lower urinary tract technology response - nih common fund · 2015. 4. 2. · lower urinary tract...
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Lower Urinary Tract Technology response
Nico J.M. Rijkhoff, MSc, PhD
Professor of Uro-Genital Rehab
Aalborg University, Denmark
Sparc, Feb 2015
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Human vs animal Pig
Kaufman et al, BJUI, 2008
• Dorsal sacral root stim • Bladder irritated by
formaline • Conclusion: Bilat. SNM is
better and should be tried in patients unresponsive to unilat. Stim
• Inflammation, acute effect, too high stim ampl.
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Human vs animal Cat
Tai et al, Am. J. Physiol, 2011
MS patients
Fjorback et al, Eur. Urol, 2007
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Human vs animal
• Difficult to create animal model with relevant disease (OAB, frequency, urgency)
• Neuromodulation may affect extensive networks – not the same in animals
• Patients: longterm – Animal: acute • Results may be obtained with parameters
not possible in patients • Where possible do human experiments! • Animals for ‘simple’ experiments
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Current devices perfect?
• Interstim for OAB & retention – 60-80% respond successful (> 50% improvement) – 10-20% are symptom free – Numbers are AFTER a test! – Better numbers for FI
• Urgent PC for OAB – Similar outcome
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Dorsal gen nerve
Puden
Sacral
Cord
• On demand genital nerve stimulation • Supresses urgency & bladder
contraction • Could fully restore continence • May also prevent habituation
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Closed loop event driven stimulation
Pressure increase
Detection Stimulation On
Inhibition
Pressure decrease
Stimulation Off
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Test conditional stimulation
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Human recordings
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Results in 13 SCI patients
Hansen et al, J. Urol, 2005
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But ..
• Surface electrodes cause problems • Implanted electrode near genital nerve • Several short term studies (1-2 weeks) shown
feasibility
• Long term pressure recording not possible • Sacral root ENG • Artificial sensor • Patient controlled
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Experimental setup
6 Patients
Skin
Rectum Bladder
S3
Spinal cord
Amp transmitter
Receiver Clitoral nerve
Kurstjens et al, J. Urol, 2005
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Cutaneous
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Bladder filling
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ENG from bladder
• Possible to record bladder related ENG in humans
• Signal amplitude and S/N is small • Technical improvements needed
– Smaller cuff on intradural dorsal root? • Extradural cuff: 2.8 – 3.6 mm diameter • Intradural cuff: 1.4 – 1.8 mm diameter
– Record from ganglion – Intrafasicular electrode – Multicontact cuff electrode
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Le
insulating ~-~.,,...,,,.cuff
k=:::; nerve
1st-rank amplifiers
0
0
etc
tripole amplifier outputs (TAO)
>----t-1 (N-1) t
(0) 't
time 2nd-rank delaysamplifiers
. Isignal processing. unit for one velocity
~
~ bandpass filter
output for one matched velocity
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Bladder sensor
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Recording in acute pig
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Patient controlled
• Most patients can ‘feel’ their bladder • Results show feasibility • ~15 patients (SCI, OAB wet) have used this at
home with good results • Fast intent detection is important
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Summary
• Limited usefulness of animal work for therapy optimization
• On demand stimulation of the DGN may fully restore continence
• Most simple: patient controlled • Automatic control most likely preferred –
requires a sensor • Invasive, complexity, userinteraction