Invasive Neurostimulation in der Neuro-Urologie: State of the Art

Zusammenfassung

Die Modulation oder Stimulation der den unteren Harntrakt versorgenden Nerven stellt bei Versagen der konservativen oder minimalinvasiven Behandlungsansätze eine mögliche Therapieoption bei Dysfunktion des unteren Harntrakts, des Beckenbodens und des Mastdarms dar. Diese Übersicht zeigt die Möglichkeiten und Grenzen der sakralen Neuromodulation, der sakralen Deafferentation mit sakraler Vorderwurzelstimulation sowie der Konus-Deafferentation auf.

Die sakrale Neuromodulation (SNM) ist ein Verfahren zur Behandlung von refraktären Beckenbodenfunktionsstörungen verschiedenster Genese (idiopathisch, neurogen oder postoperativ), wie überaktive Blase, nicht obstruktive Retention und Stuhlinkontinenz. Besonderer Vorteil der SNM ist die Möglichkeit einer vorherigen Teststimulation mit einer hohen prognostischen Aussagekraft. Das Verfahren ist minimalinvasiv, reversibel und mit relativ niedrigen Morbiditätsraten verbunden.

Nach der Einführung von MRT-kompatiblen SNM-Systemen wurde das Interesse an der Behandlung von neurogenen Blasenfunktionsstörungen neu entfacht. Eine neuere Metaanalyse berichtet dabei über ähnliche Erfolgsraten, wie bei der idiopathischen Patientenpopulation.

Die sakrale Deafferentation mit Implantation eines sakralen Vorderwurzelstimulators (SARS/SDAF) stellt eine exzellente therapeutische Option für Patienten mit Querschnittlähmung dar, welche einerseits die Lebensqualität der Betroffenen erheblich verbessert und andererseits neben der Behandlung der neurogenen Dysfunktion des unteren Harntrakts auch die neurogene Darmfunktionsstörung, die neurogene Sexualfunktionsstörung oder eine autonome Dysreflexie positiv beeinflussen kann. Entscheidend für den Erfolg dieser Operation ist es, bei Versagen der konservativen bzw. minimalinvasiven Therapie frühzeitig die SDAF/SARS in Erwägung zu ziehen, um irreversible organische Schäden zu vermeiden.

Die Konus-Deafferentation (KDAF) stellt eine weniger invasive operative Behandlungsmöglichkeit für Querschnittgelähmte dar, bei denen eine sakrale Deafferentation indiziert wäre, welche jedoch von der gleichzeitigen Implantation eines sakralen Vorderwurzelstimulators nicht profitieren würden. Grundsätzlich bleibt auch diesen Patienten später die Möglichkeit, mit einem extraduralen Implantat versorgt zu werden und damit die Vorteile der Vorderwurzelstimulation zu nutzen. Indikationen für eine KDAF sind die autonome Dysreflexie, die therapierefraktäre Detrusorüberaktivität, rezidivierende Harnwegsinfekte, Harninkontinenz und die durch die Detrusorüberaktivität getriggerte Spastik. Mit der KDAF verfügen wir über ein sicheres und effizientes Verfahren mit einem hohen Potenzial für die Verbesserung des paraplegiologischen und neuro-urologischen Therapiespektrums.

Abstract

Modulation or stimulation of the nerves supplying the lower urinary tract is a possible treatment option for dysfunction of the lower urinary tract, pelvic floor and rectum if conservative or minimally invasive treatment approaches fail. This overview shows the possibilities and limitations of sacral neuromodulation, sacral deafferentation with sacral anterior root stimulation and conus deafferentation.

Sacral neuromodulation (SNM) is a procedure for the treatment of refractory pelvic floor dysfunction of various origins (idiopathic, neurogenic or post-operative), such as overactive bladder, non-obstructive retention and faecal incontinence. A particular advantage of SNM is the possibility of prior test stimulation with a high prognostic value. The procedure is minimally invasive, reversible and associated with relatively low morbidity rates.

Following the introduction of MRI-compatible SNM systems, there has been renewed interest in the treatment of neurogenic bladder dysfunction. A recent meta-analysis reports similar success rates as in the idiopathic patient population.

Sacral deafferentation with implantation of a sacral anterior root stimulator (SARS/SDAF) is an excellent therapeutic option for patients with spinal cord injury, which can significantly improve the quality of life of those affected and, in addition to treating neurogenic lower urinary tract dysfunction, can also have a positive effect on neurogenic bowel dysfunction, neurogenic sexual dysfunction or autonomic dysreflexia. If conservative or minimally invasive treatment fails, it is crucial for the success of this procedure to consider SDAF/SARS at an early stage in order to avoid irreversible organic damage.

Conus deafferentation (KDAF) is a less invasive surgical treatment option for patients with spinal cord injury for whom sacral deafferentation would be indicated but who would not benefit from the simultaneous implantation of a sacral anterior root stimulator. In principle, these patients also have the option of being subsequently treated with an extradural implant and thus utilising the advantages of anterior root stimulation. Indications for KDAF are autonomic dysreflexia, therapy-refractory detrusor overactivity, recurrent urinary tract infections, urinary incontinence and spasticity triggered by detrusor overactivity. With KDAF, we have a safe and efficient procedure with great potential for improving the spectrum of paraplegiological and neuro-urological treatment.

Schlüsselwörter

Funktion des unteren Harntraktes bei neurogener Dysfunktion - sakrale Neuromodulation - Stimulation der Sakralwurzel - Deafferentation - dorsale Rhizotomie

Keywords

neurogenic lower urinary tract dysfunction (NLUTD) - sacral neuromodulation - sacral root stimulation - dorsal rhizotomy - deafferentation

Publication History

Received: 05 February 2024

Accepted after revision: 13 March 2024

Article published online:
17 April 2024

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