Bladder stim cases

[PMROralBoards]

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I have a basically untapped market for bladder stim/gi stim trials and implants where I live due to patients being historically referred out to the major closest city which is about two hours away. I only found out about this after being referred an interstim explant and taking care of it last week while talking with the rep in the OR before the case.

Has anyone here been doing these? They seem almost stupidly straightforward when compared to drg trials and implants. Is there any increased legal risk because they are not generally considered pain procedures?

Thank you

 

[lobelsteve]

Only explants.

 

[BobBarker]

I think they will even let FM do them in some markets. I tried to get both MDT and Axonics to let me do them several years ago but both refused. I was doing drg at the time and still do them. I also wanted to start doing them after an explant. I know they let Tory McJunkin implant them. I don’t really need to do them anymore since I relocated. But at the time, I was isolated and working for the hospital. It made sense for everyone to get that service line going. I think you should try. Interstim micro is the smaller than a lot of thumb drives. Michael Fishman told me directly he uses them off label as PNS. But for some reason MDT will let McJunkin and Fishman do these things but not most doctors.

 

[Agast]

I could probably implant a Medtronic pacemaker too, but they won’t let us do that. They are very very careful about crossing specialties. My assumption is it’s because they need to post high success rates and they don’t trust interventional pain physicians to appropriately work up and treat urology patients in the algorithm.

And frankly I wouldn’t trust some of you either.

 

[BobBarker]

We have like 4-5 urologists at the ASC. They together do a little less than 120 a year cumulatively.

 

[PMROralBoards]

I could probably implant a Medtronic pacemaker too, but they won’t let us do that. They are very very careful about crossing specialties. My assumption is it’s because they need to post high success rates and they don’t trust interventional pain physicians to appropriately work up and treat urology patients in the algorithm.

And frankly I wouldn’t trust some of you either.

I have no idea how to work up urology or gi patients either. I would primarily be a technician in this situation.

 

[PMROralBoards]

We have like 4-5 urologists at the ASC. They together do a little less than 120 a year cumulatively.

Are they doing trials at the ASC as well? The rep was telling me that most of the time they are doing it in clinic, but I’m assuming that would most likely be pp clinics rather than hospital based.

 

[BobBarker]

They do them in the surgery center. They don’t have a c arm at their office. They are private practice and owners at the surgery center.

 

[PMROralBoards]

They do them in the surgery center. They don’t have a c arm at their office. They are private practice and owners at the surgery center.

Apparently most urologists do it blind by palpating the coccyx and then measuring 11cm proximal and just inserting two tuoys and the leads, then tape it up and connect to the epg

 

[Gnarvin]

Apparently most urologists do it blind by palpating the coccyx and then measuring 11cm proximal and just inserting two tuoys and the leads, then tape it up and connect to the epg

This seems like all kinds of crazy to me.

 

[BobBarker]

Yes, there are videos showing the blind technique online from MDT. They basically stick them blind and try to get a bellows response.

 

[Orin]

I did a few in training for patients with comorbid pelvic pain. One of the easiest cases we do but the documentation and technique are a little different, and if you're not used to working in the sacrum, it's a bit weird.

The therapy works well for function, iffy for pain and these days I've shifted over to DRG
Documentation is different as you've got to cover functional aspects for the bladder/bowel depending
Placement with functional testing is great as you can do it all with that motor capture
You can do in office with landmarks but we generally have C-arms or ultrasound in office to make things easier

 

[lobelsteve]

I did a few in training for patients with comorbid pelvic pain. One of the easiest cases we do but the documentation and technique are a little different, and if you're not used to working in the sacrum, it's a bit weird.

The therapy works well for function, iffy for pain and these days I've shifted over to DRG
Documentation is different as you've got to cover functional aspects for the bladder/bowel depending
Placement with functional testing is great as you can do it all with that motor capture
You can do in office with landmarks but we generally have C-arms or ultrasound in office to make things easier

80% effective for frequency
50% for urgency
placebo for pain.

 

[nvrsumr]

I just learned a lot.

 

[anonperson]

Are they doing trials at the ASC as well? The rep was telling me that most of the time they are doing it in clinic, but I’m assuming that would most likely be pp clinics rather than hospital based.

For interstim, you have three options:
1. In office PNE (peripheral nerve evaluation). Done in clinic/office using landmarks. If successful response, go on to full tined lead implant ( using fluoro) with placement of the pulse generator.

This reimburses the office pretty well with minimal cost/overhead.

2. Stage 1- Tined lead placement with fluoroscopy in the OR. If good response after a week, go back to place the pulse generator.

3. Skip any testing and just do the full implant. I've had most insurance companies go ahead and approve this and will sometimes utilize this route in select patients.

I see a decent number of colleagues just do option 3 to minimize back and forth.