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What Is A Sacral Anterior Root Stimulator?
This is an electronic implant that allows you to control your bladder and possibly your bowels. In men, it may also help erections. It involves an operation at the middle of the spine to divide the sensory nerves that supply the bladder, (S2, S3 & S4). Although this deprives the bladder of any sensation which would have caused over-activity, it also improves bladder volume and elasticity and virtually eliminates the risk in the vast majority of patients of the serious consequences of autonomic dysreflexia completely.
The implant consists of surgically implanted internal components, and an external control box. Internally the pacemaker-type receiver-stimulator is surgically implanted under the skin of the abdomen.
How Does The Implant Work?
The implant sends electrical signals through electrodes to the nerves that lead to the bladder and bowel. The user controls the implant with the external control box. This is about the size of a personal stereo/CD player.
You will need to stimulate the implant at regular intervals through the day to empty your bladder. This requires a certain amount of hand control and if you have a high spinal cord lesion you may require assistance with this. When the implant is stimulated (using the control box) it is important that there is a receptacle for your urine to drain into. This may be achieved by transferring onto a toilet or men may choose to wear a condom.
Why Do I Need A Sacral Anterior Root Stimulator?
You may be experiencing uncontrolled/troublesome bladder activity which might be causing you to be dysreflexic or might be causing you to have repeated urinary tract infections, reflux of urine to the kidneys, or some degree of kidney damage as a result of the bladder over activity. A sacral anterior root stimulator might allow you to become independent of catheters and condoms, and can reduce the number of urinary tract infections and the risk of kidney damage.
The stimulator gives you the advantage of controlling your bladder evacuation when you want to empty it. It also gives a good chance of improving your bowel management, by shortening the time period of bowel care to less than half an hour in most instances. Although it does not actually empty the bowel by stimulation, it does make manual evacuation an easier procedure, by bringing the stool lower into the rectum. There is a 50-60% chance that you will have a full erection (for as long as you want it) when you use the stimulator on a specific programme for erection.
Am I Suitable For This Operation?
There are 4 main criteria for this implant:
- You need to be skeletally mature. That is you need to have finished growing (over 18 years old).
- You will need to have a complete spinal cord lesion. Those with incomplete lesions may experience pain when they stimulate the implant.
- You need to be neurologically stable. This usually means that this surgery would not be considered soon after your spinal cord lesion, and not before at least one or two years post-injury.
- You need to have reflex bladder contractions. This will be assessed during video-urodynamic studies of your bladder.
In addition the following information needs to be considered:
- In the female it will mean transferring to the toilet 4-5 times a day to empty the bladder. It is therefore important to consider lifestyle implications.
- Men who have reflex erections will lose this.
- You will be advised against self-transferring and any other manual lifting for 6 weeks after the surgery. Instead you will be assessed using a hoist or other transfer methods after the surgery.
- You may not be completely dry between the times that you stimulate the implant. Therefore you may need to wear a condom or a pad.
What Will Happen Before The Operation?
You will need to have Video-urodynamics to assess your suitability for the implant. You will not need to be admitted to hospital for this as it can be carried out as an outpatient procedure. After your bladder has been assessed and if you are considered suitable for the implant you will be placed on a waiting list.
When the time comes you will be admitted to hospital the day before the operation. Routine blood samples will be taken. The doctor will explain the operation to you again, and will ask you to sign an Operation Consent Form.
On the day before the operation, you will be asked to eat nothing further after midnight. You may drink clear fluids up until 4 hours before the operation, after which you will be asked not to drink at all. It will be necessary for you to wear an identity band (with your personal details on it) on your wrist / ankle.
The Operation
You will have a general anaesthetic. The operation takes 6-8 hours and involves the placement of electrodes on the 2nd, 3rd, and 4th sacral nerve roots through an incision at the base of the spine. To stop reflex bladder activity it is necessary to cut the sensory nerves from the bladder (this is often done through a second incision). The receiver is placed, under the skin, in the upper left side of the abdomen and the wires are tunnelled round the chest wall to meet the electrodes at the base of the spine.
The 2nd, 3rd, and 4th sensory nerves supply sensation to the bladder and the anal canal. Even though you may not have experienced any bladder or bowel sensation before the operation, the nerves are still alive. Cutting these nerves interrupts the reflex action of the bladder and bowel, and substantially reduces if not completely eliminates the risk of autonomic dysreflexia (of bladder and bowel origin) in the future. It will also allow the bladder muscle to relax completely and only respond to contraction when the implant is stimulated.
The operation involves separate incisions: one in the back between T12 and L2, one between the buttocks, one on your side, and one in the upper part of the abdomen. You may need a blood transfusion.
What Will Happen After The Operation?
You will need to remain on bed rest for a few days (approximately 5) to allow you to recover from the operation. You will have an indwelling catheter in place to drain your bladder and an infusion (‘drip’) in your arm. On the 4th or 5th day after the operation, the catheter will be removed. Your bladder will be filled with fluid and the implant will be stimulated. The first attempt might not succeed. Sometimes the nerves, due to being handled, can take severalmonths to recover. If this occurs your bladder will be managed with an indwelling catheter or by self-intermittent catheters during this time.
It is important that the operation site is not strained in any way, so you will be advised against self-transferring and any other manual lifting for 6 weeks after the surgery. You will be assessed using a hoist or other transfer equipment. Your Community Occupational Therapist and/or District Nurse will be requested to supply any equipment that you will require at home. You may require help with your bowel care. This will be assessed and, if necessary, a District Nurse will be arranged to visit you at home. You are likely to be discharged from hospital approximately one week after the surgery. You will be advised to stay off work for at least six weeks and to avoid contact sports and excessive trunk movement.
Stimulation may cause spasm of your legs. This is quite normal and should not cause concern.
Problems Which May Occur With The Implant
There may be temporary damage to the nerves so that the stimulator may not be useable for several months. Bladder capacity may take several weeks to increase. The implant can get infected and underlying wires may break and require further surgery to re-position or replace these.
Long Term Follow-up
You will need to attend regular appointments at the Spinal Centre for as long as you are a patient here. The Spinal Centre will help you with any technical problems you may have. It may be necessary to repeat Video-urodynamics at regular intervals to check the implant is working efficiently.
Some Of Your Questions Answered
- Will the implant enable me to have erections?
Nearly 60% of the time the implant causes erection for as long as you activate the system. The operation will make you lose reflex erections and reflex ejaculation. However, medication or injection will address this. - Will I be able to do without continence appliances?
The majority of people who have this surgery do not need to wear continence appliances. However, if you are not completely dry between the times that you stimulate you may need to wear a condom or a pad. - Will it be painful when I stimulate the implant?
The operation is only considered for people with a complete spinal cord injury, so you should not experience any pain when using the implant. Some patients may experience increased spasm when they stimulate the implant. - When I stimulate my bladder will my bowels also be stimulated?
No. The control box allows you to select different programmes. The programme for your bladder is separate from the programme for your bowels. - Will I still get autonomic dysreflexia?
You may still experience this caused by sources other than the bladder or bowel. It is very likely that the procedure would have greatly reduced this or completely abolished it. - Can the operation be reversed?
It is not possible to reverse this operation because nerves have been cut. The implant can be taken out if necessary. - How often does the implant have to be replaced?
The implant needs to be replaced approximately every seven years.
Useful Telephone Numbers
Spinal Outpatient Nurses: 01722 429291 or 01722 429130
We hope this leaflet will have answered some of your questions. If you need more information please do not hesitate to contact the above people.
