In Sacral Neuromodulation (SNM) therapy approximately 20-30% of implanted patients need a surgical revision, while 15-18% of them undergo a definitive explantation. Whatever the reason for quadripolar lead removal, it is estimated that up to 7.5% of procedures are associated with a lead damage and consequently breakage. It is still unclear what the consequences of leaving fragments in the pelvis could be. Aim of our study is to describe the new technique we have been using for the last two years in our centre to remove the quadripolar lead, using the straight stylet disposable in the electrode kit.

We searched SNM database of our institution for all the patients that underwent a quadripolar lead removal from January 2018 to January 2020, using our standardized technique and after informed consent. The novelty of the technique consists in the use of the straight stylet, which typically comes pre-packaged with the quadripolar tined-lead. The stylet gives the electrode greater stiffness, reducing interactions with surrounding tissues, probability of damage of the lead and its breakage during removal.

59 patients (41 women and 18 men) underwent a quadripolar lead removal using our standardized technique from January 2018 to January 2020. 44 out of 59 patients removed a tined-lead within 3 months from SNM-test, due to the absence of significant benefits on symptoms (negative first stage SNM). In 15 patients the electrode was removed due to failure of definitive implant. Mean time from definitive IPG implant to lead removal was 67.9 months (5.6 years). In 10 out of this cohort of patients, the lead was replaced, while it was permanently removed in 5 cases. Reasons for lead removal were a loss of efficacy of SNM with no evidence of electrode displacement or malfunctioning (6 cases); a sub-optimal electrode position at X-ray or CT-scan (5 cases); pain (1 case); need for magnetic resonance for other clinical reasons (1 case); device malfunctioning (1 case); substitution of IPG 3023 model with an IPG 3058 model (1 case). We recorded only 1 case of lead-breakage during lead-removal in the whole population: a female patient with a quadripolar lead placed 18 years before, with an open technique and a surgical fixation on periosteum of sacral bone (non-tined electrode). Lead removal by gentle traction was not possible, and it was decided not to proceed with a deeper surgical extraction.

Quadripolar lead breakage during removal procedure is not uncommon. A few data about possible adverse effects of leaving fragments in the pelvis are available. Our technique has been safely used for the last 2 years in our centre, with no episodes of lead breakage or retained fragments, except for one non-tined electrode.