The objective was to develop an instructional video that utilizes fluoroscopic images and anatomical landmarks to increase the surgeon's ability to troubleshoot optimal placement of the foramen needle and lead during a stage I sacral neuromodulation (SNM) procedure. Eight different examples of suboptimal foramen needle placement with subsequent corrections during a SNM procedure were performed and recorded on a fresh female cadaver. Fluoroscopic images were obtained during the procedure, and illustrations of the posterior aspect of the sacrum highlighting the S3 foramina and nerve are shown for anatomical comparison. This video demonstrates how to efficiently identify and correct suboptimal foramen needle placement in order to obtain optimal lead placement during an SNM procedure. Understanding the relationship between the bony landmarks on fluoroscopy and the S3 nerve and foramen are important in order to understand how to correct a suboptimal foramen needle and thus achieve optimal lead placement. © 2021. The International Urogynecological Association.