Sakrale Neuromodulation in der Urologie – Entwicklung und aktueller Stand

Zusammenfassung

Die sakrale Neuromodulation (SNM) wird in der Urologie zur Behandlung therapierefraktärer Funktionsstörungen des unteren Harntraktes und bei chronischen Beckenschmerzen eingesetzt. Mittels elektrischer Stimulation sakraler Afferenzen (S2 – S4) werden eine Triggerung und Konditionierung übergeordneter autonomer und somatischer Nervenstrukturen erreicht und somit efferent die Harnblase, der Enddarm sowie die jeweiligen Schließmuskelsysteme angesteuert. Es können sowohl Zustände der Hyperaktivität als auch Hypokontraktilität und einer funktionellen Blasenhalsobstruktion behandelt werden. Die SNM verläuft zweiphasig. Bei der Peripheren Nervenevaluation (PNE-Test) werden nach Anlage der Testelektroden die Änderungen der Miktions- / Schmerzparameter evaluiert. Das in den letzten Jahren favorisierte Two stage Verfahren mit initialer Anlage der Dauerelektroden zur Testung scheint die Testerfolgsraten zu verbessern. Die zweite Phase beinhaltet die definitive Implantation des Impulsgenerators. Langzeiterfolgsraten der SNM schwanken in der Literatur aufgrund der inhomogenen Patientenkollektive und der in den letzten Jahren veränderten Operationstechnik erheblich (50 – 80 %). Mit der Einführung der „Tined lead Elektrode“ (2002) wird die Gewebedestruktion äußerst gering gehalten. Technische Innnovationen und die Finanzierbarkeit (seit 2004 in Deutschland), aber auch der Einsatz gerade bei austherapierten Patienten und komplexen Funktionsstörungen im Becken haben die SNM als Therapieoption in der Urologie mittlerweile fest etabliert.

Abstract

Sacral neuromodulation (SNM) in urology is employed to treat refractory lower urinary tract dysfunction as well as chronic pelvic pain. Electrical stimulation of the sacral afferents (S2 – S4) causes activation and conditioning of higher autonomic and somatic neural structures and thereby influences the efferents controlling the urinary bladder, the rectum and their related sphincter systems. It is therefore possible to treat overactivity as well as hypocontractility and functional bladder neck obstruction. SNM treatment is conducted biphasically. Initially, test electrodes are placed to evaluate changes in micturition and pain parameters. If, in this first phase − called peripheral nerve evaluation (PNE test) − sufficient improvements are observed, the patient progresses to phase two which involves implantation of the permanent electrodes and impulse generator system. In recent years, the “two stage approach” with initial implantation of the permanent electrodes has been favoured as it increases treatment success rates. Long-term success rates of SNM vary significantly in the literature (50 – 80 %) due to heterogeneous patient populations as well as improved surgical approaches. With the introduction of “tined lead electrodes” (2002), tissue damage is reduced to a minimum. Technical innovation, financial feasibility (reimbursed in Germany since 2004) and wider application, especially in otherwise therapy-refractory patients or complex dysfunctions of the pelvis, have established SNM as a potent treatment option in urology.

Schlüsselwörter

Neuromodulation - sakrale Neurostimulation - überaktive Blase - Blasenfunktionsstörungen - Harnretention

Key words

neuromodulation - sacral neurostimulation - overactive bladder - voiding dysfunctions - urinary retention

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