Sacral neuromodulation (SNM) is successfully used for multiple indications. However, in some instances a trial lead or complete device needs to be removed. Traditionally permanent lead and/or implantable pulse generator (IPG) removals are done in the operating room under sedation and local anesthesia. However, SNM removal is a short operative case and given its simplicity, monitored anesthesia may not be necessary. We have been removing SNM devices in the office for the past several years. Our objective in this video presentation is to present a single surgeon’s technique to remove all SNM components under pure local in the office.

From 2017-2021 30 SNM leads with and without IPGs were removed in the office using local anesthesia. After obtaining informed patient consent, we present a video showing our technique for SNM lead and IPG removal performed under local anesthesia in the office by a single surgeon.

We present a 71-year-old female with past medical history notable for Myasthenia Gravis, kidney and liver transplant and a BMI of 33.5 with refractory overactive bladder and urgency incontinence. She previously failed oxybutynin and appropriately decided to undergo third-line treatment options. Given her Myasthenia Gravis, she underwent peripheral nerve evaluation, which was successful, and then went onto full SNM implantation. After 4 months with her SNM device, the patient continued to have pain with stimulation despite reprogramming and therefore desired SNM removal. She consented for office removal with local anesthesia using a mixture of 0.25% Bupivacaine and 2% Lidocaine as per our protocol. To remove the tined lead, we use gentle traction and tactile feedback to pull the lead from the lateral incision. The medial site where the lead was initially placed can be identified with skin dimpling while placing gentle traction on the lead. The site is marked with a marking pen in case a medial incision is needed for lead removal. It should be noted that if we detect extensive stretching or tension on the lead, we make a medial incision over the lead placement site and remove it from there. However, we have been able to remove leads from the lateral incision up to 12 years after implantation. With gentle traction and circular motion, the lead can be brought through the lateral incision. Of our 30 patients, 13 (43%) required removal of their leads and IPGs, with mean time to removal of 4.2 (0.3-12.3) years. 46% (6/13) of these patients required a separate medial incision. After removal, the incision is irrigated with sterile water and then closed. A 2-0 Vicryl is used to close the deeper layer ensuring to incorporate the bottom of the capsule to eliminate any dead space. The skin is closed with a 4-0 Vicryl subcuticular closure and Steri-Strips. All office leads and IPGs have been removed completely intact, no additional pain medications have been required and there have been no complications.

Herein we demonstrate our technique for removing SNM leads and IPGs in the office using local anesthesia. It is effective, well-tolerated, and safe.