How does sacral modulation work best? Placement and programming techniques to maximize efficacy

Since receiving approval from the US Food and Drug Administration in 1997, sacral neuromodulation (SNM) has become the recommended treatment of urinary urge incontinence, urgency-frequency, nonobstructive urinary retention, and fecal incontinence. The manufacturer has introduced different technical modifications while surgeons and researchers have adapted and published various innovations and alterations of the technique. This review summarizes the current knowledge and recommendations of SNM preoperative decision making, the implantation technique, and available programming parameters and algorithms based on MEDLINE research, manufacturer instructions, and the approach of an experienced neurourological team. The primary steps and technical aspects to optimize SNM efficacy were the introduction of the tined-lead electrode and the development of the InterStim II impulse generator (both developed by Medtronic, Inc., Minneapolis, MN). The initiation of the staged implantation technique for sequential evaluation and implantation with the definitive quadripolar electrode completes the treatment algorithm so that an increased responder rate of SNM for all indications can be achieved.