Long-term Sacral Neuromodulation Reprogramming Rates: Identifying Office Burden

Objectives: Sacral neuromodulation (SNM) is a common procedure for refractory urinary urgency (UI), retention and fecal incontinence (FI). Stimulation reprogramming options, including self-management or office-based provider guidance, make modification after implantation relatively accessible; however, the rate and associated patient and provider burden of office-based reprogramming is poorly reported in current literature. Therefore, the objective of this study was to investigate the rates of office-based SNM programming in a large multisite cohort and to further examine differences based on implantation indication.

Methods: The Trinetx database, combining 5 countries and 89 health systems, was utilized for comparison using ICD10 and CPT codes from deidentified electronic medical record. Cohort selection included adult (>18 years), females with history of SNM generator placement without documented removal. Selected patients had diagnosis of urinary retention, UI and/or FI at time of implantation. Analysis included demographics, rates, incidence, and survival curves for patients with SNM reprogramming identified with CPT codes. A time period of 6 weeks to 5 years after SNM implant was selected to represent time following perioperative period and prior to battery failure. Further comparisons were completed between implantation diagnoses of grouped urinary (urgency and retention) verse fecal indications. Urinary indications (urgency and retention) were grouped given many patients had multiple urinary diagnoses; however, any patient with diagnosis of FI was analyzed in the fecal group regardless of urinary diagnoses.

Results: A total of 9,501 patients meet inclusion criteria out of the 65 million adult female patients in cohort. The mean age at implantation was 62.1±14.9 years (range 18-90). The cohort demographics were similar between groups, Table 1. Office-based SNM reprogramming was identified in 31.5%. The probability of never having reprogramming at five years was 52.5%. The mean number of reprogramming sessions was 2.5±2.1. Most of the cohort (44%) had only one reprogramming session outside of the perioperative period, and < 10% required greater than four visits, Figure 1A. About half (48%) of the patients with FI also had a diagnosis of UI and about 25% had urinary retention. The group with FI was older at the time of implantation with higher rates of reprogramming (risk ratio of 0.81 [0.77, 0.86]) compared to UI/retention group, Table 1. The probability of never having reprogramming was, 55%, higher in patients with a fecal incontinence indication than those with only urinary indications at 50%, p< 0.001, Figure 1B.

Conclusions: Office-based SNM reprogramming occurs in about one third of implanted patients, thus representing high patient or provider burden given rates are likely underreported. This data is limited by lack of inclusion of patient self-management, customer service reprogramming, and non-billed encounters. Patients with any FI diagnosis have a lower risk of requiring reprogramming. Further study could identify risk factors in patients requiring higher reprogramming rates.