Aktuelle Urol 2012; 43(1): 39-48
DOI: 10.1055/s-0031-1283879
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Sakrale Neuromodulation in der Urologie – Entwicklung und aktueller Stand

Sacral Neuromodulation in Urology – Development and Current Status
T. Schwalenberg
1   Klinik und Poliklinik für Urologie, Universitätsklinikum Leipzig AöR
,
J.-U. Stolzenburg
1   Klinik und Poliklinik für Urologie, Universitätsklinikum Leipzig AöR
,
C. Kriegel
1   Klinik und Poliklinik für Urologie, Universitätsklinikum Leipzig AöR
,
A. Gonsior
1   Klinik und Poliklinik für Urologie, Universitätsklinikum Leipzig AöR
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
23. Januar 2012 (online)

Zusammenfassung

Die sakrale Neuromodulation (SNM) wird in der Urologie zur Behandlung therapierefraktärer Funktionsstörungen des unteren Harntraktes und bei chronischen Beckenschmerzen eingesetzt. Mittels elektrischer Stimulation sakraler Afferenzen (S2 – S4) werden eine Triggerung und Konditionierung übergeordneter autonomer und somatischer Nervenstrukturen erreicht und somit efferent die Harnblase, der Enddarm sowie die jeweiligen Schließmuskelsysteme angesteuert. Es können sowohl Zustände der Hyperaktivität als auch Hypokontraktilität und einer funktionellen Blasenhalsobstruktion behandelt werden. Die SNM verläuft zweiphasig. Bei der Peripheren Nervenevaluation (PNE-Test) werden nach Anlage der Testelektroden die Änderungen der Miktions- / Schmerzparameter evaluiert. Das in den letzten Jahren favorisierte Two stage Verfahren mit initialer Anlage der Dauerelektroden zur Testung scheint die Testerfolgsraten zu verbessern. Die zweite Phase beinhaltet die definitive Implantation des Impulsgenerators. Langzeiterfolgsraten der SNM schwanken in der Literatur aufgrund der inhomogenen Patientenkollektive und der in den letzten Jahren veränderten Operationstechnik erheblich (50 – 80 %). Mit der Einführung der „Tined lead Elektrode“ (2002) wird die Gewebedestruktion äußerst gering gehalten. Technische Innnovationen und die Finanzierbarkeit (seit 2004 in Deutschland), aber auch der Einsatz gerade bei austherapierten Patienten und komplexen Funktionsstörungen im Becken haben die SNM als Therapieoption in der Urologie mittlerweile fest etabliert.

Abstract

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2 – S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase − called peripheral nerve evaluation (PNE test) − sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the “two stage approach” with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50 – 80 %) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of “tined lead electrodes” (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology.

 
  • Literatur

  • 1 [Anonym]. Pflügers Archiv European Journal of Physiology. Pflugers Archiv; 1868 1.
  • 2 Saxtorph M. Strictura urethrae – Fistula perinei – Retentio urinae. In: Clinisk Chirurgi. Copenhagen: Gyldendalske Forlag; 1878: 265-280
  • 3 Katona F, Benyo I, Lang I. [Experiences with the use of quadrangular current in direct electrotherapy of dynamic ileus and acute postoperative intestinal paralysis]. Wiener klinische Wochenschrift 1959; 71: 918-921
  • 4 Katona F, Benyo I, Lang I. [Intraluminary electrotherapy of various paralytic conditions of the gastrointestinal tract with the quadrangular current]. Zentralbl Chir 1959; 84: 929-933
  • 5 Katona F. Stages of vegatative afferentation in reorganization of bladder control during intravesical electrotherapy. Urol Int 1975; 30: 192-203
  • 6 Ingersoll EH, Jones LL, Hegre ES. Effect on urinary bladder of unilateral stimulation of pelvic nerves in the dog. The American journal of physiology 1957; 189: 167-172
  • 7 McGuire W. Response of the neurogenic bladder to various electrical stimuli. Bowman Gray School of Medicine; 1955
  • 8 Bradley WE, Wittmers LE, Chou SN. An Experimental Study of the Treatment of the Neurogenic Bladder.. J Urol 1963; 90: 575-582
  • 9 Bradley WE, Chou SN, French LA. Further Experience with the Radio Transmitter Receiver Unit for the Neurogenic Bladder. J Neurosurg 1963; 20: 953-960
  • 10 Boyce WH, Lathem JE, Hunt LD. Research Related to the Development of an Artificial Electrical Stimulator for the Paralyzed Human Bladder: A Review. J Urol 1964; 91: 41-51
  • 11 Caldwell KP. The electrical control of sphincter incompetence. Lancet 1963; 2: 174-175
  • 12 Hopkinson BR, Lightwood R. Electrical treatment of anal incontinence. Lancet 1966; 1: 297-298
  • 13 Erlandson BE, Fall M, Carlsson CA et al. Mechanisms for closure of the human urethra during intravaginal electrical stimulation. Scand J Urol Nephrol Suppl 1977; 44: 49-54
  • 14 Erlandson BE, Fall M, Sundin T. Intravaginal electrical stimulation. Clinical experiments of urethral closure. Scand J Urol Nephrol Suppl 1977; 44: 31-39
  • 15 Fall M, Erlandson BE, Nilson AE et al. Long-term intravaginal electrical stimulation in urge and stress incontinence. Scand J Urol Nephrol Suppl 1977; 44: 55-63
  • 16 Fall M, Erlandson BE, Sundin T et al. Intravaginal electrical stimulation. Clinical experiments on bladder inhibition. Scand J Urol Nephrol Suppl 1977; 44: 41-47
  • 17 Diokno AC, Davis R, Lapides J. The effect of pelvic nerve stimulation on detrusor contraction. Invest Urol 1973; 11: 178-181
  • 18 Lindstrom S, Fall M, Carlsson CA et al. The neurophysiological basis of bladder inhibition in response to intravaginal electrical stimulation. J Urol 1983; 129: 405-410
  • 19 Nashold BS, Friedman H, Glenn JF et al. Electromicturition in paraplegia: implantation of a spinal neuroprosthesis. Proc Veterans Adm Spinal Cord Inj Conf 1971; 18: 161-165
  • 20 Friedman H, Nashold Jr BS, Senechal P. Spinal cord stimulation and bladder function in normal and paraplegic animals. J Neurosurg 1972; 36: 430-437
  • 21 Brindley GS. Electrode-arrays for making long-lasting electrical connexion to spinal roots. The Journal of physiology 1972; 222: 135P-136P
  • 22 Brindley GS, Craggs MD. One-way stimulation of the large fibres of spinal roots through chronically implanted electrodes [proceedings]. The Journal of physiology 1978; 281: 12P-12
  • 23 Jonas U, Tanagho EA. Studies on vesicourethral reflexes. II. Urethral sphincteric responses to spinal cord stimulation. Invest Urol 1976; 13: 278-285
  • 24 Jonas U, Tanagho EA. Studies on the feasibility of urinary bladder evacuation by direct spinal cord stimulation. II. Poststimulus voiding: a way to overcome outflow resistance.. Invest Urol 1975; 13: 151-153
  • 25 Jonas U, Heine JP, Tanagho EA. Studies on the feasibility of urinary bladder evacuation by direct spinal cord stimulation. I. Parameters of most effective stimulation. Invest Urol 1975; 13: 142-150
  • 26 Thuroff JW, Bazeed MA, Schmidt RA et al. Regional topography of spinal cord neurons innervating pelvic floor muscles and bladder neck in the dog: a study by combined horseradish peroxidase histochemistry and autoradiography. Urol Int 1982; 37: 110-120
  • 27 Thuroff JW, Bazeed MA, Schmidt RA et al. Functional pattern of sacral root stimulation in dogs. I. Micturition. J Urol 1982; 127: 1031-1033
  • 28 Thuroff JW, Bazeed MA, Schmidt RA et al. Functional pattern of sacral root stimulation in dogs. II. Urethral closure. J Urol 1982; 127: 1034-1038
  • 29 Thuroff JW, Schmidt RA, Bazeed MA et al. Chronic stimulation of the sacral roots in dogs. Eur Urol 1983; 9: 102-108
  • 30 Schmidt RA, Bruschini H, Van Gool J et al. Micturition and the male genitourinary response to sacral root stimulation. Invest Urol 1979; 17: 125-129
  • 31 Schmidt RA, Bruschini H, Tanagho EA. Sacral root stimulation in controlled micturition. Peripheral somatic neurotomy and stimulated voiding. Invest Urol 1979; 17: 130-134
  • 32 Tanagho EA, Schmidt RA. Bladder pacemaker: scientific basis and clinical future. Urology 1982; 20: 614-619
  • 33 Tanagho EA. Neural stimulation for bladder control. Semin Neurol 1988; 8: 170-173
  • 34 Tanagho EA, Schmidt RA. Electrical stimulation in the clinical management of the neurogenic bladder. J Urol 1988; 140: 1331-1339
  • 35 Tanagho EA. Sacral root stimulation. Neurourol Urodyn 1993; 12: 505-505
  • 36 Juenemann KP, Lue TF, Schmidt RA et al. Clinical significance of sacral and pudendal nerve anatomy. J Urol 1988; 139: 74-80
  • 37 Tanagho EA, Schmidt RA, de Araujo CG. Urinary striated sphincter: what is its nerve supply?. Urology 1982; 20: 415-417
  • 38 Schmidt RA. The winding path to sacral foramen neural modulation: a historic chronology. Int Urogynecol J 2010; 21 (Suppl. 02) 431-438
  • 39 Leng WW, Chancellor MB. How sacral nerve stimulation neuromodulation works. The Urologic clinics of North America 2005; 32: 11-18
  • 40 van der Pal F, Heesakkers JP, Bemelmans BL. Current opinion on the working mechanisms of neuromodulation in the treatment of lower urinary tract dysfunction. Current opinion in urology 2006; 16: 261-267
  • 41 Schultz-Lampel D, Jiang C, Lindstrom S et al. Experimental results on mechanisms of action of electrical neuromodulation in chronic urinary retention. World journal of urology 1998; 16: 301-304
  • 42 Dijkema HE, Weil EH, Mijs PT et al. Neuromodulation of sacral nerves for incontinence and voiding dysfunctions. Clinical results and complications. Eur Urol 1993; 24: 72-76
  • 43 Bosch JL, Groen J. Sacral (S3) segmental nerve stimulation as a treatment for urge incontinence in patients with detrusor instability: results of chronic electrical stimulation using an implantable neural prosthesis. J Urol 1995; 154: 504-507
  • 44 Bosch JL, Groen J. Sacral nerve neuromodulation in the treatment of patients with refractory motor urge incontinence: long-term results of a prospective longitudinal study. J Urol 2000; 163: 1219-1222
  • 45 Shaker HS, Hassouna M. Sacral nerve root neuromodulation: an effective treatment for refractory urge incontinence. J Urol 1998; 159: 1516-1519
  • 46 Jonas U, Fowler CJ, Chancellor MB et al. Efficacy of sacral nerve stimulation for urinary retention: results 18 months after implantation. J Urol 2001; 165: 15-19
  • 47 Swinn MJ, Kitchen ND, Goodwin RJ et al. Sacral neuromodulation for women with Fowler’s syndrome. Eur Urol 2000; 38: 439-443
  • 48 Shaker HS, Hassouna M. Sacral root neuromodulation in idiopathic nonobstructive chronic urinary retention. J Urol 1998; 159: 1476-1478
  • 49 von Heyden B, Bothe HW, Hertle L. Urinary retention after hysterectomy: sacral neuromodulation to restore micturition. J Urol 1999; 162: 2094-2095
  • 50 Chai TC, Zhang C, Warren JW et al. Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology 2000; 55: 643-646
  • 51 Zermann DH, Weirich T, Wunderlich H et al. Sacral nerve stimulation for pain relief in interstitial cystitis. Urol Int 2000; 65: 120-121
  • 52 Siegel S, Paszkiewicz E, Kirkpatrick C et al. Sacral nerve stimulation in patients with chronic intractable pelvic pain. J Urol 2001; 166: 1742-1745
  • 53 Fariello JY, Whitmore K. Sacral neuromodulation stimulation for IC / PBS, chronic pelvic pain, and sexual dysfunction. Int Urogynecol J 2010; 21: 1553-1558
  • 54 Marinkovic SP, Gillen LM, Marinkovic CM. Minimum 6-year outcomes for interstitial cystitis treated with sacral neuromodulation. Int Urogynecol J 2011; 22: 407-412
  • 55 Marinkovic SP, Gillen LM. Sacral neuromodulation for multiple sclerosis patients with urinary retention and clean intermittent catheterization. Int Urogynecol J 2010; 21: 223-228
  • 56 Minardi D, Muzzonigro G. Sacral neuromodulation in patients with multiple sclerosis. World Journal of Urology 2011; [Epub ahead of print]
  • 57 Matzel KE, Stadelmaier U, Hohenfellner M et al. Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. Lancet 1995; 346: 1124-1127
  • 58 Matzel KE, Kamm MA, Stosser M et al. Sacral spinal nerve stimulation for faecal incontinence: multicentre study. Lancet 2004; 363: 1270-1276
  • 59 Matzel KE, Schmidt RA, Tanagho EA. Neuroanatomy of the striated muscular anal continence mechanism. Implications for the use of neurostimulation. Diseases of the Colon and Rectum 1990; 33: 666-673
  • 60 Gill BC, Swartz MA, Rackley RR et al. Improvement of bowel dysfunction with sacral neuromodulation for refractory urge urinary incontinence. Int Urogynecol J 2011; [Epub ahead of print]
  • 61 Kaufmann S, Naumann CM, Hamann MF et al. Unilateral vs bilateral sacral neuromodulation in pigs with formalin-induced detrusor hyperactivity. BJU Int 2009; 103: 260-263
  • 62 Pham K, Guralnick ML, O’Connor RC. Unilateral versus bilateral stage I neuromodulator lead placement for the treatment of refractory voiding dysfunction. Neurourol Urodyn 2008; 27: 779-781
  • 63 Hohenfellner M, Schultz-Lampel D, Dahms S et al. Bilateral chronic sacral neuromodulation for treatment of lower urinary tract dysfunction. J Urol 1998; 160: 821-824
  • 64 Scheepens WA, de Bie RA, Weil EH et al. Unilateral versus bilateral sacral neuromodulation in patients with chronic voiding dysfunction. J Urol 2002; 168: 2046-2050
  • 65 van Kerrebroeck EV, Scheepens WA, de Bie RA et al. European experience with bilateral sacral neuromodulation in patients with chronic lower urinary tract dysfunction. The Urologic clinics of North America 2005; 32: 51-57
  • 66 Janknegt RA, Weil EH, Eerdmans PH. Improving neuromodulation technique for refractory voiding dysfunctions: two-stage implant. Urology 1997; 49: 358-362
  • 67 Spinelli M, Giardiello G, Gerber M et al. New sacral neuromodulation lead for percutaneous implantation using local anesthesia: description and first experience. J Urol 2003; 170: 1905-1907
  • 68 Possover M, Chiantera V. Neuromodulation of the superior hypogastric plexus: a new option to treat bladder atonia secondary to radical pelvic surgery?. Surg Neurol 2009; 72: 573-576
  • 69 Gruenewald V, Jonas U. Neurostimulation for lower urinary tract voiding problems. Current Urology Reports 2000; 1: 199-203
  • 70 Weil EH, Ruiz-Cerda JL, Eerdmans PH et al. Clinical results of sacral neuromodulation for chronic voiding dysfunction using unilateral sacral foramen electrodes. World journal of urology 1998; 16: 313-321
  • 71 Schmidt RA, Jonas U, Oleson KA et al. Sacral nerve stimulation for treatment of refractory urinary urge incontinence. Sacral Nerve Stimulation Study Group. J Urol 1999; 162: 352-357
  • 72 Bosch JL. An update on sacral neuromodulation: where do we stand with this in the management of lower urinary tract dysfunction in 2010?. BJU Int 2010; 106: 1432-1442
  • 73 Van Kerrebroeck PE. Advances in the role of sacral nerve neuromodulation in lower urinary tract symptoms. Int Urogynecol J 2010; 21 (Suppl. 02) 467-474
  • 74 Kessler TM, Fowler CJ. Sacral neuromodulation for urinary retention. Nature clinical practice Urology 2008; 5: 657-666
  • 75 De Ridder D, Ost D, Bruyninckx F. The presence of Fowler’s syndrome predicts successful long-term outcome of sacral nerve stimulation in women with urinary retention. Eur Urol 2007; 51: 229-233 discussion 233–224
  • 76 Peters KM, Carey JM, Konstandt DB. Sacral neuromodulation for the treatment of refractory interstitial cystitis: outcomes based on technique. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 223-228 discussion 228
  • 77 Comiter CV. Sacral neuromodulation for the symptomatic treatment of refractory interstitial cystitis: a prospective study. J Urol 2003; 169: 1369-1373
  • 78 Signorello D, Seitz CC, Berner L et al. Impact of sacral neuromodulation on female sexual function and his correlation with clinical outcome and quality of life indexes: a monocentric experience. The Journal of Sexual Medicine 2011; 8: 1147-1155
  • 79 Lombardi G, Mondaini N, Giubilei G et al. Sacral neuromodulation for lower urinary tract dysfunction and impact on erectile function. The Journal of Sexual Medicine 2008; 5: 2135-2140
  • 80 Chaabane W, Guillotreau J, Castel-Lacanal E et al. Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study. Neurourol Urodyn 2011; 30: 547-550
  • 81 Groen J, Blok BF, Bosch JL et al. Sacral neuromodulation as treatment for refractory idiopathic urge urinary incontinence: 5-year results of a longitudinal study in 60 women. J Urol 2011; 186: 954-959
  • 82 Pascual I, Gomez Cde C, Ortega R et al. Sacral nerve stimulation for fecal incontinence. Revista espanola de enfermedades digestivas. organo oficial de la Sociedad Espanola de Patologia Digestiva 2011; 103: 355-359
  • 83 Sharma U, Liu U, Waudby P et al. Sacral neuromodulation for the management of severe constipation: development of a constipation treatment protocol. International Journal of Colorectal Disease 2011; 26: 1583-1587
  • 84 Vaarala MH, Tammela TL, Perttila I et al. Sacral neuromodulation in urological indications: the Finnish experience. Scandinavian Journal of Urology and Nephrology 2011; 45: 46-51
  • 85 Yazdany T, Bhatia N, Nguyen J et al. Determining outcomes, adverse events, and predictors of success after sacral neuromodulation for lower urinary disorders in women. Int Urogynecol J 2011; 22: 1549-1554
  • 86 Govaert B, Melenhorst J, van Kleef M et al. Sacral neuromodulation for the treatment of chronic functional anorectal pain: a single center experience. Pain Pract 2010; 10: 49-53
  • 87 Wexner SD, Coller JA, Devroede G et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Annals of Surgery 2010; 251: 441-449
  • 88 Goh M, Diokno A. Sacral neuromodulation for nonobstructive urinary retention – is success predictable?. J Urol 2007; 178: 197-199 discussion 199
  • 89 Braun PM, Bohler G. Results of sacral nerve modulation for treatment of overactive bladder. Der Urologe Ausg A 2006; 45: 835-840
  • 90 Whitmore KE, Payne CK, Diokno AC et al. Sacral neuromodulation in patients with interstitial cystitis: a multicenter clinical trial. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 305-308 discussion 308 – 309
  • 91 van Voskuilen AC, Oerlemans DJ, Weil EH et al. Long term results of neuromodulation by sacral nerve stimulation for lower urinary tract symptoms: a retrospective single center study. Eur Urol 2006; 49: 366-372
  • 92 van Kerrebroeck PE, van Voskuilen AC, Heesakkers JP et al. Results of sacral neuromodulation therapy for urinary voiding dysfunction: outcomes of a prospective, worldwide clinical study. J Urol 2007; 178: 2029-2034
  • 93 Leong RK, Marcelissen TA, Nieman FH et al. Satisfaction and patient experience with sacral neuromodulation: results of a single center sample survey. J Urol 2011; 185: 588-592
  • 94 Chartier-Kastler E, Ballanger P, Belas M et al. [Sacral neuromodulation with InterStim system: Results from the French national register]. Progres en urologie. journal de l’Association francaise d’urologie et de la Societe francaise d’urologie 2011; 21: 209-217
  • 95 Sutherland SE, Lavers A, Carlson A et al. Sacral nerve stimulation for voiding dysfunction: One institution’s 11-year experience. Neurourol Urodyn 2007; 26: 19-28 discussion 36