Averbeck Marcio Augusto, Gajewski Jerzy B, Finazzi-Agrò Enrico, Chermansky Christopher John, Sahai Arun, Późniak Michał, Sinha Sanjay, Mosiello Giovanni, Harding Christopher, Hashim Hashim, Dmochowski Roger, Belal Mohammed, Abrams Paul
Department of Urology, Moinhos de Vento Hospital, Porto Alegre, Brazil.
Department of Urology, Sao Lucas Hospital, PUCRS, Porto Alegre, Brazil.
Neurourol Urodyn. 2025 Mar;44(3):676-682. doi: 10.1002/nau.25600. Epub 2024 Oct 10.
Sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) are strongly recommended by international guidelines bodies for complex lower urinary tract dysfunctions. However, treatment failure and the need for rescue programming still represent a significant need for long-term follow-up. This review aimed to describe current strategies and future directions in patients undergoing such therapies.
This is a consensus report of a Think Tank discussed at the Annual Meeting of the International Consultation on Incontinence - Research Society (ICI-RS), June 6-8, 2024 (Bristol, UK): "Is our limited understanding of the effects of nerve stimulation resulting in poor outcomes and the need for better 'rescue programming' in SNM and PTNS, and lost opportunities for new sites of stimulation?"
Rescue programming is important from two different perspectives: to improve patient outcomes and to enhance device longevity (for implantable devices). Standard SNM parameters have remained unchanged since its inception for the treatment of OAB, nonobstructive urinary retention, and voiding dysfunction. SNM rescue programming includes intermittent stimulation (cycling on), increased frequency and changes in pulse width (PW). The effect of PW setting on SNM outcomes remains unclear. Monopolar configurations stimulate more motor nerve fibers at lower stimulation voltage; hence, this could be an option in patients who failed bipolar stimulation in the long term. Unfortunately, there is little evidence for rescue programming for PTNS. However, the development of implantable devices for intermittent stimulation of the tibial nerve may increase long-term adherence to therapy and increase interest in alternative programming. There has been recent promising neurostimulation targeting the pudendal nerve (PNS), especially in BPS/IC. More recently, preliminary data addressed the benefits of high-frequency bilateral pudendal nerve block for DESD and adaptive PNS on both urgency and stress UI in women.
The exploration of rescue programming and new stimulation sites remains underutilized, and there are opportunities that could potentially expand the therapeutic applications of nerve stimulation. By broadening the range of target sites, clinicians may be able to tailor treatments according to individual patient needs and underlying conditions, thereby improving overall outcomes. However, further studies are still needed to increase the level of evidence, potentially allowing for an individualized treatment both in patients who are candidates for electrostimulation and in those who have already received surgical implants but seek a better outcome.
国际指南机构强烈推荐骶神经调节（SNM）和经皮胫神经刺激（PTNS）用于治疗复杂的下尿路功能障碍。然而，治疗失败以及进行挽救性程控的需求仍然表明长期随访具有重大必要性。本综述旨在描述接受此类治疗的患者的当前策略和未来方向。
这是一份关于在2024年6月6日至8日于英国布里斯托尔举行的国际尿失禁咨询会 - 研究学会（ICI - RS）年会上讨论的一个智囊团的共识报告：“我们对神经刺激效果的有限理解是否导致了不良结果，以及在SNM和PTNS中需要更好的‘挽救性程控’，并失去了新刺激部位的机会？”
挽救性程控从两个不同角度来看很重要：改善患者预后以及延长设备使用寿命（对于可植入设备而言）。自SNM最初用于治疗膀胱过度活动症（OAB）、非梗阻性尿潴留和排尿功能障碍以来，其标准参数一直未变。SNM挽救性程控包括间歇性刺激（循环开启）、增加频率以及改变脉宽（PW）。PW设置对SNM结果的影响仍不清楚。单极配置在较低刺激电压下能刺激更多运动神经纤维；因此，对于长期双极刺激失败的患者而言，这可能是一种选择。遗憾的是，几乎没有关于PTNS挽救性程控的证据。然而，用于间歇性刺激胫神经的可植入设备的研发可能会提高患者对治疗的长期依从性，并增加对替代程控的兴趣。最近有针对阴部神经（PNS）的神经刺激显示出前景，尤其是在膀胱疼痛综合征/间质性膀胱炎（BPS/IC）中。最近，初步数据表明高频双侧阴部神经阻滞对女性排尿功能障碍（DESD）以及适应性PNS对尿急和压力性尿失禁均有益处。
对挽救性程控和新刺激部位的探索仍未得到充分利用，存在一些有可能扩大神经刺激治疗应用范围的机会。通过拓宽靶部位范围，临床医生或许能够根据个体患者需求和潜在病情来定制治疗方案，从而改善总体治疗效果。然而，仍需要进一步研究以提高证据水平，这可能使电刺激候选患者以及已接受手术植入但寻求更好治疗效果的患者都能实现个体化治疗。
