InterStim in the ASC Setting: 2 Surgeons Weigh In

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InterStim Therapy is a sacral neuromodulation therapy from Medtronic. InterStim has been regularly used for urinary incontinence for more than a decade, but recently received additional approval as treatment for fecal incontinence.

Anand Lodha, MD, a colorectal surgeon with North Texas Surgery Center, and Russell Harrell, MD, an OB/GYN physician in Toms River, N.J., discuss how they have used InterStim in the ambulatory surgery center environment for both indications.

Question: When did you first begin to perform InterStim procedures?

Dr. LodhaDr. Anand Lodha: I am performing InterStim procedures at a hospital and in the surgery center. We first got the ball rolling in 2012. After long discussions with the credentialing office, the hospital's colorectal department earned the privilege to perform these procedures last month. We have been performing the procedures at the surgery center since August.

The first candidate for the procedure was a 45 year old woman who was experiencing fecal incontinence when she slept. Right away we were able to make a difference with the sacral nerve stimulator. Another patient, an elderly woman, was having an episode every day. Now she is down to once or twice a week. The expectation of the procedure is 50 percent improvement, but our goal is to push for 100 percent improvement.

Dr. Russell Harrell: I started performing InterStim procedures for urinary incontinence since 2003. Initially I was doing these procedures in a hospital, but I now do them Dr. Harrellexclusively in an ASC. The procedure really lends itself to the ASC setting.

Q: How did InterStim come to have indications for both urinary and fecal incontinence?

AL: InterStim has been around for some time. It has been regularly used in Europe and here, by urologists as a treatment for urinary incontinence. A multi-centered prospective trial in 2010 examined the long-term efficacy data of InterStim for fecal incontinence. Eighty percent of subjects had a greater than 50 percent therapeutic improvement in their symptoms and was consistent long-term. With many other procedures, efficacy rates decline with time, but with this long-term data demonstrates long-term effects.

Q: Why is InterStim an important tool in fecal incontinence treatment?

AL: Fecal incontinence is a taboo subject. It bears a social stigma. It is a major reason that elderly patients are admitted to nursing homes. We now have technology with great, lasting results. Of patients treated with InterStim, 80 percent have shown a 50 percent or greater improvement after implantation and 30 to 50 percent of patients have shown 100 percent improvement.

RH: In the past, the treatments for fecal incontinence ranged from dietary restrictions to invasive procedures such as sphincteroplasty. When you compare the long-term efficacy of InterStim with these treatments it's like looking at apples and oranges.

Q: What does an ASC need for physicians to perform InterStim?

RH: Good news from an ASC perspective, the cost of instrumentation is very low. The procedure requires only light sedation, not general anesthesia. Centers do need a C-Arm, which is an expensive piece of equipment. For centers that do not already have a C-Arm or the means to acquire one, the equipment can be rented on a day-to-day basis. While a C-Arm is the biggest expense, the cost of renting one will be covered after only a couple of cases. Centers can stack cases and complete three to four within a couple of hours.

Q: What kind of learning curve can surgeons expect when taking on InterStim?

RH: When I first began, I scheduled three cases. An instructor sat down with me to show me how the procedure was done. It is user-friendly and as with any procedure, the more you do the more proficient you become.

Q: Why does InterStim make sense for use in an ASC?

RH: The procedure is exactly the same, whether it is treating fecal or urinary incontinence. All nerves that InterStim is stimulating lead to the pelvic floor. The procedure is minimally invasive. You can do several in a couple of hours and the results for patients are good.

AL: It is definitely something that is very appropriate for the surgery center. The Medtronic reps go through an extensive training process and are really hands-on.  They come and make sure everything is set up properly and are an integral part of the patient's follow-up.  We always check to see if there needs to be any adjustment done to the patients' program. Surgery centers also offer the patients the benefit of enhanced comfort and safety.

Q: What kind of reimbursement can physicians expect from performing procedures with InterStim?

AL: Thus far we have performed three to four procedures and experienced middle of the road reimbursement.

RH: Reimbursement rates I have seen are really good.

Q: How can gastroenterologists work with surgeons to bring this procedure to ASCs?

RH: As it stands right now, gynecologists, urologists and colorectal surgeons are performing procedures with InterStim. Thus far, I have received a few referrals for this procedure from gastroenterologists, but I think it will eventually take off. As gastroenterologist awareness grows, I think InterStim will be like any new tool, something to add to their repertoire for patient treatment.

In the past, there was not a great answer to fecal incontinence. The attitude may have been "if there is no solution, don't ask the question." But, patients do suffer from fecal incontinence and now we have that great answer. InterStim is an added value to any GI center, whether an existing surgeon-owner begins performing cases or the owners recruit a surgeon to bring the procedure to the center. It is good for the patient and good for the center.

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