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The future has a way of arriving unannounced. -George Will

A Primary Care Review of Emerging Technologies in Urology. Joseph Endrizzi, M.D.UrologistGundersen Lutheran Medical CenterLa Crosse, WI. Disclosures. Senior Partner, USHPPSurgical Mentor, Boston ScientificAdvisor, Allergan. "Change is the law of life. And those who look only to the past or present are certain to miss the future." -John F. Kennedy .

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The future has a way of arriving unannounced. -George Will

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    1. "The future has a way of arriving unannounced." -George Will

    2. A Primary Care Review of Emerging Technologies in Urology Joseph Endrizzi, M.D. Urologist Gundersen Lutheran Medical Center La Crosse, WI

    3. Disclosures Senior Partner, USHPP Surgical Mentor, Boston Scientific Advisor, Allergan

    4. "Change is the law of life. And those who look only to the past or present are certain to miss the future." -John F. Kennedy

    8. Futurist Ray Kurzweil “Turing Test” By 2029, a computer will be able to carry on a conversation indistinguishable from a human’s.

    9. Futurist Ray Kurzweil “Singularity” The point when your life expectancy rises at a rate faster than which you age. In the 2040’s people spend the majority of their time in full immersion virtual reality.

    10. Singularity

    11. Emerging technology Technology as a modality for treating patients with different disease states. Risk : Benefit : Cost

    12. Multi-factorial etiology deserves multi-modal therapy

    13. Emerging technology Focus on 3 different technologies changing the treatment of 3 different disease states Robot assisted surgery for prostate cancer Laser surgery for BPH Neurostimulation for overactive bladder

    14. Robot assisted surgery

    16. Robotic platform

    17. Robotic platform

    18. Robotic platform

    19. Robot assisted surgery The robot has the capability of moving and accessing areas that are not possible with traditional surgical techniques. Allows development of less invasive and more precise surgical techniques.

    20. Radical prostatectomy 1904 Perineal 1947 Retropubic 1991 Laparoscopic 2000 Robot assisted

    21. Robotic platform 3 dimensional magnified stereoscopic vision Intuitive motion of instruments Dampening of tremor, 1:3 scale of motion Articulated instruments mimic hand/wrist movements

    22. Putting advantages into practice Lower blood loss 103cc robot v 418cc RRP (UC Irvine) 191cc v 664cc (Vanderbilt) Lower positive margin rate (Vanderbilt) 9% v 24% in T2 disease 50% v 60% in T3 disease

    23. Putting advantages into practice Less pain 4 v 7 (Vattikuti) Home quicker 36 hours v 56 hours (Vattikuti)

    24. Where it may make a difference Continence 68% to 98% Robot 70% to 93% RRP Potency 43% to 97% Robot 14% to 81% RRP No survival data available

    25. Future of Robotic surgery Natural orifice surgery Urethra, mouth, vagina Single port laparoscopic surgery Utilize a single port and deploy multiple instruments through it Programmed robotic surgery

    26. Greenlight Laser PVP

    27. Greenlight PVP 1998 Malek, Barrett and Kuntzman published series of 10 patients.

    28. Medical laser application Ophthalmologic Dermatologic Vascular Dental

    29. TURP and BPH Performed essentially without modification for 50 + years. “Gold standard” for BPH treatment.

    30. 2006 AUA Guide on BPH treatment “Medical therapies are not as efficacious as surgical therapies but may provide adequate symptoms relief with fewer and less serious associated adverse events”.

    31. Incidence Histopathologically, age dependent Age 60, 50% affected Age 85, 90% affected. Symptomatically, age dependent ˝ of histopath have symptoms

    32. Comparing Outcomes QOL Improvement

    33. 2006 AUA BPH Treatment Options Mild to severe symptoms with little bother should be managed with watchful waiting

    34. 2006 AUA BPH Treatment Options Moderate to severe symptoms with bother can be managed with surgery, medical therapy or watchful waiting

    35. Therapy Watchful waiting and behavioral modification Medical Management Surgical Management

    36. Alpha Blockers Equal clinical effectiveness Slight differences in adverse event profile Large differences in cost Flomax $2.83/day Terazosin $0.36/day

    37. 5-Alpha Reductase Inhibitors “Agents are effective and appropriate treatment for patients with lower urinary tract symptoms and demonstrable enlargement of the prostate”.

    38. 5-Alpha Reductase Inhibitors Less effective for relief of BPH symptoms than alpha blockers Adverse events include Decreased libido Worsened sexual function Breast enlargement and tenderness

    39. Combination Therapy Concomitant use of alpha blockers and 5-alpha reductase inhibitors “Should be reserved for patients who are at significant risk of progression and adverse outcome.”

    40. Surgical Management OR based therapies Open simple prostatectomy TURP Laser photoselective vaporization of the prostate (green light laser PVP)

    41. 2006 AUA BPH Surgical Management Guidelines “Patients may select surgical treatment as initial therapy if moderate or severe bother is present.” “Patients who have developed complications of BPH are best treated surgically.”

    42. TURP Adverse events Overnight hospital stay TUR syndrome (acute hyponatremia from free water absorption) 65% have retrograde ejaculation Greater than 5% risk of: Irritative voiding symptoms Bladder neck contracture UTI Hematuria

    43. What you didn’t know about TURP Minimal risk of incontinence (<1%) Decline in erectile function equivalent to watchful waiting

    44. Greenlight PVP KTP Absorbed by hemoglobin Vaporizes prostatic tissue

    45. Greenlight PVP TURP-equivalent symptom improvement Decreased risk of bleeding and TUR syndrome May be done on anti-coagulated patients

    46. Greenlight PVP Minimal risk of incontinence (<1%) Decline in erectile function equivalent to watchful waiting

    47. TURP v PVP Costello et al. in Journal of Endourology, 2006 38 patients in TURP arm 38 patients in PVP arm

    48. TURP v PVP Length of stay 1.1 days PVP v 3.4 days TURP Length of catheterization 12 hours PVP v 44 hours TURP Similar outcomes QOL, AUA sx score, Qmax

    49. TURP v PVP Decreased complications Clot retention and hemorrhage 1 PVP v 13 TURP Urethral stricture 5 PVP v 8 TURP

    50. Summary “Multiple therapeutic options for the BPH” “Tailor treatment to patient symptoms and expectations”.

    51. Summary “Surgery is more effective than medical therapy in the treatment of BPH.” “Medical therapies may provide adequate symptoms relief with fewer and less serious associated adverse events.”

    52. The illiterate of the 21st century will not be those who cannot read or write; they will be those who cannot learn, unlearn, and relearn. -Alvin Toffler

    53. Replacement parts Artificial urinary sphincter Penile prosthesis Dialysis ICSI Pelvic floor reconstruction Autologous myoblasts in ext. urinary sphincter

    54. Artificial DNA Made Exclusively of Nonnatural C-Nucleosides with Four Types of Nonnatural Bases ScienceDaily (July 7, 2008) — Chemists in Japan report development of the world's first DNA molecule made almost entirely of artificial parts.

    57. Interstim therapy Sacral nerve stimulation for the treatment of urinary urgency and urge incontinence

    58. Urgency treatment Medical therapy has been a mainstay of treatment. Anti-cholinergics Detrol LA, Dec 2000. Beta-adrenergic agents Currently undergoing phase 3 trials.

    59. History of Sacral Nerve Stimulation 1981 – Department of Urology, UCSF, initiated clinical program. 1997 – FDA approves Interstim for treatment of urge incontinence in the US. 2008 – Over 45,000 patients implanted worldwide. Over 9,500 in 2008.

    60.

    61. Urgency and Urge Incontinence Overwhelming need to urinate May or may not result in an incontinence episode Key in door Change in position Unaware of episode Water running

    62. Normal urination The sacral reflex arc Sympathetics (store) Parasympathetics (pee) CNS (inhibitory) Somatic (inhibitory)

    63. Overactive bladder Multi-factorial etiology Genetic predisposition Age Hormonal status Labor / birth trauma Activity level Concomitant medical conditions Neurologic disease Multi-modal therapy Physical Therapy Behavioral modification Dietary modification Medication Nerve stimulation Botox

    64. Refractory urgency Worst of the worst patients Age = 51 Duration of symptoms = 116 months Voids/day = 12 Leaks/day = 5 Pads/day = 3

    65. INTERSTIM Therapy Electrode placed through the foramen of the S3 nerve root Hooked up to external stimulator Helps clarify signals to/through the reflex arc

    66. Benefits of InterStim Therapy 2 stage procedure allows informed choice for patient and doctor Safe Reversible Does not preclude use of alternative treatments

    67. Test Stimulation The test stimulation phase is conducted to assess a patient’s functional response to SNS. Note: Other than test stimulation, there are no pretreatment tests — including urodynamics — that can help to predict the outcome of surgery. The test stimulation phase is conducted to assess a patient’s functional response to SNS. Note: Other than test stimulation, there are no pretreatment tests — including urodynamics — that can help to predict the outcome of surgery.

    68. INTERSTIM evidence Successful treatment 70% reported >50% improvement in their symptoms Surgically implanted compliance?

    69. Future of neuromodulation Peripheral nerve stimulation Posterior tibial nerve stimulation

    70. Questions?

    71. A Primary Care Review of Female Urinary Incontinence Joseph Endrizzi, M.D. Urologist Gundersen Lutheran Medical Center La Crosse, WI

    72. Urgency and Urge Incontinence Overwhelming need to urinate May or may not result in an incontinence episode Key in door Change in position Unaware of episode Water running

    73. Stress Incontinence Activity related incontinence Cough Laugh Sneeze Physical stressor increasing intra-abdominal pressure

    74. Mixed Incontinence Most common form As age increases Urgency increases Stress plateaus Most symptomatic gets treatment s=u, s>u, s<u

    75. Etiology Genetic Vaginal delivery/labor Pelvic trauma Age Hormonal status Activity level Dietary: food and drink Obesity Cognitive status Concomitant medical issues to include stroke, diabetes

    76.

    77. Normal urination The sacral reflex arc Sympathetics (store) Parasympathetics (pee) CNS (inhibitory) Somatic (inhibitory)

    78. Voiding Reflex Rc within the PMC GABA, ENK, Ach, DA Rc within the urothelium Ach, ATP, NO, UDIF Afferent and efferents

    79.

    80. Anatomy

    81. Diagnosis Urgency History Stress Physical Exam

    82. History What activities bring on an incontinence episode? Quantify severity in pads/day Incontinence episodes/day Trips to bathroom/day Nocturia

    83. History Previous treatments Success Define and quantify Why did you stop?

    84. History Voiding diary Time Leak with urge or activity Voided volume Pad or clothes change +/- fluid intake

    85. Physical Exam Limited gyn exam pelvic prolapse, atrophy, inflammation Bladder stress test Pelvic floor muscle contraction

    86. Ancillary Tests Urinalysis and culture Post void residual Bladder scan or straight cath

    87. Multi-factorial etiology deserves multi-modal therapy

    88. Treatment – Mixed Incontinence Direct primary therapy at the complaint that is more bothersome.

    89. Treatment – Stress Incontinence Physical therapy and behavioral interventions weight loss, limit activity, wear pads modify diet and fluid intake pelvic floor muscle id. and strengthening consistent and persistent will improve 65%

    90. Treatment – Stress Incontinence Pharmacotherapy Pseudophed Imipramine SSRI duloxetine for sui Off label in US secondary to SE profile ? Beta adrenergic medication

    91. Treatment – Stress Incontinence Surgical therapy Suburethral sling 75-90% satisfaction Outpatient surgery Limited complications -Periurethral bulking agent

    92. Treatment – Urgency Physical therapy and behavioral interventions weight loss, limit activity, wear pads modify diet and fluid intake biofeedback strategies pelvic floor muscle id. and strengthening consistent and persistent will improve 80%

    93. Treatment – Urgency Pharmacotherapy Anticholinergic medications Only modestly better than placebo Costly Concern about side effects Non-compliance

    94. Treatment – Urgency Pharmacotherapy Anticholinergic medications Generic: oxybutynin IR and ER low cost titratable formula (1/2 tab po bid) Branded Lower side effects

    95. Treatment – Urgency Pharmacotherapy Selective Beta 3 adrenergic agonist Phase 3 trials ongoing

    96. Treatment – Urgency Pharmacotherapy Vaginal estrogen replacement premarin cream intravaginal pea-sized amount qod 

    97. Treatment – Urgency Surgery Interstim sacral nerve stimulation Botox into detrusor…not FDA approved

    98. Questions?

    99. http://www.israel21c.org/bin/en.jsp?enDispWho=Articles%5El2202&enPage=BlankPage&enDisplay=view&enDispWhat=object&enVersion=0&enZone=Health&

    101. Interstim therapy Tape 2 2613 to 2655 2720 to 2800 2818 to 2902

    102. Motor Response

    103. Efficacy: Overactive Bladder

    104. Benign Prostatic Hyperplasia The symptom complex brought on by enlargement of the prostate and dysfunction of the prostatic and bladder muscle causing obstructive lower urinary tract symptoms.

    105. Benign Prostatic Hyperplasia Nocturia Urgency Decreased force of urinary stream Hesitancy Intermittency Straining Sense of incomplete emptying Leading to “symptom bother” and worsened QOL

    106. Symptoms and Bother Mr A. is 65 y.o has AUA sx score = 20 with minimal bother. Mr. B has AUA sx score of 12 with severe bother. What is the appropriate evaluation and treatment?

    107. Laser Procedure is right for you.

    108. Because the tissue is removed and not left in the body

    109. Questions?

    110. Comparing Outcomes Adverse events – urinary retention

    111. Comparing Outcomes Adverse events - sexual dysfunction

    112. Initial Evaluation History and focused physical exam to include DRE and neurologic exam. Validated symptom questionnaire. Urinalysis to exclude UTI and hematuria. PSA for those with 10 year life expectancy or for whom the diagnosis of prostate cancer may affect their management.

    113. Watchful Waiting and Behavioral Modification “is the preferred management technique in patients with mild symptoms and minimal bother”

    114. Summary “Medical therapies may provide adequate symptoms relief with fewer and less serious associated adverse events”.

    115. Other futurist predictions Solar power will be cost competitive with fossil fuel in the next 20 years. Once computers can communicate, they will ask for rights.

    116. Urge incontinence Urge video Tape 2 1837 to 1850 Tape 2 1923 to 2002 Tape 2 20:36 to 21:47

    118. Robot assisted surgery Radical prostatectomy for prostate cancer performed at Gundersen Lutheran in August 2008. Utilized currently by Drs. Van Every and Hofland of Urology and Drs. Benden and Renwick of Gynecology

    119. Incidence

    120. Treatment Algorithm Overactive Bladder

    121. Test Stimulation Procedure A 15-30 minute office-based test implant in which a temporary lead wire is placed near the S3 nerve Lead is connected to an external device worn on the patient’s belt for a period of 2-4 days Patient will record his/her voiding behavior in a diary

    122. Comparing Outcomes Flow Rate Improvement

    123. Comparing Outcomes AUA symptom score

    124. Orthopedic replacement parts Hips Knees Ankles Elbows Shoulders Intervertebral discs Bone grafts

    125. Test Stimulation

    126. What replacement parts do we currently have on stock Organ assisting devices Nervous system Baclofen pump Deep brain stimulator Parkinson’s, Tourette’s, Depression, OCD, Phantom limb pain Neuro Stimulator Chronic pain Overactive bladder

    127. What replacement parts can we stock ? Replacement connective tissue Alloderm Permanent and semi-permanent mesh Hernia Pelvic reconstruction Replacement Vessels Endovascular AAA

    128. What replacement parts can we stock? Organ assisting devices Heart Ventricle AV node Defibrillator Pancreas Insulin pump

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