Sacral neuromodulation (SNM) plays a critical role in the management of patients with lower urinary tract disorders and fecal incontinence.  It approved for the treatment of urinary urgency incontinence in patients who failed or could not tolerate oral medication, idiopathic non-obstructive urinary retention and fecal incontinence as well. Electrode entry marking for foramen needle placement is crucial step for ideal lead placement. In regular way, A-P X-Ray view is suggested to find the medial edges of foramina on both sides are marked vertically, and the line between the distal edges of the sacroiliac joints is marked horizontally on the skin, forming an “H” sign. We aimed with double-needle technique (DNT-SNS) to use less X-Ray without A-P view using double needle to control right reflexes for finding the best feedbacks in S3 foramina.

30 patients enrolled the study. Non-neurogenic idiopathic urinary retention and overactive bladder were the main indications. Vertebral anatomic anomalies, neurogenic conditions, childhood period, morbid obese patients were excluded. All patients had standard patient positioning modified prone position to decrease lombar lordosis. For all patients, only lateral X-Ray view was used to check the S3 foramina needle and lead placement. The steps of SNS;Sedation, Patient Positioning, Drawing lines (S2-S4), Local Anesthesia- Needle Placement (Double-Needle), Control Reflexes (Lateral View) (4 to 1 mAmP), Directional Guide- Introducer Sheet Placement, Tined Lead Placement with continues X-Ray (0-1-2-3), Preparation the battery pocket, Tunelling- control the electrode
Wait 1 week, Permanent Implant (2nd Step SNS).  
Identification of double-needle technique:
- Drawing midline from tip of coxys to upper site of sacrum
- Mark two fingerbreadth (lower border of sacral bone) from tip of coxys for five sacral bone border 
- Marka one fingerbreadth to the lateral sites of each sacral bone border point to identify approximate foramina entry points (S2-S3-S4)
- Target S3 needle entry, check the bellow sign and toe reflexes, if the reflexes show S2 or S4 reflexes, do not move the needle, use another needle in terms of previous one to find S3 location
No A-P view, control reflexes, check the needle with lateral view.
Double-needle technique starts with first needle insertion targeted to S3, if S3 reflexes present, we do not place the second needle. If the first needle shows S4 or S2 reflexes, we targeted S3 foramina in terms of the first needle anatomic position. We herewith present the video in which the first attempt for needle placement to S3 was succesfull.

In all patients, double-needle technique achieved to find S3 foramina location without using A-P view. We found decreased needle entry time, x-ray exposure in terms of using a-p view with crosshair technique. Average skin entry number to find S3 was 4.5 (3-9).  All patients had succesful advance evaluation step followed by permanent implant surgery as a second step of SNS. We did not have any per-operative and post-operative complication.

Double-needle technique in SNS without using A-P view is promising alternative way to find S3 in easy and fast way. Knowing the anatomic sacral foramina position with reflexes types are crucial to use this technique sufficiently. Less X-Ray exposure will also important for surgeon and OR comfort and avoid the side effects.