Q: Has this type of technology been used in other surgical specialties A: Yes, Similar technology has been standard of care for over a decade in spine surgery, maxillofacial surgery, and neurosurgery.
Q: Anyone doing a prostatectomy should know where the nerves are. What’s the value? A: The value is in giving you better information. Technology like this is standard of care for spine, maxillofacial, and neurosurgery even in the hands of experts. Literature as recent as 2011 points to the disconnect between what looks good visually and what results in good functional outcomes. ProPep replaces judgment with real-time information. By knowing for sure where important nerves are, you can do a better job as a surgeon avoiding injury to those structures. In addition, the ProPep System allows you to assess the integrity of these nerves prior to and post prostate dissection to not only validate nerve preservation but to also identify pre-existing conditions.
Q: The nerves for urinary control lie just to the outside of the nerves for sexual function. That means if I do nerve sparing I’m automatically sparing these nerves for urinary control and don’t need this product: A: As is true of most anatomy, the location of these nerves varies. Although they often lie lateral to the nerves for sexual function, in our initial clinical use trials we found these nerves to lie not only lateral to, but also medial to, and sometimes under, the neurovascular bundle. Their location was often different on opposing sides of the prostate in the same patient.
Q: So this is another Cavermap? A: No. Cavermap measures the strength of an erection (i.e., it measures an end organ response) whereas ProPep measures the actual ability of a nerve to transmit a signal. ProPep technology is real-time, fast, and accurate. It employs technology that is standard of care in spine surgery, maxillofacial surgery, and neurosurgery.
Q: How much time does this add to the operation? A: Because the signal is delivered through your existing robotic bipolar instrument, the only additional time is the placement of the electrodes through the introducer which takes approximately two minutes.
Q: How difficult is this? How will this change the way I do the operation? A: Because the ProPep System employs your existing robotic instruments you can perform the surgery the same way you always have. When you are ready to monitor the nerves you just tap a foot switch to change your surgical instrument to stimulation mode and then touch the tissue of interest to identify the location of the nerve in the tissue and to verify the integrity of that nerve. The feedback is instant. After performing nerve monitoring, just tap the foot switch and your robotic instrument returns to cauterizing mode. The electrode placement is procedure specific and is very straight forward.
Q: If I can see the muscle contract why do I need the waveform validation? A: Localized muscle contractions can be caused by direct stimulation of the muscle without stimulating the nerve and without producing a compound motor action potential. When the nerve is stimulated, the entire pelvic floor (levator ani muscle) contracts and a compound motor action potential is present. In some patients, the prostate can obscure the view of the levator, and/or the muscle contraction can be muted by varying degrees of muscle relaxation, diabetes, and other medical conditions. The presence of a compound motor action potential is thus not only more sensitive but also more definitive.
Q: At what point in the procedure is the device used ? A: After the seminal vesicles and vas deferens have been mobilized; the anterior and posterior bladder neck have been separated from the prostate; and prior to pedicle dissection until the prostate dissection is complete.
Q: Where are the electrodes placed? A: Electrodes are placed into the levator ani muscle proximal to the urethral sphincter on either side of the prostate and a ground electrode is placed into the external abdominal wall.
Q: Is there validation that the waveform on the EMG is actually monitoring the nerve. A: Yes this is the standard compound motor action potential
Q: Will I as a physician be reimbursed for this? A: Currently there is no specific code for nerve monitoring during a robotic prostatectomy because this is a first to market technology. Coding verification, however, indicates ProPep Nerve Monitoring is considered intraoperative nerve monitoring (IOM).
Commercial Payers – Surgeon experience to date indicates many commercial insurers allow separate payments to the operating surgeon for intraoperative nerve monitoring. However, criteria for commercial payers may vary, so surgeons should contact their provider-relations representative.
Medicare - Currently does not pay the operating surgeon separately for intraoperative nerve monitoring. However, if medically necessary, Medicare may allow separate payment for physician of different specialty to perform intraoperative monitoring.
Q: What codes should I use? A: The primary CPT codes for intra-operative neurophysiology monitoring are 95940, 95941, and G0453 (continuous intraoperative neurophysiology monitoring performed during surgical procedures). These codes are add-on codes and should always be reported with parent code 95907 (1 – 2 nerve conduction testing).
Q: Do you have outcomes studies using the ProPep nerve monitoring system? A: ProPep does not have outcomes studies at this time. Similar to the da Vinci® Surgical System providing the surgeon a better surgical tool to perform the procedure, the ProPep Nerve Monitoring System provides the surgeon better information to make more informed decisions during surgery. Outcomes are determined by the skill of the surgeon.
Q: Is this tool a greater benefit for less experienced surgeons? A: It’s real time information surgeons have never had available in the past. With better information all levels of experience can potentially improve outcomes.
For more information about ProPep Surgical products, please contact us.
