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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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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 humans.
9. Futurist Ray Kurzweil Singularity
The point when your life expectancy rises at a rate faster than which you age.
In the 2040s 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 OutcomesQOL 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 didnt 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 patients 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 patients 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 OutcomesAdverse events urinary retention
111. Comparing OutcomesAdverse 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 AlgorithmOveractive 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 patients belt for a period of 2-4 days
Patient will record his/her voiding behavior in a diary
122. Comparing OutcomesFlow Rate Improvement
123. Comparing OutcomesAUA 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
Parkinsons, Tourettes, 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