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Multidisciplinarietà in uro-oncologiaAviano - 10 Settembre 2010

La terapia dell’incontinenza urinariapost-prostatectomia radicale : dove siamo oggi

• The increasing of RRPs entails an increasenumber of patients suffering from PPI

• The incidence of early SUI varies between 0.8 and 87%

Due to the influence of the operatingphysician and a lack of standardizedof “incontinence”

Augustin HEur Urol 42: 112, 2002

Wei JTSemin Urol Oncol 18 : 76, 2000

Penson DFJ Urol 173 : 1701, 2005

Borgemann CDtsch Arzteblatt Int 107 : 484, 2010

•• BecauseBecause incontinenceincontinence rate are rate are notednoted toto decreasedecreaseoverover timetime fromfrom surgerysurgery the the durationduration followfollow--up up isis importantimportant

12 12 monthsmonths followfollow--up are up are necessarynecessarytoto definedefine continencecontinence statusstatus

ICI 2009

• Non invasive therapies

• Pharmacologic treatment

• Surgical treatment

Hot Topics

Non invasive therapies

• It is the first-line treatmentfor early incontinence within 6 mo to 12 mo

Bauer RMEur Urol 55 : 322, 2009

Non invasive therapies

Ribeiro LHSJ Urol 184 : 1034, 2010

Pharmacologictreatment

Bauer RM55 : 322, 2009

• At present there is no approvedpharmacologic therapy for male SUI

• In the recent years the efficacyof duloxetine in men

During the storage phase glutamateactivates efferent somatic pudendalnerve to release acetylcholineto contract the striated muscleof the distal urethra

the additional presence of serotoninand noradrenaline are activated to elicitgreater contraction of urethral striated muscle

Michel MC and Peters SLMBJU 94 : 23, 2004

Pharmacologictreatment

Borgemann CDtsch Arzteblatt Int 107 : 484, 2010

Surgical treatment

Bauer RM55 : 322, 2009

• 2-5% of patients with incontinenceexhibit a persistent incontinencefor >1 yr postoperatively despite conservative therapy

in these patients surgical treatment is recommended

• Injection therapy

• Stem-cell therapy

• Slings

• Pro-ACT system

• Artificial urinary system

Injection therapy(level of evidence 3 - Grade of recommendation C)

• Various substances as collagen, teflon, silicone, autologous fat, autologous condrocytes and hyaluronic cid have been usedfor decades

the short-term effectsare good

the long-term success rate is poor because they are subject to quick migration

Stenberg AScand J Urol Nephrol 33 : 355, 1999

Injection therapy(level of evidence 3 - Grade of recommendation C)

Bauer RMEur Urol 55 : 322, 2009

Stem cell therapy

Mitterberger MJ Urol 179 : 225, 2008

Slings(level of evidence 3 - Grade of recommendation C)

Kaufman JJSurg Gynecol Obstet131 : 295, 1970

• The male sling procedureis based upon the concept of passive external urethral compression

Bone anchoredsling system

Readjustablesling system

Functional retrourethral sling

Migliari RJ Urol 176 : 2114, 2006

•• The The LiteratureLiterature seemsseems toto indicate indicate thatthat pullingpulling or or compresscompresson the on the bulbarbulbar portionportion withwith anan artificialartificial meshmesh cancanrestorerestore continencecontinence in in midlymidly toto moderatlymoderatly incontinentincontinent patientspatients

• Less invasive than artificial sphincter(there is no circunferential dissection)

• Less expensive

• No surgical revisions(due to abnormal function or urethral atrophy)

• Few complications

• Normal micturition

Male sling advantages

Migliari RJ Urol 176 : 2114, 2006

•• DespiteDespite no no availableavailable longlong--termterm resultsresults some data some data indicate indicate thatthat progressive progressive failurefailure occursoccurs overover timetime

Male sling disadvantages

Bone anchored sling system

J Urol 181 : 2204, 2009

Readjustable slingand Remeex system

Readjustable slingand Remeex system

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n. 51 n. 51 patientspatients (58(58--81 81 yrsyrs oldold) ) withwith mildmild incontinenceincontinence

33/51 (64%) 33/51 (64%) curedcured10/51 (19.6%) 10/51 (19.6%) improvedimproved8/51 (15.7%) 8/51 (15.7%) unchangedunchanged

meanmean followfollow--up : 32 up : 32 monthsmonths

Sousa Escandon AEur Urol 52 : 1473, 2007

Readjustable slingand Remeex system

•• It was firsty described by It was firsty described by Sierra in 2006Sierra in 2006

•• The system The system is composedis composedof a of a radiopaque cushined radiopaque cushined system system with with silicone silicone foam foam 42 mm x 26 mm x 9 mm 42 mm x 26 mm x 9 mm thick for thick for soft soft bulbar urethral bulbar urethral compressioncompression

Sierra MJArch Esp Urol 59 : 607, 2006

Readjustable slingand Argus system

BJU 97 : 533, 2006

Readjustable sling and Argus system

Functional retrourethral sling

•• AdvanceAdvance isis a a slingsling suspensionsuspensionwhichwhich offersoffers a a nonobstructivenonobstructiveand and functionalfunctional therapeutictherapeuticapproachapproach

•• The The slingsling waswas first first describeddescribedbyby RhederRheder and Gozziand Gozzi

Bauer MREur Urol 56 : 928, 2009

N. 124 pts1 yr F-U

N. 124 pts1 yr F-U

N. 124 pts1 yr F-U

Herschorn SNeuro Urol Urodyn 29 : 179, 2010

PRO - ACT system

PRO - ACT system

•• The optimal baloon placement is considered as being 5-10 mm distal the bladder neck and 2.5 mm lateral from the urethra

Artificial Sphincter

•• The AUS The AUS remainsremains the the mostmost effectiveeffectivelonglong--termterm surgicalsurgical treatment treatment forfor PPIPPI

Artificial Sphincter

N. 47 N. 47 ptsptsUrologyUrology 71 : 90, 200871 : 90, 2008

Conclusions

• Bulking Agents havean overall lower successs rate

• New technologies need furtherinvestigations before to definetheir clinical role

• After a century of PPI therapyare we back to where we started ?

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