Non-invasive massage technique to aid in removal of a tined sacral neuromodulation lead.

INTRODUCTION AND HYPOTHESIS: Describe a novel technique for retrieval of the Interstim lead in part based on techniques used in massage therapy. METHODS: Retrospective review of patients (single surgeon) identified by CPT code 64585 over 10 years. Exclusion criteria included patients who (1) had explantation for active infection or (2) did not proceed with a stage 2 implant (in the event of a staged procedure). To effect removal, the surgeon applies a focused massage with firm deliberate pressure in deep circular motions to the insertion site and surrounding tissue. At the same time, gentle steady traction is applied to the lead (from the IPG pocket) by the surgeon. RESULTS: Sixty women were identified. Mean implant duration was 24 (6-60) months. There were three lead fractures at retrieval (5%). In all three occurrences, the inner conductor wire was removed despite leaving the tined fragment in place. The author did not perform a cutdown to retrieve the retained fragment. There were no peri- or postoperative complications. CONCLUSIONS: Lead removal is safely accomplished in a matter of a few minutes with the presented technique without the need for a cutdown. Lead breakage was 5% and similar to more invasive techniques.

Successful Treatment of Paradoxical Puborectalis Contraction and Intractable Anorectal Pain With Sacral Neuromodulation.

BACKGROUND: Paradoxical puborectalis contraction (PPC) is a syndrome of obstructed defecation associated with a cluster of complaints including rectal pain, incomplete evacuatory sensation, prolonged repetitive straining with bowel movements, and the need for digital manipulation. Traditional treatment has yielded mixed results. CASE: We present a case of PPC successfully treated with staged sacral neuromodulation and review her diagnostic features, medical regimen, and prior unsuccessful interventions tried. Symptoms were analyzed using a visual analog scale pain score (0-10). Criteria to progress to implantation of the pulse generator included a pain score less than 3 during test stimulation and/or greater than 50% decrease in the pain score compared to baseline.Our patient had a pain score of 0 (baseline 8) with stage 1 sacral neuromodulation. In addition, she had dramatic relief in her straining with bowel movements and need for digital manipulation. Her pulse generator was implanted after a 2-week trial, and she has experienced a lasting improvement at her follow-up of 2 years. CONCLUSIONS: Sacral neuromodulation is an established therapy for overactive bladder syndrome, urinary retention, and fecal incontinence. In urology, the use of sacral neuromodulation has been described to benefit some patients with pelvic floor pain. Sacral neuromodulation can be a successful treatment for PPC and functional anorectal pain with resulting improvement in quality of life without the sequelae of an invasive and irreversible surgery.

Sacral Neuromodulation and Twiddler's Syndrome.

Twiddler's syndrome is the deliberate, inadvertent, or subconscious manipulation of an implantable generator within its subcutaneous pocket that can lead to malposition and fracture of the associated lead. The syndrome is well recognized in patients with pacemakers, implantable cardioverter defibrillators, deep brain stimulators, and more recently in intrathecal drug delivery devices. Here we present an instance of Twiddler's syndrome after sacral neuromodulation.

Safe Simultaneous Use of Sacral Neuromodulation and Vagal Nerve Stimulation.

INTRODUCTION: The potential for costimulation with competitive effects between implanted electronic devices remains speculative both at the level at the implanted device and with active programming but also at the retrograde site of action. We present a patient with an implanted vagal nerve stimulator for refractory epilepsy who underwent successful staged sacral neuromodulation (SNS) and benefits from both technologies. CASE: This is a case report of a 42-year-old female patient with a history notable for medically intractable epilepsy, temporal lobectomy, and vagal nerve stimulation who subsequently underwent staged SNS for refractory overactive bladder syndrome. The patient continues to benefit from sustained reduction in her bladder issues and without dimunition of her seizure threshold at 6-month follow-up. DISCUSSION: Different action sites for SNS as well as vagal nerve stimulation are possible. The role of the thalamus in continence and seizure activity is reviewed. There does not seem to be an interactive effect during the simultaneous use of these 2 modalities.

Serratia marcescens thigh infection after transobturator sling without associated mesh exposure.

INTRODUCTION: Soft tissue complications of the thigh occur after transobturator slings and are reported to uniformly accompany mesh exposure. Most commonly identified microorganisms cultured from such soft tissue infections include Bacteroides and Streptococcus species. This is the first reported case of Serratia marcescens leading to thigh cellulitis after a transobturator sling and the complication occurred in the absence of exposed mesh. CASE: A 54-year-old presented 7 days after a transobturator sling with right thigh cellulitis and sepsis in the absence of mesh exposure. She underwent explantation of the sling and incision and drainage of the groin incision. Cultures grew S. marcescens. DISCUSSION: Soft tissue infections of the thigh after transobturator tape are rare, but commonly associated with exposed mesh. Mesh exposure does not lead to thigh complications uniformly. The fact that this patient had no exposed mesh poses several questions about the pathogenesis of soft tissue infections of the thigh after transobturator slings.

Laparoscopic mesh explantation and drainage of sacral abscess remote from transvaginal excision of exposed sacral colpopexy mesh.

Sacral colpopexy may be complicated by mesh exposure, and the surgical treatment of mesh exposure typically results in minor postoperative morbidity and few delayed complications. A 75-year-old woman presented 7 years after a laparoscopic sacral colpopexy, with Mersilene mesh, with an apical mesh exposure. She underwent an uncomplicated transvaginal excision and was asymptomatic until 8 months later when she presented with vaginal drainage and a sacral abscess. This was successfully treated with laparoscopic enterolysis, drainage of the abscess, and explantation of the remaining mesh. Incomplete excision of exposed colpopexy mesh can lead to ascending infection and sacral abscess. Laparoscopic drainage and mesh removal may be considered in these patients.

Pre-ramus passage of inside-out transobturator sling.

Groin pain after transobturator tape is not uncommon. Differential diagnosis and treatment strategies are becoming elaborated in the literature. A patient presented with partial improvement in her stress incontinence and persistent groin and vulvar discomfort for 3 months after "inside-out" transobturator tape. The sling was removed secondary to malposition anterior to the inferior pubic ramus, i.e., a trans-vulvar passage. Her vulvar and groin complaints resolved. Recommendations are made to facilitate the "inside to out" transobturator dissection and trocar passage to prevent this complication.

Sacral neuromodulation and cardiac pacemakers.

INTRODUCTION AND HYPOTHESIS: Potential for cross-talk between cardiac pacemakers and sacral neuromodulation remains speculative. METHODS: We present a case series of patients with cardiac pacemakers who underwent staged Interstim (Medtronic, Minneapolis, MN) implantation and patients who had pulse generator implantation who later required cardiac pacemakers. RESULTS: No cross-talk was demonstrated in either group. CONCLUSIONS: Sacral neuromodulation appears to be safe in the setting of cardiac pacemakers without cardioversion/defibrillation technology.

Subcapsular relocation for sacral neuromodulation pulse generator implant revision.

OBJECTIVES: We describe our technique and experience with subcapsular placement of the Interstim (Medtronic, Minneapolis, MN, USA) pulse generator in cases of revision for implant site pain. METHODS: The pulse generator and electrode are carefully exteriorized and the floor of the capsule is incised. The system is placed beneath the floor of the original capsule, which then becomes the roof of the new pocket. A layered closure is performed. RESULTS: Five patients have undergone the technique described with successful resolution of their pain. Conclusions Utilizing the capsule presumably improves defects in skin microcirculation, but also creates additional cushion superior to the pulse generator, helping to counteract the vertical mechanical forces of the pulse generator.

An unexpected cause of dyspareunia and partner dyspareunia following TVT-Secur.

TVT-Secur is a new "less" invasive derivative of the tension-free vaginal tape (TVT). We report an unusual case of dyspareunia for both the patient and her husband resulting from a retained finger pad from the TVT-Secur introducer. The sling was also explanted because of malposition.

Blunt trauma leading to delayed extrusion of sacral nerve implant.

Sacral neuromodulation is an effective treatment for refractory urge urinary incontinence, frequency, and urgency. Post pulse generator (IPG) adverse events requiring revision or explantation are typically pain, loss of response, and infection. We report a case of trauma-induced soft tissue injury and delayed extrusion of the IPG through the subcutaneous fat and skin. The device was explanted.

Management of persistent groin pain after transobturator slings.

Prolonged groin pain after transobturator tape is uncommon. Three women reported groin pain that had not improved by 3 months postoperatively. Combined steroid and local anesthetic was effective for pain relief in all patients. The differential diagnosis of persistent groin pain after transobturator tape includes adductor muscle strain, osteitis pubis, obturator/groin abscess, structural adhesions, and inflammation, edema or nerve entrapment of the anterior branch of the obturator nerve. No side effects of treatment were noted. Patients that do not respond to local injection may require mesh dissection and excision.

Pyometra and recurrent prolapse after Le Fort colpocleisis.

The Le Fort colpocleisis is a surgical option for advanced pelvic organ prolapse in elderly and infirm women who no longer desire coital function. It is thought that the creation of adequate lateral drainage channels will prevent the occurrence of a pyometra. The author describes the occurrence of a pyometra, despite adequate vaginal channels, necessitating hysterectomy. A 78-year-old woman presented with a 3-year history of purulent vaginal discharge that began shortly after an uncomplicated Le Fort colpocleisis. She also complained of recurrent symptomatic prolapse. Radiologic evaluation revealed a pyometra, which was confirmed at the time of laparotomy. At the time of hysterectomy, she benefitted from total colpocleisis, vaginectomy, and levator plication. The approach to recurrent prolapse after Le Fort colpocleisis is discussed. The occurrence of pyometra despite adequate drainage should affect how patients undergoing obliterative procedures for pelvic organ prolapse are counseled.

Sacral neuromodulation and lower urinary tract dysfunction in cerebral palsy.

Given the emerging role of sacral neuromodulation in treatment of neurogenic voiding dysfunction, the author describes the use of sacral neuromodulation in a patient with voiding dysfunction caused by cerebral palsy (CP). A 45-year-old patient with cerebral palsy presented with progressive complaints of urgency and overflow incontinence and was found to be in retention. She underwent sacral neuromodulation and had complete resolution of her symptoms. The literature of lower urinary tract dysfunction in CP is reviewed. It is concluded that sacral neuromodulation may be a valuable tool in treating storage and voiding disorders associated with CP.

Interstitial cystitis in a woman with systemic mastocytosis.

Studies have reported detrusor mastocytosis in patients with interstitial cystitis. The author describes a patient with systemic mastocytosis who was confirmed to have detrusor mastocytosis and interstitial cystitis. She responded to therapy with pentosanpolysulfate. The literature on systemic mastocytosis and the role of mast cells in the pathophysiology of interstitial cystitis are reviewed.

Expression profile of several genes in human myometrium and uterine leiomyoma.

OBJECTIVE: To screen several genes that are differentially expressed in uterine leiomyoma and matched unaffected myometrium by using microarray-based hybridization and real-time polymerase chain reaction analyses. DESIGN: Screen by arrays for < or =2,400 known genes in leiomyoma and control myometrium. SETTING: University clinical research laboratory. PATIENT(S): Four patients with leiomyoma scheduled for surgery during the proliferative phase. INTERVENTION(S): Four paired samples of leiomyoma and adjacent myometrium were obtained from patients undergoing hysterectomy. MAIN OUTCOME MEASURE(S): Fold-changes in expression of leiomyoma and matched myometrium (L/M). RESULT(S): A comparison of expression patterns revealed 73 genes significantly up- or down-regulated in each paired tissue sample, of which 30 genes showed increased expression (mean L/M of >2) and 43 showed decreased expression (mean L/M of <0.5) in leiomyoma compared with normal myometrium. When considering only growth factors, pleiotropin (PTN) was expressed 3.5-fold more in leiomyomas compared with in myometrium. No other growth factors were similarly affected. In addition, real-time polymerase chain reaction analysis correlated well with microarray data. CONCLUSION(S): Data obtained from the present study suggest that several genes are selectively overexpressed in leiomyomas compared with in myometrium. Increased expression of growth factor PTN may represent a promising target for therapy.

Tuboovarian abscess: a postoperative complication of endometrial ablation.

BACKGROUND: Global endometrial ablation may be associated with serious complications. CASE: We present a case of bilateral tuboovarian abscesses that developed 50 days postoperatively after a thermal ablation. The patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. CONCLUSION: Infectious morbidity is known to occur after thermal endometrial ablation. Further investigation is required into ways of reducing the risks of endometrial ablation.