Sacral nerve stimulation (neuromodulation)

What is the evidence base for this information?

This leaflet includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence based sources; it is, therefore, a reflection of best practice in the UK. It is intended to supplement any advice you may already have been given by your Urologist or Nurse Specialist as well as the Surgical team at Addenbrooke’s. Alternative treatments are outlined below and can be discussed in more detail with your Urologist or Specialist Nurse.

What does the procedure involve?

This procedure involves initially temporarily stimulating the nerves in the sacrum to see if stimulation alters bladder function. If the test is successful, the stimulating implant is inserted into the buttock area and connected to the stimulating electrode.

What are the alternatives to this procedure?

Bladder re-training, physiotherapy, drug treatment, BoTox injections into the bladder, bladder enlargement or replacement using bowel, urinary diversion into a stoma.

What should I expect before the procedure?

You will usually be admitted on the day of your surgery. You will normally undergo pre-assessment on the day of your clinic, or an appointment for pre-assessment will be made from clinic, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the Medical team which may include the consultant, junior urology doctors and your named nurse.

You will be asked not to eat or drink for six hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your Urologist in advance of your surgery if you have any of the following:

• an artificial heart valve
• a coronary artery stent
• a heart pacemaker or defibrillator
• an artificial joint
• an artificial blood vessel graft
• a neurosurgical shunt
• any other implanted foreign body
• a prescription for Warfarin, Aspirin, Rivaroxaban, Dabigatran, Apixaban, Edoxaban or Clopidogrel , Ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

What happens during the procedure?

Currently, the procedure consists of two different admissions. During the first admission (the test phase), the permanent tined lead is placed into one of the sacral nerves in your lower back. The test electrode is connected to a device which generates electrical impulses for three to five days, but sometimes up to two to four weeks. During this time, you will be at home and will be asked to complete an input/output chart. You will have a wireless hand controller that allows you turn the power of stimulation up, down or off.

You will then be reviewed to see if you have had improvement during this test phase. If you have not, you will need another short anaesthetic to remove the lead. If you have had a good response, you will need a second short general anaesthetic procedure to place the permanent stimulator (also known as the implantable pulse generator or IPG).

What happens immediately after the procedure?

On the day of your surgery, your implant will be switched on and programmed so that you obtain maximum benefit with regard to your symptoms whilst ensuring maximum comfort for you. When the implant is switched on, you will feel a tapping sensation in the genital or rectal area.

We will teach you how to use the programmer.

You will be given an injection under the skin of a drug (Dalteparin), which, along with the help of elasticated stockings provided by the ward, will help prevent thrombosis (clots) in the veins.

The average hospital stay is 12 to 24 hours.

Are there any side effects?

Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

Common (greater than one in 10)

☐ Replacement, relocation or removal of the implanted pulse generator

☐ Replacement, relocation or removal of the lead

☐ Pain

☐ Inability to pass urine requiring a bladder catheter

Occasional (between 1 in 10 and 1 in 50)

☐ Wound infection

☐ Urinary infection

☐ Implanted pulse generator malfunction

Rare (less than 1 in 50)

☐ Adverse effect on bowel function

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your in-patient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

If you have problems using your programmer, please contact your named specialist nurse.

What else should I look out for?

If you experience any flu-like symptoms, redness/throbbing in the wound, pain/ burning when passing urine or difficulty passing a catheter, please contact your GP.

You may require repeated contact with your named Specialist Nurse or repeated visits to Hospital to “fine tune” your programmer. Over time, the body can become conditioned (used) to the programmer settings and you may need advice on re-programming.

Are there any other important points?

The Urology specialist nurses will keep in contact with you after your discharge from hospital and you will have an out-patient review appointment within four months of your discharge.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery.

You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/ or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007)

Is there any research being carried out in this field at CUH?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060