Elsevier

Urology

Volume 76, Issue 1, July 2010, Pages 225-230
Urology

Voiding Function and Dysfunction
Intravesical Injections of Botulinum Toxin Type A for Management of Neuropathic Bladder: A Comparison of Two Methods

https://doi.org/10.1016/j.urology.2009.09.087Get rights and content

Objectives

To evaluate and compare the efficacy of botulinum toxin intravesical injections with and without injections in external urethral sphincter in treating bladder hyper-reflexia in children suffering from myelomeningocele.

Methods

A total of 60 patients with bladder hyper-reflexia due to myelomeningocele were randomly allocated to treatment groups A and B and were followed up for 6 months. Under cystoscopic guidance, 10 IU/kg of botulinum toxin A was injected into the detrusor muscle, sparing the trigone and ureteral orifices in group A. Group B received 8 IU/kg of toxin via the same method compared with group A and 2 IU/kg of toxin through 4 injections in external urethral sphincter. Conventional urodynamics, daily incontinence score, constipation, and creatinine level were evaluated at baseline, 3 months, and 6 months after intervention. Vesicoureteral reflux was also assessed before and after 3 months of injections.

Results

All patients showed significant improvement in bladder capacity (P <.01), maximal detrusor pressure (P <.01), and detrusor-sphincter dyssynergia (P <.01) after 3 and 6 months of receiving injections. Significant improvement in postvoiding residual volume was observed only among patients of group B (P <.05). Both methods resulted in a significant reduction in daily incontinence grade, constipation, and vesicoureteral reflux (P <.05), but comparison between the study groups showed better outcomes for group B in relation to incontinency, constipation, vesicoureteral reflux, and creatinine level.

Conclusions

Botulinum toxin type A injections in both sphincter and detrusor seems to have extra benefits such as decreasing postvoiding residual volume and more symptom diminution compared with intradetrusal injections alone.

Section snippets

Material and Methods

An interventional, single-center, prospective, double-blind, randomized study was conducted to assess the efficacy and durability of botulinum toxin type A injections in detrusor alone vs injections in both detrusor and external urethral sphincter. Children with MMC who attended a medical center in Tehran from August 2007 to September 2008 were the patients in this study.

General Findings

The study included 60 patients with MMC in whom we had no success on previous management with anticholinergic medications and clean intermittent catheterization, hyper-reflexive neurogenic bladder, vesicourethral reflux, and urinary incontinency, from August 2007 to September 2008. Using block randomization, all patients were assigned to one of the treatment groups.

The mean age (± standard deviation) for group A was 6.58 years (± 2.53) and 6.71 years (± 3.23) for group B. There were no

Comment

Neuropathic bladder abnormalities in patients with MMC require treatment for preservation of the upper urinary tract, bladder continence, autonomy, and social integration. The mainstay of treatment includes clean intermittent catheterization and anticholinergic medication for urinary incontinency. A minority of children will not respond to conservative therapy and will ultimately require surgical intervention. We have previously reported our surgical experience in the management of neuropathic

Conclusions

In conclusion, botulinum toxin type A intravesical injections seem to be safe and partially effective in patients with MMC and nonresponders to medical management and our results point toward a better short-term outcome for intradetrusal and intrasphincter injections together compared with intradetrusal injections.

References (27)

Cited by (32)

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    The limited number of studies presenting comparable data meant there were minimal comparisons to be made between the high and low LE studies in children for OAB and DSD. However, three LE 2 studies showed significant improvements in children with NDO in terms of improvement in MCC by 50% and a reduction in MDP by 50% [32–34]. The data on children still remains of low quality; higher LE studies are necessary before more definitive conclusions can be reached.

  • Evidence-based review and assessment of botulinum neurotoxin for the treatment of urologic conditions

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    The technique for administration was transperineal injection under cystoscopic guidance. The Class I study and one of the Class II studies (de Seze et al., 2002; Gallien et al., 2005) used a dose of 100 U of A/Ona, one Class II study (Dykstra and Sidi, 1990) used doses of 140 and 240 U of A/Ona, and one Class II study (Safari et al., 2010) involving children with myelomeningocele compared two doses of A/Abo: 10 U/kg into bladder vs. 8 U/kg into bladder plus 2 U/kg into external urethral sphincter. The Dykstra study was deemed Class II because only 5 patients were studied and no rationale for administering two doses in the active-treatment arm was provided.

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This project has been supported by a research grant from Tehran University of Medical Sciences.

Abdol-Mohammad Kajbafzadeh, Hamid Arshadi and Farideh Nejat take the responsibility for data integrity and accuracy and both were involved in patient selection, management, and data acquisition. Saeed Safari and Sarah Jamali were involved in study management and conducting blind allocation. They also reviewed the manuscript content for intellectual content. Peiman Habibollahi analyzed and interpreted the data and drafted the manuscript.

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