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BackTable / Urology / Podcast / Transcript #20
Podcast Transcript: Advanced Treatments for Overactive Bladder (OAB)
with Dr. Daniel Hoffman
Dr. Daniel Hoffman, a urogynecologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders. Listen to hear more about patient selection criteria for each treatment, botox and neuromodulation procedure techniques, and treatment side effects and complications. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Botox vs. Neurostimulators for Overactive Bladder
(2) Administering Botox for Overactive Bladder
(3) Pain Management during Botox Injections for Overactive Bladder
(4) Managing BPH with Overactive Bladder
(5) Choosing the Right Neurostimulator Device for Overactive Bladder
(6) Complications from Neurostimulators
(7) Peripheral Nerve Evaluation for Overactive Bladder
(8) Bulking Agents for Overactive Bladder
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[Dr. Jose Silva]
Hello, everyone. And welcome back to Backtable Urology podcast, your source for all things Urology, you can find all previous episodes of our podcast on iTunes, Spotify, and backtable.com. This is Oche Silva, your host this week, and we have Danny Hoffman. Danny is a female urologist in the Orlando area.
Uh, we went to residency together, down in Puerto Rico. After that Danny went to do his fellowship of female urology with Dr. Victor Nitti at, in New York. And then afterwards he wants to Intuit academics. So Danny, welcome to backtable.
[Dr. Daniel Hoffman]
Thank you for having me, Oche. It's a real pleasure.
[Dr. Jose Silva]
So, so then he went to academics. Uh, he was a couple of years there and, and now he's, he's in our group in, uh, Advent health, central Florida area. So Danny, let's talk first about, uh, why academics, what, why after you went into, after being in, in the, fellowship with Dr. Nitti, you went into academics.
What was it a place? I mean, you went to Tampa tell us about the process.
[Dr. Daniel Hoffman]
So, you know, when you go into that sort of fellowship or that, that sort of academic fellowship, there's certainly a pressure, not, maybe pressure's not the right word or expectations, not the right word, but there's certainly an inclination to go into academic medicine. And, uh, you know, when you're interviewing for jobs, Dr. Nitti’s always telling you, well, I've got this guy at the university of Miami that wants to talk. I've got this guy at mass general that wants to talk. I've got to say, you know, most of the job interviews that land your way when you're graduating from fellowship, tend to be in academic institutions.
And, uh, I just had the fortunate situation where I had an opportunity at the university of South Florida in Tampa and, uh, I have some family in Tampa, so, uh, it kind of was a, a good fit for me. And that's what took me to Tampa. I mean, uh, you, you know, me, my career has basically been a story of being at the right place at the right time.
I've been very fortunate so far. And, uh, I think it was just one of those things that it sort of fell in my lap if you will. And, uh, and I had, uh, you know, it was a great experience at the university of South Florida, Dr. Raphael Carrion is the chairman there now. He's very well-known in sexual medicine and, uh, you know, my experience was overwhelmingly positive there.
[Dr. Jose Silva]
Definitely. I mean, Tampa, great weather, great beaches, great food.
[Dr. Daniel Hoffman]
Great city. yeah, absolutely.
[Dr. Jose Silva]
Great staff there at USF. So definitely you couldn't go wrong with that. But academics was not for you, I guess, you wanted something more.
[Dr. Daniel Hoffman]
Well, it was, it was a matter of, of priorities for me, right? When I went into academic medicine or made the decision to, to go into academic medicine, I had a one child and a wife that worked full-time. now I have three kids and a stay-at-home mom, so my priorities have shifted a little bit. So, you know, while the, the, the quality of life is certainly good in academic medicine, it was, uh, a decision that, that I had to make personally for myself and my family. Right?
[Dr. Jose Silva]
Definitely and right now, I mean, you're, you're doing great. here. So no question about that part.
[Dr. Daniel Hoffman]
No, it's been, it's been a great experience.
[Dr. Jose Silva]
So, So, let's talk about, I mean, in terms of the practice per se, how was your practice, in Tampa compared to what you're doing?
[Dr. Daniel Hoffman]
So, you know, in Tampa, in the academic setting, you really do have the benefit of being able to pick and choose what you want to see. Right. So there, my practice set up was basically 70% voiding dysfunction, neuro urology, female urology. I don't just see women. I do voiding dysfunction in men as well. So, you know, guys would be age incontinence, things like that.
We did a lot of sphincter work with my fellowship. so anything that had to do with neuro urology or MS, Parkinson's stroke? I would say it would be, it was like 70% voiding dysfunction, female urology, 30% general urology, like stones. You can't get around that, right. And I love doing stones. I don't think I would ever stop doing stones. And, uh, you know, just general lumps and bumps that you get along the way. I think it's, it's shifted a bit.
[Dr. Jose Silva]
Did they tell you, Hey, you need to do a little bit of Urology or it was just part of what you wanted?
[Dr. Daniel Hoffman]
No, it was part of what I wanted. So for me to keep my fellowship certification, my practice actually has to be 50% Female urology. So I would say at this point it's like, it's, it shifted a little bit. It's like 60, 40, female urology to general urology. Um, but it, you know, just happy to be busy and, and, and doing the good work that I do.
But I think that certainly now that I'm almost a year here in central Florida, I've definitely seen the shift, in terms of seeing more, complex voiding dysfunction. I'm seeing more consults for neurogenic bladder. complex incontinence patients refractory, you know, failed slings, failed for a second-line therapies. So I'm very happy with that.
[Dr. Jose Silva]
And definitely within our group, uh, we have a lot of guys that do oncology, and not enough that do what you do. And you came in at the right time and everybody's sending patients your way.
[Dr. Daniel Hoffman]
And, you know, yeah, I, I'm very fortunate in my practice set up where both my, my partners are oncologists and, uh, I have zero interest in doing oncology. They have zero interest in doing voiding dysfunction. So we play very well together and we refer each other patients and it, it just works very well for us.
[Dr. Jose Silva]
So, yeah. And definitely even though I do some bladder dysfunction, definitely the complex cases, I'm sending your way.
[Dr. Daniel Hoffman]
Thank you for thinking of me.
(1) Botox vs. Neurostimulators for Overactive Bladder
[Dr. Jose Silva]
So Danny, so, so let's talk about what you do. I mean, what is dysfunction? And, uh, but, uh, specifically, talk about Botox versus, uh, neurostimulators, uh, for that overactive bladder or for some frequency, urgency, things like that. Are you doing Botox? Are you doing both here right now? Uh, compared to what we're doing in the, in fellowship?
[Dr. Daniel Hoffman]
when I was at NYU, Dr. Nitti did the, was, you know, he had just done the registration trials for Botox. So we did quite a bit of Botox in my, in my training. and it was mostly because we were a referral center for, for neurogenic patients. We were seeing a lot of the, that patient population and.
That is really the patient population that I think of when I think of bladder Botox. If, if you're neurogenic overactivity, or you have tissue overactivity with impaired contractility, that's the patient that I'm thinking bladder Botox for. So, you know, I had an overwhelming experience of, of, of Botox.
We did it. Both in the operating room and in the office, mostly in the office. Uh, when I went to Tampa, kind of shifted a little bit. They didn't like doing office-based procedures there so much. So I was doing most of my Botox in the operating room. And now I think I've, I've shifted again. I, I like to do the women in the office.
The guys in the OR just for comfort.
[Dr. Jose Silva]
Yeah definitely. I think that's the beauty of Botox. I mean, it's, it's about doing it in the office and that's the, the, the upside to it. very low risk procedure. Uh, what's your ideal patient for Botox?
[Dr. Daniel Hoffman]
My ideal patient for Botox is the patient that's in urinary retention because that's the, the, the patient that you don't really have to worry about side effects, right? Because, when you're selling patients on Botox, you're having that discussion on Botox. You lose most of them when you start talking about urinary retention and that, you know, it's a, it's a discussion that you have to have right, with your patients. So, I think that, uh, patients select themselves for therapy and they tend to de-select themselves for Botox. Once you start talking about retention of urine.
(2) Administering Botox for Overactive Bladder
[Dr. Jose Silva]
Are you doing a hundred or 200 or what’s your thought process when you decide what to do?
[Dr. Daniel Hoffman]
So for, for the, the neurogenic population, I started 200 units. So if you're coming in with a massive stroke, you have Parkinson's you're, you're getting 200 units. Detrusor overactivity, I'll start at a hundred units. Um, go up to two, if a hundred fails. I'll usually wait three months between injections, have gone up to 300 units on some patients off-label use, but uh, can work.
Uh, I've done it, especially in the neurogenic patients. Patients can develop antibodies to Botox and, uh, the Botox stops becoming as effective. That's a tough patient population.
[Dr. Jose Silva]
And these are patients that either have a suprapubic catheter, they self catheterize. They leak around it. That, that that's that's what, what you're talking about of those patients.
[Dr. Daniel Hoffman]
Correct. If you have a patient that's wet and you could put them in retention and there'll be dry, they'll be grateful.
[Dr. Jose Silva]
Yep. And I do have some patients of those types. I started doing a hundred cause that's what I knew, uh, when, when I first started. But then definitely after talking to you, I started doing the two hundreds, patient much better. I mean, the, the, the they're they're, they're dry that, like you say, they're dry and they're, they're pretty happy with it. What type of templates are you, are you using any, is there a difference between templates.
[Dr. Daniel Hoffman]
So, you know, when we trained, we did the umbrella thing, right. And, uh, I think we, we moved, we went in my fellowship, we moved towards a grid template, and that's what I was very used to doing. Um, just half CC injections, depending on how much Botox you're using. And I just go.
You know, from UO to UO, up and down the posterior bladder wall, up to the dome and back. And then I always save a CC for the trigone. And I believe in injecting the trigone, you know, if you believe that whole theory of, of the, the bladder contraction, I mean, it, it should involve the trigone as well. So we always injected the trigone. That last trigone shot can be a little challenging, but if you, you get it at the right angle, you'll get it in there.
[Dr. Jose Silva]
And you will use that for both, for both patients and retention or active bladder, or just.
[Dr. Daniel Hoffman]
I do. Yeah. And it, it's just my, my mechanism now there's been new studies that come out suggesting that you can do just like four or five injections of Botox in the bladder, just larger injections. And they've, they've been successful as well. So, you know, I question does the template really matter? I think that the issue is just getting the medication in there.
What we were doing initially, when we were doing the wheel. I think we weren't getting the medicine in the, in the detrusor per se. So I think moving away from that wheel and just getting the, the, needle in the muscle was really what changed.
[Dr. Jose Silva]
And to your point, I had done a few patients that when you go for cystitis, I mean, they have overactive bladder when, when you go in half of the bladder is red and, and, you know, th those areas are very vascular, so you don't want to go, they start bleeding. So, so, I had done five six injections putting all the, the, the, the hundred units and they do good.
They do good. I mean, maybe doesn't last six months, but, but they're two, three months.
[Dr. Daniel Hoffman]
and I, you know, that's, if you get three, three to six months efficacy on a Botox injection, I think you're doing well.
[Dr. Jose Silva]
you doing for, for these patients with Botox? Are you scaling, scaling and everything six month or you're waiting for them to start having symptoms? Or how do you start doing it?
[Dr. Daniel Hoffman]
first couple of injections are sort of a trial run until you figure out what that schedule is. And they will let you know, I have a lot of patients that are on a routine at this point, right. We know that every three to six, every four to six months, we're going to do an injection. Some patients that's once a year, you know, some patients can go nine to 12 months with, with a Botox injection.
Now that we have telehealth virtual visits, it makes it very easy. They just hop on, Hey doc, it's time for my Botox injection. I put the orders in for the procedure. They come in, they get it done.
(3) Pain Management during Botox Injections for Overactive Bladder
[Dr. Jose Silva]
Are you doing it with a flexible or do you have a rigid at the office?
[Dr. Daniel Hoffman]
So for the, for the women, it's preferable to use a rigid scope. If you have it, it makes it very easy. we're using a flexible scope and it's almost like a two person job, but when you're using a flexible scope,
[Dr. Jose Silva]
Yeah,
The ones that, yeah, I have the flexible, we have the same stuff, which is pretty nice for diagnostic.
[Dr. Daniel Hoffman]
it's great for diagnostic. It's tough for procedures.
[Dr. Jose Silva]
And definitely it is. I mean, I, it is a two-man job and definitely the, the, the MA has to inject inject. Go ahead. Go ahead. So, so, so there's a learning curve in the, in that part
[Dr. Daniel Hoffman]
There is. And that's why, you know, like the guys, I take them to the operating room because it's just so much easier to rigid scope them and be able to do it yourself.
[Dr. Jose Silva]
Yeah. And, and, you know, yeah, I don't know about you, but doing a cystoscope is in the office. Every time, it’smore challenging. I think. People. I mean, at least the guys are not as comfortable. I started doing some valium for patients that, that when you, when I say what a cystoscopy is, I see I looked at their face. Uh, so I started doing a five milligram valium to see if that helps. I haven't seen that much difference. If he was going to scream he’s going to scream.
[Dr. Daniel Hoffman]
I do ativan two milligrams for a lot of my procedures. you know, if the patient is very anxious and it, it, I, I find it helps to some degree, you know, always, you know, in the office, you're in a rush, you put that lidocaine jelly in, are you really waiting five or 10 minutes for it to take effect?
The tough patients going to be a tough patient, right? No matter what you do, but there are things that you can do to, to minimize the misery in the office. Right. And I think that those things are important.
[Dr. Jose Silva]
So you’re using two milligrams.
[Dr. Daniel Hoffman]
I'll do two milligrams of Ativan one hour before the procedure.
For example, uh, I try to not use it for things like PNEs, because I liked them to be able to give me the feedback then and there, but for a scope or something like that, a bladder biopsy, something like that. No issues
(4) Managing BPH with Overactive Bladder
[Dr. Jose Silva]
Okay. And are you doing, for example, a patient, a male patient that has, some overactivity that also has BPH. How do you treat that? I mean, do you treat the BPH first and see what happens? Are you doing Botox at the same time that you're doing BPH treatment? I had a patient that I did Urolift and Botox, and he went into retention. So, he was catheterized and the and then, two months after he was doing good.
[Dr. Daniel Hoffman]
Takes a couple of weeks for them to get out of that retention. Right. And if they can get by with catheterizations, those, you know, if they're doing CIC, they do very well. I, tend to think of it as you know, uh, it's the chicken or the egg phenomenon, what happened first and, you know, in my mind, it's, it's, it's the, Bladder outlet obstruction causes the detrusor hypertrophy and the, the, the overactivity. Right. And, uh, I always focus on treating the outlet first, and then we go from there, it's easy to medically manage. Right. So I don't have any issues, you know, I don't like to do shotgun therapy, so I'm not going to start a guy on tamsulosin and Mirabegron at the same. But I'll, I'll stagger it by two weeks and we'll see how we're doing. And if he's not better at that point, then, you know, I typically we'll scope him, get a urodynamic test. If they're, if they've got mixed symptoms, right. Figure out is the obstruction really a problem? Is the bladder still squeezing?
Right? And then typically go after the outlet. If, the overactive symptoms don't settle down after you go after the outlet, then. I'll go after the OAB pathway. And those are the patients that I try to avoid things like doing green lights on. I find that if you have retention, but irritative, voiding symptoms, those patients don't do well postoperatively with green lights, you really makes the irritative symptoms bad,
[Dr. Jose Silva]
They’re miserable for three months. And really, uh, I mean, I do a lot, a lot of green lights and patients that do have, overactivity after I do the green light. I mean, they're, they're there. The flow is good, but th they're they're going to the hour, every hour, every hour. Eventually they do good.
[Dr. Daniel Hoffman]
Eventually, I tell them at the bare minimum, six weeks of, you know, if they're insistent on getting a green light or they're on an anticoagulant and we have to do a green light, I tell them it's going to be a bare minimum of six weeks of burning with urination. And you're not going to be happy with urinary symptoms before things get better.
So, you know, it's all about setting expectations too.
[Dr. Jose Silva]
Yeah, exactly. So I don't know, maybe resume works better for those patients. I don't know. I'm going to try to start doing other stuff there. Danny. So let's talk about the male patient again, and the overactivity. when you do the Botox first, let's say you look into do the cystoscopy. You do the urodynamics, you do the Botox and now he has slow stream, but he's emptying completely. Do you wait until, uh, the Botox is gone to assess? I mean, cause you, you, then you don't know that if it's the obstructive part now or, or, or what is the Botox, how do you deal with that?
[Dr. Daniel Hoffman]
So when I do Botox first, I try to wait three months before I make a judgment call on a secondary procedure. Cause that, that really allows the Botox time to declare itself. I mean, in, in theory, Botox takes seven days to reach maximum efficacy. But if you're having mixed symptoms like retention, it can take up to three months to really wean off.
So if I'm going to flip therapies, like go from Botox to sacral neuromodulation, I'll wait three months before I go down that pathway, but with the BPH guys, right. Um, it's, it's tough if they're in, if they're not emptying their bladder. Right. So I always try to push CIC as much as I can, but if they're catheter dependent and they're miserable and they really want the outlet reduction, well, you go after it.
[Dr. Jose Silva]
I don't know in your clinic, but I'm seeing more patients that have over irritative symptoms over activity versus the classic. Hey, I can't pee. I don't know if it's, if that's what you're seeing also or.
[Dr. Daniel Hoffman]
I mean, I see, I see a lot of overactive bladder just because of the nature of my practice. So I would agree with that sentiment. I see a lot of guys with irritative voiding symptoms, uh, that are not obstructed. A lot of them have bad diabetes or other comorbidities that lead to overactive bladder.
Like there are multiple diuretics or things like that. And, uh, you know, you have to manage those symptoms because they need to manage their comorbidities.
[Dr. Jose Silva]
And it takes time to convince them that it's not the prostate. I think that's the, that's the difficult part is convincing them that it’s not the prostate.
[Dr. Daniel Hoffman]
But that's where I go to diagnostic testing. Right? If these guys aren't getting better on alpha blockers, I don't hesitate to pull the trigger on doing a urodynamic test or a scope because it really, you know, it's in the guidelines, it's in the algorithm and it's, it's indicated, and it gives you the information that you need to move forward with therapy.
And I really push it on my guys that are 65 or older, you know, the incidents of detrusor underactivity can be very high. So you don't know if these guys are, are having impaired contractility versus overactivity or obstruction. So it could be, it could be very telling
(5) Choosing the Right Neurostimulator Device for Overactive Bladder
[Dr. Jose Silva]
Danny, so let let's talk about nerve stimulators. So for your activity or avoidance function, those are, I mean, Botox and nerve stimulator are the tools that, that when you use, I use the Medronics the Axonics you use both any difference?
[Dr. Daniel Hoffman]
I use both. So, you know, we, we could go down the rabbit hole of constant, current direct current. I, you know, that's, that's not a conversation that I think is, is, is within our scope. I think that as long as the energy is being delivered and you put the lead in the right place, the therapies are relatively equivalent.
I, I. Uh, found that, you know, not everyone is a candidate for a rechargeable device. Right. And Axonics still has the only primary cell on the market.
[Dr. Jose Silva]
You found out the hard way
[Dr. Daniel Hoffman]
yeah.
[Dr. Jose Silva]
I did. I did. So.
[Dr. Daniel Hoffman]
It's true though. You know, you have to, you have to think about that because you don't want to put the burden of recharging on the caretaker.
And if, if that does become a burden, they're not going to recharge it. They're not going to get to therapy in that patient. Go with a battery operated device.
[Dr. Jose Silva]
Yeah, because definitely, I mean, one thing the control is much easier on the Axonics, uh, for someone that might not be so savvy with the Medtronics one, but then that person might not be able to recharge it as well. So, so it's, I mean, Yeah. so It's, it's that catch 22 in that sense. so who's your ideal candidate for a neurostimulator versus Botox for example.
[Dr. Daniel Hoffman]
Well, again, you know, I like the patients in retention for neurostimulation. I think the patients in nonobstructive retention do really well. but for me again, it's all about what the patient wants. And once you start talking about neurostimulation and how it works, most patients tend to select that pathway.
I think that you know, when you talk about a staged approach where you can actually take the therapy out on a test drive and get a sense of whether it works for you or not, before you have to make a commitment to that therapy. I think a lot of people buy into that. And at least in my practice, I do a lot of, of percutaneous nerve evaluations.
So, you know, you come in. 15 to 20 minute procedure, you wear the device for three to five days, and then you can make a decision as to whether that's right for you or not. And if it's not right for you, then we can talk about Botox or tibial nerve modulation. But I think, you know, tibial nerve modulation, sacral neuromodulation right they’re, flip sides of the same coin.
[Dr. Jose Silva]
So for a patient that has a Foley catheter and are you doing a PNE, or are you doing a stage one for those patients?
[Dr. Daniel Hoffman]
if they're catheter dependent and you know, we, we have to get them out of that state. So I learned that one, the hard way too you, you either need to put a suprapubic tube in them or you need to teach them CIC. If they're in retention, I'll go in, I'll put, and they refuse to learn catheterization, I'll put a suprapubic tube in and then I'll do a stage approach for that patient in particular. Cause when they're in chronic retention like that, it takes them a little longer for the bladder to get going. It's not going to be that, that three to five day PNE that's going to jumpstart their bladder.
So for that patient, a staged approach is often a little better, but for your frequency urgency, and you know, I don't know if you see it in your practice, but my overactive bladder patients, you know, even more so they're coming younger and younger. And, um, those patients do really well with neuromodulation because it's, uh, they understand that it's a device, it's something they can control.
It's something they can recharge, and it puts them in the driver's seat of their symptoms.
(6) Complications from Neurostimulators
[Dr. Jose Silva]
And in, in terms of, uh, let's talk about some complications. So of the, of the, devices, I mean, some patients complain of, chronic pain, chronic pain down the leg, do you try to replace it, or what do you do with those patients?
[Dr. Daniel Hoffman]
you know, if they're having pain down the leg, first thing I do is reprogram. I try to get the, the arc of the energy, as far away from S4 as possible. So you try to bring it up closer to S3. And, uh, you know, usually if you're getting referred pain down the leg, it's because you're getting closer to four.
The patient that doesn't do well with a reprogram, I would consider lead revision and I’m not hesitant to do a lead revision on a patient. I think that the patient that has pain at the stimulator site can be a little bit more challenging. Sometimes you have to do battery revisions or, you know, with generator revisions, get it a little deeper if it's too superficial.
I like to, I like to really stick to the two centimeters. So I take the, the, long end of an army navy, it's actually three centimeters. And it's, it's a good little trick to make sure that you're like in the right plane and just using that long end of the army Navy gives you like that, right depth of penetration.
[Dr. Jose Silva]
That's for both?
[Dr. Daniel Hoffman]
for both, right, the micro or the rechargeable device
[Dr. Jose Silva]
you use the same depth?
[Dr. Daniel Hoffman]
They're both supposed to be approximately two centimeters from the skin sites so they can connect, communicate to the, to the connected device. So I use the same depth, but for the, the, the rechargeable device, I like that technique where you take the army Navy and you just make your pocket with the backend of the army Navy, and you slip the battery underneath that.
[Dr. Jose Silva]
Exactly. So that's what I'm doing for, for, for the Axonics one. Have you used the, recharger of the Medronics?
[Dr. Daniel Hoffman]
I have I have, I have, I have, and I've, I've had some patients come in with, uh, dead primary cells and, uh, they want to upgrade to a, a rechargeable device, uh, or an MRI compatible device. And do they want to stick with Medtronic? And we absolutely go down that pathway.
[Dr. Jose Silva]
you don't need to change the lead, right. I mean, as long as, as the lead was MRI compatible
[Dr. Daniel Hoffman]
that's the catch, right? So the, the, the primary cells where the things that were not MRI compatible, the lead was MRI compatible, but the lead is not interchangeable. So if you're going to go from primary cell to rechargeability, you've got to do a full swap. If you're just going to put in a MRI compliant primary cell, you can keep the same lead.
[Dr. Jose Silva]
So I think it was like a three, three weeks ago before all this COVID stuff that we cannot do surgery started,
[Dr. Daniel Hoffman]
Yeah. It's tough.
[Dr. Jose Silva]
I did a patient that she had. She has an IC and, over at the University of Michigan, they, they put two devices, two InterStims, but somebody else had already placed one. So she had three leads and two devices. So I was able to remove the batteries with the leads, but the other lead, uh, the, the, the original one that was like 15 years ago, it broke. So it stayed down there. I mean, I sent her to a neurosurgeon. What's what was the next step?
[Dr. Daniel Hoffman]
So, I mean, the, package insert says, leave it alone right there that you, if you have a fractured lead, you don't go after it. You know, that, that being said, uh, you know, when I was in my fellowship, we, we, we did do some aggressive, uh, manipulations to try to extract leads in patients that needed to get MRIs. And, uh, you know, we have done, you can't do it in conjunction with neurosurgery. If you just completely lose the lead inside the foramen. Cause at that point, you're really digging in a space that's not familiar to most urologists.
[Dr. Jose Silva]
Yeah, cause I mean, I think down, but well, on the C-arm the, the, the, the lead dive fracture was, anterior to the, to the sacrum. So I say, hey, there's no, there's no way of I'm getting there. So, yeah, so I sent her to...cause definitely that person needs an MRI for some reason. Uh, so, so she's gonna have to get the lead removed.
[Dr. Daniel Hoffman]
Yep. And that more than likely. And I mean, I think the spine guys are much more comfortable in that space than we are, and it's, it's definitely not wrong to get them involved.
(7) Peripheral Nerve Evaluation for Overactive Bladder
[Dr. Jose Silva]
Yeah. Then you mentioned the PNEs. So, so you're doing a PNE and then if it works going straight to the full implant.
[Dr. Daniel Hoffman]
Correct. And I do, I, you know, a lot of people have the, the, the facility of fluoro in the office. I don't, and I'm, I'm doing blind PNEs in the office. And I do really well with them, my conversion rate’s in the mid nineties. So I think that if you're doing good technique and you just spend a minute or two to get the needle in the right place, we'll have good results.
[Dr. Jose Silva]
Yeah, I think, uh, I think that there's, there's some, a group or there's, one of the guys from the group that are doing that also.
[Dr. Daniel Hoffman]
We have that option. I think there's a third party vendor that will bring fluoroscopy into your office.
[Dr. Jose Silva]
does it make a difference in terms of the billing? For us in the RVU model or does it matter?
[Dr. Daniel Hoffman]
for us in the RVU model, that does not matter. So for the office urologists, perhaps he can bill the fluoroscopy with interpretation of images up to one hour. But, uh, at the cost of getting that C-arm in the office, right what I can tell you is that in my fellowship, we had a C-arm in the office.
We used it a lot, right? Not just for, PNEs but for video urodynamics. And we did drugs and cystograms and every, you know, catheter that needed to be pulled was studied before. But, when we were doing our PNEs, we always marked the patient as if we were doing a blind PNE. And nine out of 10 times we would go with our markings when we were using the C-arm.
So I found in my practice that doing blind PNEs works very well.
[Dr. Jose Silva]
And definitely, I mean, you, you, you can bill for that and then bill for the, for the, for the full implant. So, so the revenue is better.
[Dr. Daniel Hoffman]
Yeah. And I, you know, I, I like to stack them, so I'll do, I'll do two PNEs on a Wednesday afternoon. So, you know, I'll block my schedule after like 2:30 or 3 o'clock and it's just an easy afternoon for me. And, uh, a relatively profitable afternoon.
[Dr. Jose Silva]
So, so you do them on Wednesdays and then, uh, you will see them again on Monday, or just have the patient called to the office and go straight to the OR.
[Dr. Daniel Hoffman]
So they'll come in on, uh, on Monday or Tuesday for the lead pull. And, uh, you know, if I'm in the office, I'll see them. Sometimes I'm in the operating room and my nurse will just take out the lead. And, uh, if they, you know, we'll, we'll, we'll set up a virtual to go over the diaries if we need to.
And we'll book the procedure.
[Dr. Jose Silva]
And does, uh, you're always in, in conjunction with the rep?
[Dr. Daniel Hoffman]
Yeah. Yeah. You know, it with, with neuromodulation, you, you have to work with your rep. You know, I, I, don't fight with my reps. Uh, you know, I listen to my reps. They're, they're there to help you. And I think they make a huge difference, right. Uh, a good rep can make or break a case. And, uh, I think a lot of the hard work of neuromodulation gets done after the fact, right. The implants, you know, what, what we have to take. But a reprogramming, uh, troubleshooting. That's where the, the, the finesse comes in with this procedure.
[Dr. Jose Silva]
Exactly. And, uh, if you have to do a stage one and stage two, how long do you wait a week 2 weeks?
[Dr. Daniel Hoffman]
So you can, you know, you can go up to 14 days. Let's say I do a PNE that doesn't do well, but still wants to move forward with the staged approach. I'll tell them we can do a seven to 14 day trial and we'll do a stage approach. And, um, I always, plan for seven days. We touch base halfway through the trial. And if they're not doing well, we'll extend. So it, you know, typically these procedures are once you're doing the stage approach, the stage two is really a 15 to 20 minute operation. So it's not really too off-putting if you've gotta stack an extra case next week to give the guy or gal an extra couple of days with the trial.
[Dr. Jose Silva]
And for a patient with nonobstructive retention does it change or would you place the full implant then? Let it wait a couple of months and see how it goes.
[Dr. Daniel Hoffman]
if I have any improvement in the nonobstructive urinary retention, I'll push them towards an implant. And, uh, I find that those patients start to do really well at about 30 days. So it takes the nerve, I think, a little longer to learn the, uh, the message right in these retention patients. Um, uh, you know, probably just the mechanism of injury is different if they see, you know, for example, I tell them a success would be going from being in retention to avoiding spontaneously throughout the day, and then needing a catheterization before you go to bed.
So that for me is a very successful trial. And, uh, that, that's, you know, the type of patient that I'm really pushing for an implant.
[Dr. Jose Silva]
And you will go straight into the implant right?
[Dr. Daniel Hoffman]
Well, if, if we're staging, no. PNEs with the retention patients. I've done them and they do well. We go for an implant if they don't do well, we'll stage it.
[Dr. Jose Silva]
You will still stage it. Okay.
[Dr. Daniel Hoffman]
If they don't do well with the PNE.
[Dr. Jose Silva]
Yeah, I, I staged those, but again, uh, at the end, like you said is 30 days. So I still, You do the full implant anyways, without them being getting better and eventually they will get better.
[Dr. Daniel Hoffman]
it's true though.
You see it at about a month.
[Dr. Jose Silva]
Yeah. At some of them, you, you get lucky and they start voiding five days with a stage one.
But, but yeah. so, so Danny, so in terms of the, let's say if you, do you try to change the entire implant, let's say a patient wants to do the batteries. Like an old InterStim the battery is getting dead, and they have great results. Do you just change the battery or. Do you ask him, hey, do you need an MRI or we'll just try to push them to change everything.
[Dr. Daniel Hoffman]
I firmly believe in shared decision-making so I, I put it up to the patient, you know, what do you want, right. Do you want the new MRI compatible device? Are you happy with your current therapy? And do you just want your battery swapped out? So I, I never pushed therapy. I think that that's a recipe for disaster. So whatever the patient wants. If now what's my, my threshold, I typically tell patients if let's say you're going in for a revision or a, some sort of issue. If anything's older than 18 months, we might as well just do a full swap out, you know, once you start to hit that two year, mark might as well just take everything out and swap it out
[Dr. Jose Silva]
Exactly. if they're having other issues. Okay.
[Dr. Daniel Hoffman]
if they're having other issues.
[Dr. Jose Silva]
Okay, Danny, anything else? And any take away or, or, or anything you want to mention in terms of Botox or, narrow stimulator therapy?
[Dr. Daniel Hoffman]
I think that you shouldn't underestimate the patient with fecal incontinence for sacral neuromodulation. When I started my practice here and in Tampa, I would say the number one indication that I was doing it for was fecal incontinence simply because I query my patients for fecal incontinence. It's part of my talk track at this point.
So, you know, everybody gets asked if they have fecal incontinence and not only does it work very well, but they are very grateful patients. And those are some of the happiest patients that I have in my clinic, because if you go from having fecal incontinence to no fecal incontinence, that's a real game changer in your quality of life..
[Dr. Jose Silva]
Definitely. And I have patients that, that for urine doesn't work, I mean, they still have overactivity. Uh, but they, they don't have the fecal incontinence and they're happy.
And, and, and I think the first time that it happened, I didn't even ask, they're having their retention I mean, or incontinence and say, well, it's not working enough, but I'm happy. I'm not having any fecal incontinence. Well, I didn't know you had it. Uh, well, yeah, so after that first patient, I definitely talk about that also. So Danny, I, I, wanted also, I mean, it's something new that, that, that we, both of us are doing, the, the, the bulking agent. I wanted to talk about this. and definitely, do you do any coaptite before or, or any bulking agent before?
(8) Bulking Agents for Overactive Bladder
[Dr. Daniel Hoffman]
little experience with durasphere and microplastique, but mostly coaptite. Um, we did most of our coaptite in the office with a Wolf scope using the sidekick needle. And, uh, you know, at NYU, all we did was lidocaine jelly and, and you go with your scope and you got your injection.
I mean, the whole procedure may take two to three minutes, right? It's a relatively quick procedure. I didn't love the results with the bulking agents. You know, my, my, my big issue with the coaptite was the minute you withdraw the needle, you start to see the coaptite coming out of the injections. And, uh, you know, I just questioned the longevity of the, the, the agent.
And that's why most of those patients I counseled them, that they're going to need a, touch-up, a repeat injection to get them dry. If they're ever catheterized, their continence is going to go away. I think that that's changed a little bit with the new bulking agent the bulkamid. I've been having some very good results with that bulking agent.
I think what was most impressive for me is that when, when you inject that gel and you withdraw the needle, there's nothing coming out that gel is staying in place. We're in the same situation right now, where unfortunately, because of COVID, uh, our, our hospitals are in black status, so we're not able to do any elective surgeries.
So I've been counseling a lot of my women to try bulking agents and I've, I've done quite a few injections in the office and they've all done really well. It's a quick procedure. It's minimal downtime, you know, I tell them you have to take it easy the day of the injection and the next day normal routine. If you're doing CrossFit, go back to doing CrossFit and tell me if you leak urine. you know, I had one patient that couldn’t void post-operatively, I've done a handful so far and, uh, we just did a quick in and out catheterization sent her home and she was fine.
[Dr. Jose Silva]
You use a 12 French or.
[Dr. Daniel Hoffman]
So I use the 12 French just, uh, uh, I liked that the Coloplast compact just because it's a very small catheter in and out. Boom.
[Dr. Jose Silva]
And you're using, uh, intravesical anesthesia. You are, you're using Uro-Jet?
[Dr. Daniel Hoffman]
I will do a Uro-Jet, and then we'll take some of that Uro-Jet, smear it on the, on the labia so that it, it gets some periurethral anesthesia topically. And then I'll do a peri urethral block, just three to five CCs at, uh, five and seven o'clock and, uh, some people could have been putting bicarbonate into the, uh, lidocaine. It does help somewhat with the irritation when you give the injection. I will also give that patient ativan two milligrams prior to the procedure and, uh, We're using the bulkamid in the mini scope, which I think also it kind of revolutionized the way that you administer bulking agent. Right? So the technique has changed a lot. It's no longer that injection where you're just gliding in and trying to inject the agent laterally. You're more creating a cushion circumferentially around the urethra. So also good results.
[Dr. Jose Silva]
And Danny, I forgot to ask you for Botox. What do you use for anesthesia?
[Dr. Daniel Hoffman]
just, just Uro-Jet.
[Dr. Jose Silva]
So now you're not using intravesical anesthesia. I mean like 30 CC, 30 ml or, or, some lidocaine wash?
[Dr. Daniel Hoffman]
no, not typically just the Uro-Jet, but I, you know, again, I find that women tolerate things much better than men do in the office. Right. A guy I wouldn't do that too in the office.
[Dr. Jose Silva]
so Danny, so bulkamid, do you think, are you going to do more bulkamid rather than sling or you think you're going to replace the patients instead of using sling? So are you going to actually have, of patients that didn't want a sling you're gonna do this more.
[Dr. Daniel Hoffman]
I think it's an easy conversation starter. It's a, uh, uh, quick office-based procedure. And, uh, downtime is maybe one day where you're back to normal activity the next day, versus doing a sling where you have to tell the patient, you know, it's going to be three weeks of no heavy physical activity.
You've got to let that thing scar into place. If not, it's not going to work as well. And given our current situation with, with, with our limitations of operating in the OR, it's gravitated my counseling towards that. And I've found that patients are doing really well with it. I can tell you anecdotally, some, some of the guys that have been doing this a little longer than I have, been doing a whole bunch of it, and, uh, it's a much easier talking track with the patient, right.
Towards an injection versus a procedure in the OR.
[Dr. Jose Silva]
And definitely, I mean, virtually zero side effects, like you mentioned, if you cannot urinate, you can remodel, the bulk that you created and that's it. So it's very, very interesting. I think I got game-changer or something easier in the office that you can do for a long time. It supposedly lasts seven years. We'll see if that's true, but yeah, for now it sounds pretty good.
[Dr. Daniel Hoffman]
and it's allowing us to keep treating patients, which is the most important part.
[Dr. Jose Silva]
Exactly. So Danny, I think it's, it's time to wrap it up. Thanks for being part of the show.
[Dr. Daniel Hoffman]
Thanks for having me.
[Dr. Jose Silva]
Yeah, and I know we will definitely continue to talk and I will talk about voiding function in man, because it is a big topic and we can also be there talking about a full show
So, thanks again for being here. Take care. Good night, man.
[Dr. Daniel Hoffman]
Thanks. And you guys have a good night as well.
Podcast Contributors
Dr. Daniel Hoffman
Dr. Daniel Hoffman is a practicing urologist with AdventHealth in Orlando, Florida.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, October 27). Ep. 20 – Advanced Treatments for Overactive Bladder (OAB) [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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