FRANCISCO CACERES

SERVICIO DE UROLOGIA

EMDA

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EMDA

Administracin de frmacos por

va sistmica.

Produce efectos txicos no

deseados en otros rganos.

Altas concentraciones al lugar elegido

IONTOFORESIS

Tcnica de aplicacin transcutanea de sustancias frmacos, mediante la corriente elctrica que utiliza sus iones (ioniza) y molculas para conseguir una mayor penetracin en tiempo y profundidad en los tejidos.

Estudios demuestran que la concentracin del frmaco es 800 veces mayor que una aplicacin tpica

EMDA

ELECTROSMOSIS

Transporte de solutos no ionizados (partculas de la dilucin) que a travs de la solucin aparece con la iontoforesis.

EMDA : iontoforesis+electro-osmosis transporta los elementos ionizados y no ionizados del

frmaco

EMDA

EMDA

Maquina Physionizer 3.0

Sencilla programacin guardando la ultima en memoria

Energa por 10 pilas (porttil)

Posibilidad de corriente pulsada continua

Reglaje de intensidad de 0 a 30 mA

Mximo voltaje de 55 Voltios

Sistema de seguridad ante sobrecarga, calentamiento fallo

Aviso de bateras bajas, error de conexiones

EMDA

CATETER URETROVESICAL

Catter de silicona de 16 Fr. con alma de plata

Baln de anclaje en cuello con 4 ml de aire

Toma positiva al aparato

Puerto de perfusin del frmaco

Puerto de baln

Conexin +

Puerto del frmaco

Baln

Orificios

EMDA

INDICACIONES

Androloga

Oncologa

Cistopatas complejas

Patologa prosttica

E. Peyronie

Tumores de vejiga

Vejiga espstica, hiperactiva Cistitis recurrentes Cistitis intersticial

Prostatitis recurrentes Prostatitis infecciosa

EMDA

OBJETIVO TERAPIA ENDOVESICAL

EVITAR IMPLANTACION

POST-RTU

ERRADICAR ENFERMEDAD

RESIDUAL

PREVENIR

RECURRENCIA TUMORAL

RETRASAR O REDUCIR LA

PROGRESION

NEO VESICAL

NEO VESICAL

Sylvester RJ, Oosterlinck W, van der Mejiden APM. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer:a meta-analysis of published results of randomized clinical trials.J Urol 2004; 171: 218690.

NEO VESICAL

Sylvester RJ, Oosterlinck W, van der Mejiden APM. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer:a meta-analysis of published results of randomized clinical trials.J Urol 2004; 171: 218690.

Note: Electronic calculators for Tables 6 and 7, which have been updated for the iPhone, iPad and Android phones and tablets, are available at http://www.eortc.be/tools/bladdercalculator/.

NEO VESICAL

NEO VESICAL

INMUNOTERAPIA

TERAPIA ADYUVANTE

BCG

Reaccin inmunolgica

Apoptosis celular

Mecanismo antitumoral

Eficacia

Nivel IL-8

Di Stasi SM, Giannantoni A, Giurioli A, et al. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. Lancet Oncol 2006;7:4351.

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QUIMIOTERAPIA

MMC

Destruccin clulas tumorales

circulantes

Evita implantes tumorales

Erradicacin de focos tumorales

Produccin superxido

Unin al DNA

Bloquea sntesis

Di Stasi SM, Giannantoni A, Giurioli A, et al. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. Lancet Oncol 2006;7:4351.

In 2008 an estimated 386 300 cases were diagnosed

Newly diagnosed bladder cancer cases

7585% present as non-muscle invasive disease

confined to the urothelium (stage Ta)

lamina propria (stage T1)

carcinoma in situ (stage Tis)

NEO VESICAL

RECIDIVA

Celulas tumorales

Durante la reseccin

Circulantes Nuevos

implantes

NEO VESICAL

Recidivas 31-78 %

Instilacin inmediata despus de RTU

Weldon TE, Soloway MS. Susceptibility of urothelium to neoplastic cellular implantation. Urology 1975; 5: 82427

NEO VESICAL

Patients received 40 mg mitomycin

Dissolved in 50 mL sterile water

within 6 h of TURBT.

Retained in the bladder for 60 min with catheter clamping

Continuous intravesical irrigation with saline for 8 h

Mitomycin immediately after TURBT

Sylvester RJ, Oosterlinck W, van der Mejiden APM. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer:a meta-analysis of published results of randomized clinical trials.J Urol 2004; 171: 218690.

NEO VESICAL

Sylvester RJ, Oosterlinck W, van der Mejiden APM. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer:a meta-analysis of published results of randomized clinical trials.J Urol 2004; 171: 218690.

Pre-TURBT intravesical EMDA

Mitomycin 30 min before anaesthesia

40 mg mitomycin

Dissolved in 100 mL sterile water

Retained in the bladder for 30 min

While 20 mA pulsed electric current for 30 min was given externally.

EMDA

Controlled electric

Intravesical electrode

Electrodes (on skin of the lower abdomen).

NEO VESICAL

TERAPIA VESICAL ADYUVANTE

low-risk

No adjuvant intravesical therapy

Intermediate-risk

3 weeks after TURBT

40 mg PD mitomycin

Once a week for 6 weeks

High-risk

Initial intravesical treatment of 81 mg BCG

Retained in the bladder for 120 min

once a week for 6 weeks

Sylvester RJ, Oosterlinck W, van der Mejiden APM. A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer:a meta-analysis of published results of randomized clinical trials.J Urol 2004; 171: 218690.

NEO VESICAL

INTERVALO LIBRE DE ENFERMEDAD

NEO VESICAL

Supone un considerable avance aplicar EMDA antes de una reseccin transuretral, ya que la perforacin de la vejiga con su consecuente extravasacin del frmaco no es una preocupacin. El incremento de concentracin y profundidad de la mitomicina en las paredes de la vejiga, que potencialmente previenen el sembrado de clulas tumorales, parece ser la explicacin ms acertada de estos excelentes resultados.

Oosterlinck, W. Nat Rev. Clin. Oncol, advanced online publication 13 September 2011; dol:10.1038/nrelinone.2011.140

EMDA presenta menor tasa de recurrencia p

ALTO RIESGO + BCG

Di Stasi SM, Giannantoni A, Giurioli A, et al. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomised controlled trial. Lancet Oncol 2006;7:4351.

ALTO RIESGO + BCG

Sequential BCG and electromotive

mitomycin versus BCG

alone for high-risk superficial bladder

cancer: a randomised

controlled trial

Savino M Di Stasi, Antonella Giannantoni, Arcangelo Giurioli, Marco Valenti, Germano

Zampa, Luigi Storti, Francesco Attisani, Andrea De Carolis,

Giovanni Capelli, Giuseppe Vespasiani, Robert L Stephen*

Lancet Oncol 2006; 7: 4351

ALTO RIESGO + BCG

El estudio con 16 aos de seguimiento compara los siguientes protocolos de tratamientos:

I. Solo BCG 81 mg BCG una vez por semana durante 6 semanas seguido por una vez por mes durante 10 meses.

Total tratamientos:

16 tratamientos con BCG

ALTO RIESGO + BCG

II. BCG con EMDA MMC 2 semanales de 81 mg BCG seguido por 3 semanales de 40 mg MMC con EMDA + 2 mensuales de 40 mg MMC seguido por 3 mensuales de 81 mg BCG.

Total tratamientos: 5 tratamientos de BCG y 5 tratamientos de EMDA MMC =

10 tratamientos total

ALTO RIESGO + BCG

BCG SOLO BCG/EMDA MMC % recidiva 62% 45% #meses hasta recurrencia 26 meses 79 meses % progresin 28% 12% % mortalidad por 23% 9% patologa

ALTO RIESGO + BCG

Savino Mauro Di Stasi*, Cristian Verri, Emanuele Liberati, Rome, Italy, Francesco Masedu, L'Aquila, Italy, Luca Topazio, Rome, Italy, Marco Valenti, L'Aquila, Italy

In patients with stage pT1 urothelial bladder cancer

intravesical BCG combined with electromotive mitomycin provided better results than BCG alone in terms of higher response rates and longer remission

times.

Savino Mauro Di Stasi*, Cristian Verri, Emanuele Liberati, Rome, Italy, Francesco Masedu, L'Aquila, Italy, Luca Topazio, Rome, Italy, Marco Valenti, L'Aquila, Italy

ALTO RIESGO + BCG

poldarkcaceres@gmail.com

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