Transcript Botulinum Toxin

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.
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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
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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).