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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
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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
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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
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EMDA
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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
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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
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INDICACIONES
Androloga
Oncologa
Cistopatas complejas
Patologa prosttica
E. Peyronie
Tumores de vejiga
Vejiga espstica, hiperactiva Cistitis recurrentes Cistitis intersticial
Prostatitis recurrentes Prostatitis infecciosa
EMDA
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OBJETIVO TERAPIA ENDOVESICAL
EVITAR IMPLANTACION
POST-RTU
ERRADICAR ENFERMEDAD
RESIDUAL
PREVENIR
RECURRENCIA TUMORAL
RETRASAR O REDUCIR LA
PROGRESION
NEO VESICAL
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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.
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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/.
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NEO VESICAL
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NEO VESICAL
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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.
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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
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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
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NEO VESICAL
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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
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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
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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
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INTERVALO LIBRE DE ENFERMEDAD
NEO VESICAL
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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
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EMDA presenta menor tasa de recurrencia p
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ALTO RIESGO + BCG
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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
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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
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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
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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
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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
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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
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