Intractable urinary difficulty has always been a big mountain in front of urologists and patients. Some patients show urinary frequency and urgency, and even urge incontinence, while others show poor urination and inability to control urination on their own, which seriously affects the quality of life. Recently, Director Wei Zhongqing of the Second Affiliated Hospital of Southern Medical University led his team to perform sacral neuromodulation surgery for a 59-year-old patient under the guidance of PUMA’s large flat-panel all-in-one mobile C-arm imaging, which successfully improved the patient’s symptoms of urinary frequency and urgency over the years.
All-in-one mobile C-arm image
Case name: Sacral neuromodulation surgery
Surgical unit: The Second Affiliated Hospital of Nanjing Medical University
Patient age: 59 years old
Patient’s gender: male
This patient was diagnosed with overactive bladder (OAB) two years ago, with symptoms such as severe urinary frequency, urgency, and thin line of urine, and the doctor performed sacral neuromodulation surgery for him. Recently, the patient’s symptoms began to worsen again and his quality of life was affected. In order to alleviate his symptoms and improve his life, the patient went to the Second Affiliated Hospital of South China Medical University. After reviewing the patient’s condition, Director Wei Zhongqing and his team decided to readjust the electrode stimulation position, changing the stimulation point from the original left sacral 4 nerve foramen to sacral 3 nerve foramen, and the new neuromodulation successfully improved the symptoms.
Patient’s preoperative image
Intraoperative image of the large flatbed integrated mobile C-arm.
Overactive Bladder (OAB)
Overactive Bladder Syndrome (OAB) refers to a series of urinary abnormalities caused by involuntary contraction of the bladder’s detrusor muscle (DO) during urination. The International Continence Society (ICS) defines OAB as urgency to urinate, usually accompanied by increased daytime frequency and/or nocturia, in the absence of a urinary tract infection or other detectable disease, with incontinence (wet urine) or without incontinence (dry urine).
Overactive Bladder Syndrome (OAB) Schematic Diagram
Treatment for OAB varies depending on the cause and degree of the condition. It can be behavioral modification, such as reducing caffeine intake and increasing pelvic floor muscle training, or pharmacological treatment, such as taking antimuscarinic classes of drugs including mirabilone. Severe OAB can also be treated with neuromodulation techniques, such as percutaneous tibial nerve stimulation (PTNS) or sacral neuromodulation (SNM).
About Sacral Neuromodulation (SNM)
In Sacral Neuromodulation or Sacral Nerve Stimulation (SNM), the practitioner will first insert an electrode through a guide needle into the sacral 3 nerve foramen under fluoroscopic guidance, and stimulate it with pulsed current to excite the nerve fibers and inhibit the contraction of the forced urethral muscle. In this step, the patient’s response to the nerve stimulation is tested and evaluated, and if the stimulation is effective, the procedure meets the surgical expectations. Next, the surgeon implants a pulsed current generator in the nearby subcutaneous fat and connects it to the electrodes so that the area can receive long-term electrical stimulation in the future to improve OAB symptoms.
Sacral Neuromodulation (SNM) Diagram
The SNM technique is a minimally invasive treatment with a short procedure time and the patient only needs to receive local anesthesia. The technique has now been proven effective in over 40 studies. The vast majority of studies have shown that the use of SNM can successfully improve OAB symptoms by at least 50%.
Advantages of SNM
❖ The traditional 9-inch flat panel detector or image intensifier C-arm, with a small imaging range, is unable to present a large field of view of the fluoroscopic image due to the limitation of the surgical bed when performing guidewire positioning observation, which requires multiple shots and reduces the efficiency of the surgery. The PUMAI large flat panel integrated mobile C-arm is equipped with a 30cm x 30cm large flat panel detector, and the large imaging area makes up for the difficulties in taking pictures due to the inconvenient positioning.
❖ Compared with the shadow-enhanced C-arm, the flat-panel detector has less distortion in imaging, which can accurately reflect the relationship between the electrodes and the position of the sacral foramen, and improve the expectation of surgical results.
*This article is for academic purposes only. For specific cases, please visit a specialized medical institution.
Putting Perlove’s large flat-panel integrated mobile C-arm into use will provide reliable image protection for orthopedics, pain, neurosurgery, urology, interventional vascular surgery, hepatobiliary surgery and other specialized fields of surgery, and escort more surgical patients.
