A. van Ophoven’s research while affiliated with Ruhr University Bochum and other places

Neuromodulative procedures have become an inherent component in the therapy of functional urinary bladder and pelvic floor function disorders. Sacral neuromodulation has been used in Germany for more than 20 years and reresents the standard neuromodulative therapy. Technical improvements in the field of test stimulation and the phasing out of the large pulse generator models represent current changes with the resulting advantages and disadvantages. Pudendal neuromodulation (PNM) has been known for many years as a procedure for treatment of chronic diseases of the urinary bladder and the lesser pelvis and is predominantly used as second-line neuromodulative therapy; however, for pelvic pain syndromes and in particular for pudendal neuralgia, it represents a promising minimally invasive first-line therapy. Due to the technically demanding puncture procedure, PNM has so far only been used in Germany in specialized centers. Through the development of new operation techniques, the prerequisites for a wider multicentric use, with the future aim of approval of the procedure, have been achieved. External transdermal pudendal neuromodulation is a promising therapeutic approach and after further testing in randomized studies could find an application as a conservative step before minimally invasive pudendal neuromodulation. Although the technique of laparoscopic electrode placement on neural structures of the lesser pelvis is technically attractive, it predominantly finds a monocentric use and must in due course be critically compared with established minimally invasive procedures.

The guideline of the "Deutsche Gesellschaft für Urologie" recommends capillary blood gas analysis for neobladder patients every 3 months. In case of chronic metabolic acidosis (CMS), treatment with oral bicarbonate is recommended. However, it is unknown how these recommendations are implemented in daily practice. The aim of this study was to evaluate the current diagnosis, rating and therapy of CMA among neobladder patients by German urologists. A survey covering diagnosis, rating, and therapy of CMA was sent to 5,539 urologists in Germany in August 2013. All 350 (6.3%) completed surveys were analyzed. Nearly all respondents (98%) perform blood gas analysis (BGA) to diagnose CMA, usually following unspecific symptoms such as general discomfort and fatigue. In addition, about half of the urologists frequently check their neobladder patients for CMA, regardless of any symptoms. The incidence of CMA directly following neobladder construction was estimated to be 64%. Approximately 17% of all patients need permanent CMA treatment. Ninety nine percent of all respondents prefer to treat CMA with oral bicarbonate at a daily dose of 1000-3000 mg, mostly with enteric coated formulations. CMA is an important comorbidity after neobladder construction. Furthermore, the respondents of the survey expressed great interest in receiving medical education regarding the management of CMA in neobladder patients.

Die pudendale Neuralgie ist eine neuropathische Erkrankung die überwiegend durch ein pelvines Trauma mit Druck- oder Zugbelastung des N. pudendus verursacht wird. Zur Differentialdiagnostik dieser Erkrankung werden die Nantes-Kriterien verwendet. Therapeutisch werden neben druckentlastenden und analgetischen Maßnahmen laparoskopische und offene Dekompressionsverfahren angewandt. Wir berichten über eine Patientin, die durch Gewalteinwirkung im Becken- und Urogenitalbereich eine pudendale Neuralgie entwickelte. Aufgrund der Komplexität des Beschwerdebildes führten wir eine kombinierte sakrale und pudendale Neuromodulation (PNM) durch. Im direkten Vergleich der neuromodulativen Techniken zeigte sich die PNM bei der pudendalen Neuralgie, mit nahezu kompletter Schmerzfreiheit, überlegen. Die PNM könnte eine therapeutische Option zur Behandlung der pudendalen Neuralgie darstellen.

Pudendal neuralgia is a neuropathic disease which is predominantly caused by pelvic trauma with pressure or stretching strain of the pudendal nerve. The Nantes criteria are used for the differential diagnostics of this disease and therapy includes pressure-relieving and analgesic measures using laparoscopic or open decompression procedures. This article reports the case of a female patient who developed pudendal neuralgia following violent trauma to the pelvic and urogenital regions. Due to the complexity of the symptoms combined sacral and pudendal neuromodulation (PNM) was carried out. A direct comparison of neuromodulative techniques revealed that PNM was superior resulting in almost complete freedom from pain. The PNM procedure could represent a therapeutic option for treatment of pudendal neuralgia.

Treatment of IC is one of the most difficult therapeutic challenges in urology, frequently resulting in frustration for both patient and therapist. Many urologists believe that conservative treatment should not be unnecessarily prolonged in severe cases with low bladder capacity, since cystectomy may provide immediate and permanent relief for the suffering patient. However, it remains unclear which surgical approach and technique is the most suitable. Generally three different techniques are performed: supratrigonal cystectomy; radical cystectomy, saving only the bladder neck; and, finally, radical cystectomy combined with excision of the urethra. All three techniques require substitution of the excised bladder tissue with bowel segments.

Due to the increasing popularity of neuromodulation, the number of indications and patient groups to which this technique is offered is also increasing. We evaluated the currently available data concerning neuromodulation in geriatric patients, children and patients with spinal cord injury and potential alternatives regarding neural targets and implantation techniques. The evidence of the use of neuromodulation in these patient groups is low. In geriatric patients, the use of neuromodulation seems to be justified. The few existing results concerning neuromulation in children are positive; however, there are no data about long term effects of neuromodulation on the growing organism. In patients with spinal cord injury, neuromodulation by microsurgical nerve anastomosis does not seem to be successful. According to the preliminary data of a single study, neuromodulation in acute spinal cord injury may prevent development of a neurogenic bladder dysfunction. The laparoscopic implantation of electrodes for neuromodulation unfolds new technical opportunities; however, until today there is no proof of the efficacy of this technique. Pudendal neuromodulation appears to be a meaningful addition to the therapeutic armamentarium for selected indications. The existing studies demonstrate the future opportunities of neuromodulation also in geriatric patients, children and patientens with spinal cord injuries. However, especially in the latter two groups, further studies concerning effectiveness and long term consequences are mandatory prior to offering these techniques to patients in everyday practise.