Surgery as an Overactive Bladder Treatment
Having all these medical advances is extremely beneficial. We have so many options to help treat OAB. However, at this point in the long list of treatments, we are getting into surgical procedures.
Surgery may not be an option for everyone, as it can be extremely expensive, and not available in most hospitals around the world. Therefore when trying to find a solution to OAB, lifestyle, natural and herbal, and medicinal are usually exhausted first before proceeding to more difficult, yet typically effective, treatments.
One of the other types of surgery for OAB treatment is called bladder augmentation. This surgery is a last case scenario, as once it is performed, it is irreversible. It is typically offered to patients who have gone through every treatment, and also meet an age requirement that the doctor feels comfortable making such an irreversible change.
Bladder augmentation increases the size of the bladder, allowing it to fill up more, and also allowing for more elasticity. It is for patients who have completely been resistant to all types of treatment and suffer from severe OAB symptoms.
It is such an invasive surgery, which the patient has to outweigh the other adverse side effects of the surgery in replacement for their OAB symptoms. This means that once bladder augmentation is performed, the patient can expect to have around 80 percent less function and control of their bladder, meaning they will feel much less, but be able to do more without their bladder getting in the way.
However, the side effects are typically having to use a catheter every time they feel the need to void. Sometimes a stoma is created outside of the bladder so that the patient can use this to void. This allows for much more freedom in their everyday lives and allows the patient to decide when to urinate verses when their bladder would make that decision.
The first one is the sacral neuromodulation with an InterStim implant. An InterStim implant is a small biscuit sized titanium device that is implanted in one buttock with a wire lead threaded through the tailbone and placed on the sacral nerves.
This is not a new form of treatment, but it is picking up speed with increased reports of successful treatment of OAB and even bladder retention and fecal incontinence. However, being approved for this surgery can be a struggle. Firstly, the idea of this surgery is only posed to patients whose OAB does not respond to medication and/or Botox.
This surgery requires a urology surgeon who is trained in it; they are usually found in large cities. The InterStim device alone is very expensive and usually costs the hospital around $45,500 USD. And lastly, to be approved for the surgery, you must go through a PNE (percutaneous nerve evaluation).
Sacral neuromodulation surgery is typically performed under general anesthesia in an operating room. Some doctors will perform it under local anesthesia to get real-time feedback from their patient on the feel and placement of the lead.
However, the surgeon still has to locate the sacral nerves and also create a pocket for the battery pack in one of the patient's buttocks, specifically closer to wherever the stimulation is the strongest. Recovery for this surgery is around 2-3 weeks, and the InterStim battery can last around 10 years before needing to be replaced.
If the InterStim implant doesn’t prove successful after adjusting it many times, the doctor may decide to do a revision surgery by replacing it and moving it closer to the sacral nerves, or removing it all together and trying something else.
The PNE Procedure
The PNE procedure is done as a trial of the InterStim implant to evaluate if the patient responds to treatment at all, and if the trial period can decrease symptoms by at least 50 percent.
Unfortunately, if the patient sees less than a 50 percent decrease in OAB symptoms, they won’t be approved for surgery. After the surgery, a decrease of 50 percent is considered successful, even though most people would want their OAB symptoms to disappear entirely.
The PNE is a procedure most surgeons perform in their office under local anesthesia. It requires the patient to lie on their stomach while their surgeon and a nurse make a few small incisions in the patients’ tailbone area and insert a camera on a rod, and lead to place on the sacral nerves.
They then begin testing the nerves to see where you can feel the stimulation. Usually, physiological signs can be seen whereas the patients’ toes will begin to contract. This part of the procedure will help the surgeon decide where to leave the placement of the lead.
Once decided where the patient feels the stimulation the best, the lead is left inside on the sacral nerves, and the battery is either taped to the patient, or left in a pouch that they are asked to carry around for the duration of the trial, along with the handheld device that adjusts the stimulation.
The Trial Period for PNE Surgery
The trial period usually lasts around 5-10 days, but no longer than two weeks as the chance of infection increases with time. During the trial, the patient is asked to record their progress as well as increase or decrease the stimulation as necessary.
There is no right or wrong stimulation number, however, the patient is required to be able to feel the stimulation at all times, otherwise, the trial may be void. Given that the implant is on the outside attached to a small wire lead inside, there will be some migration of the lead.
That is taken into consideration, as the 50 percent decrease of symptoms is the goal the patient must see. The patient must record all bathroom visits and sometimes fluid intake on a voiding chart for the entire trial. These results will be compared to the voiding chart that the patient did before the PNE.
When the patient sees the doctor again in the office, they will gently remove the wire, and within seconds the patients’ life may go back to ‘normal.’ The stimulation may take some time to get used to, however once removed their symptoms can come back immediately. At this point, the doctor will usually decide if InterStim is right for you, and book your surgery day.
OAB is a complicated and difficult condition that a lot of people don’t understand what to do with, and how to treat. Fortunately, there are a huge variety of treatments that exist, and most of them are fairly accessible.
For those who have struggled with OAB for their whole lives and have tried everything, there is still hope. There are all kinds of new medications and procedures being researched and tested every year.
Not all OABs and treatments are alike, which is why there are so many options. We just need to stand strong and keep looking for the treatment that suits us best.