An updated systematic review and statistical comparison of standardised mean outcomes for the use of botulinum toxin in the management of lower urinary tract disorders

Adolescence transitional care in neurogenic detrusor overactivity and the use of OnabotulinumtoxinA: A clinical algorithm from an Italian consensus statement

AIMS

OnabotulinumtoxinA (onaBNTa) for treating neurogenic detrusor overactivity (NDO) is widely used after its regulatory approval in adults. Although the administration of onaBNTa is still considered off-label in children, data have already been reported on its efficacy and safety. Nowadays, there is a lack of standardized protocols for treatment of NDO with onaBNTa in adolescent patients in their transition from the childhood to the adult age. With the aim to address this issue a consensus panel was obtained.

METHODS

A panel of leading urologists and urogynaecologists skilled in functional urology, neuro-urology, urogynaecology, and pediatric urology participated in a consensus-forming project using a Delphi method to reach national consensus on NDO-onaBNTa treatment in adolescence transitional care.

RESULTS

In total, 11 experts participated. All panelists participated in the four phases of the consensus process. Consensus was reached if ≥70% of the experts agreed on recommendations. To facilitate a common understanding among all experts, a face-to-face consensus meeting was held in Rome in march 2015 and then with a follow-up teleconference in march 2017. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed.

CONCLUSIONS

This manuscript represents the first report on the onaBNTa in adolescents. Young adults should be treated as a distinct sub-population in policy, planning, programming, and research, as strongly sustained by national public health care. This consensus and the algorithm could support multidisciplinary communication, reduce the extent of variations in clinical practice and optimize clinical decision making.

OnabotulinumtoxinA in urinary incontinence: Prospective Study of a Case Series

OBJECTIVE

To assess the safety and efficacy of a single intravesical injection of onabotulinumtoxinA (OnaBTA) for treating urge urinary incontinence (UUI) in women.

METHOD

We performed a prospective case-series study of consecutive patients with refractory UUI treated with an intravesical injection of OnaBTA. The patients were administered 100 units of OnaBTA injected into the bladder wall following 4 weeks of flushing with anticholinergic agents or beta 3 agonists. The urodynamic and clinical endpoints were evaluated before and 6 months after the injection of OnaBTA. The primary study endpoint was the number of episodes of urinary leakage.

RESULTS

A total of 204 of the 210 selected patients conducted a valid visit 6 months after the therapeutic application. At 6 months of treatment with OnaBTA, 110 (53.9%) patients remained continent and were considered a success. However, 57 (27.9%) patients experienced one episode of urinary leakage per day, and 37 (18.2%) had 2 or more. In terms of the urodynamic parameters, we observed the following changes: increase in maximum bladder capacity (P<.0001) and reduced maximum pressure of the detrusor (P<.0001). In terms of the safety profile, 8 (3.9%) patients had self-limiting haematuria during the procedure, which resolved spontaneously, and 9 (4.4%) patients had acute urinary retention that required intermittent catheterisation.

CONCLUSIONS

This study supports the use of OnabotulinumtoxinA in patients with urge urinary incontinence that does not respond to medical treatment.

Overactive bladder treatment: application of methylene blue to improve the injection technique of onabotulinum toxin A

OBJECTIVE

The aim of this study was to test the addition of methylene blue (MB) to onabotulinum toxin A (BTX-A) solution in overactive bladder (OAB) treatment, as a means of facilitating observation of the injection site and assessing the distribution of the drug under the bladder mucosa during injection. Pharmacological interactions between BTX-A and MB were also evaluated.

MATERIALS AND METHODS

The study was conducted between December 2014 and April 2016 on 30 patients: six males and 24 females (median age 57.7, range 23-80 years) diagnosed with OAB, who qualified for intravesical BTX-A injection. Each received 100 IU of BTX-A (Botox^®; Allergan), dissolved in 9.5 ml of 0.9% NaCl with the addition of 0.5 ml of MB. Cystoscopy with submucosal injection of the solution was performed systematically, including the bladder triangle. For pharmacological evaluation, quantitative determination of MB was performed on a capillary electrophoresis system with diode array detection.

RESULTS

In the course of 600 injections, the addition of MB facilitated the observation of the procedure; the exact distribution of the solution could not be observed in only 43 injections in seven patients. The range of distribution of the drug varied from 1 to 2.5 cm. Pharmacological evaluation based on visual observations and experiments showed that pharmaceutical interactions do not occur between MB and this commercially available formulation of BTX-A.

CONCLUSIONS

Applying a coloured solution of BTX-A significantly facilitates observation of the procedure and assessment of drug distribution. There are no pharmaceutical interactions between MB and BTX-A.

Recent research on the role of urodynamic study in the diagnosis and treatment of male lower urinary tract symptoms and urinary incontinence

Although evidence shows that urodynamic study may not improve outcomes, it can be used to evaluate men with lower urinary tract symptoms (LUTSs) which have not been adequately delineated and treated. In young men with LUTS not responding to treatment based on clinical examination, or elderly men with LUTS and incontinence, a complete urodynamic evaluation is mandatory to understand the pathophysiology underlying LUTS, such as bladder outlet obstruction (BOO), detrusor overactivity, and detrusor underactivity. Preoperative urodynamic study-proven BOO is a predictor of a successful surgical outcome. An urodynamic study should be performed when patients with LUTS are planning to undergo surgical treatment for benign prostatic obstruction.

Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies

The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

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Zusammenfassung. Die funktionelle Urologie befasst sich mit der Diagnostik und Therapie von Störungen der Harnblasen- und Beckenbodenfunktion und der Harninkontinenz. Die urodynamische Funktionsdiagnostik als zentrale diagnostische Methode ermöglicht durch die Messung einfacher physiologischer Parameter eine direkte Beurteilung der Funktion des unteren Harntraktes. Die Urodynamik dient dazu, klinische Symptome quantitativ zu reproduzieren, die Änderung physiologischer Parameter während der Messung in einen pathophysiologischen Zusammenhang zu stellen, eine Diagnose abzuleiten, eine Behandlung einzuleiten und im Verlauf deren Erfolg zu kontrollieren. Facetten der funktionellen Urologie sind die Neurourologie, die Urologie der Frau, die funktionelle Kinderurologie, die psychosomatische Urologie und die Behandlung der Harninkontinenz bei Frauen und Männern jeglichen Alters.

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Zusammenfassung. Dieser Übersichtsartikel beleuchtet den aktuellen Kenntnisstand zur Ätiologie, Diagnostik und Therapie der Harninkontinenz des Mannes. In der Ätiologie der Harninkontinenz beim Mann spielt die radikale Prostatektomie eine herausragende Rolle, aber auch das benigne Prostatasyndrom, neurologische Erkrankungen oder metabolische Störungen können zu einer Harninkontinenz beim Mann führen. In der Diagnostik ist neben der Basisdiagnostik eine qualifizierte urodynamische Beurteilung unabdingbar, um die zugrunde liegenden pathophysiologischen Mechanismen aufzudecken und Chancen und Risiken der verfügbaren Therapie- bzw. Operationstechniken abschätzen zu können. Die Primärtherapie der Harninkontinenz beim Mann ist konservativ und schliesst eine qualifizierte Beckenboden- und Sphinktertherapie einschliesslich Biofeedback ein. Die Auswahl der operativen Techniken unterliegt dem Ausmass der Inkontinenz, den individuellen Gegebenheiten des Patienten, der Patientenpräferenz, der Expertise des Operateurs und einzelnen Kontraindikationen für bestimmte Verfahren. Auch ein längeres Intervall nach radikaler Prostatektomie oder ein Tumorprogress sind keine Ausschlusskriterien für eine operative Therapie. Der oft hohe Leidensdruck und das breite Spektrum von in geübten Händen wenig invasiven Operationstechniken rechtfertigen eine breite Indikationsstellung für eine prothetische Versorgung.

[Minimally invasive treatment of benign prostatic hyperplasia]

Novel minimally invasive treatment options for the management of male lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) aim to provide equal efficacy compared to standard techniques with a more favourable safety profile. The preservation of all aspects of male sexual function including antegrade ejaculation is increasingly important to patients. It should be ideally performed in an outpatient setting under local anesthesia to assure a short recovery time. Novel injectables for intraprostatic application (botulinum neurotoxin A, NX-1207, PRX302) have emerged and first phase III results could not confirm the promising initial data. For mechanical devices like Urolift® the early and mid-term benefits demonstrate a rapid and durable symptom relief without compromising sexual function. Novel innovative procedures like aquablation (AquaBeam®) are entering the scene, but their feasibility, efficacy and safety still need to be addressed in randomized controlled trials.

Supraspinal Projection of Serotonergic and Noradrenergic Pathways Modulates Nociceptive Transmission in the Lower Urinary Tract of Rats

OBJECTIVES

To investigate the effect of descending serotonergic and noradrenergic pathways on nociception in the lower urinary tract (LUT).

METHODS

Female Sprague-Dawley rats were used. Following intraperitoneal administration of Vehicle or Milnacipran (30 mg/kg), which is one of serotonin-noradrenaline reuptake inhibitors (SNRI), 0.1% AA was infused into the bladder in normal (n = 4, each) and spinal cord injury (SCI) (n = 4, each) rats for 2 h on consciousness, and c-Fos, 5-HT and DβH were stained using immunohistochemistry at the L6 spinal cord as spinal areas associated with LUT.

RESULTS

In SCI rats, 5-HT or DβH-positive fibers were not observed at the L6 spinal cord, while there were many 5-HT and DβH-positive fibers in normal rats. The total number of c-Fos-positive cells was significantly increased in SCI rats compared to Normal rats (209.4 ± 7.1 in Normal, 336.4 ± 28.9 in SCI, P < 0.05), which indicated that interruption of supraspinal modulation enhances nocieptive transmission in the LUT. Regarding the effect of Milnacipran administration, the number of c-Fos-positive cells was significantly decreased at all region of the L6 spinal cord in normal rats (P < 0.05), while this reduction was not observed in SCI rats. This result demonstrated that administration of SNRI attenuates nocieptive transmission in the LUT, indicating that 5-HT and noradrenaline work as mediators of endogenous analgesic mechanisms through the supraspinal descending pain pathways.

CONCLUSIONS

Supraspinal projections of descending serotonergic and noradrenergic pathways to the lower lumbar spinal cord modulate nocieptive transmission in the LUT. Administration of SNRI attenuates nocieptive transmission in the LUT, which could result from enhancement of modulating descending serotonergic and noradrenergic pathways.

Antibiotic prophylaxis may not be necessary in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections for neurogenic detrusor overactivity

Many of the patients undergoing intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity (NDO) present with chronic bacteriuria. In these patients, antibiotic prophylaxis has been widely recommended since bacteriuria might impair treatment efficacy and cause urinary tract infections (UTI) but the evidence is limited. The aim of this study was to evaluate if an antibiotic prophylaxis is needed in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections. Between 06/2012 and 12/2014, a consecutive series of 154 patients undergoing a total of 273 treatment cycles were prospectively evaluated. Before treatment urine samples were collected, patients with no clinical signs for UTI underwent onabotulinumtoxinA injections, no antibiotic prophylaxis was given. Asymptomatic bacteriuria was found in 73% (200/273 treatments). Following treatment, UTI occurred in 5% (9/200) and 7% (5/73) of patients with and without bacteriuria, respectively. Intradetrusor onabotulinumtoxinA injections were clinically and urodynamically successful in 70% (192/273). There was no association between bacteriuria and treatment-related adverse events (odds ratio 0.64, 95% CI 0.23–1.81, p = 0.4) nor between bacteriuria and therapy failure (odds ratio 0.78, 95% CI 0.43–1.43, p = 0.4). Thus, we conclude that antibiotic prophylaxis needs to be critically reconsidered in patients undergoing intradetrusor onabotulinumtoxinA injections, especially taking into account the alarming antibiotic resistance worldwide.

OnabotulinumtoxinA in the treatment of overactive bladder: a cost-effectiveness analysis versus best supportive care in England and Wales

The cost-effectiveness of onabotulinumtoxinA (BOTOX(®)) 100 U + best supportive care (BSC) was compared with BSC alone in the management of idiopathic overactive bladder in adult patients who are not adequately managed with anticholinergics. BSC included incontinence pads and, for a proportion of patients, anticholinergics and/or occasional clean intermittent catheterisation. A five-state Markov model was used to estimate total costs and outcomes over a 10-year period. The cohort was based on data from two placebo-controlled trials and a long-term extension study of onabotulinumtoxinA. After discontinuation of initial treatment, a proportion of patients progressed to downstream sacral nerve stimulation (SNS). Cost and resource use was estimated from a National Health Service perspective in England and Wales using relevant reference sources for 2012 or 2013. Results showed that onabotulinumtoxinA was associated with lower costs and greater health benefits than BSC in the base case, with probabilistic sensitivity analysis indicating an 89 % probability that the incremental cost-effectiveness ratio would fall below £20,000. OnabotulinumtoxinA remained dominant over BSC in all but two scenarios tested; it was also economically dominant when compared directly with SNS therapy. In conclusion, onabotulinumtoxinA appears to be a cost-effective treatment for overactive bladder compared with BSC alone.

Botulinun A toxin urethral sphincter injection for neurogenic or nonneurogenic voiding dysfunction

Voiding dysfunction due to detrusor underactivity or urethral sphincter dysfunction is a treatment challenge for urologists. Recently, urologists have used botulinum toxin A (BoNT-A) injection into the urethral sphincter to treat voiding dysfunction. This treatment has been found to decrease urethral pressure and postvoid residual volume, and increase voiding efficiency in patients with neurogenic detrusor sphincter dyssynergia, nonneurogenic dysfunctional voiding, and detrusor underactivity. Although not all patients can achieve excellent therapeutic outcomes, patients with idiopathic detrusor underactivity might have recovery of detrusor contractility after urethral sphincter BoNT-A injection. However, urinary incontinence might be a de novo adverse event after treatment. Repeat urethral injection is necessary to maintain therapeutic efficacy. Patients should be fully informed of the limited therapeutic efficacy and possible adverse events prior to treatment. This article reviews recent studies of urethral sphincter BoNT-A treatment for voiding dysfunction.

Urothelial ATP signaling: what is its role in bladder sensation?

AIM

Bladder functional disorders are common health problems; however, their pathologies are poorly understood. Adenosine triphosphate (ATP) released from the urothelium has been suggested to have an essential role in the micturition reflex, and its involvement in bladder functional disorders has been intensively investigated. Here, we review the latest advances in research on urothelial ATP signaling.

METHODS

We reviewed research articles on the role of the urothelium and urothelial ATP release in bladder function.

RESULTS

Mice lacking purinergic receptors have been reported to exhibit marked bladder hyporeflexia. Based on this observation, it was commonly believed, according to the widely held ATP urothelial signaling theory, that stretch-induced urothelial ATP release mediates the sensation of bladder filling via purinergic receptors. However, recent studies employing novel experimental methods and approaches have demonstrated that there are no significant differences in bladder function between wild-type and purinergic receptor knockout mice under physiological conditions. Nonetheless, under pathological conditions, inhibition of purinergic receptors has been shown to improve bladder hyperactivity. Moreover, enhanced urothelial ATP release has been reported in patients with bladder functional disorders.

CONCLUSIONS

Recently, conflicting evidence has led us to question the role of urothelial ATP signaling in normal micturition reflex. In contrast, under pathological conditions, it seems likely that enhanced urothelial ATP signaling mediates bladder hyperactivity. These recent findings suggest that the urothelial ATP signaling pathway is a potential therapeutic target for bladder functional disorders.

Long-term follow-up of intravesical botulinum toxin-A injections in women with idiopathic overactive bladder symptoms

INTRODUCTION

Intravesical botulinum toxin (BoNT-A) is a safe and effective treatment for overactive bladder syndrome. There are many reports on the clinical experience with BoNT-A, especially in patients with neurogenic detrusor overactivity. The US Food and Drug Administration has recently approved its use for idiopathic overactive bladder (iOAB). Various studies have reported positive results for iOAB in the short-term. Yet little is known about the results after repeated BoNT-A injections. In this study, we evaluated the long-term results of botulinum toxin (BoNT-A) in women with iOAB.

METHODS

Patients treated with BoNT-A from 2004 until 2009 were evaluated in a non-academic teaching hospital (Zuyderland MC, Heerlen, the Netherlands). All female patients with a follow-up of >5 years with idiopathic bladder dysfunction were included. All patients received 200 U of onabotulinum toxin-A in 20 intradetrusor injections. In some patients, we applied a dose adjustment for repeated injections. Patients were instructed how to use clean intermittent self-catheterization (CISC) before the treatment. We advised patients to commence CISC if post-void residual exceeded 150 ml.

RESULTS

A total of 128 women were included. All patients had at least 5-year follow-up after their first injection. The mean follow-up was 97 (60-125) months. The mean age was 67 (46-88) years. Of all patients, 30 % were still on BoNT-A treatment at the last follow-up visit. Of the 70 % that discontinued treatment, 27 % had insufficient effect and 43 % had tolerability issues. Most patients discontinued treatment after the first (79 %) and second (19 %) injections. Only 2 % of patients discontinued treatment after more than two injections during follow-up.

CONCLUSION

Intravesical BoNT-A is an effective treatment for women with idiopathic OAB. However, in time, almost two-thirds of patients in our study discontinued therapy. Most patients discontinue treatment after one or two injections and mainly due to tolerability issues.

Reduction in Bladder-Related Autonomic Dysreflexia after OnabotulinumtoxinA Treatment in Spinal Cord Injury

Bladder-related events, including neurogenic detrusor overactivity, are the leading cause of autonomic dysreflexia in spinal cord injured individuals. Self-reported autonomic dysreflexia is reduced following onabotulinumtoxinA treatment for neurogenic detrusor overactivity; however, none of these trials have assessed autonomic dysreflexia events using the clinical cutoff of an increase in systolic blood pressure ≥20 mm Hg. This study used a prospective, open-labelled design from 2013 to 2014 to quantitatively assess the efficacy of one cycle 200 U intradetrusor-injected onabotulinumtoxinA (20 sites) on reducing the severity and frequency of bladder-related autonomic dysreflexia events and improving quality of life. Twelve men and five women with chronic, traumatic spinal cord injuries at or above the sixth thoracic level, and concomitant autonomic dysreflexia and neurogenic detrusor overactivity, underwent blood pressure monitoring during urodynamics and over a 24 h period using ambulatory blood pressure monitoring pre- and 1 month post-treatment. Post-onabotulinumtoxinA, autonomic dysreflexia severity was reduced during urodynamics (systolic blood pressure increase: 42 ± 23 mm Hg vs. 20 ± 10 mm Hg, p < 0.001) and during bladder-related events across the 24 h period (systolic blood pressure increase: 49 ± 2 mm Hg vs. 26 ± 22 mm Hg, p = 0.004). Frequency of 24 h bladder-related autonomic dysreflexia events was also decreased post-onabotulinumtoxinA (4 ± 2 events vs. 1 ± 1 events, p < 0.001). Autonomic dysreflexia and incontinence quality of life indices were also improved post-onabotulinumtoxinA (p < 0.05). Intradetrusor injections of onabotulinumtoxinA for the management of neurogenic detrusor overactivity in individuals with high level spinal cord injuries decreased the severity and frequency of bladder-related episodes of autonomic dysreflexia, and improved bladder function and quality of life.

OnabotulinumtoxinA in overactive bladder: Evidence-based consensus recommendations

OBJECTIVE

To offer a set of useful recommendations for urologists who are starting to provide treatment of overactive bladders with onabotulinumtoxinA.

METHODS

A literature search to December 2013 was conducted, as well as a subsequent critical reading of the selected publications. The coordinators prepared a document that was submitted for review by the members of the Spanish Group for the use of Botulinum Toxin in Urology.

RESULTS

The expert group considered that onabotulinumtoxinA may be used for overactive bladder syndrome with urinary urge incontinence secondary to neurogenic or idiopathic detrusor overactivity for patients for whom conservative treatment and first-line medical treatment has failed, is not tolerated or is contraindicated. Treatment in most cases was performed with local intravesical anesthesia, although it can also be performed under epidural or general anesthesia. Patients must be informed of the possibility of requiring self-catheterization or temporary catheterization. Clinicians should ensure that the patients are capable of performing this catheterization before the treatment is conducted. Patients must also be informed of the need for antibiotic prophylaxis to reduce the risk of urinary tract infections. At least 2 follow-up visits are recommended: the first at days 7-14 after the injection and the second at 2-3 months. Reinjection is indicated when the effect of the treatment decreases.

CONCLUSION

These guidelines can help clinicians in their daily decisions and limit the potential risks associated with the incorrect use of the drug.

Use of Botulinum Toxin A in the Treatment of Lower Urinary Tract Disorders: A Review of the Literature

Botulinum neurotoxin (BoNT) is used to treat a variety of ailments, and its therapeutic application in lower urinary tract disorders (LUTDs) is well studied. Robust evidence supporting the efficacy and tolerability of BoNT in the treatment of neurogenic detrusor overactivity (NDO) and non-neurogenic overactive bladder (OAB) has led to regulatory approval for these conditions. Use of BoNT in the treatment of interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and detrusor sphincter dyssynergia has demonstrated some promise, but is still evolving and off-label for these indications. Trials to date do not support the use of BoNT for benign prostatic hyperplasia. This comprehensive review outlines the mechanisms of BoNT in the treatment of LUTDs in adults and presents background and updated data examining the efficacy and adverse events associated with the use of BoNT in common urologic applications.

The management of overactive bladder: percutaneous tibial nerve stimulation, sacral nerve stimulation, or botulinum toxin?

PURPOSE OF REVIEW

We have reviewed the evidence published on botulinum toxin A (BoNT/A), percutaneous tibial nerve stimulation (PTNS), and sacral nerve stimulation (SNS) in the management of overactive bladder (OAB).

RECENT FINDINGS

BoNT/A is effective irrespectively of the number of previous anticholinergic treatments and of the reason for failure. Doses up to 360U 3-monthly are well tolerated. BoNT/A is well tolerated and effective also in the pediatric population. Bladder instillation of liposome encapsulated BoNT/A is a new approach, deserving further research. When using PTNS, motor response from the electrical stimulus is not required, a sensory response suffices. PTNS has a lasting effect compared to oxybutynin alone. SNS is superior to standard medical treatment but the combination of SNS and anticholinergics is more effective than anticholinergic alone.

SUMMARY

The evidence published in the last 18 months has increased the level of evidence on safety and effectiveness of BoNT/A, PTNS, and SNS in the management of OAB. BoNT/A is now recommended as standard third-line treatment for OAB (in the USA) and urgency incontinence (in the USA and in Europe) in selected patients refractory to pharmacological therapy. All available third-line treatment options for OAB/urgency urinary incontinence should be offered before surgery is contemplated.

VIDEO ABSTRACT

http://links.lww.com/COU/A7.

Treatment of painful bladder syndrome/interstitial cystitis with botulinum toxin A: why isn't it effective in all patients?

Botulinum toxin A (BTA) is currently used to treat a variety of painful disorders, including painful bladder syndrome/interstitial cystitis (PBS/IC). However, BTA is not consistently effective in all patients. This may be due to the disparity of causes of pain, but this may also relate to the processes by which BTA exerts anti-nociceptive effects. This review discusses mechanisms by which BTA may inhibit pain and studies of the use of BTA in PSB/IC patients. It is doubtful that any single treatment will effectively control pain in PBS/IC patients, and it is highly probable that multiple strategies will be required, both within individual patients and across the population of PBS/IC patients. The purpose of this review is to discuss those mechanisms by which BTA acts, with the intent that alternative strategies exploiting these mechanism, or work through alternative pathways, can be identified to more effectively treat pain in PBS/IC patients in the future.

Practical Aspects of Botulinum Toxin-A Treatment in Patients With Overactive Bladder Syndrome

Intravesical onabotulinumtoxinA (BoNT-A) injection is an effective treatment for overactive bladder syndrome (OAB) that is refractory to antimuscarinics. An injectable dose of 100 U has been suggested to achieve the optimal balance of benefit and safety in patients with OAB. BoNT-A (total volume of 10 mL) was administered as evenly distributed intradetrusor injections (5 U) across 20 sites approximately 1 cm apart (0.5 mL per site) using a flexible or rigid cystoscope. Treatment with BoNT-A was generally well tolerated by most patients, and most treatment-related adverse events were localized to the urinary tract. The prevalence of OAB increases with age, and elderly patients are more vulnerable to complications. The short-term efficacy of intravesical BoNT-A injection for refractory OAB with no treatment-related complications in the elderly population has been documented. Frail elderly patients can experience the same treatment results, such as significantly improved urgent urinary incontinence and quality of life, as young and nonfrail elderly patients with 100-U BoNT-A injections. However, increased risk of larger postvoid residual (PVR) urine and lower long-term success rates were noted in frail elderly patients; around 11% had acute urinary retention, while 60% had PVR urine volume >150 mL after treatment. In addition, intravesical injection of BoNT-A effectively decreased urgency symptoms in elderly patients with OAB and central nervous system lesions. The adverse effects were acceptable, while the long-term effects were comparable to those in patients with OAB without central nervous system lesions. Nonetheless, the possibility of longstanding urinary retention and chronic catheterization in this vulnerable population requires careful evaluation before treatment with intravesical BoNT-A. In conclusion, the current findings indicate that intravesical BoNT-A is an effective and safe treatment for OAB in elderly patients.

Neural control of micturition in humans: a working model

Results from functional brain scanning have shown that neural control of the bladder involves many different regions. Yet, many aspects of this complex system can be simplified to a working model in which a few forebrain circuits, acting mainly on the midbrain periaqueductal grey (PAG), advance or delay the triggering of the voiding reflex and generate bladder sensations according to the volume of urine in the bladder, the safety of voiding and the emotional and social propriety of doing so. Understanding these circuits seems to offer a route to treatment of conditions, such as urgency incontinence or overactive bladder, in patients without overt neurological disease. Two of these circuits include, respectively, the medial prefrontal cortex and the parahippocampal complex, as well as the PAG. These circuits belong to a well-known network that is active at rest and deactivated when attention is required. Another circuit, comprising the insula and the midcingulate or dorsal anterior cingulate cortex, is activated by bladder filling and belongs to a salience network that generates sensations such as the desire to void. Behavioural treatments of urgency incontinence lead to changes in brain function that support the working model and suggest the mechanism of this type of treatment.

Efficacy and safety of botulinum toxin injection for benign prostatic hyperplasia: a systematic review and meta-analysis

PURPOSE

The aim of this study was to overcome the limitation of overlooking the placebo effect in previous studies and to demonstrate the overall treatment efficacy and safety of botulinum toxin type A (BTX-A) compared with placebo.

METHODS

We conducted a systematic review and meta-analysis of the published literature in PubMed, Cochrane Library, and Embase reporting on BTX use in lower urinary tract symptoms (LUTS)/benign prostate hyperplasia (BPH). Single-group analysis for the placebo effect and meta-regression analysis for the moderator effect were performed with high-quality RCTs compared with placebo.

RESULTS

A total of three studies were included, with a total sample size of 522 subjects (260 subjects in the experimental group and 262 subjects in the control group). Study duration ranged from 8 to 24 weeks. The pooled overall SMD in the mean change in IPSS for the BTX-A group versus the placebo group was -1.02 (95 % CI -1.97, -0.07). The other outcomes (Q max, prostate volume, and post-voided residual volume) were not statistically different between the two groups. The placebo effect in single-group analysis ranged from 0 to 27.9 % for IPSS, and from -1.1 to 28.7 % for Q max (lowest to highest, respectively).

CONCLUSIONS

This evidence-based systematic review and meta-analysis of the BTX-A injection for LUTS/BPH showed no differences in efficacy compared with placebo and also showed no difference in procedure-related adverse events occurred. Thus, the results of this study do not provide evidence of clinical benefits of using the BTX-A injection for LUTS/BPH in real clinical practice.

Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the management of adult non-neurogenic overactive bladder

Due to the myriad of treatment options available and the potential increase in the number of patients afflicted with overactive bladder (OAB) who will require treatment, the Female Urology Special Advisory Group (FUSAG) of the Urological Society of Australia and New Zealand (USANZ), in conjunction with the Urogynaecological Society of Australasia (UGSA), see the need to move forward and set up management guidelines for physicians who may encounter or have a special interest in the treatment of this condition. These guidelines, by utilising and recommending evidence-based data, will hopefully assist in the diagnosis, clinical assessment, and optimisation of treatment efficacy. They are divided into three sections: Diagnosis and Clinical Assessment, Conservative Management, and Surgical Management. These guidelines will also bring Australia and New Zealand in line with other regions of the world where guidelines have been established, such as the American Urological Association, European Association of Urology, International Consultation on Incontinence, and the National Institute for Health and Care Excellence guidelines of the UK.

Drug therapy of overactive bladder--what is coming next?

After the approval and introduction of mirabegron, tadalafil, and botulinum toxin A for treatment of lower urinary tract symptoms/overactive bladder, focus of interest has been on their place in therapy versus the previous gold standard, antimuscarinics. However, since these agents also have limitations there has been increasing interest in what is coming next - what is in the pipeline? Despite progress in our knowledge of different factors involved in both peripheral and central modulation of lower urinary tract dysfunction, there are few innovations in the pipe-line. Most developments concern modifications of existing principles (antimuscarinics, β₃-receptor agonists, botulinum toxin A). However, there are several new and old targets/drugs of potential interest for further development, such as the purinergic and cannabinoid systems and the different members of the transient receptor potential channel family. However, even if there seems to be good rationale for further development of these principles, further exploration of their involvement in lower urinary tract function/dysfunction is necessary.

Lower urinary tract dysfunction in the neurological patient: clinical assessment and management

Lower urinary tract (LUT) dysfunction is a common sequela of neurological disease, resulting in symptoms that have a pronounced effect on quality of life. The site and nature of the neurological lesion affect the pattern of dysfunction. The risk of developing upper urinary tract damage and renal failure is much lower in patients with slowly progressive non-traumatic neurological disorders than in those with spinal cord injury or spina bifida; this difference in morbidity is taken into account in the development of appropriate management algorithms. Clinical assessment might include tests such as uroflowmetry, post-void residual volume measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the indication. Incomplete bladder emptying is most often managed by intermittent catheterisation, and storage dysfunction by antimuscarinic drugs. Intradetrusor injections of onabotulinumtoxinA have transformed the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. An individualised, patient-tailored approach is required for the management of LUT dysfunction associated with neurological disorders.

Current and potential urological applications of botulinum toxin A

Botulinum toxin subtype A (BoNT-A) is a potent neurotoxin that can selectively modulate neurotransmitter release from nerve endings, resulting in muscular paralysis. BoNT-A might also act on sensory nerves, and have an anti-inflammatory effect. In the first urological use of BoNT-A, injection into the urethral sphincters of patients with detrusor-sphincter dyssynergia resulted in a reduction of urethral resistance and improved voiding efficiency. Subsequently, intravesical BoNT-A injections have received regulatory approval for treatment of neurogenic detrusor overactivity owing to spinal cord lesions or multiple sclerosis, and idiopathic overactive bladder in adults. BoNT-A has also been widely used to treat patients with the off-label indications of neurogenic or non-neurogenic voiding dysfunction and male lower urinary tract symptoms owing to BPH and bladder-neck dysfunction. Other indications for which urologists have applied BoNT-A injections include interstitial cystitis/bladder pain syndrome, bladder oversensitivity and chronic pelvic pain syndrome. BoNT-A is currently delivered as an intravesical injection; however, use of liposome encapsulated formulations is also beginning to show some therapeutic potential.

Intraprostatic injections for lower urinary tract symptoms treatment

PURPOSE OF REVIEW

The purpose of this study is to review and discuss recently published (2013-2014) experimental and clinical studies of intraprostatic injection therapy as an alternative treatment of lower urinary tract symptoms (LUTS).

RECENT FINDINGS

Recent focus has been on intraprostatic injection of botulinum toxin both with regard to mechanism of action and efficacy. In contrast to the promising findings in several previous studies, a recent large, randomized, placebo-controlled trial found no differences between onabotulinumtoxin A treatment and placebo. There is little new information on the use of anhydrous ethanol and agents such as NX-1207 and PRX302, which previously have been reported to have promising effects.

SUMMARY

Intraprostatic injection of different agents as a minimally invasive surgical therapy for LUTS associated with benign prostatic hyperplasia seems attractive and may have a potential as a treatment alternative, but so far, available results are not convincing. Further studies on the mechanisms of action of novel agents, and controlled clinical trials documenting their efficacy and side-effects when injected into the prostate are needed before their place in the treatment of benign prostatic hyperplasia/LUTS can be properly assessed.

New intraprostatic injectables and prostatic urethral lift for male LUTS

Treatment modalities for male lower urinary tract symptoms (LUTS) comprise a broad spectrum of medical and surgical options. Interest is growing in minimally invasive treatment options, which should ideally be performed in an outpatient setting and have a short recovery time, durable efficacy and a good safety profile. The preservation of all aspects of sexual function, including antegrade ejaculation, seems to be increasingly important for patients. Initial experimental data on new minimally invasive procedures-such as the intraprostatic injection of novel agents including botulinum neurotoxin A (BoNT-A), NX-1207 and PRX302-were promising, but clinical trials have not confirmed the findings. Trials of the mechanical prostatic urethral lift device-Urolift(®) (Neotract, Inc., USA)-have been positive, but further long-term results are needed to confirm its beneficial effects.

OnabotulinumtoxinA intravesical treatment in patients affected by overactive bladder syndrome: best practice in real-life management

PURPOSE

We evaluated intradetrusorial OnabotulinumtoxinA (Onabot/A) treatment protocols in patients with idiopathic overactive bladder (OAB), in order to assess the care of patients before, during and after treatment.

METHODS

In 64 OAB patients injected with Onabot/A, we reviewed the length of the hospital stay, frequency of catheterization, frequency of intraoperative and postoperative complications, and patients' satisfaction to the proposed treatment protocol (as assessed by VAS). We also compared the results of the 3-day voiding diary, uroflowmetry with postvoid residual urine (PVR) and VAS to score the bother of urinary symptoms on quality of life (QoL) before and after treatment.

RESULTS

Twenty-one patients were firstly treated in an 'inpatient' setting. The mean ± SD duration of hospitalization and catheterization was 39.4 ±12.6 and 37.8 ± 10.6 h, respectively. The mean ± SD VAS values of treatment satisfaction and of bother of urinary symptoms on QoL were 6.3 ± 1.1 and 8.2 ± 1.3, respectively. The mean ± SD PVR value was 74.3 ± 15.2 ml. Frequency of UTIs was 2.4 ± 1.6. Forty-three patients were treated on an outpatient basis; the mean ± SD duration of catheterization, the 'outpatient' stay and the mean ± SD frequency of UTIs were lower than those of patients treated in an inpatient setting. The mean ± SD VAS value to score QoL was high.

CONCLUSIONS

Intradetrusorial Onabot/A injection is a simple and fast procedure that can be easily carried on in an outpatient setting under local anesthesia, with low rates of intraoperative and postoperative complications.

OnabotulinumtoxinA intradetrusorial injections improve sexual function in female patients affected by multiple sclerosis: preliminary results

PURPOSE

To investigate the effects of onabotulinum toxin type A (Onabot/A) intravesical injections on urinary and sexual function in a group of patients affected by multiple sclerosis (MS).

METHODS

We enrolled 31 MS female patients with symptoms of overactive bladder and detrusor overactivity. All patients underwent urodynamics and were administered 3-day voiding diary, Incontinence Quality of Life (I-QoL) questionnaire, Female Sexual Function Index (FSFI) questionnaire, Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) before and 3 months after Onabot/A intravesical injection.

RESULTS

Onabot/A injection significantly improved urinary symptoms as shown by the 3-day voiding diary, I-QoL questionnaire and the urodynamic variables. In addition, it also significantly improved sexual functioning in continent patients and psychological status as demonstrated by the increase in FSFI, HAM-A and HAM-D scores.

CONCLUSIONS

The Onabot/A-induced positive effect on sexual dysfunction in our MS patients is likely due to an indirect effect exerted by the overall urological clinical improvement on sexual function at both the psychological and emotional levels. The positive effect exerted by Onabot/A on the anxiety and depression scale also suggests that urinary symptoms have a negative impact on the psychological status of the patients.

A current perspective on geriatric lower urinary tract dysfunction

Lower urinary tract dysfunction-such as urinary incontinence (UI), detrusor overactivity, and benign prostatic hyperplasia-is prevalent in elderly persons. These conditions can interfere with daily life and normal functioning and lead to negative effects on health-related quality of life. UI is one of the most common urologic conditions but is poorly understood elderly persons. The overall prevalence of UI increases with age in both men and women. Elderly persons often neglect UI or dismiss it as part of the normal aging process. However, UI can have significant negative effects on self-esteem and has been associated with increased rates of depression. UI also affects quality of life and activities of daily living. Although UI is more common in elderly than in younger persons, it should not be considered a normal part of aging. UI is abnormal at any age. The goal of this review is to provide an overview of the cause, classification, evaluation, and management of geriatric lower urinary tract dysfunction.

Novel therapeutic uses and formulations of botulinum neurotoxins: a patent review (2012 - 2014)

INTRODUCTION

Botulinum neurotoxins (BoNTs) are among the most toxic of known biological molecules and function as acetylcholine release inhibitors and neuromuscular blocking agents. Paradoxically, these properties also make them valuable therapeutic agents for the treatment of movement disorders, urological conditions and hypersecretory disorders. Greater understanding of their molecular mechanism of action and advances in protein engineering has led to significant efforts to improve and expand their function with a view towards broadening their therapeutic potential.

AREAS COVERED

Searches of Espacenet and Google Patent have revealed a number of patents related to BoNTs. This review will focus on novel therapeutic uses and formulations disclosed during 2012 - 2014. The seven patents discussed will include nanoformulations of FDA-approved BoNTs, additional BoNT subtypes and novel BoNT variants and chimeras created through protein engineering. Supporting patents and related publications are also briefly discussed.

EXPERT OPINION

The clinical and commercial success of BoNTs has prompted investigation into novel BoNTs or BoNT-mediated chimeras with promising in vitro results. Distinct strategies including the use of nanoformulations and targeted delivery have been implemented to identify new indication and improved functionality. Greater understanding of their systemic exposure, efficacy and safety profiles will be required for further development.

The ultimate radiochemical nightmare: upon radio-iodination of Botulinum neurotoxin A, the introduced iodine atom itself seems to be fatal for the bioactivity of this macromolecule

Background

Botulinum neurotoxin A (BoNT-A) is a highly neurotoxic drug and frequently used in patients. Knowledge on the optimal way of administration of BoNT-A and its subsequent distribution is still rather limited. An accurate method for monitoring these processes might be the use of radiolabelled BoNT-A. In this paper, we report our feasibility study on labelling BoNT-A with high-dose iodine-125 (¹²⁵I) via IODOGEN-coated BoNT-A method.

Methods

Using cetuximab as model substrate for BoNT-A, a miniaturization of the IODOGEN-coated mAb method was developed with special attention to the minimum required amount of the oxidant IODOGEN, while the amount of substrate, reaction volume and reaction time were downsized. Labelling efficiency and radiochemical purity were determined by TLC, integrity by SDS-PAGE and HPLC and immunoreactivity by cell-binding assay. BoNT-A (50 μg) was labelled with ¹²⁵I by coating with 2.5 μg IODOGEN, in a total reaction volume of 250 μL and a reaction time of 90 s. ¹²⁵I-BoNT-A was purified by size exclusion chromatography (PD10 column) using ascorbic acid solution (5 mg/ml, pH = 5) as eluent. Quality analysis of ¹²⁵I-BoNT-A was performed by an in vitro bladder strip model, an electrochemiluminescence assay and an Endopep assay.

Results

Cetuximab (50 μg) labelling with ¹²⁵I (15 to 150 MBq) resulted in a labelling efficiency of 70% to 80%, a radiochemical purity of >99%, an immunoreactivity of >95% and a retained integrity on SDS; HPLC analysis revealed partly affected integrity when 110 to 150 MBq ¹²⁵I was used, i.e. when the averaged I/mAb molar ratio exceeded 3. Addition of HEPES (20 mM) and lactose (1.25%) (lyophilized BoNT-A contains HEPES and lactose) decreased the labelling efficiency to 44% to 54%. BoNT-A (50 μg) labelling with ¹²⁵I (97.2 to 98.3 MBq) resulted in labelling efficiency of 51% to 52% with a radiochemical purity >98.5%, a specific activity of 150.5 to 152.9 MBq/nmol and an I/BoNT-A molar ratio of 1.86 to 1.90. The in vitro bladder strip model showed no bioactivity of ¹²⁵I-BoNT-A when compared to unlabelled BoNT-A. The electrochemiluminescence and Endopep assay demonstrated around 10% and 15% bioactivity of ¹²⁵I-BoNT-A compared to unlabelled BoNT-A, respectively. The remaining bioactivity correlates within the Poisson distribution with the amount of BoNT-A molecules that does not bear an iodine atom.

Conclusions

BoNT-A was successfully radio-iodinated with an activity high enough to enable in vivo measurement of nanograms of BoNT-A, which could be used in studying optimization of administration techniques of BoNT-A. The bioactivity of a BoNT-A molecule is, however, lost upon the introduction of an iodine atom into the tyrosine moiety of this sensitive molecule.

Progress in the treatment of small fiber peripheral neuropathy

Small fiber neuropathy is a syndrome of diverse disease etiology because of multiple pathophysiologic mechanisms with major presentations of neuropathic pain and autonomic symptoms. Over the past decade, there has been substantial progress in the treatments for neuropathic pain, dysautonomia and disease-modifying strategy. In particular, anticonvulsants and antidepressants alleviate neuropathic pain based on randomized clinical trials.