Dry Starts HereProPep® Nerve Monitoring System
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.
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. The ProPep® Nerve Monitoring System 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 it 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.
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. The ProPep® Nerve Monitoring System 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 it 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 somatic nerves for sexual function and urinary control lie just to the outside of the parasympathetic nerves for sexual function. That means if I do nerve sparing, I’m automatically sparing these nerves 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 parasympathetic 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.
A: As is true of most anatomy, the location of these nerves varies. Although they often lie lateral to the parasympathetic 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 the ProPep® Nerve Monitoring System measures the actual ability of a nerve to transmit a signal. The technology is real-time, fast, and accurate. It employs technology that is standard of care in spine surgery, maxillofacial surgery, and neurosurgery.
A: No. Cavermap measures the strength of an erection (i.e., it measures an end organ response) whereas the ProPep® Nerve Monitoring System measures the actual ability of a nerve to transmit a signal. The technology is real-time, fast, and accurate. It employs technology that is standard of care in spine surgery, maxillofacial surgery, and neurosurgery.
Q: Since this is standard of Care in other Specialties are there Medical/Legal implications if the technology is not used?
A: To date we are not aware of any lawsuits regarding Prostate procedures. However, the same technology has existed for years in other procedures such as Spine, Thyroid, and Maxiofacial surgeries which have experienced medical/legal implications.
A: To date we are not aware of any lawsuits regarding Prostate procedures. However, the same technology has existed for years in other procedures such as Spine, Thyroid, and Maxiofacial surgeries which have experienced medical/legal implications.
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.
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® Nerve Monitoring 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.
A: Because the ProPep® Nerve Monitoring 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. In some patients, the prostate can obscure the view of the target muscle contraction and 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.
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. In some patients, the prostate can obscure the view of the target muscle contraction and 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 and until the apical dissection is complete.
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 and until the apical dissection is complete.
Q: Where are the electrodes placed?
A: For pedical dissection: 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.For apical dissection: electrodes are placed in external urethral sphincter to either side of the urethra.
A: For pedical dissection: 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.For apical dissection: electrodes are placed in external urethral sphincter to either side of the urethra.
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
A: Yes this is the standard compound motor action potential
Q: Will I as a physician be reimbursed for this?
A: The ProPep® Nerve Monitoring System is considered intraoperative nerve monitoring (IOM). For nerve monitoring/identification during prostate surgery, typical CPT codes billed would be 95907 (nerve conduction velocity), 51785 (anal/urethral sphincter EMG).
A: The ProPep® Nerve Monitoring System is considered intraoperative nerve monitoring (IOM). For nerve monitoring/identification during prostate surgery, typical CPT codes billed would be 95907 (nerve conduction velocity), 51785 (anal/urethral sphincter EMG).
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).
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: A single highly experienced surgeon, prospective cohort study was performed at Indiana University for patients undergoing robotic assisted radical prostatectomy from 2015-2017. These patients were aligned 1:2 with contemporary controls from the same surgeon on age (within 5 years), biopsy Gleason score, and nerve-sparing status. Study results can be found at Dry Starts Here. A second clinical trial has been starte with the University Hospital in Herlev Denmark. Our Nerve Monitoring System (NMS) is currently used nationwide, and with Herlev Hospital being the first hospital in Europe to acquire the ProPep Nerve Monitoring System, the benefits of this technology will now impact patients undergoing RARP worldwide. The University Hospital houses the largest Urology Center in Northern Europe, and their adoption of our Nerve Monitoring System is an example of how they continually look for technologies that can help their physicians provide the best care possible to their patients.
A: A single highly experienced surgeon, prospective cohort study was performed at Indiana University for patients undergoing robotic assisted radical prostatectomy from 2015-2017. These patients were aligned 1:2 with contemporary controls from the same surgeon on age (within 5 years), biopsy Gleason score, and nerve-sparing status. Study results can be found at Dry Starts Here. A second clinical trial has been starte with the University Hospital in Herlev Denmark. Our Nerve Monitoring System (NMS) is currently used nationwide, and with Herlev Hospital being the first hospital in Europe to acquire the ProPep Nerve Monitoring System, the benefits of this technology will now impact patients undergoing RARP worldwide. The University Hospital houses the largest Urology Center in Northern Europe, and their adoption of our Nerve Monitoring System is an example of how they continually look for technologies that can help their physicians provide the best care possible to their patients.
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.
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.