icnmgrjill
10-30-2010, 06:34 AM
ICN Feature Story - Would you choose a procedure that costs $1800 or $22,614 if they had similar results?
(By Jill Osborne MA - ICN President) In the1990's, urology researchers determined that if you delivered a mild electronic pulse to the nerves ennervating the bladder that it could reduce episodes of incontinence as well as some frequency or urgency. Developed by Richard Schmidt MD while he worked at UC-San Francisco, sacral nerve stimulation (SNS) involved the implantation of an electrical lead in the lower back and a battery device near the hip. Since 1997, numerous research studies have shown that this method can be successful but is fraught with numerous obstacles, including the cost of surgery, the risk of both mild and serious adverse events (18 fatalities were reported to the FDA in the past two years) and the need for constant medical supervision and/or multiple surgeries to maintain the implanted units.
At roughly the same time, another researcher at UCSF, Dr. Marshall Stoller, developed a non-invasive approach to nerve stimulation. Called post tibial nerve stimulation (PTNS) procedure, it involved the insertion of an acupuncture needle near the post-tibial nerve, slightly above the ankle bone. This nerve travels through the pelvis and down the leg. Research results were similarly favorable. The cost and risk of this procedure are far less, involving no need for surgery, few adverse events and much lower cost.
Yet, of the two, the surgical method became quite popular across the country due, in great part, to extensive marketing and financial resources offered by Medtronic. Sadly, the non-invasive PTNS technique and device was juggled between several companies that didn't have significant financial resources. The current version, known as Urgent PC, is being marketed by Uroplasty. Both have received FDA approval and will be covered by Medicare (PTNS coverage begins in 2011),
So the logical question to ask is "Will the cheaper, safer procedure replace the more extensive, risky method?" In the November issue of the Journal of Urology, Dr. Ragi Doggweiler reviews the pros and cons of both. Research studies show effectiveness with both methods in reducing symptoms. She compares costs with SNS, suggested to cost $22,614 with a cumulative cost of $27,357, while PTNS would cost $1800 for 12 sessions .(1)
One factor in support of neuromodulation is research released in 2008 that revealed that anticholinergic medications commonly prescribed for bladder symptoms may cause increasing cognitive decline in healthy, older people.(2) She offers "It does make sense to consider PTNS as a replacement for pharmacotherapy in patients on multiple medications to avoid accumulation and interactions. It would be easy to treat patients in assisted living or nursing homes with PTNS and avoid the side effects of anticholinergic medications. However, will it be a substitute for SNS? Time will show, given the economic implications, that PTNS will be considered a first line treatment and cases of treatment failure will undergo testing for SNS."
I agree. Before committing to a significant, expensive surgery, it makes sense to try the easier, less invasive and more short term therapy first.
I also must admit to some bias. In 1993, I was referred to UCSF by my urologist where I landed in Dr. Stoller's clinic in tears and desperate for relief. This simple, easy acupuncture needle technique worked for me. I had my first two hours without pain at week 4 and my first day without pain at week 8. In contrast, many of my friends who were Interstim patients had multiple, and often traumatic, SNS procedures.
Ultimately, the decision to undergo any form of neurostimulation requires careful research and, of course, a physician well experienced in the technique to be used. It's also important to talk with patients who have tried these therapies and learn what the experience was like and what challenges they faced, if any. You can meet others directly in the ICN Support Forum where you'll find four message boards dedicated to neurostimulation. The ICN also offers a Sacral Neuromodulation Checklist that can help guide you through the decision making process and talk with your doctor about the pros and cons.
(1) Doggweiler R. Will posterior tibial nerve stimulation replace sacral nerve root stimulation as the salvage management of drug resistant urinary urge incontinence? J Urol. 2010 Nov;184(5):1835-6. Epub 2010 Sep 17.
(2) Han et al. Cumulative Anticholinergic Exposure Is Associated with Poor Memory and Executive Function in Older Men. Journal of the American Geriatrics Society, 2008; 56 (12): 2203..
(By Jill Osborne MA - ICN President) In the1990's, urology researchers determined that if you delivered a mild electronic pulse to the nerves ennervating the bladder that it could reduce episodes of incontinence as well as some frequency or urgency. Developed by Richard Schmidt MD while he worked at UC-San Francisco, sacral nerve stimulation (SNS) involved the implantation of an electrical lead in the lower back and a battery device near the hip. Since 1997, numerous research studies have shown that this method can be successful but is fraught with numerous obstacles, including the cost of surgery, the risk of both mild and serious adverse events (18 fatalities were reported to the FDA in the past two years) and the need for constant medical supervision and/or multiple surgeries to maintain the implanted units.
At roughly the same time, another researcher at UCSF, Dr. Marshall Stoller, developed a non-invasive approach to nerve stimulation. Called post tibial nerve stimulation (PTNS) procedure, it involved the insertion of an acupuncture needle near the post-tibial nerve, slightly above the ankle bone. This nerve travels through the pelvis and down the leg. Research results were similarly favorable. The cost and risk of this procedure are far less, involving no need for surgery, few adverse events and much lower cost.
Yet, of the two, the surgical method became quite popular across the country due, in great part, to extensive marketing and financial resources offered by Medtronic. Sadly, the non-invasive PTNS technique and device was juggled between several companies that didn't have significant financial resources. The current version, known as Urgent PC, is being marketed by Uroplasty. Both have received FDA approval and will be covered by Medicare (PTNS coverage begins in 2011),
So the logical question to ask is "Will the cheaper, safer procedure replace the more extensive, risky method?" In the November issue of the Journal of Urology, Dr. Ragi Doggweiler reviews the pros and cons of both. Research studies show effectiveness with both methods in reducing symptoms. She compares costs with SNS, suggested to cost $22,614 with a cumulative cost of $27,357, while PTNS would cost $1800 for 12 sessions .(1)
One factor in support of neuromodulation is research released in 2008 that revealed that anticholinergic medications commonly prescribed for bladder symptoms may cause increasing cognitive decline in healthy, older people.(2) She offers "It does make sense to consider PTNS as a replacement for pharmacotherapy in patients on multiple medications to avoid accumulation and interactions. It would be easy to treat patients in assisted living or nursing homes with PTNS and avoid the side effects of anticholinergic medications. However, will it be a substitute for SNS? Time will show, given the economic implications, that PTNS will be considered a first line treatment and cases of treatment failure will undergo testing for SNS."
I agree. Before committing to a significant, expensive surgery, it makes sense to try the easier, less invasive and more short term therapy first.
I also must admit to some bias. In 1993, I was referred to UCSF by my urologist where I landed in Dr. Stoller's clinic in tears and desperate for relief. This simple, easy acupuncture needle technique worked for me. I had my first two hours without pain at week 4 and my first day without pain at week 8. In contrast, many of my friends who were Interstim patients had multiple, and often traumatic, SNS procedures.
Ultimately, the decision to undergo any form of neurostimulation requires careful research and, of course, a physician well experienced in the technique to be used. It's also important to talk with patients who have tried these therapies and learn what the experience was like and what challenges they faced, if any. You can meet others directly in the ICN Support Forum where you'll find four message boards dedicated to neurostimulation. The ICN also offers a Sacral Neuromodulation Checklist that can help guide you through the decision making process and talk with your doctor about the pros and cons.
(1) Doggweiler R. Will posterior tibial nerve stimulation replace sacral nerve root stimulation as the salvage management of drug resistant urinary urge incontinence? J Urol. 2010 Nov;184(5):1835-6. Epub 2010 Sep 17.
(2) Han et al. Cumulative Anticholinergic Exposure Is Associated with Poor Memory and Executive Function in Older Men. Journal of the American Geriatrics Society, 2008; 56 (12): 2203..