Dr. Goldman on removing sacral neuromodulation devices in the office

In this video, Howard Goldman, MD, discusses findings from the recent paper, “Removal of sacral neuromodulation devices is an office procedure,” which he co-authored alongside Sarah Martin, DO. Goldman is a vice chairman of the department of urology at Glickman Urologic Institute at the Cleveland Clinic and Martin is an FPMRS fellow at Cleveland Clinic and a urologist with Duly Health and Care.

Video Transcript:

We had 41 patients where we removed either just the lead or the entire system. It was about 50/50, so just under half the patients were just leads. So, patients had had a trial with a permanent lead placement, and they weren't successful, so they came in to have the lead taken out, or they were patients up to 6 years after having had the full implant done. So, some of them had been there for quite a while, and again about half just the lead and half the entire thing.

The company teaching for when you take these out is that you take the generator out of the pocket in the buttock, and then you make another incision in the middle, right where the lead is, and then you pull the lead out that way. Whereas we always try first from that pocket on the side. So that way, we can have just 1 incision. What we found is that almost every patient who just had a lead in, we were able to pull it out from that pocket. Half the patients, including 1 of the patients who'd had it in for, I think 2 or 3 years, who had the entire system in, we were able to pull the lead out through that pocket.

Now what's important there is you don't want the lead to break, because then you may not be able to get it; it'll be stuck in the body. What we generally do is we make an incision over the pocket, we get the generator out. I usually cut the wire there. And then we sort of gently pull on the lead and part of it is sort of a feel, but you can feel if it starts to stretch. If you feel like it starts to stretch, and it's stretching a little too much, then we stop, and then by just pulling on it, we can see a little indentation under the skin in the middle. Then we know exactly where the wire is, and then we numb up that area, just enough for us to put our finger in, feel it, and then pull it out in that direction.

Now 3 of the cases, even when we had that incision in the middle, and started to pull on it, it didn't want to come. So, in those cases, we actually go ahead and inject a mixture of lidocaine and Marcaine, so short acting and long acting anesthetic, all the way down to the fascia. In 1 or 2 cases, we literally followed the lead all the way down to the fascia with our scissors, through the fascia, so we're able to grab it at the level of the little tines that hold it in, and pull that out. So, the important things were, we're able to get patients done. Again, half was just the lead – those we almost all got through the pocket – the ones that had the full system in, half we got out through the pocket and half we had to make an incision in the middle to get those out.

So, essentially, out of 41 patients, 40 of them, we got it on the front end, and none of them broke. All were taken out completely. We did have that 1 patient I just described where we did have to close it up and do a second stage in a sense, to get the wire out at a later date under X-ray. But otherwise, it's pretty simple. Again, for those who may want to do it, the procedure is simple. Since we obviously consent the patient, do all that, they're in a prone position on their stomach. We use an alcohol based prep over the site of the generator and also over the middle, we put drapes on, and then we use a lot of both short and long acting numbing medicine, lidocaine/marcaine. I actually inject it all the way down onto the metal of the generator. What that does is it makes like a little pocket of lidocaine. So, when I cut down there, as soon as you cut through there, you see it in front of you. Then again, we try to pull it out.

Another thing that I started doing, sometimes when you pull, even when you pull the wire out from the pocket, and you're successful, it actually hurts them a little bit as it gets pulled out. What I do is once we start to pull a little bit, and I see the little dimple in the midline, I actually do inject some lidocaine/marcaine there, even if I'm not making an incision there, just so they don't feel it as much, so then we can pull it out. If it's not coming easily, then we numb up that middle area, make an incision that my pinky or my finger could fit in so we can feel it, and then take it out that way.

Then we just wash it out with water, close everything up. Nobody had an infection. We call these patients 2 days afterwards. There was only 1 patient who needed pain medicine beyond a day or 2. Everyone did great. My thinking is this is something [that] makes a lot easier for the patient, it's a lot less costly to the healthcare system to stay out of the operating room, and it's a lot quicker for me. To me, this makes a lot of sense, and I think we've shown that it can be very successfully done without too much trouble.

This transcription has been edited for clarity.