred in 4 of 30 (13%). Postoperative responses revealed statistically significant improvements in QoL and most questions of UDI-6 at median 18 months. SUI was surgically managed in 3 patients using bulking agent injections (2) and autologous fascial sling placement (1). Overall, 3 of 61 (5%) underwent SUI intervention post-UD repair. CONCLUSION: Without prophylactic SUI corrective procedures performed during UD repair, we observed a low rate of de novo SUI, and only 5% with bothersome SUI opting for surgical intervention.

Changes in patient reported outcome measures after treatment for female urethral stricture.

INTRODUCTION: There is a paucity of patient reported outcome measure (PROM) data for women with urethral strictures. To address this gap, we aim to evaluate change in PROM among women who underwent surgery for a stricture. METHODS: American Urological Association Symptom Index (AUA-SI) and Urogenital Distress Inventory (UDI-6) data from a multi-institutional retrospective cohort study of women treated for urethral stricture was assessed. RESULTS: Fifty-seven women had either AUA-SS or UDI-6 and 26 had baseline and postoperative data for either. Most women underwent urethroplasty (77%) and the majority (73%) remained stricture free at median follow-up of 21 months (interquartile range [IQR] 7-37). The median baseline AUA-SI was 21 (IQR 12-28) and follow-up was 10 (IQR 5-24). After treatment, there was a median decrease of 12 (IQR -18 to -2) in AUA-SI (p = 0.003). The median AUA Quality of life (QOL) score at baseline and follow-up were 6 (IQR 4-6) and 3 (IQR 2-5), respectively. There was a median AUA-QOL improvement of 2 points (-5,0; p = 0.007) from a baseline 5 (unhappy) to 3 (mixed). Median UDI-6 scores were 50 (IQR 33-75) at baseline and 17 (IQR 0-39), at follow-up. After treatment, there was a median decrease of 19 (-31 to -11; p = 0.01). CONCLUSION: Women with urethral strictures have severe lower urinary tract symptoms which improved after surgery. This study substantiates the claims that recognizing and treating women with urethral stricture disease greatly improves lower urinary tract symptoms and QOL.

Urology Program Directors' Perception of Pregnancy During Residency.

OBJECTIVE: To assess urology program directors' (PDs) perception of pregnancy during residency training. METHODS: A 30 question anonymous survey was sent to 142 urology PDs regarding their demographics, program information, institution policies, and self-reported opinions. Results were assessed via descriptive analysis. RESULTS: A total of 63 PDs responded with a response rate of 44%: 19% were female, 73% between 40 and 59 years of age, and 91% had children. A minority (17%) of programs had 40% or more female residents. 37% of PDs had never had a pregnant resident during their time as PD while 57% had 1 to 5 pregnant residents. On multivariate analysis, PDs age > 60 years or PD having their first child when > 30 years old were predictors for poor support of maternity leave. The majority of PDs felt their program was better/much better at being supportive toward maternity leave compared to other surgical specialties at their institution. Only 21% of PDs felt that taking maternity leave burdened other residents unfairly. Of respondents, 62% felt prepared/completely prepared to advise residents on pregnancy during residency. However, 91% of PDs affirmed it would be helpful to have formal policies in place regarding maternity/paternity leave. CONCLUSION: While the majority of PDs do not have a negative perception of pregnancy during residency, a small portion feels that pregnancy during residency is a burden on other residents. More than half of PDs feel prepared to discuss this issue with their residents. However, a large majority would find formal policies helpful.

Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network.

AIM: Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS: This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS: Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION: This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

Domain Comparison Between 6 Validated Questionnaires Administered to Women With Urinary Incontinence.

OBJECTIVES: To compare patients' questionnaire-reported urinary incontinence (UI) symptoms to determine which have the best concordance. METHODS: Women with self-reported mixed UI were asked to report quality of life (QoL) due to urinary problems on a visual analog scale and complete 6 standardized validated questionnaires with questions on mixed UI (Medical Epidemiological and Social Aspects of Aging questionnaire, the Urogenital Distress Inventory short form [UDI-6], the Incontinence impact questionnaire short form [IIQ-7], the International Consultation on Incontinence Questionnaire Urinary Incontinence short form [ICIQ-SF], the King's Health Questionnaire [KHQ], and Patient Global Impression of Severity Scale [PGI-S]). Specific questions related to stress urinary incontinence (SUI), urgency urinary incontinence (UUI), UI severity, and QoL were compared within surveys from each patient with a Pearson correlation coefficient. RESULTS: Twenty consecutive women participated in the study with a mean age of 64 ± 13 years and mean time to complete all surveys of 11.2 ± 5.4 minutes. In SUI and UUI subdomains, KHQ, UDI-6, and Medical Epidemiological and Social Aspects of Aging questionnaire were well correlated, however, specific ICIQ questions related to SUI and UUI were less often well correlated. For severity subdomains the UDI-6 score was poorly correlated with the KHQ, PGI-S, and ICIQ scores (all P> .1). KHQ correlated well with the PGI-S (0.64, P= .003) and ICIQ score (0.58, P= .008). PGI-S and ICIQ severity scores were also well correlated (0.56, P= .012). QoL on a VAS (range: 1-10) was significantly well correlated with both KHQ (0.75, P<.001) and the IIQ-7 (0.64, P= .003). KHQ and IIQ-7 were also well correlated (0.64, P= .003). CONCLUSION: In this pilot study, validated questionnaires with questions regarding UI are mostly well correlated in women for subdomains of SUI, UUI, QoL, and severity. For UI symptoms and UI symptom severity the ICIQ and UDI-6, respectively, are poorly correlated with other survey results and may be less indicative of patient's complaints.

Prospective Evaluation of Urodynamic Utility in a Subspecialty Tertiary Practice.

OBJECTIVE: To prospectively evaluated the utility of urodynamic evaluations (UDS) ordered in a tertiary referral center as part of a quality improvement project. METHODS: Patients with UDS ordered by 3 subspecialty physicians were included. Physicians were surveyed when ordering UDS and at the post-UDS clinic visit to assess indications for UDS, pre- and post-UDS diagnosis, treatment plan, confidence level, and perceived helpfulness of UDS. UDS trained nurses conducting studies were surveyed on patient reported reproducibility of their symptoms and perceived difficulty of UDS. RESULTS: From April 2017 to October 2017, 127 UDS were included of which 102 met study criteria. UDS were done for neurogenic (23%) and non-neurogenic lower urinary tract symptoms (76%). The majority were conducted for incontinence evaluation (79%), or after prior lower urinary tract surgery (33%). UDS nurses reported 90% of UDS fully or partially reproduced patient symptoms. Nurses found 18% of UDS difficult due to catheter malfunctions, physical limitations, and communication abilities. Post-UDS, providers found 97% of UDS interpretable. UDS resulted in a change in treatment plan in 78% of patients. On a Likert scale, mean pre-UDS confidence level was 2.9 ± 0.8 (range 0-5). This increased to 4.1 ± 0.6 post-UDS with 76% of evaluations having a change of at least 1 point. CONCLUSION: UDS in a tertiary referral center result in change in patient treatment plans over three-fourths of the time with high rates of interpretability.

Urodynamics findings in transverse myelitis patients with lower urinary tract symptoms: Results from a tertiary referral urodynamic center.

AIMS: To characterize urodynamic findings in patients referred with transverse myelitis (TM) and lower urinary tract symptoms (LUTS), as well as to identify any characteristics predictive of urodynamics findings. METHODS: This is a retrospective review of an IRB-approved neurogenic bladder database of patients followed by a single surgeon between 2001 and 2013. Patient characteristics, questionnaire data, radiologic studies, and urodynamic parameters were analyzed. RESULTS: Of the 836 patients in the neurogenic bladder database, 28 patients (17 females, 11 males) were referred with a principle diagnosis of TM (3%). Twenty-one of twenty-eight patients (75%) underwent urodynamics testing. Bladder management at initial urologic evaluation was CIC or urethral catheter for 16/28 patients (57.1%). Median MCC was 303 ml (85-840 ml), detrusor overactivity (DO) was present in 16/21 (76%), detrusor sphincter dyssynergia (DSD) in 10/21 (48%), and decreased compliance in 7/21 (33%). For those voiding, mean Qmax was 12 ± 10 ml/sec and pdet at Qmax was 41 ± 17 cmH2 O. Longitudinally extensive TM (LETM) was the only patient characteristic associated with DO (P = 0.0276). No other patient characteristics were associated with urodynamics parameters. CONCLUSIONS: Significant urodynamic testing abnormalities are noted in the majority of TM patients undergoing urodynamics, with 95% having DO, DSD, altered compliance, or detrusor underactivity. Other than the association between LETM and DO, there were no patient characteristics predictive of urodynamics findings. Based on the severity of urodynamics findings in our series, patients with TM and LUTS should have thorough baseline urological evaluations including urodynamics and be offered ongoing surveillance. Neurourol. Urodynam. 36:360-363, 2017. © 2015 Wiley Periodicals, Inc.

Postoperative Imaging after Surgical Repair for Pelvic Floor Dysfunction.

Pelvic floor dysfunction encompasses an extremely common set of conditions, with various surgical and nonsurgical treatment options. Surgical options include injection of urethral bulking agents, native tissue repair with or without bioabsorbable or synthetic graft material, placement of synthetic midurethral slings or use of vaginal mesh kits, and mesh sacrocolpopexy procedures. Numerous different synthetic products with varied imaging appearances exist, and some of these products may be difficult to identify at imaging. Patients often present with recurrent or new symptoms after surgery; and depending on the presenting complaint and the nature of the initial intervention, imaging with ultrasonography (US), magnetic resonance (MR) imaging, voiding cystourethrography, or computed tomography (CT) may be indicated. US and MR imaging can both be used to image urethral bulking agents; US is often used to follow potential changes in bulking agent volume with time. Compared with MR imaging, US depicts midurethral slings better in the urethrovaginal space, and MR imaging is better than US for depiction of the arms in the retropubic space and obturator foramen. Mesh along the vaginal wall may be depicted with both US and MR imaging; however, the distal arms of the mesh traversing the sacrospinous ligaments or within the ischiorectal fossae (ischioanal fossae) are better depicted with MR imaging. Scarring can mimic slings and mesh at both US and MR imaging. MR imaging is superior to US for depiction of sacrocolpopexy mesh and associated complications. Voiding cystourethrography and CT are used less commonly because they rarely allow direct depiction of implanted material. Online supplemental material is available for this article. (©)RSNA, 2016.

Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women.

AIM: We present the surgical management and outcomes of patients who underwent transvaginal neo-bladder vaginal fistula (NBVF) repair at our institution. METHODS: Between 2002 and 2012, eight patients underwent transvaginal NBVF repair. The surgical management entailed placing a Foley catheter into the fistula tract. A circumferential incision was made around the fistula tract after which a plane between the serosa of the neobladder and the vaginal epithelium was created. Interrupted polyglycolic acid sutures were used to close the fistula. An additional layer of vaginal wall, Martius, or omental flap was interposed before vaginal wall closure. A urethral catheter was placed for a minimum of 14 days and removed after a negative cystogram and pelvic exam with retrograde neobladder filling without leakage. RESULTS: All patients presented with a fistula following radical cystectomy with orthotopic ileal neobladder. Two patients had failed two prior transvaginal fistula repairs. A unilateral Martius flap was used in five patients and an omental flap was used in one patient. The surgery was successful in all patients. After a mean follow up of 33 months [4-117], five patients underwent or are waiting to undergo management of stress urinary incontinence with bulking agents. No patient had a recurrent fistula. CONCLUSIONS: Management of NBVF is challenging but cure is possible using a transvaginal approach. Most patients will suffer from incontinence after the repair because of a short and incompetent urethra. Patients should be counseled about the high probability of requiring a secondary procedure to achieve continence.

Definition of Success after Surgery for Female Stress Incontinence or Voiding Dysfunction: An Attempt at Standardization.

CONTEXT: There is currently no standardized definition of success for surgery for stress urinary incontinence (SUI) and voiding dysfunction (VD) in women. OBJECTIVE: To review the use of outcome measures (OMs) and definitions of success in the literature on SUI and VD surgery in women in an attempt to provide recommendations for future publications. EVIDENCE ACQUISITION: A PubMed search of all English language full-text articles on SUI and VD surgery in women published between 2010 and 2015 was performed. A list of randomized trials and prospective and retrospective studies was obtained. Specific objective and subjective OMs used to define success were reviewed. EVIDENCE SYNTHESIS: Some 95 articles met the inclusion criteria for SUI surgery outcomes. Most trials reported outcomes at 12 mo after surgery. The majority (n=48) reported their primary outcomes using both objective and subjective success measures, 24 defined success using subjective OMs alone, and 23 using objective OMs alone. The OMs most frequently used for objective success were a negative cough stress test (CST), a negative pad test, and the absence of retreatment for SUI. The definition of subjective success most often involved questionnaires. The questionnaires most frequently used were Patient Global Impression of Improvement (PGI-I), Urinary Distress Inventory (UDI)/UDI-6, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) and Medical Epidemiologic and Social Aspects of Aging (MESA). Only 11 studies on OMs used for VD surgery were published between 2010 and 2015. The two most common criteria used for success were measurement of postvoid residual urine (PVR) and subjective resolution of VD symptoms. CONCLUSIONS: There is great heterogeneity in the definition of success used after surgery for SUI or VD in women. For SUI surgery, we recommend use of the CST and a 1-h pad test for the definition of objective success, and of the UDI/UDI-6, Incontinence Impact Questionnaire (IIQ), King's Health Questionnaire (KHQ), ICIQ-SF, or PGI-I questionnaire for subjective success. For VD surgery, cure should include measurement of PVR and self-reported resolution of VD symptoms. PATIENT SUMMARY: We looked at the definition of success used for surgery for stress urinary incontinence (SUI) and voiding dysfunction (VD) in women. We found that there is great heterogeneity among studies, making study comparison extremely difficult. According to the outcome measures used most frequently, we make recommendations regarding the definition of cure for SUI and VD in women to be used in future publications.

Patterns of hardware related electrode failures in sacral nerve stimulation devices.

PURPOSE: Abnormal electrical impedance in sacral nerve stimulation devices is a cause of device failure. Currently, there is scant literature evaluating the incidence and management of this problem. We evaluated the presentation, characteristics and management of sacral nerve stimulation devices with abnormal electrical impedance. MATERIALS AND METHODS: A total of 565 patients were permanently implanted with sacral nerve stimulation devices using a tined lead between 2003 and 2011. Devices were interrogated postoperatively and at followup. Abnormal electrical impedance was classified as open circuit--impedance greater than 4,000 Ω or short circuit--impedance less than 50 Ω and/or equivalence of impedance. Details on presentation, characteristics and management were recorded. RESULTS: Of the 565 patients 72 (12.7%) experienced a total of 86 abnormal electrical impedance events, of which 57 (66.2%) were open circuits and 28 (32.5%) were short circuits. One event (1.1%) was a simultaneous open and short circuit. Short circuits presented earlier than open circuits (median 3.5 months, IQR 2-7.5 vs 15, IQR 5.5-30.5, p <0.0001) and required surgical intervention more often (75.0% vs 54.3%, p = 0.09). Patient specific factors, such as trauma history and change in body mass index class, were not associated with abnormal electrical impedance. No electrode failure patterns could be identified. CONCLUSIONS: Abnormal electrical impedance occurred in approximately 13% of cases permanently implanted in our series. Short circuits presented earlier and often required surgical intervention. Open circuits presented later and may have potentially been secondary to microfractures that accumulate with time at the sacral plate, resulting in later presentation. Almost a third of patients with abnormal electrical impedance associated with clinical inefficacy were treated conservatively, primarily with reprogramming.

Troubleshooting sacral neuromodulation issues.

In the past decade, the use of sacral neuromodulation has increased exponentially. The introduction of the tined lead, the posterior location, and the smaller IPG has changed the frequency and types of complications. These facts explain the reduction of the revision and explantation rates in the most contemporary series, as compared with the earlier data. Infection, pain at the IPG site, and reduced clinical response with or without impedance abnormalities are now the most frequently reported complications. Although infection should be managed with explantation of the entire system, device interrogation should be part of the physician's algorithm for managing patients with decreased sensation or new onset of pain, in order to check the integrity of the system. Patients who are not improved with new programs will most likely need surgical revision. The implanting physician should be aware of the ways to evaluate and manage complications and suboptimal responses, to appropriately troubleshoot patients, and to reduce the need for surgical revision.