Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

AIMS: To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM). METHODS: Patients enrolled in our longitudinal neuromodulation database were reviewed. Medical records data, and voiding diaries, Interstitial Cystitis Symptom-Problem Indices (ICSI-PI), and Overactive Bladder Questionnaires (OAB-q) at baseline and 3 months were analyzed with Pearson's χ2 , Fisher's Exact test, Wilcoxon rank tests, and multivariable logistic regression. RESULTS: Of 407 patients, 134 (33%) had at least one reoperation over median 28.9 months follow-up (range 1.6-121.7); 78/407 (19%) were revised, and 56/407 (14%) were explanted. The most common reason for reoperation was lack of efficacy/worsening symptoms (n = 87). The reoperations group had a higher proportion of women (P = 0.049), lower mean body mass index (BMI; P = 0.010), more reprogramming events (P < 0.0001), longer median follow-up (P = 0.0008), and higher proportions with interstitial cystitis (P = 0.013), using hormone replacement therapy (P = 0.0004), and complications (P < 0.0001). Both reoperations/no reoperations groups had similar improvements in ICSI-PI (P < 0.0001 for both), OAB-q severity (P < 0.0001 for both) and quality of life (P < 0.0001 for both). On multivariate analysis, only longer follow-up (P = 0.0011; OR 1.048; CI 1.019, 1.078) and having a complication (P < 0.0001; OR 23.2; CI 11.47, 46.75) were significant predictors of reoperations. In women only, using HRT at time of implant was also predictive of reoperation (P = 0.0027; OR 3.09; CI 1.48, 6.46). CONCLUSIONS: In this largest known series to date, one third of the patients required reoperation and the most common reason was lack of efficacy/worsening symptoms. Ongoing study is needed as the technology continues to evolve. Neurourol. Urodynam. 36:354-359, 2017. © 2015 Wiley Periodicals, Inc.

Clinical outcomes of sacral neuromodulation in patients with neurologic conditions.

OBJECTIVE: To examine the outcomes in patients with and without a comorbid neurologic diagnosis (ND) or neurogenic bladder dysfunction after a staged neuromodulation procedure for refractory bladder symptoms. MATERIALS AND METHODS: Patients enrolled in our prospective neuromodulation database study were grouped according to the presence of a coexisting ND. The implantable pulse generator implant rates were evaluated. Those who had received an implantable pulse generator were further evaluated over time for complications, revisions, explantations, and reprogramming sessions collected from the medical records. The symptom changes from baseline over 2 years were measured using patient-completed voiding diaries, the Interstitial Cystitis Symptom-Problem Index, Overactive Bladder Questionnaire, the Medical Outcomes Study short form, 12-item health survey, version 2, physical and mental component subscales, and a scaled global response assessment. The data were examined using Pearson's chi-square test or Fisher's exact test, Wilcoxon rank tests, and repeated measures analyses. RESULTS: Of 340 patients, 63 of 71 (88.7%) with an ND and 241 of 269 (89.6%) without an ND had an implantable pulse generator implanted (P = .82). The NDs consisted of stroke (n = 17), multiple sclerosis (n = 13), Parkinson's disease (n = 10), incomplete spinal cord injury (n = 4), cerebral palsy (n = 1), and others. The complications, revisions/explants, and reprogramming sessions were similar between the 2 groups. Statistically significant improvements were seen in both groups over time on the voiding diary variables (except for incontinence episodes and severity in the ND group), Interstitial Cystitis Symptom-Problem Index, and Overactive Bladder Questionnaire. The short form, 12-item, physical and mental component subscale scores only improved significantly in those without an ND. Most patients (>50%) in both groups reported moderate or marked improvement in overall bladder symptoms at each point using the global response assessments. CONCLUSION: Patients with neurogenic bladder dysfunction experience benefits after neuromodulation similar to the benefits experienced by those without coexisting neurologic conditions.

Secondary changes in bowel function after successful treatment of voiding symptoms with neuromodulation.

AIMS: Expanded indications for neuromodulation are continually being explored. We evaluated secondary changes in bowel function after successful neuromodulation for voiding symptoms. METHODS: Patients in our prospective neuromodulation database study with comorbid irritable bowel syndrome (IBS), constipation and/or diarrhea, or fecal incontinence (FI) at baseline were evaluated. Pre- and 3, 6, and 12 months post-operative measures included Interstitial Cystitis Symptom Index and Problem Index (ICSI-PI), bowel diaries (assessing bowel movement frequency; constipation, diarrhea, and FI episodes), and scaled global response assessments (GRA) ("markedly worse" to "markedly improved" bowel function). RESULTS: Most patients reporting secondary bowel problems (128/199; 64.3%) were female (89%; mean age 56 ± 15.4 years). Primary voiding complaints were urgency/frequency (U/F) with or without urinary incontinence (n=74), interstitial cystitis/painful bladder syndrome (IC/PBS; n=43), and urinary retention (n=11). Secondary bowel complaints included constipation and/or diarrhea (49%), IBS (27%), and FI (23%). Urinary (ICSI-PI) scores improved after treatment (P<0.0001 for IBS and constipation/diarrhea; P=0.0021 for FI). Bowel diary data only indicated that mean FI episodes/day increased over time (P = 0.0100) in the FI group. Only the 12-month value (1.4 ± 2.2; n=8) was significantly different from baseline (0.3 ± 0.5; n = 18). On the GRA, only the IBS group consistently reported bowel function improvement versus worsening at each time point. Many reported no change. CONCLUSIONS: Studies have indicated that neuromodulation improves FI in carefully selected patients. The impact on other bowel conditions, including IBS, is unclear. Since voiding and bowel symptoms often coexist, it is crucial to fully evaluate all potential treatment benefits.

Group session teaching of behavioral modification program for urinary incontinence: establishing the teachers.

In a past study it was determined that a nurse scientist and an urologist were able to prevent incontinence in women through teaching strategies in a group setting. This study determined that the same knowledge could be taught by an experienced nurse practitioner and an experienced urology nurse.