Sacral neuromodulation (SNM) has, since the 1990s, effectively improved outcomes in patients suffering from genitourinary disorders. SNM is currently indicated by the FDA for disorders such as urinary frequency and urgency, urinary urgency incontinence, non-obstructive urinary retention, and fecal incontinence. Off-label, SNM may improve pelvic pain, interstitial cystitis, dyspareunia, pelvic floor dysfunction, chronic constipation, sexual dysfunction, and persistent genital arousal. 
Neuromodulation is achieved by implanted electrical leads which stimulate sacral nerve roots. The first iterations of stimulator implants, developed in the 1990s, were not designed to be compatible with technology of today, namely MRI. Although current models of stimulator implants are MRI-compatible, a great number of patients still retain MRI-incompatible titanium leads which may heat up during magnetic imaging. For this reason, as well as lead migration, loss of efficacy, or adverse events, implanted leads may need to be removed.

Current medical literature offers few techniques to successfully remove outdated or ineffective leads. We present novel, effective methods of intact and broken lead removal in MRI and non-MRI compatible interstim devices.

Our first patient is a 53-year-old female who was referred for interstim replacement. Patient had several lead revisions at an outside hospital and had two leads in place, one in each S3 foramen.  In order to explant the intact lead, the lead was first freed from the implantable pulse generator (IPG). Next, a counter incision was made over the sacral insertion site. The lead was then translocated to the sacral incision and removed. In this video we present a novel technique of lead removal that decreases the risk of lead breakage. Using a hemostat, the inner wire is first grasped and pulled. This process results in a wireless “ghost lead”, which on its own is MRI-compatible. However, by pulling the inner wire, the distal lead contracts, creating an accordion effect on its tines. The tines are freed from the surrounding tissue, thus completely removing the intact lead. Our second patient is a 54-year-old female with a MRI-compatible device. Newer leads differ from older models in that they demonstrate firmer adherence to the wire. Even in this case, our same technique can be applied.  Newer leads don’t disengage as easily from the wire and oftentimes both components can be freed in one motion. 
Occasionally during lead removal, the lead can break. Often times the breakage occurs above the bone plate at which point the incision is extended and dissection is performed down to the level of the broken lead. The lead is then removed. Rarely, the lead breaks below the sacral bone plate, resulting in a more challenging removal.  In this video, we present a novel, minimally invasive technique of lead removal. First, an incision is made over the sacrum. The lead introducer is advanced into the foramen alongside the fractured lead and the inner trocar is removed. Next, a flexible grasper is advanced through the lead introducer down to the foramen. Under fluoroscopic guidance the lead introducer and grasper are manipulated down to the fractured lead which is then grasped and removed intact.

In conclusion, there is a pressing need for removal of outdated leads and replacement with MRI compatible ones. We present previously undescribed minimally invasive methods for easier lead removal and fractured lead removal, both above and below the sacral bone plate.

Continence 7S1 (2023) 101018
DOI: 10.1016/j.cont.2023.101018