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.

ObjectivesTo report the findings and management of patients with persistent Müllerian duct syndrome (PMDS).Patients and methodsNineteen phenotypically male patients (aged 8 months to 27 years) presented with testicular maldescent. All of them had normal male external genitalia. Two of them had had a previous diagnosis of persistent Müllerian structures. All patients were karyotyped, and had a hormonal profile, diagnostic laparoscopy, retrograde urethrocystogram, gonadal biopsies, and surgical management according to the findings. The follow-up was based on a clinical examination, abdominal ultrasonography (US) and scrotal colour-Doppler US at 3 and 6 months after surgery, and every 6 months thereafter.ResultsDiagnostic laparoscopy showed the presence of persistent Müllerian structures in all 19 patients. All patients had a normal male karyotype (46XY). Ten patients had a laparoscopic excision of their Müllerian structures while the remaining nine patients had their Müllerian structures left in place. No malignant changes were found in the excised Müllerian tissues. Of the 37 gonadal biopsies taken, 31 (84%) indicated normal testes.ConclusionsThe incidence and prevalence of PMDS are not well estimated. Müllerian structures should be removed whenever possible to avoid the risk of malignant transformation. The early diagnosis of PMDS makes possible the excision of Müllerian structures and a primary orchidopexy. A long-term follow-up is needed for patients with intact Müllerian structures and magnetic resonance imaging might be a better method than US for that purpose. Most of the patients had normal testicular histology, which might allow fertility.

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What's known on the subject? and What does the study add? Sacral neuromodulation (SNM) is an effective treatment option of different pelvic‐related dysfunctions. SNM evaluation by either temporary or permanent electrodes is generally accepted. Extended testing with temporary electrodes has been reported on before but less is known about infection‐related risks during prolonged evaluation with definitive electrodes. The present findings show that prolonged testing (mean = 52.3 days) with permanent electrodes does not increase infection‐associated explantation rates, although bacterial colonization was found in more than one‐third of the patients. Prolonged SNM evaluation under everyday conditions might improve long‐term success. Objective To evaluate the impact of prolonged stage 1 testing on bacterial electrode colonization, infection and treatment success. Materials and Methods In all, 21 patients who underwent sacral neuromodulation (SNM) for periods ≥1 month were prospectively evaluated; nine patients had overactive bladder syndrome (OAB), 10 had urinary retention, two had faecal incontinence (FI), and 13 had diabetes and overweight/obesity. After stage 1 testing electrode extension leads were microbiologically analysed to assess bacterial colonization. The primary measurements were pre‐ and post‐SNM treatment comparisons based on patient‐agreed criteria using an increased 70% minimum improvement rate; secondary measurements were bacterial colonization and impact of infection. Results The mean stage 1 evaluation period was 52.3 days; 16 patients (76%) progressed to stage 2, and five patients were explanted due to inadequate improvement (<70%). There was bacterial colonization in 42.9% of patients and 38.2% of extension leads. Stage 2 patients showed no infection or wound‐healing disorders at a mean follow‐up of 33.9 months. The success rate for stage 2 implantation treatment was 94%. Conclusions There are few studies in the literature evaluating SNM testing periods vs the risk of clinically relevant implant infection rates. The present study shows that prolonged testing could potentially enhance treatment efficacy without infection‐related explantations of the chronic implant, despite the identification of bacteria. SNM‐implanted patients with diabetes mellitus or obesity should be followed closely. Clinicians might consider using prolonged testing under everyday conditions. Prolonged SNM stage 1 testing is a very effective minimally invasive treatment option to evaluate pelvic‐related dysfunction.

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Objectives: To present our center's experience in the management of adrenal myelolipoma in the context of shifting from the open to the laparoscopic adrenalectomy approach. Materials and Methods: A retrospective search of our center's records was done for reported cases of adrenal myelolipoma during the period July 2001-June 2016. All the cases with histopathologically-documented adrenal myelolipoma diagnosis were included. Relevant demographic and clinical variables were studied with a comparison between the open and laparoscopic approaches. Results: Of more than 82,000 urological surgeries, 238 adrenalectomies were done with only 22 cases of myelolipoma that had a mean age and body mass index of 52.4 ± 10.3 years and 30.23 kg/m2, respectively. The main clinical presentation was accidental discovery. The largest dimension of tumors varied from 6 to 16 cm. Computed tomography described a characteristic picture of hypodense heterogeneous adrenal tumors in all cases, while magnetic resonance imaging was indicated for malignancy suspicion in only 5 cases. Adrenal tumor markers were normal in all cases. Open and transperitoneal laparoscopic adrenalectomies were used in 14 and 8 cases, respectively. The latter approach was insignificantly advantageous in the need for blood transfusion, postoperative pain degree, need for analgesia, and hospital stay duration (p = 0.22). Histo-pathological examination revealed benign adipose tissue and myeloid cells and confirmed the diagnosis of adrenal myelolipoma in all cases. Conclusions: Adrenal myelolipoma is a rare non-functioning benign tumor. Laparoscopic excision seems to be a promising alternative approach to the traditional open adrenalectomy, even in the context of large tumors and obesity.