PREOPERATIVE DIAGNOSIS:
Refractory urge incontinence.
POSTOPERATIVE DIAGNOSIS:
Refractory urge incontinence.
PROCEDURE:
1. Insertion of InterStim percutaneous nerve stimulator, Stage 1- incision and implantation of electrodes into S3
2. Fluoroscopic guidance for needle placement
SURGEON:
ASSISTANT:
(no qualified first assist resident available).
ANESTHESIA:
MAC
ESTIMATED BLOOD LOSS:
Less than 5.
INTRAVENOUS FLUIDS:
300
COMPLICATIONS:
None.
DRAINS:
None.
SPECIMENS:
None.
STATEMENT OF MEDICAL NECESSITY:
is a 73 y.o. female with a refractory urge incontinence. After failure of multiple anticholinergics, she now presents for Interstim Stage 1 test stimulation.The inherent risks were outlined and she signed informed consent.
FINDINGS AND TECHNIQUE:
After consent was obtained, the patient was taken to the operating room, placed in the prone position. After adequate general anesthesia was
established, the patient was prepped and draped in the usual sterile manner. Following injection of 0.25% Marcaine with epinephrine,
fluoroscopy was used in AP position as well as the lateral position to confirm appropriate finder needle placement into the S3 foramen on the right. Proper needle position was confirmed by direct observation of bellowing and plantar flexion of the great toe using the external test stimulator.
The foramen needle stylet was removed and a directional guide was placed and confirmed fluoroscopically. The foramen needle was removed. An
incision was made peripheral to the directional guide through the fascial layer. The lead introducer sheath with dilator was placed over the
directional guide and directed into the foramen to ensure the radiopaque marker of the lead introducer did not extend beyond the anterior edge of
the sacrum. The dilator was unlocked and removed along with the directional guide. The lead was then placed through the introducer sheath
to the first white line. Position was once again checked fluoroscopically. The lead was then further introduced until 3 electrodes were visible below
the sacrum. Each electrode was tested for visualization of bellowing and plantar flexion, which was confirmed on all 4 leads. After satisfactory
positioning was confirmed, the introducer sheath was retracted under continuous fluoroscopy, deploying lead tines into the perisacral tissue.
After additional topical anesthesia was introduced, further incision was made into the subcutaneous tissue posterior to the iliac crest lateral to
the sacrum. Blunt dissection was continued until the gluteal fascia was identified. Hemostasis was achieved with the Bovie electrocautery. A
tunneling tool with straw was placed from the lead exit site subcutaneously to the incised pocket site. The tunneling tool was removed and the lead
was fed through the straw and pulled out at the pocket site. The lead was cleansed of bodily fluids and dried, and a protective boot was placed over the lead. The lead was inserted into the temporary Percutaneous Extension, and the metal bands were aligned. The 4 setscrews were tightened with the hex wrench. The boot was pushed over the connection and 2 silk ties were sutured to the boot grooves on either side of the connnection.
A tunnel was made subcutaneously and exited to a puncture site above the contralateral buttock. The Percutaneous Extension was placed through the straw and exposed and connected to the Twist Lock gray cable.
The wound was then irrigated and closed with a running 3-0 Vicryl suture, followed by a running 4-0 Biosyn subcuticular suture. 0.25 inch Steri-Strips were applied followed by Telfa and Tegaderm. Dermabond was used to close the lead entry site and the contralateral exit site. The patient was then awakened from anesthesia and taken to the day surgery unit in stable condition. Using the clinician programmer, the patient was programmed to the electrode of optimum sensation, on Program 1 settings with lead III being negative and lead 0 being positive, at 0.4 mA.
MEDICATIONS:
Tylenol #3
She is instructed to remove her dressing in 72 hours. She will follow up in my office next week for symptom check.
Refractory urge incontinence.
POSTOPERATIVE DIAGNOSIS:
Refractory urge incontinence.
PROCEDURE:
1. Insertion of InterStim percutaneous nerve stimulator, Stage 1- incision and implantation of electrodes into S3
2. Fluoroscopic guidance for needle placement
SURGEON:
ASSISTANT:
(no qualified first assist resident available).
ANESTHESIA:
MAC
ESTIMATED BLOOD LOSS:
Less than 5.
INTRAVENOUS FLUIDS:
300
COMPLICATIONS:
None.
DRAINS:
None.
SPECIMENS:
None.
STATEMENT OF MEDICAL NECESSITY:
is a 73 y.o. female with a refractory urge incontinence. After failure of multiple anticholinergics, she now presents for Interstim Stage 1 test stimulation.The inherent risks were outlined and she signed informed consent.
FINDINGS AND TECHNIQUE:
After consent was obtained, the patient was taken to the operating room, placed in the prone position. After adequate general anesthesia was
established, the patient was prepped and draped in the usual sterile manner. Following injection of 0.25% Marcaine with epinephrine,
fluoroscopy was used in AP position as well as the lateral position to confirm appropriate finder needle placement into the S3 foramen on the right. Proper needle position was confirmed by direct observation of bellowing and plantar flexion of the great toe using the external test stimulator.
The foramen needle stylet was removed and a directional guide was placed and confirmed fluoroscopically. The foramen needle was removed. An
incision was made peripheral to the directional guide through the fascial layer. The lead introducer sheath with dilator was placed over the
directional guide and directed into the foramen to ensure the radiopaque marker of the lead introducer did not extend beyond the anterior edge of
the sacrum. The dilator was unlocked and removed along with the directional guide. The lead was then placed through the introducer sheath
to the first white line. Position was once again checked fluoroscopically. The lead was then further introduced until 3 electrodes were visible below
the sacrum. Each electrode was tested for visualization of bellowing and plantar flexion, which was confirmed on all 4 leads. After satisfactory
positioning was confirmed, the introducer sheath was retracted under continuous fluoroscopy, deploying lead tines into the perisacral tissue.
After additional topical anesthesia was introduced, further incision was made into the subcutaneous tissue posterior to the iliac crest lateral to
the sacrum. Blunt dissection was continued until the gluteal fascia was identified. Hemostasis was achieved with the Bovie electrocautery. A
tunneling tool with straw was placed from the lead exit site subcutaneously to the incised pocket site. The tunneling tool was removed and the lead
was fed through the straw and pulled out at the pocket site. The lead was cleansed of bodily fluids and dried, and a protective boot was placed over the lead. The lead was inserted into the temporary Percutaneous Extension, and the metal bands were aligned. The 4 setscrews were tightened with the hex wrench. The boot was pushed over the connection and 2 silk ties were sutured to the boot grooves on either side of the connnection.
A tunnel was made subcutaneously and exited to a puncture site above the contralateral buttock. The Percutaneous Extension was placed through the straw and exposed and connected to the Twist Lock gray cable.
The wound was then irrigated and closed with a running 3-0 Vicryl suture, followed by a running 4-0 Biosyn subcuticular suture. 0.25 inch Steri-Strips were applied followed by Telfa and Tegaderm. Dermabond was used to close the lead entry site and the contralateral exit site. The patient was then awakened from anesthesia and taken to the day surgery unit in stable condition. Using the clinician programmer, the patient was programmed to the electrode of optimum sensation, on Program 1 settings with lead III being negative and lead 0 being positive, at 0.4 mA.
MEDICATIONS:
Tylenol #3
She is instructed to remove her dressing in 72 hours. She will follow up in my office next week for symptom check.
