UNASSIGNED: In males, prostate cancer is the second most diagnosed cancer worldwide and the sixth leading cause of cancer death. Radiation therapy is a common treatment modality for prostate cancer but carries a multitude of adverse effects, ranging from radiation cystitis to post-radiation neuropathy. Proton beam therapy has gained attention as a valuable alternative, due to its improved precision with targeted dose delivery and reduced toxicity. However, the risk for radiation-induced complications, such as radiation-induced lumbar radiculopathy, is not fully understood and requires further investigation.
UNASSIGNED: We present a 68-year-old man with delayed-onset lumbosacral polyradiculitis following proton precision beam therapy for localized prostate cancer. The patient underwent proton therapy treatment for the prostate and seminal vesicles with favorable results and tumor remission. However, five months after completing radiation therapy, the patient presented with chronic lower extremity pain, weakness, and bilateral lower extremity paresthesias. MRI showed diffuse hyperintensity of bilateral L5-S3 nerve roots and an intramuscular edema-like signal involving the bilateral obturator externus and internus muscles, likely due to radiation. Additionally, EMG findings suggested the presence of chronic bilateral L5 radiculopathy.
UNASSIGNED: The clinical manifestation of delayed-onset radiation-induced lumbosacral plexopathy is a rare and uncommon complication of external beam radiation therapy that presents as radicular or myelopathic symptoms based on the location and severity of the inflammation. This case highlights the need for continued follow-up post-radiation and emphasizes the need for a comprehensive review of the oncological history of cancer patients.

BACKGROUND: Intravenous Ferumoxtran-10 belongs to ultra-small superparamagnetic iron oxide particles and can be used for magnetic resonance neurography (MRN) as an alternative to other imaging methods which use contrast agents.
OBJECTIVE: To examine the impact of intravenous Ferumoxtran-10 on vascular suppression and compare image quality to gadolinium (Gd)-enhanced image acquisition in MRN of lumbosacral plexus (LS).
METHODS: Prospective.
METHODS: 17 patients with Ferumoxtran-10-enhanced MRN, and 20 patients with Gd-enhanced MRN.
UNASSIGNED: 3T/3D STIR sequence.
RESULTS: Image quality, nerve visibility and vascular suppression were evaluated by 3 readers using a 5-point Likert scale.
METHODS: Inter-reader agreement (IRA) was calculated using intraclass coefficients (ICC). Quantitative analysis of image quality was performed by signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) measurements and compared using Student\'s t-testing.
RESULTS: Image quality, nerve visibility and vascular suppression were significantly higher for Ferumoxtran-10-enhanced MRN compared to Gd-enhanced MRN sequences (p < 0.05). IRA for image quality of nerves was good in Gd-enhanced and Ferumoxtran-10 MRN with ICC values of 0.76 and 0.89, respectively. IRA for nerve visibility was good in Gd- and Ferumoxtran-10 enhanced MR neurography (ICC 0.72 and 0.90). Mean SNR was significantly higher in Ferumoxtran-10-enhanced MRN for all analyzed structures, while mean CNR was for significantly better for S1 ganglion and femoral nerve in Ferumoxtran-10-enhanced MRN (p < 0.05).
CONCLUSIONS: Ferumoxtran-10-enhanced MRN of the LS plexus showed significantly higher image quality and nerve visibility with better vascular suppression as compared to Gd-enhanced MRN.
METHODS: 2 TECHNICAL EFFICACY: Stage 3.

BACKGROUND: Despite the growing body of literature on sacral neuromodulation (SNM) outcomes, research focusing on male patients remains limited and often represented by small cohorts nested within a larger study of mostly women. Herein, we evaluated the outcomes of SNM in a male-only cohort with overactive bladder (OAB), fecal incontinence (FI), chronic bladder pain, and neurogenic lower urinary tract dysfunction (NLUTD).
METHODS: This retrospective cohort study included 64 male patients who underwent SNM insertion between 2013 and 2021 at a high-volume tertiary center. Indications for SNM therapy included OAB, FI, chronic pelvic pain, and NLUTD. Descriptive statistics, Fisher\'s and t-test were used in analysis.
RESULTS: The mean age was 57.7 ± 13.4 years, and the most frequent reason for SNM insertion was idiopathic OAB (72%), FI (16%), pelvic pain (11%), and NLUTD (11%). A majority (84%) of men received treatment prior to SNM insertion. 84% reported satisfaction and 92% symptom improvement within the first year, and these improvements persisted beyond 1 year in 73% of patients. Mean follow up was 52.7 ± 21.0 months. The complication rate was 23%, and the need for adjunct treatments was significantly reduced (73% to 27%, p < 0.001). Treatment outcomes did not differ significantly between various indications for SNM therapy or the presence of benign prostatic hyperplasia (BPH).
CONCLUSIONS: SNM is an effective and safe procedure for male patients with neurogenic and non-neurogenic OAB, pelvic pain, and FI. Over 70% of patients experienced symptomatic improvement and remained satisfied in the mid to long term follow up. BPH does not seem to hinder treatment outcomes.

BACKGROUND: Together with an increased interest in minimally invasive lateral transpsoas approach to the lumbar spine goes a demand for detailed anatomical descriptions of the lumbar plexus. Although definitions of safe zones and essential descriptions of topographical anatomy have been presented in several studies, the existing literature expects standard appearance of the neural structures. Therefore, the aim of this study was to investigate the variability of the extrapsoas portion of the lumbar plexus in regard to the lateral transpsoas approach.
METHODS: A total of 260 lumbar regions from embalmed cadavers were utilized in this study. The specimens were dissected as per protocol and all nerves from the lumbar plexus were morphologically evaluated.
RESULTS: The most common variation of the iliohypogastric and ilioinguinal nerves was fusion of these two nerves (9.6%). Nearly in the half of the cases (48.1%) the genitofemoral nerve left the psoas major muscle already divided into the femoral and genital branches. The lateral femoral cutaneous nerve was the least variable one as it resembled its normal morphology in 95.0% of cases. Regarding the variant origins of the femoral nerve, there was a low formation outside the psoas major muscle in 3.8% of cases. The obturator nerve was not variable at its emergence point but frequently branched (40.4%) before entering the obturator canal. In addition to the proper femoral and obturator nerves, accessory nerves were present in 12.3% and 9.2% of cases, respectively.
CONCLUSIONS: Nerves of the lumbar plexus frequently show atypical anatomy outside the psoas major muscle. The presented study provides a compendious information source of the possibly encountered neural variations during retroperitoneal access to different segments of the lumbar spine.

BACKGROUND: Our objective was to evaluate long-term outcomes of sacral nerve stimulation (SNS) for children with functional and organic defecation disorders.
METHODS: We performed a prospective study of children <21 years of age who started SNS treatment between 2012 and 2018. We recorded demographics, medical history, and diagnostic testing. We obtained measures of symptom severity and quality of life at baseline and follow up at 1, 6, 12, 24, 36, 48, and ≥60 months. Successful response was defined as bowel movements >2 times/week and fecal incontinence (FI) <1 time/week. Families were contacted to administer the Glasgow Children\'s Benefit Inventory and to evaluate patient satisfaction.
RESULTS: We included 65 patients (59% female, median age at SNS 14 years, range 9-21) with median follow-up of 32 months. Thirty patients had functional constipation (FC), 15 had non-retentive FI (NRFI), and 16 had an anorectal malformation (ARM). The percentage with FI <1 time/week improved from 30% at baseline to 64% at 1 year (p < 0.001) and 77% at most recent follow-up (p < 0.001). Patients with FC, NRFI, and ARM had sustained improvement in FI (p = 0.02, p < 0.001, p = 0.02). Patients also reported fewer hard stools (p = 0.001). Bowel movement frequency did not improve after SNS. At most recent follow-up, 77% of patients with a functional disorder and 50% with an organic disorder had responded (p = 0.03). Nearly all families reported benefit.
CONCLUSIONS: SNS led to sustained improvement in FI regardless of underlying etiology, but children with functional disorders were more likely to respond than those with organic disorders.

OBJECTIVE: Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM.
METHODS: This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses.
RESULTS: A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy.
CONCLUSIONS: Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.

Sacral neuromodulation (SNM) is a safe, efficacious, and minimally invasive advanced therapy that involves electrical stimulation to sacral nerve root to modulate neural pathway. Indications for SNM include symptoms of overactive bladder (OAB), urinary incontinence, urinary retention, urgency and frequency and, regarding bowel dysfunction, fecal incontinence . In Europe and Canada, indication is also established for chronic constipation. The mechanism of action is still not fully elucidated and complete understanding is yet to be determined. It is proposed that SNM modulates neural circuits in both central and peripheral pathways, thus having an impact on the brain, as well as on the bladder-targeting neuronal activity. Another possible significant effect on irregular bladder activity is through inhibition of the bladder afferent pathways by stimulation of the pudendal nerve. Over the past two decades, with more than 300 000 treated patients, SNM has confirmed its efficacy to relieve refractory OAB symptoms, as well as urinary retention or fecal incontinence. First SNM applications in Croatia were uneventful and we are glad to offer our patients this novel therapy in the future.

BACKGROUND: Continuous peripheral nerve blocks are widely used for anesthesia and postoperative analgesia in lower limb surgeries. The authors aimed to develop a novel continuous sacral plexus block procedure for analgesia during total knee arthroplasty.
METHODS: The study comprised two stages. In Stage I, the authors built upon previous theories and technological innovations to develop a novel continuous sacral plexus block method, ultrasound-guided continuous parasacral ischial plane block (UGCPIPB) and subsequently conducted a proof-of-concept study to assess its effectiveness and feasibility. Stage II involved a historical control study to compare clinical outcomes between patients undergoing this new procedure and those receiving the conventional procedure.
RESULTS: The study observed a 90% success rate in catheter placement. On postoperative day (POD) 1, POD2, and POD3, the median visual analog scale (VAS) scores were 3 (range, 1.5-3.5), 2.5 (1.6-3.2), and 2.7 (1.3-3.4), respectively. Furthermore, 96.3% of the catheters remained in place until POD3, as confirmed by ultrasound. The study revealed a significant increase in skin temperature and peak systolic velocity of the anterior tibial artery on the blocked side compared with those on the non-blocked side. Complications included catheter clogging in one patient and leakage at the insertion site in two patients. In Stage II, the novel technique was found to be more successful than conventional techniques, with a lower catheter displacement rate than the conventional procedure for continuous sciatic nerve block.
CONCLUSIONS: UGCPIPB proved to be an effective procedure and safe for analgesia in total knee arthroplasty.
UNASSIGNED: ChiCTR2300068902.

BACKGROUND: Sacral neuromodulation is an effective treatment for fecal incontinence in the long term. Efficacy is typically assessed using bowel diary, symptom severity, and quality-of-life questionnaires, and \"success\" is defined as more than 50% improvement in these measures. However, patient satisfaction may be a more meaningful and individualized measure of treatment efficacy.
OBJECTIVE: To assess patient-reported satisfaction with long-term sacral neuromodulation and compare it to the frequently applied efficacy measures.
METHODS: An observational study of a prospectively maintained database.
METHODS: A single tertiary pelvic floor referral unit.
METHODS: Data from 70 patients (68 women, median age 69 [60-74] years) were available. The median time since implantation was 11 (9-14) years. Nineteen patients reported inactive neuromodulation devices.
METHODS: Bowel diaries, the Manchester Health Questionnaire, and the St. Mark\'s Incontinence Score were recorded at baseline, after percutaneous nerve evaluation, and at the last follow-up. Patient-reported satisfaction, using a 0% to 100% visual analog scale, with treatment since implantation (overall) and in the 2 weeks preceding completion of the last outcome measures (current) were also assessed.
RESULTS: Satisfaction was significantly higher in those with active sacral neuromodulation devices (75% vs 20%, p < 0.001) at follow-up. No significant relationships exist between symptom improvement using conventional measures and patient-reported satisfaction. Current satisfaction was not associated with changes in bowel diary data after percutaneous nerve evaluation. Despite improvements in the St. Mark\'s Incontinence Score and Manchester Health Questionnaire below the 50% improvement threshold used to define \"success,\" patients reported high (80%) satisfaction.
CONCLUSIONS: Retrospective design with gaps in the available data.
CONCLUSIONS: High patient satisfaction with sacral neuromodulation can be achieved; however, the response to percutaneous nerve evaluation may not predict treatment satisfaction in the long term. The change in questionnaire results, which measure the use of compensatory behaviors and quality-of-life impact, may better correspond to treatment satisfaction.
UNASSIGNED: ANTECEDENTES:La neuromodulación sacra es un tratamiento eficaz para la incontinencia fecal a largo plazo. La eficacia suele evaluarse mediante cuestionarios sobre la frecuencia diaria intestinal, la gravedad de los síntomas o la calidad de vida, y el \"éxito\" se define como una mejoría >50% en estas medidas. Sin embargo, la satisfacción del paciente puede ser una medida más significativa e individualizada de la eficacia del tratamiento.OBJETIVO:Evaluar la satisfacción a largo plazo de los pacientes con la neuromodulación sacra y compararla con las medidas de eficacia aplicadas con frecuencia.DISEÑO:Estudio observacional de una base de datos mantenida prospectivamente.LUGAR:Unidad terciaria única de referencia de suelo pélvico.PACIENTES:Se dispuso de datos de 70 pacientes (68 mujeres, mediana de edad 69 [60-74]). La mediana de tiempo transcurrido desde la implantación fue de 11 (9-14) años. Diecinueve pacientes informaron de dispositivos de neuromodulación inactivos.PRINCIPALES MEDIDAS DE VALORACIÓN:Diarios intestinales, el Cuestionario de Salud de Manchester y la Puntuación de Incontinencia de St Marks registrados al inicio, tras la evaluación percutánea del nervio y en el último seguimiento. Los pacientes informaron de su satisfacción, utilizando una escala analógica visual de 0%-100%, con el tratamiento desde la implantación (global) y en las dos semanas anteriores a la realización de las últimas medidas de resultado (actual).RESULTADOS:La satisfacción fue significativamente mayor en los pacientes con dispositivos de neuromodulación sacra activos (75% frente a 20%, p < 0,001) durante el seguimiento. No existen relaciones significativas entre la mejoría de los síntomas mediante medidas convencionales y la satisfacción comunicada por el paciente. La satisfacción actual no se asoció con los cambios en los datos de la frecuencia diaria intestinal tras la evaluación percutánea de los nervios. A pesar de que las mejoras en la puntuación de incontinencia de St Mark y el Cuestionario de Salud de Manchester se situaron por debajo del umbral de mejora del 50% utilizado para definir el \"éxito\", los pacientes declararon un alto grado de satisfacción (80%).LIMITACIONES:Retrospectivo con lagunas en los datos disponibles.CONCLUSIONES:Puede lograrse una alta satisfacción de los pacientes con la neuromodulación sacra; sin embargo, la respuesta a la evaluación percutánea del nervio puede no predecir la satisfacción con el tratamiento a largo plazo. El cambio en los resultados del cuestionario, que mide el uso de conductas compensatorias y el impacto en la calidad de vida, puede corresponder mejor a la satisfacción con el tratamiento. (Traducción-Dr. Ingrid Melo ).

Diffusion tensor imaging (DTI) is commonly used to establish three-dimensional mapping of white-matter bundles in the supraspinal central nervous system. DTI has also been the subject of many studies on cranial and peripheral nerves. This non-invasive imaging technique enables virtual dissection of nerves in vivo and provides specific measurements of microstructural integrity. Adverse effects on the lumbosacral plexus may be traumatic, compressive, tumoral, or malformative and thus require dedicated treatment. DTI could lead to new perspectives in pudendal neuralgia diagnosis and management. We performed a systematic review of all articles or posters reporting results and protocols for lumbosacral plexus mapping using the DTI technique between January 2011 and December 2023. Twenty-nine articles published were included. Ten studies with a total of 351 participants were able to track the lumbosacral plexus in a physiological context and 19 studies with a total of 402 subjects tracked lumbosacral plexus in a pathological context. Tractography was performed on a 1.5T or 3T MRI system. DTI applied to the lumbosacral plexus and pudendal nerve is feasible but no microstructural normative value has been proposed for the pudendal nerve. The most frequently tracking parameters used in our review are: 3T MRI, b-value of 800 s/mm2, 33 directions, 3 × 3 × 3 mm3, AF threshold of 0.1, minimum fiber length of 10 mm, bending angle of 30°, and 3DT2 TSE anatomical resolution. Increased use of DTI could lead to new perspectives in the management of pudendal neuralgia due to entrapment syndrome, whether at the diagnostic, prognostic, or preoperative planning level. Prospective studies of healthy subjects and patients with the optimal acquisition parameters described above are needed to establish the accuracy of MR tractography for diagnosing pudendal neuralgia and other intrapelvic nerve entrapments.