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XVI WORKSHOP UROLOGIA ONCOLÓGICA 28 E 29 OUTUBRO Overactive bladder SUI Mixed Mixta (IUU+ (IUU+IUS) SUI) UUI • Urgency • Frequency • Nocturia THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER TREATMENTS ORAL MEDICATIONS •ANTICHOLINERGIC •ELMIRON •ANTIDEPRESSANTS •ANTI-INFLAMMATORY •ANTIHISTAMINES BLADDER DISTENSION BLADDER INSTILLATION DMSO HEPARIN CAPSAICIN AND RESINFEROTOXINA CYSTISTAT THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Neuromodulation Throughout history the neuromodulation has proven to be an effective alternative in the treatment of different types of pelvic floor dysfunction. Different techniques have tried to achieve a common goal, however, the therapeutic success is unequal depending on the severity and type of pathology THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Clinical Applications in Neuromodulation Clinical area Symptoms Urological pathology Overactive bladder Non-obstructive urinary retention Bladder pain syndrome Intestinal pathology Fecal incontinence Chronic constipation Soft tissue Chronic pelvic pain Dyspareunia THE SACRAL NEUROMODULATION AND TOXIN BOTULINUM IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Types of Neuromodulation Central Neuromodulation ( SNS, continuos sacral stimulation) Peripheral or posterior tibial Neuromodulation Pudendal Neuromodulation THE SACRAL NEUROMODULATION AND TOXIN BOTULINUM IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Types of Neuromodulation 1980 Estimulación intravesical transuretral Siglo XX Forster Estimulación Occipital Chaffe Estimulación de diversas neuronas Glenn marcapaso cardíaco THE SACRAL NEUROMODULATION AND TOXIN BOTULINUM IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Types of Neuromodulation Katona Estimulación intravesical en vejigas paralíticas 1954 McGuire Estimulación vesical en perros con electrodos monopolares y multipolares 1963 Bradley estimuladores implantables Tanagho, estimulación intradural, extradural, unilateral, bilateral 1996 aprobación FDA vejigas hiperactivas 1998 Aprobación FDA VN no obstructivas THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Central Neuromodulation PNE test 1) Installation of quadrupole electrode of third sacral foramina to check the effectiveness of the procedure in relieving the symptoms that have led to its realization (urgeincontinence, chronic pelvic pain, fecal incontinence). This electrode connects to an external neurostimulator that the patient carries during the trial period. In the case the trial period –no longer than 15 days- is successful, with, at least, a 50% of improvement in relation to the basal value, we can continue to the second stage. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Central Neuromodulation Implantation Insterstim 2) Installation of the final quadrupole electrode and connection to a short life battery, which is placed in a supra-aponeurotic pocket in the upper gluteal region, previously carved in the first stage of the procedure. Battery life time means 10 years for the I Interstim model (currently available in our country). Once the procedure is performed battery can be programmed using an external system that sets the intensity and stimulation parameters . THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER TREATMENTS OTHER TREATMENTS NEUROMODULATION TRANSCUTANEOUS NERVE (POSTERIOR TIBIAL NERVE STIMULATION) THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Pudendal Neuromodulation In the case Central or Sacred neuromodulation has failed, Pudendal afferents can be also neurostimulated THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Pudendal Neuromodulation The use of the device called Bion ® (Advanced Bionics Corporation, Valencia, CA) has achieved a 60% of urinary continence in those patients in whom central stimulation of S3 nerve root has failed. Bibliografia NEUROMODULACIÓN EN PATOLOGÍAS DE PISO PÉLVICO Valentín Manríquez G. 1, César Sandoval S. 1, Jorge Lecannelier A. 1, Michel Naser N. 1, Rodrigo Guzmán R. 1, Raúl Valdevenito S. 1, Mario Abedrapo M. 1 1 Unidad de Piso Pélvico Femenino, Hospital Clínico Universidad de Chile, Departamento de Obstetricia y Ginecología, Facultad de Medicina, Universidad de Chile. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Overactive bladder syndrome New pharmacological agent Botulinum Toxin THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER EFFECTIVENESS Relieve and improve symptoms TOLERABILITY Minimize side effects ADHERENCE TO TREATMENT Persistence THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Botulinum Toxin • There are 7 types of botulinum toxins that have been isolated from Clostridium Botulinum. A and B types have clinical applications THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Botulinum Toxin It has been used since 1988 for the management of different pathologies in Urology: detrusor sphincter dyssynergia and, more recently, in detrusor hyperactivity. It is being tested in the treatment of other pathologies of the pelvic floor, prostate and urinary tract painful syndromes. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Pharmacological presentations Four types of botulinum toxin are currently available in the market : - Botox, the botulinum toxin type A, by Allergan (100 MU/vial). - Dysport, botulinum toxin type A, by Ipsen (500 MU/vial). THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER The is a significant difference between patients with neurogenic and idiopathic bladder overactivity: neurogenic ones are usually part of a catheterism program. That is why there is an increased risk of urinary retention in the idiopathic ones. This may occur with a range of frequency between 0-45%, leading to 1 to 2 temporal catheterisms (3 weeks on average). THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Some of the new indications that are currently being tested are: uncoordinated urination, pelvic floor dysfunction, anal pain (This means that the external Anal Sphincter or the perineal floor muscles remain contracted and not relaxed during defecation. They can be contracted even more than usually, leading to what the English literature calls a spastic pelvic floor syndrome), vaginismus and urethral spasm THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Many prospective controlled studies are being developed, trying to answer the controversial points in the use of botulinum toxin. Which is the ideal dosage depending on the pathology and the commercial presentation?. Which are the ideal places for injection?. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Which is the ideal dosage depending on the pathology and the commercial presentation?. Botox 200 a 300 unidades de Toxina A Dysport de 500 a 750 unidades de Toxina A THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Which are the ideal places for injection?. Title: The trigono botulinum toxin injection does not produce vesicoureteral reflux. Authors: Gilles Karsenty, Ehab Elzayat, Thomas Delapparent, Benoit St-Denis, Marie-Claude Lemieux and Jacques Corcos. Department of Urology. Hospital General Sir Mortimer. McGill University. Montreal. Canada. Date: The journal of medicine, Vol. 177, 1011-1014. March 2007. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER Title: Safety and tolerability of botulinum injection under sedation and flexible cystoscope. Authors: Brian l. Cohen, Rolando Rivera, Paholo Barboglio, and Angelo Gousse. Department of Urology. University of Miami. Florida. Date: The journal of medicine, Vol. 177, 1006-1010. March 2007. THE SACRAL NEUROMODULATION AND BOTULINUM TOXIN IN WOMEN WITH IDIOPATHIC OVERACTIVE BLADDER It has been widely demonstrated that this therapy is safe, useful in refractory patients or in those with low adherence to conventional treatments (less than 18% of patients keep the anticholinergic drugs within 6 months) and with very few contraindications (active urinary tract infection, myasthenia gravis, Eaton Lambert syndrome and pregnancy).