SUFU 2019: Salvaging a Neuromodulation Implant - Panel Discussion

Miami, FL ( Dr. Kobashi leads the panel with Drs. Elterman, Siegel, and Gupta with a question and answer session related to different neuromodulation implant cases. 

Case 1: Overactive Bladder (OAB) dry patient with a device but can’t feel the stimulation anymore. What are the first steps? Is it on? Consider other types of incontinence, comorbidities check IPG, lead migration, lead fracture. Impedance should be checked. 

Dr. Elterman talks about how a well-placed lead is very important. There are typically 7 combinations and work through each of this. Recommends patient try a program for 2 weeks at a time. Amplitude should be high enough so the patient should be feeling it. 

When to change pulse width (PW) and frequency? PW anecdotally can be changed in spinal cord patients.  Frequency change in pain patients (anecdotal).. Changing the stimulation high to where the patient is in pain is neither recommended nor necessary. He emphasizes that the lead should be in the upper medial aspect of the S3 foramen. 

Dr. Siegel responds to: When to change PW and frequency? Changing the frequency too low frequency might work better for idiopathic non-obstructive retention (10-20Hz). 

Lead positioning important in pain and OAB wet. This lead is in a neutral position. While this is radiographically acceptable, clinical response was not optimal. Maybe could be higher or more medial. After revision, the clinical response was better. 
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Before and after revision.

If reprogramming does not work then botox, revise lead, use other approaches, PTNS, pudendal, bilateral neuromodulation.  Sometimes other approaches still do not work. What do you do after Botox and still not achieving success. Dr. Elterman recommends 2 injection trials before considering it a failure then wait 6 months to do PNE again.

Dr. Kobashi asks “Would you consider PTNS after failing SNM?” Dr. Gupta has offered this to patients but she has a limited number of patients in her practice.

Case 2: 53 year old female with urgency incontinence and did great with PNE, not great with permanent lead. The consensus is that it is likely the delivery of the permanent lead that is the issue.

Case 3: SNM placed 2012, modest efficacy with antimuscarinic, “never perfect”, no sensation, IPG life: 0.

Dr. Gupta would start with imaging to see if lead needs to be revised with IPG replacement. Dr. Elterman argues this is an opportunity to make it better and consider total revision of the device. Dr. Siegel asks “how long did the battery last”? If it is in a short amount of time, then lead placement could be better.

Case 4: SNM placed outside the hospital. Take home message, get imaging to assess what device is in place and location. It is unknown when this device was placed.

Case 5: 48 year old female with refractory OAB and pelvic pain

Dr. Gupta considers adjunctive therapy. Medications and physical therapy should be offered. Alternative neuromodulation like pudendal neuromodulation should be considered. 90% of pts can have good success rates in salvaging.  Pudendal neuromodulation can be technically difficult.

Dr. Kobashi concludes the session with her own personal experience with a 19 ear old female with idiopathic retention with 4 leads implanted. She shows the evolution of neuromodulation. The patient is now doing well!
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Final take-home messages: successful options exist, know the tricks, practice, keep learning and as techniques improve and technology improves so should we!

Moderator: Kathleen C. Kobashi, MD, FACS, Head of the Section of Urology and Renal Transplantation at Virginia Mason Medical Center, Director of the Pelvic Floor Center and clinical fellowship in Female Pelvic Medicine and Reconstructive Surgery (FPMRS), and Clinical Professor at the University of Washington in Seattle

When to Reprogram It
Panelist: Dean S. Elterman, MD, MSc, FRCSC, Division of Urology, University of Toronto

When to Reposition Your Lead
Panelist: Steven W. Siegel, MD, Director of the Metro Urology Centers for Female Urology and Continence Care, CornerStone Medical Specialty Centre – Woodbury, Metro Urology

When to Explant and Consider Novel Approaches (Bilateral, Tibial, Pudendal)
Panelist: Priyanka Gupta, MD, Assistant Professor, Urology, Urologic Surgeon, Michigan Medicine

Written by: M Lira Chowdhury, DO, Fellow, Female Urology, Pelvic Reconstructive Surgery & Voiding Dysfunction, The University of California Irvine, Department of Urology, @lirachowdhury at the Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction Winter Meeting, SUFU 2019, February 26 - March 2, 2019, Miami, Florida

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