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Objectives: To assess if the preoperative lymph node invasion (LNI) risk could be used to tailor the extent of pelvic lymph node dissection (PLND) according to individual profile in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP), and to identify those who would benefit from the removal of the common iliac and pre‐sacral nodes. Patients and Methods: A total of 471 patients with high‐risk PCa treated with RP and a super‐extended PLND that included the removal of the pre‐sacral and common iliac nodes between 2006 and 2016 were identified. The risk of LNI was calculated according to the Briganti nomogram. Multivariable logistic regression analyses assessed the association between LNI risk and involvement of the common iliac and pre‐sacral regions. The risk of positive common iliac and pre‐sacral nodes was plotted over the LNI risk using the LOWESS‐smoothed fit curve. Results: The median preoperative LNI risk was 25.5%. The median number of nodes removed was 23, and 171 (36.3%) patients had LNI. Overall, 61 (13.0%) and 28 patients (5.9%), respectively, had positive common iliac and pre‐sacral nodes alone or in combination with other sites. The LNI risk was associated with the involvement of the common iliac and pre‐sacral regions (all P < 0.001). The proportion of patients with positive common iliac and pre‐sacral nodes progressively increased according to the LNI risk. The adoption of a 30% threshold would result in avoiding the removal of the common iliac and pre‐sacral nodes in >60% cases, with a risk of missing LNI in these regions of <5%. Conclusions: Fewer than 5% of patients with an LNI risk of <30% harbour positive common iliac and pre‐sacral nodes. A super‐extended PLND that includes the dissection of these regions should be considered exclusively in patients with an LNI risk ≥30%. [ABSTRACT FROM AUTHOR]

Objective To estimate the long-term cost-effectiveness of specialised treatment options for medically refractory idiopathic overactive bladder ( OAB) wet. Patients and Methods The cost-effectiveness of competing treatment options for patients with medically refractory idiopathic OAB wet was estimated from the perspective of the National Health Service in the UK. We compared sacral nerve stimulation ( SNS) with percutaneous nerve evaluation ( PNE) or tined-lead evaluation ( TLE) with optimal medical therapy ( OMT), botulinum toxin type A ( Bo NT- A) injections, and percutaneous tibial nerve stimulation ( PTNS). We used a Markov model with a 10-year time horizon for all treatment options with the exception of PTNS, which has a time horizon of 5 years. Costs and effects (measured as quality-adjusted life years) were calculated to derive incremental cost-effectiveness ratios ( ICERs). Direct medical resources included are: device and drug acquisition costs, pre-procedure and procedure costs, and the cost of managing adverse events. Deterministic sensitivity analyses were performed to test robustness of results. Results At 5 years, SNS ( PNE or TLE) was more effective and less costly than PTNS. Compared with OMT at 10 years, SNS ( PNE or TLE) was more costly and more effective, and compared with Bo NT-A, SNS PNE was less costly and more effective, and SNS TLE was more costly and more effective. Decreasing the Bo NT-A dose from 150 to 100 IU marginally increased the 10 year ICERs for SNS TLE and PNE ( SNS PNE was no longer dominant). However, both SNS options remained cost-effective. Conclusion In the management of patients with idiopathic OAB wet, the results of this cost-utility analysis favours SNS ( PNE or TLE) over PTNS or OMT, and the most efficient treatment strategy is SNS PNE over Bo NT- A over a 10-year period. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Sacral neuromodulation ( SNM) is an effective treatment option of different pelvic-related dysfunctions. SNM evaluation by either temporary or permanent electrodes is generally accepted. Extended testing with temporary electrodes has been reported on before but less is known about infection-related risks during prolonged evaluation with definitive electrodes., The present findings show that prolonged testing (mean = 52.3 days) with permanent electrodes does not increase infection-associated explantation rates, although bacterial colonization was found in more than one-third of the patients. Prolonged SNM evaluation under everyday conditions might improve long-term success., Objective To evaluate the impact of prolonged stage 1 testing on bacterial electrode colonization, infection and treatment success., Materials and Methods In all, 21 patients who underwent sacral neuromodulation ( SNM) for periods ≥1 month were prospectively evaluated; nine patients had overactive bladder syndrome ( OAB), 10 had urinary retention, two had faecal incontinence ( FI), and 13 had diabetes and overweight/obesity., After stage 1 testing electrode extension leads were microbiologically analysed to assess bacterial colonization., The primary measurements were pre- and post- SNM treatment comparisons based on patient-agreed criteria using an increased 70% minimum improvement rate; secondary measurements were bacterial colonization and impact of infection., Results The mean stage 1 evaluation period was 52.3 days; 16 patients (76%) progressed to stage 2, and five patients were explanted due to inadequate improvement (<70%)., There was bacterial colonization in 42.9% of patients and 38.2% of extension leads., Stage 2 patients showed no infection or wound-healing disorders at a mean follow-up of 33.9 months., The success rate for stage 2 implantation treatment was 94%., Conclusions There are few studies in the literature evaluating SNM testing periods vs the risk of clinically relevant implant infection rates. The present study shows that prolonged testing could potentially enhance treatment efficacy without infection-related explantations of the chronic implant, despite the identification of bacteria., SNM-implanted patients with diabetes mellitus or obesity should be followed closely., Clinicians might consider using prolonged testing under everyday conditions., Prolonged SNM stage 1 testing is a very effective minimally invasive treatment option to evaluate pelvic-related dysfunction. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Electrical stimulation of the dorsal nerve of the penis, the compound pudendal nerve and the S1 sacral nerve have been used clinically to treat the symptoms of overactive bladder, but the relative efficacy of the three locations was unclear and the optimal stimulation parameters across locations had not been determined. In the present paper we quantified the effects of acute electrical stimulation location, frequency and amplitude on isovolumetric reflex bladder contractions and maximum cystometric capacity in anaesthetized male cats. Our results could influence the selection of anatomical targets for clinical neuromodulation and how neuromodulation devices are programmed. OBJECTIVE To quantify the effects of acute electrical stimulation frequency and amplitude at the dorsal nerve of the penis (DNP), pudendal nerve (PN) and S1 sacral nerve (S1) on isovolumetric reflex bladder contractions and maximum cystometric capacity in anaesthetized male cats., MATERIALS AND METHODS Experiments were conducted in 14 adult male cats anaesthetized with α-chloralose., The effects of stimulation on the pressure - time integral of reflex bladder contractions were evaluated using a randomized block design with the following factors randomized: stimulation intensity (0.8, 1, or 2× the threshold for evoking a reflex electromyogram response in the external anal sphincter [T]), frequency (2 Hz, 5 Hz, 7.5 Hz, 10 Hz, 15 Hz, 20 Hz, or 33 Hz) and location (PN, S1 or DNP)., The effects of stimulation (with parameters that produced maximum inhibition of isovolumetric bladder contractions) on cystometric capacity were evaluated using a randomized block design, with the order of stimulation location randomized and control trials interleaved with stimulation trials., RESULTS Inhibition of isovolumetric bladder contractions was significantly dependent on stimulation location, frequency, amplitude and the interactions between any two of these variables., Stimulation of the DNP, at 5 Hz, 7.5 Hz or 10 Hz, and at 2T caused greater reductions in normalized bladder contraction area than any other location, frequency or amplitude tested., Stimulation of the PN or S1 at 7.5 Hz or 10 Hz and 2T, or of the DNP at 5 Hz, 7.5 Hz or 10 Hz and 0.8T, 1T or 2T generated maximum inhibition of isovolumetric bladder contractions., Cystometric capacity was significantly larger with stimulation (10 Hz, 1T-2T) than control., There was no significant difference in cystometric capacity based upon stimulation location., CONCLUSIONS There was no significant difference in the maximum degree to which the respective optimum parameters inhibited bladder contractions or increased cystometric capacity by location., The range of amplitudes and frequencies that caused maximum inhibition was larger for DNP stimulation than for PN or S1 stimulation., These findings have implications on the selection of anatomical target and device programming for clinical neuromodulation for treatment of the symptoms of overactive bladder. [ABSTRACT FROM AUTHOR]

The article discusses updates on sacral neuromodulation in the management of lower urinary tract dysfunction in 2010 in the Netherlands. It mentions that the SNM has no precise mode of action and its effects can only be explained through modulation of reflex pathways at the spinal cord level. In this regard, it cites experimental work in animals, human volunteers and patients to better understand the physical problems and find the appropriate procedures.

OBJECTIVES To describe the development of screening tests and to identify re-operation rates after the permanent implant phase, and its characteristics, of the Interstim® (Medtronic, Inc., Minneapolis, MI, USA) device for sacral nerve stimulation (SNS). PATIENTS AND METHODS We retrospectively reviewed the charts of women who had SNS between January 1998 and December 2005; their demographic, clinical and surgical information was abstracted. Descriptive statistics, chi-square and analysis of variance were used to compare the results. RESULTS In all, 95 patients had 105 test procedures; 30 peripheral nerve evaluation (PNE) and 75 staged tined leads. Response rates were lower in the PNE than in the tined lead (40% vs 67%, P = 0.01). The indication for SNS was associated with the response rate, with urinary retention having the highest response (71%, P = 0.01). For the 55 implanted devices, there were 18 revisions (33%) and eight explants (15%). The main reasons for revision or explants were loss of efficacy (16/26) and pain at the implant site (six of 26). The median (range) time to intervention after implantation was 17 (1.2–75.0) months, and this was significantly associated with the indication. Revisions due to pain at the implant site were within the first year, and re-operations due to loss of efficacy after 1–2 years, whereas battery replacement was required on average 4 years after initial implantation. CONCLUSIONS This study confirms the higher response rates of the tined-lead staged technique over PNE. Unobstructive urinary retention had the highest response rates. The reason for revision appeared to be largely predicted by the length of time since implantation. [ABSTRACT FROM AUTHOR]

OBJECTIVES To report our 10-year experience of sacral neurostimulation (SNS) for women in urinary retention, comparing the original one-stage with the newer two-stage technique, as SNS therapy is a well-established treatment for urinary retention secondary to urethral sphincter overactivity (Fowler’s syndrome). PATIENTS AND METHODS Between 1996 and 2006, 60 patients with urinary retention had a SNS device inserted; their case records were reviewed and data on efficacy, follow-up, need for continued clean intermittent self-catheterization (CISC), complications and operative revision rate were assessed. RESULTS Overall, 43 of 60 (72%) women were voiding spontaneously, with a mean postvoid residual volume of 100 mL; 30 (50%) no longer needed to use CISC. During a total of 2878 months of SNS experience, adverse event episodes included lead migration in 20, ‘box-site’ pain in 19, leg pain/numbness in 18 and loss of response/failure in 18 patients; 53% of the women required a surgical revision related to their implanted stimulator. The efficacy of the two-stage was similar to that of the one-stage procedure (73% vs 70%). Women with a normal urethral sphincter electromyogram had worse outcomes than women with an abnormal test (43% vs 76%). Although the efficacy was no different in those taking analgesia/antidepressant medication, this group of women had a higher surgical revision rate. Failure and complications for the one-stage procedure were not restricted to the early follow-up period. The mean battery life of the implant was 7.31 years. CONCLUSIONS SNS has sustained long-term efficacy but the procedure has a significant complication rate. At present, the two-stage technique has comparable efficacy to the one-stage technique but a longer-term follow-up is required. The National Institute of Clinical Excellence recommended the use of SNS in women with urinary incontinence who fail to respond adequately to anticholinergic therapy, but patients choosing this treatment should be made aware of the high complication rate associated with the procedure. [ABSTRACT FROM AUTHOR]

Objective To evaluate lead migration for two different test electrodes and the response to trial stimulation of the S3 nerve root during the selection of patients for a sacral neuromodulation implant to manage lower urinary tract dysfunction. Patients and methods Twelve women (mean age 49 years, range 23–79; seven with detrusor instability and five with sensory urgency) undergoing peripheral nerve evaluation for refractory lower urinary tract symptoms were recruited. Urodynamics and a urinary diary were completed before and during test stimulation. Two electrodes (the original 041830–002 and new 3057 models, Medtronics Inc, USA) were inserted under local anaesthesia into the S3 nerve roots bilaterally. The location was determined by the functional response to stimulation. Stimulation was applied for one week using the new lead; a positive response was defined as a subjective improvement (> 50%) in urinary symptoms. Lateral sacral X-rays were taken after placement and before removing the lead. The distance from the lead tip to the ventral aspect of the S3 sacral foramen was measured by two assessors. Results Ten of the women had a positive response; the mean (range) migration of the new lead (on X-ray) was 4 (2–11) mm, and of the old lead was 12 (10–45) mm (P = 0.02). Conclusion The response rate to trial stimulation was greater than in previous studies, possibly reflecting reduced migration of the new lead. The new electrode may reduce the number of test failures caused by lead migration rather than no response. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of sacral neuromodulation on interstitial cystitis (IC) and determine the underlying mechanism of neuromodulation in the treatment of IC. Materials and methods Twenty Sprague–Dawley rats (body weight 220–250 g) were randomly divided into four equal groups; normal controls, a sham treatment (IC induced by 0.4 mol/L HCl, + saline), a second sham treatment (HCl-induced IC + acetic acid) and a stimulated group (HCl-induced IC + acetic acid, with electrical stimulation). In the last group bilateral electrodes were implanted into the S1 dorsal foramina and electrical stimulation applied for 8 h/day for 3 weeks. Acetic acid was instilled into the bladder to induce c-fos expression. After 3 weeks the rats were perfused with 4% paraformaldehyde, spinal segments dissected out and an immunocytochemical method used to stain the segments for fos protein encoded byc-fos. Results The mean (sem) micturition frequency (voids/17 h) in the sham groups increased from 10.8 (2.7) to 23.4 (3.4) 3 weeks after the intravesical instillation of HCl. The micturition frequency in the stimulated group, at 16.2 (2.7), was significantly less than in the sham group (P = 0.04) after electrical stimulation for 3 weeks. There was no significant difference in the mean (sem) number of fos-positive neurones in the L6 spinal cord segment between the stimulated and the sham + acetic acid group, at 43.6 (9.4) and 35.8 (7.8) cells/section, respectively (P = 0.32). Conclusions In rats with HCl-induced cystitis, electrical stimulation reduced the micturition frequency, but not by inhibiting afferent c-fibre activity. [ABSTRACT FROM AUTHOR]

Objective To determine whether sacral root neuro‐modulation (a promising therapeutic modality in patients with refractory voiding and storage problems) has its effect through the blockade of C‐afferent fibres that form the afferent limb of a pathological reflex arc responsible for the dysfunction of bladder storage. Materials and methods The study comprised 39 female Sprague Dawley rats divided into three equal groups: normal controls (group 1); spinally transected at T10 (group 2); spinally transected and electrically stimulated bilaterally at S1 for 6 h daily (group 3). Three weeks after transection the rats were assessed using urodynamics; substance P, neurokinin A and calcitonin gene‐related peptide (CGRP) were extracted from the dorsal root ganglia (DRG) of the L5 and L6 roots and quantified by radioimmunoassay. Results Spinally transected rats developed urinary bladder hyper‐reflexia after 3 weeks. This was associated with a significant increase in the neuropeptide content of the DRG of L6. Electrostimulation of S1 significantly decreased the neuropeptide content of L6. In contrast, transection and S1 neurostimulation did not affect the neuropeptide content of the L5 DRG, except for CGRP, which increased after spinal transection and decreased with neurostimulation. Conclusions In spinally transected rats, sacral root neurostimulation abolished bladder hyper‐reflexia and attenuated the rise in neuropeptide content of the L6 DRG. These results suggest that the blockade of C‐afferent fibre activity is one of the mechanisms of action of sacral root neuromodulation. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor on sacral neuromodulation, published in March 2003 issue of the journal 'BJU International'. Brief description of the role of sacral neuromodulation in functional urinary retention.

Examines the effect of sacral nerve stimulators in patients with severe leg pain. Number of patients experiencing distressing sensory symptoms in the ipsilateral lower limb; Persistence of sensory symptoms despite temporary cessation of stimulation; Conduction of plain postero-anterior and lateral pelvic radiographs and CT of the lumbosacral spine.

Silke Walleser Autiero, Natalie Hallas, Christopher D. Betts, Jeremy L. Ockrim. The above article from BJU International, published online on 25 June 2015 in Wiley Online Library ( http://wileyonlinelibrary.com) has been retracted, at the authors' request, by agreement between the authors, the Journal Editor‐in‐Chief Prokar Dasgupta and John Wiley & Sons Inc. on behalf of BJU International. The retraction has been agreed following errors identified during an in‐depth review of the model and the analyses. Whilst the authors are confident that the model inputs (literature, unit cost sources and clinical expert advice) were valid at the time of the analysis, there are integral errors in the structure of the model, which result in treatment costs and utility values being applied incorrectly to the patient population in both treatment arms. Consequently, the costs and QALYs calculated for both Sacral Neuromodulation and Botox are erroneous which affects the overall outcomes and conclusions of the publication. The principal source of the errors has been found to be the original model initially developed for Spain (Arlandis et al. Value Health. 2011 Mar‐Apr;14(2):219–28), which was adapted for the UK for this analysis. The nature and complexity of the original model structure will not allow for any correction or revision; therefore, these errors are intractable. In view of this, the above article is being retracted. Reference 1 Autiero SW, Hallas N, Betts CD, Ockrim JL. The cost‐effectiveness of sacral nerve stimulation (SNS) for the treatment of idiopathic medically refractory overactive bladder (wet) in the UK. BJU Int 2015; 116: 945–54 [ABSTRACT FROM AUTHOR]

The article offers the authors' insight regarding the study investigating the extended stage one of sacral neuromodulation (SNM) test period. They mention the significance of the notes of the researchers saying that low stage two failure rate play important role in the issue of health care expenditure. They state that the result of the study shows that SNM is not conclusive.