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Aim: Sacral neuromodulation (SNM) is approved for the treatment of faecal incontinence (FI) in a two‐stage technique. With standardized implantation, approximately 90% of patients undergo successful Stage I operation and proceed to a permanent implant (Stage II). The aim of this work was to explore the feasibility of SNM as a one‐stage procedure and report the 24‐week efficacy. Method: This study included patients diagnosed with idiopathic FI or FI due to an external anal sphincter defect ≤160° and one or more episodes of FI per week despite maximal conservative therapy. Patients were offered a one‐stage procedure if a motor response of the external anal sphincter was achieved in three or more poles with at least one at ≤1.5 mA at lead placement. Patients were followed for 24 weeks. Their evaluation included the Wexner/St Mark's Incontinence Score, Faecal Incontinence Quality of Life score (FIQoL), a visual analogue scale (VAS) for assessing patient satisfaction and a bowel habit diary. Results: Seventy‐three patients with a median age of 60 years (interquartile range 50–69 years) completed this prospective study. Episodes of FI were significantly reduced at the 24‐week follow‐up, from 13 (8–23) at baseline to 2 (0–5) (p‐value = 0002). A ≥50% reduction in the number of FI episodes was achieved in 92% of participants. The Wexner score improved significantly from 16 (14–17) at baseline to 9 (5–13) (p‐value < 0.001), and the St Mark's score improved significantly from 18 (16–20) to 11 (7–16) (p‐value < 0.001). All domains in the FIQoL score and VAS for patient satisfaction improved significantly following the one‐stage procedure. Conclusion: A one‐stage implantation procedure is feasible in selected patients with FI, significantly improving continence, quality of life and patient satisfaction after 24 weeks of follow‐up. [ABSTRACT FROM AUTHOR]

Aim: Sacral neuromodulation (SNM) is a minimally invasive treatment option for functional constipation. Evidence regarding its effectiveness is contradictory, driven by heterogeneous study populations and designs. The aim of this study was to assess the effectiveness, safety and cost‐effectiveness of SNM in children and adults with refractory idiopathic slow‐transit constipation (STC). Method: OVID Medline, OVID Embase, Cochrane Library, the KSR Evidence Database, the NHS Economic Evaluation Database and the International HTA Database were searched up to 25 May 2023. For effectiveness outcomes, randomized controlled trials (RCTs) were selected. For safety outcomes, all study designs were selected. For cost‐effectiveness outcomes, trial‐ and model‐based economic evaluations were selected for review. Study selection, risk of bias and quality assessment, and data extraction were independently performed by two reviewers. For the intervention 'sacral neuromodulation' effectiveness outcomes included defaecation frequency and constipation severity. Safety and cost‐effectiveness outcomes were, respectively, adverse events and incremental cost‐effectiveness ratios. Results: Of 1390 records reviewed, 67 studies were selected for full‐text screening. For effectiveness, one cross‐over and one parallel‐group RCT was included, showing contradictory results. Eleven studies on safety were included (four RCTs, three prospective cohort studies and four retrospective cohort studies). Overall infection rates varied between 0% and 22%, whereas reoperation rates varied between 0% and 29%. One trial‐based economic evaluation was included, which concluded that SNM was not cost‐effective compared with personalized conservative treatment at a time horizon of 6 months. The review findings are limited by the small number of available studies and the heterogeneity in terms of study populations, definitions of refractory idiopathic STC and study designs. Conclusion: Evidence for the (cost‐)effectiveness of SNM in children and adults with refractory idiopathic STC is inconclusive. Reoperation rates of up to 29% were reported. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to evaluate the long‐term cost‐effectiveness of sacral neuromodulation in the treatment of severe faecal incontinence as compared with symptomatic management. Methods: In the public health field, a micro‐costing evaluation method was conducted from the perspectives of the health system and the society. The incremental cost‐effectiveness ratio was used as a decision index, and we considered various scenarios to evaluate the impact of the cost of symptomatic management and percutaneous nerve evaluation success rate in its calculation. Clinical data were retrieved from a consecutive cohort of 93 patients with severe faecal incontinence undergoing sacral neuromodulation after a failure of conservative (pharmacological and biofeedback) and/or surgical (sphincteroplasty) first‐line treatments were considered. Results: The long‐term incremental cost‐effectiveness ratio comparing sacral neuromodulation versus symptomatic management was 14347€/QALY and 28523€/QALY from the societal and health service provider's perspectives, respectively. If the definitive pulse generator implant success rate was 100%, incremental cost‐effectiveness would correspond to 6831€/QALY and 16761€/QALY, respectively. Conclusions: Sacral neuromodulation may be considered a cost‐effective technique in the long‐term treatment of severe faecal incontinence from the societal and health care sector perspectives. Improving patient selection and determining the predictive outcome factors for successful sacral neuromodulation in the treatment of faecal incontinence would improve cost‐effectiveness. [ABSTRACT FROM AUTHOR]

Background: The rectosigmoid brake, characterised by retrograde cyclic motor patterns on high‐resolution colonic manometry, has been postulated as a contributor to the maintenance of bowel continence. Sacral neuromodulation (SNM) is an effective therapy for faecal incontinence, but its mechanism of action is unclear. This study aims to investigate the colonic motility patterns in the distal colon of patients with faecal incontinence, and how these are modulated by SNM. Methods: A high‐resolution fibreoptic colonic manometry catheter, containing 36 sensors spaced at 1‐cm intervals, was positioned in patients with faecal incontinence undergoing stage 1 SNM. One hour of pre‐ and post meal recordings were obtained followed by pre‐ and post meal recordings with suprasensory SNM. A 700‐kcal meal was given. Data were analysed to identify propagating contractions. Results: Fifteen patients with faecal incontinence were analysed. Patients had an abnormal meal response (fewer retrograde propagating contractions compared to controls; p = 0.027) and failed to show a post meal increase in propagating contractions (mean 17 ± 6/h premeal vs. 22 ± 9/h post meal, p = 0.438). Compared to baseline, SNM significantly increased the number of retrograde propagating contractions in the distal colon (8 ± 3/h premeal vs. 14 ± 3/h premeal with SNM, p = 0.028). Consuming a meal did not further increase the number of propagating contractions beyond the baseline upregulating effect of SNM. Conclusion: The rectosigmoid brake was suppressed in this cohort of patients with faecal incontinence. SNM may exert a therapeutic effect by modulating this rectosigmoid brake. [ABSTRACT FROM AUTHOR]

Aim: The aim of this work was to evaluate the effectiveness, patient satisfaction and quality of life (QoL) and the safety of sacral neuromodulation (SNM) with the InterStimTM system for the treatment of faecal incontinence (FI) and establish whether results published predominantly by expert sites are generalisable. Method: This is a prospective, multicentre, observational study that invited all French sites treating FI with the InterStim™ system to enrol subjects indicated for an SNM therapy evaluation. Data were collected at three follow‐up visits within 1 and 15 months. Therapeutic effectiveness was evaluated by the reduction in leakages per week and improvements over time in the ability to defer defaecation and QoL (as measured with the Faecal Incontinence Quality of Life score). Safety was assessed through reported adverse events. Results: A total of 221 subjects with a mean age of 62.1 years were tested (184 women) and 178 received a permanent implant. For all implanted subjects with diary data at baseline and follow‐up, a reduction in leakage of more than 50% was observed in 80%, 76% and 83% at 1–3, 4–8 and 9–15 months, respectively. The mean number of leakage episodes and urgency improved significantly compared with the baseline (p < 0.0001). Subjects showed improvements in QoL and time to defer defaecation and were generally satisfied with their therapy. The main device‐related adverse event was the requirement to undertake reprogramming (in 52% of subjects with actions following an event). The rates of infection (in 6% of subjects) and surgical revision (in 10% of subjects) were in agreement with literature reports. Conclusion: This study confirms the clinical effectiveness, safety and positive effect of SNM on QoL as well as high patient satisfaction for the treatment of FI in real‐life. [ABSTRACT FROM AUTHOR]

Aim: Sacral neuromodulation (SNM) is a widely adopted treatment for overactive bladder, non‐obstructive urinary retention and faecal incontinence. In the majority, it provides sustained clinical benefit. However, it is recognized that, even for these patients, stimulation parameters (such as amplitude, electrode configuration, frequency and pulse width) may vary at both initial device programming and at reprogramming, the latter often being required to optimize effectiveness. Although some recommendations exist for SNM programming, the scientific data to support them are understood by few clinicians. Methods: This is a narrative review of the literature covering some of the science behind stimulating a mixed peripheral nerve and available preclinical data in the field of SNM. It covers electrode configuration, amplitude, frequency, pulse width and cycling considerations. The review is targeted at clinicians with an interest in the field and does not seek to provide exhaustive detail on basic neuroscience. Results and conclusions: Knowledge of the science of neuromodulation provides some guiding principles for programming but these are broad. These principles are not refuted by preclinical data but specific parameters in clinical use are not strongly supported by animal data, even after the limitations of small and large animal models are considered. The review presents a shortlist of programming principles on a theoretical basis but acknowledges that current practice is as much derived from evolved experience as science. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013. Method: This was a multi‐centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow‐up of 5 years, complications and requirement for further interventions were recorded. Results: A total of 461 patients (median age 56 years, range 24–90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re‐siting or removal). At the time of last follow‐up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow‐up 32 patients (18.1%) crossed over to SNM. Comparing two 4‐year periods (2000–2003 and 2007–2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05). Conclusion: The paradigm of surgical intervention for FI has changed with increasing use of SNM. [ABSTRACT FROM AUTHOR]

Aim: The aim of this retrospective study was to evaluate the clinical effect of sacral neuromodulation (SNM) on bowel dysfunction in patients with neurogenic bladder using the neurogenic bowel dysfunction (NBD) score. Method: Between July 2012 and July 2019, 41 patients with both neurogenic bladder and bowel dysfunction underwent permanent SNM implantation. The NBD score was used to evaluate the bowel symptoms before the testing phase and at follow‐up. The first follow‐up was at the time of discharge after permanent implantation. The second follow‐up was conducted by telephone after discharge. Results: The mean NBD score before the testing phase was 11.0 ± 5.83, whilst it significantly decreased to 5.2 ± 5.32 (n = 41, P < 0.05) at the first follow‐up (32 ± 3.9 days). Before the testing phase, there were 9 patients with very minor NBD, 10 with minor NBD, 13 with moderate NBD and 9 with severe NBD. At the first follow‐up, there were 26 patients with very minor NBD, 7 with minor NBD, 4 with moderate NBD and 4 with severe NBD (P < 0.05). Twenty‐six patients were interviewed in the long‐term follow‐up (34 ± 30.9 months). The NBD score in these 26 patients was 5.6 ± 5.18, which was not significantly different from the NBD score (5.5 ± 5.33) at the first follow‐up (n = 26, P > 0.05). Conclusion: SNM facilitates a significant reduction in NBD score in patients with neurogenic bladder and bowel dysfunction. The improvement in NBD symptoms can also be used as a future indicator to determine the clinical efficacy of permanent SNM implantation in the treatment of neurogenic bladder. [ABSTRACT FROM AUTHOR]

Aim: The aim of this work was to review our institutional series of patients treated with sacral neuromodulation (SNM) for low anterior resection syndrome (LARS) and evaluate possible factors associated with therapeutic success. Method: Twenty‐five patients were treated with SNM for LARS between 2008 and 2019. SNM was performed as per our institutional protocol. Patients were evaluated with Wexner and LARS scores before and after SNM treatment. A visual analogue scale (1–10) was used to evaluate overall patient satisfaction with SNM. Results: There were significant differences between the mean LARS score values before (37.82) and after (29) SNM therapy (P < 0.004). The mean Wexner score was higher (16.24) before SNM treatment than afterwards (11.13) (P < 0.004). There was a direct relationship between the height of anastomosis and LARS score (P = 0.035): there were big changes in LARS scoring (pre‐/post‐SNM therapy) in patients with higher anastomoses, and vice versa. Patients who received radiotherapy scored lower in mean satisfaction (6.38) than patients without previous radiotherapy (8.22) (P = 0.008). There was an important positive association between Wexner score and patient satisfaction (P = 0.001): relevant changes in Wexner scoring after SNM therapy were associated with high patient satisfaction, and vice versa. Conclusion: Our study showed a relationship between changes in Wexner and LARS scores before and after SNM and overall patient satisfaction with SNM therapy. These findings also suggest patients with previous radiotherapy may have worse results with SNM (based on lower overall satisfaction), and that higher anastomoses have a greater impact on the post‐SNM LARS score. [ABSTRACT FROM AUTHOR]

Aim: There is an ongoing debate as to whether or not the efficacy of sacral neuromodulation (SNM) is optimized by maximizing the total number of active electrode poles (AEPs) during lead placement because there are more programming options. However, this is at the cost of increased operating time. The aims of this study were to establish if a higher number of AEPs improves SNM efficacy during the trial period and after permanent implantable pulse generator (IPG) placement and if there is there a correlation between number of AEPs and battery life of the first placed IPG. Method: This was a single centre retrospective cohort study of new patients with faecal incontinence who underwent SNM between 2000 and 2018. Exclusion criteria were sphincter defect > 30%, rectocele/enterocele Grade 3 or higher and incomplete records. Results: In all, 288/456 (63%) patients (women 91%; mean age 58.5 ± 11.7 years) were eligible for analysis. The number of AEPs during lead placement was two (n = 42, 14.5%), three (n = 82, 28.5%) and four (n = 164, 57%). There was no association between the number of AEPs during tined lead placement and long‐term efficacy. Neither the success rate of the trial phase nor the battery life after first placed IPG was influenced by the number of AEPs. Conclusion: In this study, the number of AEPs does not seem to influence long‐term efficacy of SNM success rate during the trial phase or the battery life of the first placed IPG. However, we also suggest that at the very least there should be two AEPs at lead placement. [ABSTRACT FROM AUTHOR]

Aim: Low anterior resection syndrome (LARS) can affect up to 70% of all patients with rectal cancer. In the last two decades, sacral nerve stimulation (SNS) has emerged as an effective treatment for faecal incontinence. There is some encouraging literature on the use of SNS in patients with LARS. The purpose of this review is to provide an up to date review on the utility of SNS on LARS. Method: A literature search was conducted using the MEDLINE, Embase and PubMed databases (January 1981–March 2019). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta‐analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses. Results: Ten studies met the inclusion criteria and were included in this study. All studies used the Cleveland Clinic Incontinence Score (CCIS), whereas the low anterior resection syndrome score (LARS score) was used in three studies. Overall median improvement in the scoring system was 67.0% (range 35.5%–88.2%) after SNS implantation. There was a significant reduction in CCIS after SNS implantation (mean difference 11.23, 95% confidence interval 9.38–13.07, Z = 11.90, P < 0.00001). The LARS score was also significantly reduced after using SNS in patients with LARS (mean difference 17.87, 95% confidence interval 10.15–25.59, Z = 4.54, P < 0.00001). Conclusion: Use of SNS may provide symptomatic benefits for patients with LARS refractory to medical therapy. However, the current level of evidence remains limited. A large multicentre study of SNS for LARS using the validated LARS score is warranted. In addition, the cost‐effectiveness of SNS for patients with LARS needs further exploration. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Sacral neuromodulation (SNM) is a minimally invasive therapy for functional constipation (FC) and is most often used to treat adults. Recent studies suggest that SNM may also beneficial in children. However, comparative data regarding preferred age of SNM for FC are lacking. Therefore, long‐term results of SNM for FC were compared between children and adults. Method: All patients treated with SNM for FC between 2004 and 2015 were evaluated. Outcomes of children (age 10–18 years) were compared with those for adults (≥ 18 years). The primary end‐point was a defaecation frequency of three or more times per week, which is consistent with the ROME‐III criteria. Secondary outcomes were quality of life (QoL; SF‐36) and the Cleveland Clinic Constipation Score. Results: One hundred and eighty patients (45 children, 135 adults) were eligible for SNM. The mean age was 15.8 (children) and 41.4 years (adults). One hundred and twenty‐six patients received permanent SNM (38 children, 88 adults). Mean follow‐up was 47 months in both groups. Defaecation frequency increased in both groups after SNM compared with baseline. Defaecation frequency in adults was higher than in children. The increased defaecation frequency was maintained during the entire follow‐up period in both groups. QoL of children was impaired compared with the Dutch population with regard to bodily pain, general health and vitality. Adults had worse QoL with regard to physical functioning, bodily pain, general health, vitality and social functioning compared with the Dutch population. QoL of children did not differ from adults. Conclusion: Sacral neuromodulation (SNM) should be considered in children (< 18 years) with FC. However, the indication of SNM for FC remains debatable considering the limited improvements and high costs. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to investigate the efficacy of sacral neuromodulation ( SNM) in the treatment of faecal incontinence and concomitant urinary incontinence in women with a history of obstetric anal sphincter injury ( OASIS). Method In this prospective study, consecutive women with faecal incontinence following OASIS accepted for SNM were screened for concomitant urinary incontinence. The primary outcome was the change in urinary incontinence score on the International Consultation on Incontinence Questionnaire for Urinary Incontinence, Short Form ( ICIQ- UI- SF), between baseline and 12 months. Secondary outcomes included the change in St Mark's score, sexual function and quality of life, change in grade of urinary incontinence and disappearance of urgency. Results From March 2012 to September 2014, 39 women with combined faecal incontinence and urinary incontinence received SNM. Thirty-seven women were available for analysis after 12 months. The mean reduction in the ICIQ- UI- SF score between the baseline and 12 months was 5.8 (95% CI 3.7-8.0, P < 0.001). ICIQ- UI- SF was reduced in 29 (78%) women, urinary incontinence resolved in 13/37 (35%, 95% CI 20%-50%) patients, and urgency disappeared in 14/33 (42%, 95% CI 26%-59%). The mean reduction in the St Mark's score was 10.6 (95% CI 8.6-12.7, P < 0.001). Disease-specific quality of life, Euroqual 5-dimension visual analogue scale ( EQ-5D VAS) and several areas of sexual function changed significantly for the better. Conclusion More than three-quarters of the women with combined faecal and urinary incontinence following OASIS reported a successful outcome with reduction in ICIQ- UI- SF at 12 months after SNM. [ABSTRACT FROM AUTHOR]

Aim This study aimed to assess the cost-effectiveness of sacral neuromodulation ( SNM) compared with conservative treatment in children and adolescents with constipation refractory to conservative management. Method A Markov probabilistic model was used, comparing costs and effectiveness of SNM and conservative treatment in children and adolescents aged 10-18 years with constipation refractory to conservative management. Input for the model regarding transition probabilities, utilities and healthcare costs was based on data from a cohort of patients treated in our centre. This cohort consisted of 30 female patients (mean age 16 years) with functional constipation refractory to conservative management. The mean duration of laxative use in this group was 5.9 years. All patients had a test SNM, followed by a permanent SNM in 27/30. Median follow-up was 22.1 months (range 12.2-36.8). The model was run to simulate a follow-up period of 3 years. Results The mean cumulative costs for the SNM group and the conservative treatment group were €17 789 ( SD €2492) and €7574 ( SD €4332) per patient, respectively. The mean quality adjusted life years ( QALYs) in the SNM group was 1.74 ( SD 0.19), compared with 0.86 ( SD 0.14) in the conservatively managed group. The mean incremental cost-effectiveness ratio was €12 328 per QALY ( SD €4788). Sensitivity analysis showed that the outcomes were robust to a wide range of model assumptions. Conclusion Chronic constipation seriously affects the quality of life of children and adolescents. Preliminary evidence suggests that SNM can improve symptoms and quality of life at a reasonable cost. [ABSTRACT FROM AUTHOR]

Aim The purpose of this trial was to compare the effectiveness of sacral neuromodulation ( SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury ( OASIS). Method This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life ( FIQL) and urinary incontinence ( ICIQ- UI- SF) scores. Results Fifty-eight women were randomly assigned to SNM ( n = 30) and Permacol® ( n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 ( SD 5.3) in the SNM group vs 2.3 ( SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ- UI- SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group ( P = 0.77). Conclusion SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ- UI- SF and the change of the FIQL in women with faecal incontinence following OASIS. [ABSTRACT FROM AUTHOR]

Aim The purpose of this study was to assess the efficacy of percutaneous nerve evaluation ( PNE) in women with faecal incontinence ( FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. Method This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. Results Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) ( P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence ( P = 0.04), body mass index ( BMI) ( P = 0.03) and pain during PNE ( P = 0.046) but not to the extent of the sphincter defect ( P = 0.1). Responders had a higher St Mark's score than nonresponders ( P = 0.046). Conclusions The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation (SNS) lead implantation is a straightforward procedure for individuals with intact spinal vertebrae. When sacral anomalies are present, however, the anatomical and radiological reference points used for the accurate placement of the electrode may be absent or difficult to identify. Method We describe an innovative surgical procedure of percutaneous nerve evaluation for SNS in a patient with faecal incontinence secondary to a congenital imperforate anus and partial sacral agenesis using a surgical imaging platform (O-arm system) under neurophysiological control. Results Using intra-operative CT and neuronavigation, the insertion point at the skin was identified. The lead was introduced into the right-sided S3 foramen and placed at the correct depth. An appropriate motor response was obtained after stimulation and neurophysiological control confirmed that the right S3 root was being stimulated. Conclusion Our experience showed that O-arm guided navigation can be used to overcome the difficulty of SNS lead placement in patients with partial sacral agenesis who have faecal incontinence. [ABSTRACT FROM AUTHOR]

Aim Internal rectal prolapse is recognized as an aetiological factor in faecal incontinence. Patients found to have a high-grade internal rectal prolapse on routine proctography are offered a laparoscopic ventral rectopexy after failed maximum medical therapy. Despite adequate anatomical repair, faecal incontinence persists in a number of patients. The aim of this study was to evaluate the outcome of sacral neuromodulation in this group of patients. Method Between August 2009 and January 2012, 52 patients who underwent a laparoscopic ventral rectopexy for faecal incontinence associated with high-grade internal rectal prolapse had persistent symptoms of faecal incontinence and were offered sacral neuromodulation. Symptoms were evaluated before and after the procedure using the Fecal Incontinence Severity Index (FISI) and the Gastrointestinal Quality of Life Index (GIQLI). Results Temporary test stimulation was successful in 47 (94%) of the patients who then underwent implantation of a permanent pulse generator. The median FISI score 1 year after sacral neuromodulation was lower than the median score before [34 (28-59) vs 19 (0-49); P < 0.01], indicating a significant improvement in faecal continence. Quality of life (GIQLI) was significantly better after starting sacral neuromodulation [78 (31-107) vs 96 (55-129); P < 0.01]. Conclusion Patients may benefit from sacral neuromodulation for persisting faecal incontinence after laparoscopic ventral rectopexy. [ABSTRACT FROM AUTHOR]

Aim The efficacy of sacral nerve stimulation ( SNS) in low anterior resection syndrome ( LARS) is largely undocumented. A review of the literature was carried out to study this question. Method Pubmed, Medline and Cochrane databases were searched for relevant articles up to August 2014. Studies were included if they evaluated the use of SNS following rectal resection and assessed at least one of the following end-points: bowel function, quality of life and ano-neorectal physiology. No restrictions on language or study size were made. Results Seven papers were identified including one case report and six prospective case series. These included 43 patients with a median follow-up of 15 months. After peripheral nerve evaluation definitive implantation was carried out in 34 (79.1%) patients. Overall, 32 (94.1%) of the 34 patients experienced improvement of symptoms which, based on intention to treat, was 32/43 (74.4%). Conclusion The review suggests that SNS for faecal incontinence in LARS has success rates comparable to its use for other forms of faecal incontinence. [ABSTRACT FROM AUTHOR]

Aim The aim of this review was to summarize current knowledge and recommendations regarding the technique of implantation of the electrode in performing sacroneuromodulation ( SNM) and the available information on programming parameters and implantation algorithms. Method All English-language articles published from January 1985 to December 2013 that reported the SNM surgical technique and results were considered for inclusion. Data were considered useful for the present review only if related to: (i) peripheral nerve evaluation; (ii) temporary nerve stimulation; (iii) definitive impulse generator placement; and (iv) parameters programming. Results The literature search revealed 193 potentially relevant studies from initial electronic search terms and eligibility criteria, and these studies were evaluated in detail. In total, 41 studies were included in the final analysis. Of the studies reviewed, the majority ( n = 37) were prospective or retrospective case series. Only three randomized clinical trials were eligible for inclusion. Conclusion Although the technique seems to be standardized, several steps still need to be clarified in order to define the best way to perform the procedure and then to maximize the outcome. [ABSTRACT FROM AUTHOR]

Aim In Europe during the last decade sacral nerve stimulation ( SNS) or sacral neuromodulation ( SNM) has been used to treat faecal incontinence ( FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/ SNM for FI and constipation. Method A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion. Results Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%). Conclusion Consensus was achieved on the majority of domains of SNS/ SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/ SNM in Europe. [ABSTRACT FROM AUTHOR]

Aim Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain. Method Ten patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3 weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a > 50% reduction in pain score. Results Of the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had > 50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5 years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS. Conclusion This study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation (SNS) is considered a first-line surgical treatment option for faecal incontinence. There is little information on long-term results. The results of SNS for faecal incontinence performed at a single centre over a 10-year period are reported. Method A cohort analysis of consecutive patients treated with SNS for faecal incontinence over a 10-year period was carried out. Data were collected prospectively using bowel habit diaries and St Mark's and Cleveland Clinic incontinence scores. Treatment success was defined as a > 50% reduction in episodes of faecal incontinence compared with baseline. Results Temporary SNS was performed in 118 patients, and 91 (77%) were considered suitable for chronic stimulation. The median period of follow up was 22 (1-138) months. Seventy patients were followed for 1 year with success in 63 (90%). Of 18 patients followed for 5 years, 15 (83%) reported continued success, 11 (61%) maintained full efficacy, 4 (22%) reported some loss, and 3 (17%) reported complete loss. Three patients with a 10-year follow up had no loss in efficacy. Overall, complete loss of efficacy was observed in 14 (16%) patients at a median of 11.5 months following implantation. A further 5 (6%) patients showed deterioration with time. In 9 (47%), no reason for the deterioration in symptoms could be identified. Conclusions SNS can be effective for up to 10 years. Some patients experience deterioration in symptoms over time. The reasons for this are often not evident. [ABSTRACT FROM AUTHOR]

Indications for sacral nerve stimulation (SNS) for faecal incontinence have expanded over the last decade. This report aims to determine the clinical outcome of the current use of SNS in the treatment of faecal incontinence. Its objective is also to review the most recent role of SNS in patients with anal sphincter lesions. The literature was searched using Medline and Cochrane databases. The search was restricted to publications in English. For the analysis, studies with < 25 patients were excluded. For SNS in patients with sphincter defects, all papers were included. Thirteen publications on the clinical outcome of SNS were included. Nine papers were identified reporting the application of SNS in patients with a morphological sphincter lesion. The most common outcome measures of clinical efficacy were frequency of incontinence using the Cleveland Clinic Incontinence Score. All studies demonstrated highly improved function across all outcome measures and improvement was statistically significant in all. Outcomes remain stable at long-term follow up. In patients with sphincteric gaps ranging from 17 to 180°, SNS was clinically effective at short-term follow up. The size of the gap appears to have no impact on outcome. SNS has evolved to become a clinical efficient therapy applicable across a wide spectrum of causes of faecal incontinence with reproducible results. SNS can be considered to be an essential part of the current surgical treatment algorithm for faecal incontinence. [ABSTRACT FROM AUTHOR]

Urinary and faecal incontinence are common conditions that are frequently associated. When conservative treatments fail, sacral nerve modulation (SNM) is considered to be a first-line treatment for patients with urge urinary incontinence and for patients with faecal incontinence. This article aims to determine the effect of SNM on the treatment of double incontinence (i.e. urinary and faecal incontinence). We searched for relevant articles in MEDLINE, PubMed and Embase, and for reviews in the Cochrane database. Articles were restricted to the English language. Only a few studies have studied the efficacy of SNM for double incontinence and in a limited number of patients. Between 30% and 100% of patients with double incontinence experience improvement in urinary and faecal incontinence at medium-term follow up. Further prospective trials are needed to determine which patients with combined problems will benefit from SNM at a long-term follow up. [ABSTRACT FROM AUTHOR]

Sacral nerve stimulation (SNS) has become an established option in the management of defaecatory disorders. There are many data on the end-organ effects of SNS, but limited consensus on its mechanism of action. The objective of this review was to determine the effect of sacral nerve stimulation (SNS) on anorectal function. Systematic literature review of the effect of sacral nerve stimulation (SNS) on anorectal function. There was significant heterogeneity of data pertaining to the effects of SNS on anorectal function, with no consistent change in physiological measures identified. Most data supported a mixed mechanism of action on anal motor and rectal sensory functioning. To date, conflicting data exist on the mechanism of action of SNS as determined by end-organ changes in anorectal physiology. Nevertheless, the data as they stand best support a mixed mechanism of action on anal motor and rectal sensory functions. [ABSTRACT FROM AUTHOR]

Aim The efficacy of sacral nerve stimulation (SNS) to treat faecal incontinence has been demonstrated in the short- and mid-term. We analysed SNS outcome in the first patients with a permanent neurostimulator in whom follow-up ranges up to 14 years. Method Of 12 patients who underwent SNS from 1994 to 1999, 9 were eligible for long-term analysis (defined as a minimum of 7 years). In 3 the device had to be removed because of pain or neurological disease. Functional outcome was monitored prospectively by standardized questionnaire. For efficacy, the recorded frequency of incontinent episodes over 2-week periods and the Wexner Score were obtained yearly after implant. Quality of life measures (FIQL scale [QoL]) were introduced in 1998. Stimulation parameter adjustments, battery longevity, and complications were documented. Results Mean follow-up in the nine patients was 9.8 years (range 7–14), over which time efficacy persisted. Clinical improvement was significant (baseline vs last follow-up): median percentage of incontinent bowel movements/week 40% (range 9–100) vs 0% (0–60%; P = 0.008), median number of incontinent episodes/week, 9 (range 2–58) vs 0 (0–29; P = 0.012); median Cleveland Clinic Score, 17 (range 12–19) vs 10 (3–14; P < 0.007); QoL improved in all categories. Pulse generator exchange was required in eight of the nine patients after a mean of 7.4 years for battery fatigue (mean 2.1 V). Complications occurred in five of the original 12 and were therapy-related, but not technique-related, in four patients. Conclusion Sacral nerve stimulation is an effective and safe long-term treatment for faecal incontinence. Clinical outcome is stable over time. [ABSTRACT FROM AUTHOR]

Objective Sacral neuromodulation (SNM) has been a successful treatment in urinary voiding disorders for years. A concomitant effect on bowel function was observed leading to the treatment of faecal incontinence with SNM. In this study we describe the effect of SNM on bowel frequency and (segmental) colonic transit time. Patients and methods Fourteen patients with faecal incontinence who qualified for permanent SNM underwent a colon transit study before and one month after permanent implant. Patients completed a three-week bowel habits diary before and during stimulation. Results Median incontinence episodes and days per week before SNM were, 8.7 and 4.2, respectively, and both decreased significantly to 0.67 ( P = 0001) and 0.5 ( P = 0001) during trial screening and to 0.33 ( P = 0001) and 0.33 ( P = 0001) after permanent implant. The median number of bowel movements per week decreased from 14.7 (6.7–41.7) to 10.0 (3.7–22.7)( P = 0005) during trial screening and to 10.0 (6.0–24.3)( P = 0008) during permanent stimulation. Resting and squeeze pressures did not change significantly during stimulation. Segmental colonic transit time before and during stimulation for right colon, left colon and recto sigmoid were, respectively, 6 (0–25) vs 5 (0–16) hours, 2 (0–29) vs 4 (0–45) hours and 7 (28) vs 8 (0–23) hours. No significant changes were found in both segmental and total colonic transit time; 17 (1–65) vs 25 (0–67) hours. Conclusion SNM in patients with fecal incontinence led to a significant decrease of bowel movements however (segmental) colonic transit time was not influenced. [ABSTRACT FROM AUTHOR]

Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a ‘Sex Life Questionnaire’ at their follow up visit to ascertain whether there was any improvement in this aspect of their life. Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35–61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1–55) to 1.5 (0–8.5) ( P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1–100) and the percentage improvement was inversely correlated to age ( r = −0.834, P = 0.005). SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients. [ABSTRACT FROM AUTHOR]