What is the Role of Anorectal Physiology Testing and Imaging in the Era of Sacral Neuromodulation? A Single-Center Experience and Literature Review

BackgroundWe aimed to investigate the association between preoperative anorectal physiology testing (APT) and outcomes of sacral neuromodulation (SNM) for fecal incontinence (FI).MethodsThis is a retrospective review of a prospective database of patients with FI who underwent SNM (2011-2020). Patients who underwent at least one preoperative APT were in the preoperative test group, those not tested served as controls. The Wexner/Cleveland Clinic Florida-Fecal Incontinence Score (Wexner/CCF-FIS) was calculated before implantation and at last follow-up. Preoperative workup included anal manometry (AM), electromyography (EMG), pudendal nerve terminal motor latency (PNTML), anal ultrasound (AUS), and defecography (DG). Primary outcome was treatment success, defined as at least 50% reduction from baseline on the Wexner/CCF-FIS at last follow-up.Results102 patients (mean age: 62.7 ± 13.9 years; 94 (92.2%) female) were included. Median preoperative Wexner/CCF-FIS was 18 (IQR: 15-20), which decreased to 10 (IQR: 4-15) at last follow-up. Anal manometry was performed in 55 (53.9%), AUS in 74 (72.5%), PNTML in 71 (69.6%), EMG in 76 (74.5%), and DG in 28 (27.5%). The overall success rate was 49%; median follow-up was 56 months (IQR: 23.25-79). Overall rates of 30-day complications, device explantation, and redo SNM were 19.6, 3.9, and 5.9%, respectively. 30-day complication rates were 25% in patients without any preoperative testing and 18.3% in those who received at least one preoperative test.ConclusionsRoutine preoperative APT was not associated with clearly better outcomes after SNM; however, the non-randomized nature of the study, selective test ordering, and limited sample size preclude definitive conclusions of absence of clinically relevant associations.