SCOTTSDALE, AZ USA (UroToday.com) - Dr. Kevin Benson moderated a panel of clinicians with expertise in neuromodulation.
Patient selection/Indications – Dr. Benson asked the panelists how they approach tier-3 treatment options. Dr. Raul Ordorica noted that many of his patients are referred from other practices, often with an incorrect diagnosis, so he always does an evaluation to confirm the correct diagnosis. Dr. Karen Noblett stressed the need to correct constipation. She prioritizes most patients to sacral neuromodulation (SNM) as a pudendal nerve evaluation (PNE) allows for a minimally invasive and completely reversible trial should it be unsuccessful. Dr. Nissrine Nakib agreed with Dr. Noblett’s remarks. Dr. Benson queried the panel regarding their age/comorbidity exclusion criteria for SNM. Dr. Ordorica does not restrict patients given the low comorbidity of a PNE trial. He remarked that he has been surprised how many patients responded to PNE when he did not think they would do well.
Implant/Programming – Dr. Benson asked the panelists what their perioperative antibiotic protocol is. Dr. Nakib uses cefazolin two grams intraoperatively followed by 3 days of cephalexin. Dr. Noblett uses an at home chlorhexidine wash the night prior to implantation. She uses vancomycin intraoperatively followed by sulfa/trimethoprim due to a MRSA outbreak at their institution a few years ago. Dr. Ordorica uses intraoperative cefazolin in conjunction with Ioban™ skin coverage. In regards to patient programing goals, the panelists agreed that they adjust their programs to optimize sensory response rather than motor response.
Loss of Efficacy – Dr. Nakib stressed the importance of reviewing a voiding diary, as many patients become accustomed to their new improved symptomatology and forget they remain consistently and significantly better than prior to SNM. Dr. Noblett recommends a 2-week trial of each program before considering a program not efficacious. This is based upon preliminary data from her institution that patient symptoms return approximately 1-2 weeks after turning off the device. She frequently uses Botox® in combination in patients with an incomplete response to SNM with excellent outcomes.
Moderated by Kevin D. Benson, MD, MS at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) Winter Meeting - February 24 - 28, 2015 - JW Marriott Camelback Inn Resort & Spa - Scottsdale, AZ USA
Panelists:
Nissrine A. Nakib, MD
Karen L. Noblett, MD
Raul C. Ordorica, MD
Reported for UroToday by Drew Freilich, MD. Dr. Freilich is a graduate of the University of Massachusetts Medical School and completed his urology residency at New York Medical College/Westchester Medical Center. He is currently a fellow in Female Urology, Neurourology and Reconstructive Urology at Medical University of South Carolina. He has authored more than 40 peer-reviewed articles, monographs, abstracts, and book chapters and abstracts. Dr. Freilich is a member of the American Urological Association and the Society for Urodynamics and Female Urology.