1 / 23

Sacral Neuromodulation

Sacral Neuromodulation. Restoring Function by Targeting Bladder-Brain Communication in Idiopathic OAB Patients Leading Theories in Mechanism of Action. Overview of Overactive Bladder ( OAB). Sacral Neuromodulation Mechanism of Action.

azia
Télécharger la présentation

Sacral Neuromodulation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Sacral Neuromodulation Restoring Function by Targeting Bladder-Brain Communication in Idiopathic OAB Patients Leading Theories in Mechanism of Action

  2. Overview of Overactive Bladder (OAB)

  3. Sacral NeuromodulationMechanism of Action Current scientific evidence supports the following concepts on the effect of SNM in OAB patients: Production of action potentials that modulate central nervous system (CNS) processing of bladder afferent input Modulation of abnormal afferent (sensory) activity Normalization of brain activity Restoration of bladder function

  4. The International Continence Society Definition of OAB Reference: 1. Abrams P, Cardozo L, Fall M, et al. Urology. 2003;61:37-49. OAB is diagnosed and defined based on symptoms1 Urgency with or without urge incontinence, usually with frequency and nocturia, in absence of pathologic or metabolic factors to explain symptoms Urgency is defined as the complaint of a sudden compelling desire to pass urine, which is difficult to defer

  5. OAB is a Widespread Problem That is Expected to Increase References: 1. Stewart WF, Van Rooyen JB, Cundiff GW, et al. World J Urol. 2003;20:327-336. 2. United Nations, Department of Economic and Social Affairs, Population Division (2011). World Population Prospects: The 2010 Revision, CD-ROM Edition. 3. Centers for Disease Control and Prevention (CDC). Air Pollution and Respiratory Health Branch, National Center for Environmental Health [asthma prevalence [asthma]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2010. 4. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Atlanta, GA: U.S. Department of Health and Human Services. 5. Whitehead WE, Borrud L, Goode PS, et al. Gastroenterology. 2009;137:512-517. 6. National Osteoporosis Foundation. What is osteoporosis. www.nof.org/articles/7. Accessed October 25, 2012. 7. Alzheimer’s Association. Alzheimer’s facts and figures. www.alz.org/alzheimers_disease_facts_and_figures.asp. Accessed August 23, 2012. Approximately 37.4 million adults in the United States have symptoms of OAB1,2 Epidemiologic surveys suggest that the incidence of OAB rises as the population ages1

  6. The Fundamental Cause of OAB May Be Multifactorial References:1. Fowler CJ, Griffiths D, de Groat WC. Nat Rev Neurosci. 2008;9(6):453-466. 2. Griffiths D, Derbyshire S, Stenger A, Resnick N. J Urol. 2005;174:1862-1867. The pathophysiology of OAB may depend on gender and age1 Myogenic and neurogenic centric hypotheses have been proposed as causes of OAB1 Functional MRI studies have shown diminished brain activity in certain regions, suggesting the central nervous system (CNS) plays a role in OAB1,2 These hypotheses may not be mutually exclusive, and may vary across patient and disease types1

  7. OAB Patients Have Altered Brain Responses Diminished response in areas responsible for voluntary voiding1,2 References:1. Griffiths D, Tadic SD. NeurourolUrodyn. 2008;27:466-474. 2. Griffiths D, Derbyshire S, Stenger A, Resnick N. J Urol. 2005;174:1862-1867. Abnormal response in areas processing urge and social propriety1,2

  8. Neurophysiology of the Bladder

  9. The Lower Urinary Tract (LUT) Reference:1. Fowler CJ, Griffiths D, de Groat WC. Nat Rev Neurosci. 2008;9(6):453-466. Urine storage and micturition depend on the coordination of the bladder, bladder neck, urethra, and urethral sphincter1 Coordination between the muscles of the LUT is mediated by neural pathways in the brain, spinal cord, and peripheral nerves1

  10. A Healthy LUT Requires Neural Coordination with the Spinal Cord and Brain References: 1. Andersson KE. Nat ClinPract Urol. 2004;1(2):103-108. 2. Chancellor MB, Chartier-Kastler EJ. Neuromodulation. 2000;3(1):15-26. 3. Fowler CJ, Griffiths D, de Groat WC. Nat Rev Neurosci. 2008;9(6):453-466. 4. de Groat WC. Br J Pharmacol. 2006;147:S25-S40. 5. Leng WW, Morrisroe SN. UrolClin N Am. 2006;33:491-501. Afferentpathways convey sensory information on bladder fullness1,2 Efferent motor pathways respond, resulting in voluntary urine control3,4 Dysfunction of the afferent neural pathways alters the balance of inhibitory and excitatory stimuli critical to voluntary bladder control5

  11. Urine Storage Reflex References:1. Fowler CJ, Griffiths D, de Groat WC. Nat Rev Neurosci. 2008;9(6):453-466.2. de Groat WC. Br J Pharmacol. 2006;147:S25-S40. Low-level afferent signals are organized in the spinal cord and promote urine storage via efferent signals from the CNS1,2

  12. Urine Voiding Reflex –A Positive Feedback Loop References:1. Andersson KE. Nat ClinPract Urol. 2004;1(2):103-108. 2. Fowler CJ, Griffiths D, de Groat WC. Nat Rev Neurosci. 2008;9(6):453-466. 3.Leng WW, Morrisroe SN. UrolClin N Am. 2006;33:491-501. High afferent signals are stimulated by intravesicalpressure, resulting in increased activity to the brain1 Descending efferent pathways then cause voluntary bladder contraction and the flow of urine2 Normal voiding is, therefore, a function of a positive feedback mechanism3

  13. Dysfunction of Afferent Signaling in OAB Reference:1. Leng WW, Morrisroe SN. UrolClin N Am. 2006;33:491-501. OAB may be a result of increased, abnormal afferent activity, resulting in increased efferent signaling1 Consequently, voluntary control of micturition is compromised1

  14. Leading Theories in Mechanism of Action for Medtronic Sacral Neuromodulation

  15. Restoring Balance May Help OAB Patients Infection, inflammation, anatomic abnormalities Voluntary Micturition Control Involuntary Reflex Mechanisms Medtronic SNM Neurological diseases References: 1. Chancellor MB, Chartier-Kastler EJ. Neuromodulation. 2000;3(1):16-26. 2. Leng WW, Morrisroe SN. UrolClin N Am. 2006;33:491-501. The goal of Sacral Neuromodulation (SNM) is to modulate the abnormal involuntary reflexes of the lower urinary tract and restore voluntary control.1,2

  16. How Does Sacral Neuromodulation Work? Reference:1. Leng WW, Morrisroe SN. UrolClin N Am. 2006;33:491-501. Sacral Neuromodulation electrically stimulates somatic afferent nerves in a sacral spinal root and sends signals to the CNS that may restore normal bladder function1 Activation of somatic afferent nerves alters bladder sensory pathways and inhibits reflex bladder hyperactivity1

  17. Neurostimulator Implant Site References:1. Buback D. AORN J. 2001;73(1):176-190. Medtronic Sacral Neuromodulation sends electrical stimulation to the sacral nerve via the InterStim®System, which includes an implanted neurostimulatorand lead The sacral nerve, in particular, influences pelvic floor behavior and is believed to modulate neural reflexes1

  18. Production of Action Potentials Modulate CNS Processing of Bladder Afferent Input Reference:1.Johnson M. Watson T, ed. Electrotherapy: Evidence-Based Practice. 12th ed. Elsevier; 2008:259-286. The neurostimulator provides an electrical charge to an area near the sacral nerve, resulting in altered neural activity This stimulation likely depolarizes the nerve, causing an action potential1 The signal propagates impulses along the axon as if the neuron had naturally fired an action potential1

  19. Modulation of Abnormal AfferentActivity within CNS References:1. Johnson M. Evidence-Based Practice. 12th ed. Philadelphia, PA: Elsevier; 2008:259-286.2. Chancellor MB, Chartier-Kastler EJ. Neuromodulation. 2000;3(1):16-26. 3. Leng WW, Chancellor MB. UrolClin N Am. 2005;32:11-18. 4. van der Pal F, Heesakkers JPFA, Bemelmans BLH. CurrOpin Urol. 2006;16:261-267. The action potentials induced by electrical stimulation are thought to alterabnormal sensory input from the bladder1,2 Efferent pathways are uninhibited so as not to suppress voluntary voiding3 Unlike other therapies that target the bladder, bladder regulation occurs without directly influencing the bladder or sphincter muscles4

  20. Areas involved in micturition Normalization of Brain Activityin OAB Patients1 Areas involved in awareness and urge Reference:1. Blok BFM, Goen J, Bosch JLHR, et al. BJU Int. 2006;98:1238-1243.

  21. Conclusions OAB is a common problem with a prevalence that is expected to increase A healthy LUT is a result of a balance between sensory and motor signaling Sensory signals convey information on bladder fullness via the sacral nerve and may be altered in OAB patients Medtronic Sacral Neuromodulation delivers electrical stimulation to the sacral nerve which is thought to modulate abnormal sensory signaling Sacral Neuromodulation is correlated with more normal patterns of brain activation in OAB patients Further research into the mechanisms of action of SNM may provide insights into the pathophysiology of OAB and lead to future improvements in neuromodulationtherapies

  22. Sacral NeuromodulationMechanism of Action Current scientific evidence supports the following concepts on the effect of SNM in OAB patients: Production of action potentials that modulate central nervous system (CNS) processing of bladder afferent input Modulation of abnormal afferent (sensory) activity Normalization of brain activity Restoration of bladder function

  23. Important Safety Information InterStim® Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. The following Warning applies only to InterStim Therapy for Urinary Control: Warning: This therapy is not intended for patients with mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture. InterStim® Therapy for Bowel Control is indicated for the treatment of chronic fecal incontinence in patients who have failed or are not candidates for more conservative treatments. Contraindications for Urinary Control and for Bowel Control: Diathermy. Patients who have not demonstrated an appropriate response to test stimulation or are unable to operate the neurostimulator. Precautions/Adverse Events: For Urinary Control: Safety and effectiveness have not been established for bilateral stimulation; pregnancy, unborn fetus, and delivery; pediatric use under the age of 16; or for patients with neurological disease origins such as multiple sclerosis. For Bowel Control: Safety and effectiveness have not been established for bilateral stimulation; pregnancy, unborn fetus, and delivery; pediatric use under the age of 18; or for patients with progressive, systemic neurological diseases. For Urinary Control and for Bowel Control: The system may be affected by or adversely affect cardiac devices, electrocautery, defibrillators, ultrasonic equipment, radiation therapy, MRI, theft detectors/screening devices. Adverse events include pain at the implant sites, new pain, lead migration, infection, technical or device problems, adverse change in bowel or voiding function, and undesirable stimulation or sensations, including jolting or shock sensations. For full prescribing information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com. Product technical manual must be reviewed prior to use for detailed disclosure. USA Rx Only. Rev 0409

More Related