Objectives To evaluate if electrodiagnostic tools can advance the understanding in the effect of sacral neuromodulation (SNM) on pelvic floor activity, more specifically if SNM induces changes in... Show moreObjectives To evaluate if electrodiagnostic tools can advance the understanding in the effect of sacral neuromodulation (SNM) on pelvic floor activity, more specifically if SNM induces changes in pelvic floor muscle (PFM) contraction. Materials and Methods Single tertiary center, prospective study (October 2017-May 2018) including patients with overactive bladder syndrome undergoing SNM. Electromyography of the PFM was recorded using the Multiple Array Probe Leiden. The procedure consisted of consecutive stimulations of the lead electrodes with increasing intensity (1-3, 5, 7, 10 V). Recordings were made after electrode placement (T0) and three weeks of SNM (T1). Patients with >50% improvement were defined as responders, others as nonresponders. For the analyses, the highest electrical PFM response (EPFMR), defined as the peak-to-peak amplitude of the muscle response, was identified for each intensity. The sensitivity (intensity where the first EPFMR was registered and the normalized EPFMR as percentage of maximum EPFMR) and the evolution (EMFPR changes over time) were analyzed using linear mixed models. Results Fourteen patients were analyzed (nine responders, five nonresponders). For nonresponders, the PFM was significantly less sensitive to stimulation after three weeks (T0: 1.7 V, T1: 2.6 V). The normalized EPFMR was (significantly) lower after three weeks for the ipsilateral side of the PFM for the clinically relevant voltages (1 V: 36%-23%; p = 0.024, 2 V: 56%-29%; p = 0.00001; 3 V: 63%-37%; p = 0.0002). For the nonresponders, the mean EPFMR was significantly lower at 8/12 locations at T1 (T0: 109 mu V, T1: 58 mu V; mean p = 0.013, range <0.0001-0.0867). For responders, the sensitivity and evolution did not change significantly. Conclusions This is the first study to describe in detail the neurophysiological characteristics of the PFM, and the changes over time upon sacral spinal root stimulation, in responders and nonresponders to SNM. More research is needed to investigate the full potential of EPFMR as a response indicator. Show less
Vaganee, D.; Voorham, J.; Borne, S. van de; Voorham-van der Zalm, P.; Fransen, E.; Wachter, S. de 2020
Purpose To assess the activation of the different parts of the pelvic floor muscles (PFM) upon electrical stimulation of the sacral spinal nerves while comparing the different lead electrode... Show morePurpose To assess the activation of the different parts of the pelvic floor muscles (PFM) upon electrical stimulation of the sacral spinal nerves while comparing the different lead electrode configurations. Material and Methods PFM electromyography (EMG) was recorded using an intravaginal multiple array probe with 12 electrodes pairs, which allows to make a distinction between the different sides and depths of the pelvic floor. In addition concentric needle EMG of the external anal sphincter was performed to exclude far-field recording. A medtronic InterStim tined lead (model 3889) was used as stimulation source. Standard SNM parameters (monophasic pulsed square wave, 210 microseconds, 14 Hz) were used to stimulate five different bipolar electrode configurations (3+0-/3+2-/3+1-/0+3-/1+3-) up to and around the sensory threshold. Of each EMG signal the stimulation intensity needed to evoke the EMG signals as well as its amplitude and latency were determined. Linear mixed models was used to analyse the data. Results Twenty female patients and 100 lead electrode configurations were stimulated around the sensory response threshold resulting in 722 stimulations and 12 times as many (8664) EMG recordings. A significant increase in EMG amplitude was seen upon increasing stimulation intensity (P < .0001). Large differences were noted between the EMG amplitude recorded at the different sides (ipsilateral>posterior>anterior>contralateral) and depths (deep>center>superficial) of the pelvic floor. These differences were noted for all lead electrodes configurations stimulated (P < .0001). Larger EMG amplitudes were measured when the active electrode was located near the entry point of the sacral spinal nerves through the sacral foramen (electrode #3). No differences in EMG latency could be withheld, most likely due to the sacral neuroanatomy (P > .05). Conclusions A distinct activation pattern of the PFM could be identified for all stimulated lead electrode configurations. Electrical stimulation with the most proximal electrode (electrode #3) as the active one elicited the largest PFM contractions. Show less
Vaganee, D.; Borne, S. van de; Voorham-van der Zalm, P.; Voorham, J.; Fransen, E.; Wachter, S. de 2020
Purpose To assess the validity, reliability, and feasibility of electromyography (EMG) as a tool to measure pelvic floor muscle (PFM) contractions during placement and (re)programming of the tined... Show morePurpose To assess the validity, reliability, and feasibility of electromyography (EMG) as a tool to measure pelvic floor muscle (PFM) contractions during placement and (re)programming of the tined lead electrodes in sacral neuromodulation (SNM) patients. Materials and Methods Single tertiary center, prospective study conducted between 2017 and 2019 consisting of three protocols including a total of 75 patients with overactive bladder (wet/dry) or nonobstructive urinary retention. PFM EMG was recorded using the multiple array probe (MAPLe), placed intravaginally. All stimulations (monophasic pulsed square wave, 210 mu sec, 14 Hz) were performed using Medtronic's standard SNM stimulation equipment. During lead implantation, all four lead electrodes were stimulated with fixed increasing stimulation intensities (1-2-3-5-7-10 V). During lead electrode (re)programming, five bipolar lead electrode configurations were stimulated twice up to when an electrical PFM motor response (EPFMR), sensory response, and pain response were noted (i.e., the threshold), respectively. Additionally, amplitude and latency of the EPFMRs were determined. Validity, reliability, and feasibility were statistically analyzed using the intraclass correlation coefficient, weighted Cohen's kappa and linear regression, respectively. Results Validity: EPFMRs were strongly associated with visually detected PFM motor responses (kappa= 0.90). Reliability: EPFMR amplitude (ICC = 0.99) and latency (ICC = 0.93) showed excellent repeatability. Feasibility: linear regression (EPFMR threshold = 0.18 mA + 0.76 * sensory response threshold) showed an increase in the sensory response threshold is associated with a smaller increase in EPFMR threshold, with the EPFMR occurring before or on the sensory response threshold in 83.8% of all stimulations. Conclusions Measuring PFM contractions with EMG during placement and (re)programming of lead electrodes in SNM patients is valid, reliable, and feasible. Therefore, the use of PFM EMG motor responses could be considered as a tool to assist in these procedures. Show less
Vaganee, D.; Voorham, J.; Panicker, J.N.; Fransen, E.; Voorham-van der Zalm, P.; Borne, S. van de; Wachter, S. de 2020
Background In sacral neuromodulation (SNM) patients, it is thought the bellows response elicited upon sacral spinal nerve stimulation is reflex-mediated. Therefore the mechanism of action of SNM is... Show moreBackground In sacral neuromodulation (SNM) patients, it is thought the bellows response elicited upon sacral spinal nerve stimulation is reflex-mediated. Therefore the mechanism of action of SNM is considered to be at the spinal or supraspinal level. These ideas need to be challenged.Objective To identify the neural pathway of the bellows response upon sacral spinal nerve stimulation.Design, Setting, and Participants Single tertiary center, prospective study (December 2017-June 2019) including 29 patients with overactive bladder refractory to first-line treatment.Intervention Recording of the pelvic floor muscle response (PFMR) using a camcorder and electromyography (EMG) (intravaginal probe and concentric needles) upon increasing stimulation during lead or implantable pulse generator placement.Outcome Measurements and Statistical Analysis The lowest stimulation intensity needed to elicit a visual PFMR and electrical PFMR was determined. Electrical PFMRs were subdivided according to their latency.Outcome: the association between visual and electrical PFMRs. Statistical analyses were performed using the weighted kappa coefficient.Results Three different electrical PFMRs could be identified by surface and needle EMG, corresponding with a direct efferent motor response (R1), oligosynaptic (R2), and polysynaptic (R3) afferent reflex response.Only the R1 electrical PFMR was perfectly associated with the visual PFMR (kappa = 0.900).Conclusions The visual PFMRs upon sacral spinal nerve stimulation are direct efferent motor responses. A reopening of the discussion on the mechanism of action of SNM is possibly justified. Show less
Wenzel, H.H.B.; Kruitwagen, R.F.P.M.; Nijman, H.W.; Bekkers, R.L.M.; Gorp, T. van; Kroon, C.D. de; ... ; Aa, M.A. van der 2020
Introduction Centralization has, among other aspects, been argued to have an impact on quality of care in terms of surgical morbidity. Next, monitoring quality of care is essential in identifying... Show moreIntroduction Centralization has, among other aspects, been argued to have an impact on quality of care in terms of surgical morbidity. Next, monitoring quality of care is essential in identifying areas of improvement. This nationwide cohort study was conducted to determine the rate of short-term surgical complications and to evaluate its possible predictors in women with early-stage cervical cancer.Material and methods Women diagnosed with early-stage cervical cancer, 2009 FIGO stages IB1 and IIA1, between 2015 and 2017 who underwent radical hysterectomy with pelvic lymphadenectomy in 1 of the 9 specialized medical centers in the Netherlands, were identified from the Netherlands Cancer Registry. Women were excluded if primary treatment consisted of hysterectomy without parametrial dissection or radical trachelectomy. Women in whom radical hysterectomy was aborted during the procedure, were also excluded. Occurrence of intraoperative and postoperative complications and type of complications, developing within 30 days after surgery, were prospectively registered. Multivariable logistic regression analysis was used to identify predictors of surgical complications.Results A total of 472 women were selected, of whom 166 (35%) developed surgical complications within 30 days after radical hysterectomy. The most frequent complications were urinary retention with catheterization in 73 women (15%) and excessive perioperative blood loss >1000 mL in 50 women (11%). Open surgery (odds ratio [OR] 3.42; 95% CI 1.73-6.76), chronic pulmonary disease (OR 3.14; 95% CI 1.45-6.79), vascular disease (OR 1.90; 95% CI 1.07-3.38), and medical center (OR 2.83; 95% CI 1.18-6.77) emerged as independent predictors of the occurrence of complications. Body mass index (OR 0.94; 95% CI 0.89-1.00) was found as a negative predictor of urinary retention. Open surgery (OR 36.65; 95% CI 7.10-189.12) and body mass index (OR 1.15; 95% CI 1.08-1.22) were found to be independent predictors of excessive perioperative blood loss.Conclusions Short-term surgical complications developed in 35% of the women after radical hysterectomy for early-stage cervical cancer in the Netherlands, a nation with centralized surgical care. Comorbidities predict surgical complications, and open surgery is associated with excessive perioperative blood loss. Show less
Vaganee, D.; Voorham, J.; Voorham-van der Zalm, P.; Wachter, S. de 2019
