Bullseye Technique to Optimize S3 Foramen Access: Applying a Trusted Endourology Technique to Pelvic Medicine

Published:November 02, 2022DOI:



      Sacral neuromodulation (SNM) is an advanced therapy that stimulates sacral spinal nerves to modulate bladder or bowel dysfunction and is approved for the treatment of overactive bladder, fecal incontinence, and non-obstructive urinary retention. Prior to implantation, a successful trial period must be performed via percutaneous nerve evaluation (PNE) or a staged trial to assess treatment efficacy. Ideal lead placement in the S3 foramen is imperative to produce an adequate response and successful outcome. Traditional lead placement with fluoroscopic guidance utilizes the anteroposterior (AP) and lateral views. In this abstract we describe an additional modification which may aid lead placement.


      This video demonstrates the bullseye technique to obtain S3 foramen access for optimal lead placement in SNM.


      Begin the procedure by placing the patient in the prone position. The medial edges of the S3 foramen are marked bilaterally in the AP view followed by a horizontal marking at the level of S3. The pelvis is imaged with live fluoroscopy starting at 0 degrees and then rotating the C-arm to 30 degrees. This rotation allows the “opening up” of the S3 foramen from an ellipsoid to an oval. The surgeon grasps the needle with a Kelly clamp, placing it at the level of the skin approximately 2 cm cephalad from the horizontal marking. Live fluoroscopy is performed to align the needle with the image intensifier to form the bullseye. Once the correct angle is identified, the needle is advanced. The procedure is repeated on the contralateral foramen.


      The bullseye technique allows quick and predictable access into S3. It can potentially decrease operating time, minimize needle entries in PNE, and allows the surgeon to access S3 while maintaining proper medial orientation.


      The bullseye technique can assist surgeons in obtaining optimal access in SNM and can quickly be integrated into current practices.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Goldman HB
        • Lloyd JC
        • Noblett KL
        • et al.
        International Continence society best practice statement for use of sacral neuromodulation.
        Neurourol Urodyn. 2018; 37 (Epub 2018 Apr 11. PMID: 29641846): 1823-1848
        • Morgan TN
        • Pace N
        • Mohapatra A
        • et al.
        Sacral neuromodulation: determining predictors of success.
        Urology. 2021; 153 (Epub 2020 Jun 30. PMID: 32619594): 124-128
        • Hendrickson WK
        • Amundsen CL
        Sacral neuromodulation: troubleshooting needle placement.
        Int Urogynecol J. 2021; 32 (Epub 2021 Jan 8. PMID: 33416966): 2549-2551
        • Hendrickson WK
        • Amundsen CL
        Sacral neuromodulation: sacral anatomy and optimal lead placement.
        Int Urogynecol J. 2021; 32 (Epub 2020 Nov 25. PMID: 33237358): 2545-2547
        • Al-zahrani AA
        • Elzayat EA
        • Gajewski JB
        Long-term outcome and surgical interventions after sacral neuromodulation implant for lower urinary tract symptoms: 14-year experience at 1 center.
        J Urol. 2011; 185 (Epub 2011 Jan 19. PMID: 21247597): 981-986