A case of lead migration after sacral neuromodulation with erosion into the rectum

Abstract

We present a case of a 73-year-old female with medication refractory overactive bladder treated with the InterStim® sacral neuromodulation device. Five months post implantation she developed drainage over the lead site and rectal bleeding. Evaluation identified lead migration with rectal perforation requiring surgical removal of the battery and lead. Post removal, the patient returned to baseline urinary symptoms with the development of de novo fecal incontinence. This is the third reported case of sacral neuromodulation lead migration causing rectal perforation in the literature, and the only case managed with endoscopic closure of the rectal defect.

Highlights

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Lead migration is a rare complication of sacral neuromodulation.
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This case involves sacral neuromodulation with lead migration and rectal perforation.
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The patient presented with abdominal pain and hematochezia five months post-op.
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Rectal perforation was corrected with endoscopic closure.

1 Introduction

Sacral neuromodulation (SNM) can reduce overactive bladder (OAB) symptoms in patients who are refractory to pharmacotherapy. A randomized trial studying SNM with Medtronic’s InterStim® sacral neuromodulation device revealed that at 5 years post implantation, 68 % of patients with urge incontinence, 56 % of patients with urinary urgency and 71 % with retention had 50 % or greater improvement of symptoms. A review from 1998 to March of 2020 revealed similar results, with a 66.2 % pooled success rate of SNM. In this analysis, adverse events were found in less than 25 % of cases, with loss of effectiveness in 4.7 %, infection in 3.6 %, pain at implant site and lead migration in 3.2 % in each case. A multicenter prospective cohort trial listed the most frequent adverse events as pain at the implant site in 28 %, paresthesia in 15 %, and infection in 10 % at an average of 36 months post-implant. Another review revealed that 33 % of implants require reoperation with lead migration being the cause in 16 %. Here, we describe a case of SNM complicated by lead migration and rectal perforation that presented as drainage over the lead site, abdominal pain, and hematochezia five months post implantation with a subsequent discussion of the proposed etiology and management.

2 Case presentation

The patient is a 71-year-old female with a history of medication refractory urinary urgency and frequency. She initially presented to urology with complaints of worsening urinary frequency and incomplete voiding. Prior to this, urinary symptoms were well controlled with extended release tolterodine 4mg, once daily. She failed to respond and had intolerable side effects (including constipation) with higher-dose tolterodine (8mg daily), so work-up for medication-refractory OAB was initiated. A urodynamic study demonstrated detrusor overactivity and increased sensation with incontinence, and a cystoscopy identified no anatomic causes of urinary urgency. Based on this, the patient was offered third line OAB treatments, and she elected to undergo SNM with the InterStim® device.

The patient subsequently had a two-stage InterStim® implant performed. Her urinary urgency and frequency symptoms improved significantly after the stage 1 procedure and the patient elected to go forward with the stage 2 implantation. During the initial procedure, a single lead was placed through the right S3 foramen, and the position confirmed with fluoroscopy ( Fig. 1 ) as well as S3 neural responses on the right. The patient was compliant with follow-up and wound check visits. At three months post-implant, the patient returned and reported scant, intermittent drainage with some fullness over the lead implantation site. There was no erythema, tenderness, or visible erosion at the site, and the patient reported no systemic symptoms of infection. The drainage was suspected to be from a resolving superficial infection and was treated with a course of oral antibiotics.

Two months later (now five months post-implant), the patient presented to her gastroenterologist with complaints of new hematochezia and abdominal pain. She also had some recurrent drainage over the lead site which did not respond to a second course of antibiotics. The patient was evaluated with a flexible sigmoidoscopy where a foreign body was found in the recto-sigmoid colon. The intra-procedure photographs demonstrated lead erosion into the rectum ( Fig. 2 ).