Transcutaneous sacral nerve stimulation for intraoperative verification of internal anal sphincter innervation
Background: The current standard for pelvic intraoperative neuromonitoring (pIONM) is based on intermittent direct nerve stimulation. This study investigated the potential use of transcutaneous sacral nerve stimulation for non‐invasive verification of pelvic autonomic nerves. Methods: A consecutive series of six pigs underwent low anterior rectal resection. For transcutaneous sacral nerve stimulation, an array of ten electrodes (cathodes) was placed over the sacral foramina (S2 to S4). Anodes were applied on the back, right and left thigh, lower abdomen, and intra‐anally. Stimulation using the novel method and current standard were performed at different phases of the experiments under electromyography of the autonomic innervated internal anal sphincter (IAS). Key Results: Transcutaneous stimulation induced increase of IAS activity could be observed in each animal under specific cathode‐anode configurations. Out of 300 tested configurations, 18 exhibited a change in the IAS activity correlated with intentional autonomic nerve damage. The damage resulted in a significant decrease of the relative area under the curve of the IAS frequency spectrum (P<.001). Comparison of the IAS spectra under transcutaneous and direct stimulation revealed no significant difference (after rectal resection: median 5.99 mVBLHz vs 7.78 mVBLHz, P=.12; after intentional nerve damage: median −0.27 mVBLHz vs 3.35 mVBLHz, P=.29). Conclusions and Inferences: Non‐invasive selective transcutaneous sacral nerve stimulation could be used for verification of IAS innervation.