CASE REPORT The Effectiveness of Sacral Neuromodulation on a Patient with a Previous Successful Cystoplasty Augmententation: A Case Report Farzaneh Sharifiaghdas* This report is about the effectiveness of sacral neuromodulation in a 32-year-old woman with a history of aug- mented cystoplasty who required clean intermittent catheterization. She was referred to our center with a medical history of bilateral vesicoureteral reflux because of neuropathic lower urinary tract dysfunction. We successfully did a sacral neuromodulation on her which lead to promising results. Keywords: clean intermittent catheterization; cystoplasty; sacral neuromodulation INTRODUCTION Sacral neuromodulation is a minimally invasive approach, which has been approved officially as a well-estab-lished procedure in the treatment of refractory urinary urge incontinence, non-obstructive urinary retention, urgency, and frequency(1,2). It has been reported to have promising results in the treatment of chronic disorders resistant to conventional therapy, including interstitial cystitis and women’s sexual dysfunction. However, none has been approved officially(3,4). This report is about the effectiveness of sacral neuromodulation in a patient with Urology and Nephrology Research Center, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran *Correspondence: Urology Nephrology Research Center, Labbafinejad Medical Center, No. 103, 9th Boostan St, Pasdaran Avenue, Tehran, Iran. Tel: +98 21 22567222. Fax: +98 21 22567282. Email: f.sharifiaghdas@gmail.com Received July 2019 & Accepted April 2020 Urology Journal/Vol 17 No. 6/ November-December 2020/ pp. 674-676. [DOI: 10.22037/uj.v0i0.5439] Figure 1. Voiding cystourethrography of the patient demonstrating the augmented bladder with a high capacity. a history of augmented cystoplasty who required clean intermittent catheterization (CIC). CASE REPORT A 32-year-old woman was referred to our center with a past medical history of bilateral high grade vesicoure- teral reflux(VUR), and two times failure of endoscopic and open surgical repair of VUR. With an obvious low back dimple sign and very low capacity, low compli- ance bladder and evidence of several episodes of high amplitude Detrusor over activity (according to multi channel urodynamic study )and urinary incontinence. She was finally diagnosed as a case of neuropathic low- er urinary tract dysfunction. She underwent augmenta- tion cystoplasty with a segment of ileum about 15 years before referring to us. The patient was in need of CIC to empty the bladder. However, she refused to perform regular daily CIC and had been admitted to hospital several times because of bladder over-distention and re- sidual urine, abdominal pain, symptomatic urinary tract infection or increased level of serum creatinine. She even had committed suicide due to her mood chang- es related to the mentioned chronic urinary problems (this was mentioned in her psychologic and psychiatric consultation reports). All procedures done in this study were in accordance with the principles of the Declara- tion of Helsinki. The patient insisted to have a more natural way of voiding. She signed a written informed consent before undergoing sacral neuromodulation to increase the ability of voiding. The preoperative evaluations including the genitouri- nary physical examination and cystourethroscopy re- sults were within normal limits. Voiding cystourethrog- raphy showed that she had a large augmented bladder, low-grade left vesicoureteral reflux and high residual urine (Figure 1). Multichannel urodynamic study showed a high capacity bladder (>800 mL), high com- pliance, acontractile detrusor with a very weak sensa- tion (just the first sensation at 400 mL). She was under- going self-catheterization once every day. There was no evidence of volitional voiding or urinary incontinence in her three-day frequency volume chart. She underwent unilateral peripheral nerve evalua- tion (PNE) by placing a temporary wire (305765SC, Medtronic, Minneapolis, Inc.) in the right S3 foramen which was connected directly to the external pulse gen- erator (Brown Box, Verify 3531, Medtronic, Minneap- olis, Inc.). According to the second frequency volume chart during the first week of PNE, the patient stated that she had regained the ability to void. The first PNE period lasted ten days. PNE test was repeated in the contralateral S3 foramen for eight days (Table 1). Ac- cording to the three-day frequency volume chart, the response rate to the PNE test phase for both sides was more than 50%. Therefore, she underwent implantation of quadripolar tined lead (3889-28, Medtronic, Min- neapolis, Inc.) and implantable pulse generator (3058, Medtronic, Minneapolis, Inc.) in a one stage surgery. At the time of writing this report, that is 12 months after the surgery, she voids volitionally and does CIC once every night in case of need. She is very satisfied with the clinical results (Figure 2). There has been no inci- dence of symptomatic urinary tract infection or abdom- inal pain and she has not stayed at the hospital since the operation. The urodynamic study four months after the surgery revealed regaining more bladder sensations at lower volumes. The detrusor pressure at the maximum flow rate was 10 cmH2O. DISCUSSION Sacral neuromodulation’s exact mechanism of action is unclear. A few studies suggest an effect on the af- ferent sensory never fibers mainly corresponding to the S3 root, modulating the filling and voiding phase of the bladder(1). Rasmussen and colleagues(5) reported the successful use of sacral neuromodulation in two women with intractable urinary frequency, urgency and urgen- cy-incontinence following bladder augmentation with ileum. Symptoms of both cases had improved after sa- cral neuromodulation. Our case had no continence and lower urinary tract symptoms, which is typically what we would expect from a successful augmented blad- der. But she became intolerant to CIC. Her urodynamic study result in follow-up revealed only 10 cmH20 in- crease in the augmented detrusor pressure during the void. So, it is not clear whether sacral neuromodulation works by increasing the contractility of neo-bladder or decreasing the muscle resistance of bladder outlet (pel- vic floor muscles or external sphincter) especially in the present case. To our knowledge, this is the first report of a successful sacral neuromodulation in a patient with a successful augmented bladder who was dependent on CIC with a promising result. CONFLICT OF INTEREST The author has no conflicts of interest. Sacral neuromodulation with previous cystoplasty-Sharifiaghdas Figure 2.a) voiding cystourethrography of the patient, full bladder with implanted tined lead and implantable pulse generator; b) her voiding cystourethrography demonstrating the residual urine after implanting the pulse generator. Case Report 675 ACKNOWLEDGEMENT The authors thank Muhammed Hussein Mousavinasab for editing this text. REFERENCES 1. Indar A, Young-Fadok T, Cornella J. A Dual Benefit of Sacral Neuromodulation. Surg Innov. 2008;15:219-22. 2. Al-Sannan B, Banakhar M, Hassouna MM. The role of sacral nerve stimulation in female pelvic floor disorders. Curr Obstet Gynecol Rep. 2013;2:159-68. 3. Chai TC, Zhang C, Warren JW, Keay S. Percutaneous sacral third nerve root neurostimulation improves symptoms and normalizes urinary HB-EGF levels and antiproliferative activity in patients with interstitial cystitis. Urology. 2000;55:643-6. 4. Chartier-Kastler EJ, Ruud Bosch JL, Perrigot M, Chancellor MB, Richard F, Denys P. Long- term results of sacral nerve stimulation (S3) for the treatment of neurogenic refractory urge incontinence related to detrusor hyperreflexia. J Urol. 2000;164:1476-80. 5. Rasmussen NT, Guralnick ML, O'Connor RC. Successful use of sacral neuromodulation after failed bladder augmentation. Canadian Urological Association journal = Journal de l'Association des urologues du Canada. 2009;3:E49-E50. Vol 17 No 05 September-October 2020 527 Sacral neuromodulation with previous cystoplasty-Sharifiaghdas Vol 17 No 06 November-December 2020 676