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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
• It is the first-line treatmentfor early incontinence within 6 mo to 12 mo
Bauer RMEur Urol 55 : 322, 2009
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
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
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
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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
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
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