The efficiency of office test stimulation for patients undergoing sacral neuromodulation.

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Background:
Sacral neuromodulation (SNS) has become an accepted modality in the treatment of refractory voiding dysfunction. Currently, the most common method used for SNS is the staged procedure where a tined quadripolar lead is initially placed in the operating room (OR) for “test” stimulation. We evaluated our results using a modified test stimulation performed in the office to determine its efficiency and role in patients undergoing SNS.
Methods:
52 consecutive patients undergoing office based percutaneous test stimulation (PTS) for refractory voiding dysfunction were evaluated retrospectively. Sensory and motor responses were confirmed with an insulated foramen needle and a coiled insulated wire was placed in both the left and right S3 foramen under fluoroscopic guidance. The patient was implanted with permanent sacral lead and implantable pulse generator (IPG) in the OR if there was at least 50% subjective and objective (voiding diary) improvement in symptoms. If the patient had an equivocal response or did not appropriately feel the stimulation, a staged procedure was performed. If the patient had “good” test stimulation (appropriate sensory responses) but did not respond, he/she was tried on other treatment options.
Results:
Of the 52 patients (mean age 59.1±18.8 yrs), 38 were women and 14 were men. Mean follow up was 7.4±2.1 days. Based on symptoms, the patients were categorized into 3 groups: frequency/urgency in 24 patients (46%), urge incontinence in 24 patients (46%), and non-obstructive retention in 4 patients (8%).
Overall results: 52 patients underwent PTS and 34 patients (65%) had 50% or greater improvement in symptoms. Of these 34, 27 patients (52% overall) have had permanent IPG placement thus far. Of the 24 patients with frequency/urgency syndrome, 16 (67%) had at least 50% improvement on test stimulation and 13 have had permanent IPG placement. Of the 24 patients with urge incontinence, 16 (67%) had at least 50% improvement on test stimulation and 13 of them also have had IPG placement thus far. Of 4 patients with non-obstructive retention, 2 (50%) were able to void. 1 of the 2 patients has had a permanent IPG.
Conclusions: The office based PTS can be an efficient procedure with reliable results in experienced hands. With increasing availability of fluoroscopy in office based practices, PTS should be an option for most patients as it is less invasive and uses far less resources. In this group of patients, the percentage of patients with 50% improvement in symptoms is similar to that reported in the staged procedure

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