Liem Spencer S, Demus Timothy, Jivanji Dhaval, Palmerola Ricardo
Department of Urology, Mount Sinai Medical Center, Miami Beach, FL.
Department of Urology, Herbert Wertheim College of Medicine at Florida International University, Miami, FL.
Urology. 2023 Jan;171:252-254. doi: 10.1016/j.urology.2022.10.011. Epub 2022 Nov 9.
Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement.
This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM.
METHODS/MATERIAL: Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the "opening up" of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen.
The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation.
The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices.
骶神经调节（SNM）是一种先进的治疗方法，通过刺激骶脊神经来调节膀胱或肠道功能障碍，已被批准用于治疗膀胱过度活动症、大便失禁和非梗阻性尿潴留。在植入之前，必须通过经皮神经评估（PNE）或分阶段试验进行成功的试验期，以评估治疗效果。在S3椎间孔中理想的电极放置对于产生足够的反应和成功的结果至关重要。传统的在荧光镜引导下的电极放置利用前后位（AP）和侧位视图。在本摘要中，我们描述了一种可能有助于电极放置的额外改进方法。
本视频展示了用于在SNM中获得S3椎间孔通路以实现最佳电极放置的靶心技术。
方法/材料：将患者置于俯卧位开始手术。在前后位视图中双侧标记S3椎间孔的内侧边缘，然后在S3水平进行水平标记。从0度开始用实时荧光镜对骨盆进行成像，然后将C形臂旋转到30度。这种旋转使S3椎间孔从椭圆形“展开”为椭圆形。外科医生用凯利钳握住针，将其放置在距水平标记约2 cm头侧的皮肤水平处。进行实时荧光镜检查以使针与影像增强器对齐以形成靶心。一旦确定正确角度，将针推进。对侧椎间孔重复该操作。
靶心技术允许快速且可预测地进入S3。它有可能减少手术时间，使PNE中的进针次数最少，并允许外科医生在保持正确的内侧方向的同时进入S3。
靶心技术可协助外科医生在SNM中获得最佳通路，并可迅速融入当前的操作中。
