Zusammenfassung
Die sakrale Neuromodulation (SNM) stellt ein innovatives, minimal-invasives Therapieverfahren dar, welches durch chronische elektrische Stimulation des Plexus sacralis physiologische Restfunktionen des Blasendetrusors, des Beckenbodens und des anorektalen Kontinenzorgans optimal rekrutiert. Klassische Indikationen für die sakrale Neuromodulation in der Urologie sind die therapierefraktäre überaktive Blase (OAB, mit/ohne Dranginkontinenz) und chronische, nichtobstruktive Harnretention. Aber auch bei therapierefraktärem chronischem Schmerzsyndrom des Beckens stellt die SNM eine therapeutische Alternative dar.
Obwohl der genaue Wirkmechanismus bislang unklar ist, scheint die elektrische Stimulation eine Neuromodulation verschiedener Bahnen des sakralen Plexus zu induzieren. Die SNM ist ein zweistufiges Verfahren. In einer Testphase, der sog. perkutanen oder peripheren Nervenevaluation (PNE), wird über Tage bis Wochen unter Führen eines Miktionstagebuches/Schmerzprotokolls der Effekt der sakralen Neuromodulation getestet. Die PNE besitzt einen sehr hohen prädiktiven Wert, Morbidität und chirurgisches Trauma dieser Technik sind gering. Das hierdurch ermöglichte Screening macht diese Technik einzigartig und erlaubt eine nahezu ideale Patientenselektion.
Nach der Implantation des definitiven Neurostimulators (InterStim II) liegen die Langzeiterfolgsraten bei 50–90%. In unserer Klinik wurden im Zeitraum vom Januar 2009 bis Juni 2010, 42 Patienten einer PNE-Testung unterzogen. Davon hatten 34 Patienten einen >50%ige Erfolgrate und es wurde InterStim II implantiert (80,9%). Die Erfolgsraten waren 83% bei OAB und 89% bei Harnretention (Nachbeobachtungszeit 7,8 Monate). Neben dem chirurgischen Eingriff stellen die Abklärung, die Indikation und die postoperative Betreuung maßgebliche Aspekte der erfolgreichen Therapie dar. Bislang sind keine Informationen über die Anzahl der implantierten Neurostimulatoren im Deutschland bekannt. Dies legt die Notwendigkeit eines prospektiven nationalen Registers nahe. Zudem wäre es zweckmäßig, dass die Implantations-Zentren sich zu einer Arbeitsgruppe zusammenschließen.
Abstract
Sacral nerve modulation (SNM) is an innovative, minimally invasive treatment that uses chronic low-level electrical stimulation of the sacral plexus to recruit residual physiological function of urinary bladder detrusor, pelvic floor muscles, and the anorectal continence structures. Classic indications for sacral neuromodulation in urology are refractory overactive bladder symptoms (urinary urgency ± incontinence) and chronic nonobstructive urinary retention. SNM also offers a therapeutic alternative in refractory chronic pelvic pain syndrome.
The exact mechanism of action is still unknown, but it is assumed that electrical stimulation of the sacral nerves leads to neuromodulation as well as clinically beneficial effects in the pelvic floor, the sphincter complex, and the distal colorectum. SNM is a multistep procedure. In a test phase of so-called percutaneous or peripheral nerve evaluation (PNE), the effect of sacral neuromodulation is evaluated over days or weeks during which a bladder diary/pain protocol is kept. The predictive value of PNE is high, while morbidity and surgical trauma are low. The screening phase provided by PNE makes this technique unique and offers an ideal instrument for patient selection.
After final implantation of the neurostimulator (InterStim II), the long-term success rate is over 60–90%. At our clinic, 42 patients underwent a PNE procedure between January 2009 and June 2010. Of these, 34 patients had a >50% success rate and had been implanted with the InterStim II device (80.9%). The success rates were 83% for overactive bladder and 89% for chronic retention (mean follow-up 7.8 months). In addition to the surgical procedure, the exact indication and postoperative care are important prerequisites of successful therapy. To date, no information on the number of implanted stimulators in Germany is available. This suggests the need for establishment of a national prospective registry. It would also be appropriate that the experts from the implantation centers form a working group.
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Hoda, M., Fornara, P. Sakrale Neuromodulation in der Urologie. Urologe 49, 1254–1259 (2010). https://doi.org/10.1007/s00120-010-2395-4
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DOI: https://doi.org/10.1007/s00120-010-2395-4