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Yu PH, Wang CC. Adverse Effects of Intravesical OnabotulinumtoxinA Injection in Patients with Idiopathic Overactive Bladder or Neurogenic Detrusor Overactivity: A Systematic Review and Meta-Analysis of Randomized Controlled Studies. Toxins (Basel) 2024; 16:343. [PMID: 39195753 PMCID: PMC11359369 DOI: 10.3390/toxins16080343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 07/24/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024] Open
Abstract
Despite the efficacy of onabotulinumtoxinA, its safety profile remains a concern. This meta-analysis reviewed the major adverse events (AEs) associated with intravesical onabotulinumtoxinA treatment in patients with neurogenic detrusor overactivity (NDO) and idiopathic overactive bladder (iOAB). Randomized controlled trials (RCTs) conducted between January 2000 and December 2022 were searched for adult patients administered different onabotulinumtoxinA dosages or onabotulinumtoxinA vs. placebo. Quality assessment was performed using the Cochrane Collaboration tool, and statistical analysis was performed using Review Manager version 5.3. A total of 26 RCTs were included in the analysis, including 8 on NDO and 18 on iOAB. OnabotulinumtoxinA vs. placebo significantly increased the urinary tract infection (UTI) incidence in patients with NDO (relative risk, or RR, 1.54) and iOAB (RR, 2.53). No difference in the RR with different onabotulinumtoxinA dosages was noted. Urinary retention was frequent with onabotulinumtoxinA use in the NDO (RR, 6.56) and iOAB (RR, 7.32) groups. Similar observations were made regarding the risks of de novo clean intermittent catheterization (CIC). The risk of voiding difficulty increased with onabotulinumtoxinA use in patients with iOAB. Systemic AEs of onabotulinumtoxinA, including muscle weakness (RR, 2.79) and nausea (RR, 3.15), were noted in patients with NDO; most systemic AEs had a low incidence and were sporadic.
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Affiliation(s)
- Ping-Hsuan Yu
- Department of Urology, En Chu Kong Hospital, College of Medicine, National Taiwan University, New Taipei City 237414, Taiwan;
- Department of Urology, Taipei Veterans General Hospital, Taipei 112201, Taiwan
- Department of Urology, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Shu-Tien Urological Science Research Center, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chung-Cheng Wang
- Department of Urology, En Chu Kong Hospital, College of Medicine, National Taiwan University, New Taipei City 237414, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan 320314, Taiwan
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2
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Nitti V, Haag-Molkenteller C, Kennelly M, Chancellor M, Jenkins B, Schurch B. Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32377. [PMID: 37499088 PMCID: PMC10374192 DOI: 10.1097/md.0000000000032377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Neurogenic detrusor overactivity (NDO) is a complication of multiple sclerosis, spinal cord injury (SCI), stroke, head injury, and other conditions characterized by damage to the upper motor neuronal system. NDO often leads to high bladder pressure that may cause upper urinary tract damage and urinary incontinence (UI). Prior to the use of onabotulinumtoxinA, oral anticholinergics and surgical augmentation cystoplasty were the treatment options. Overactive bladder (OAB) is non-neurogenic and affects a much larger population than NDO. Both NDO and OAB negatively impact patients' quality of life (QOL) and confer high health care utilization burdens. Early positive results from pioneering investigators who injected onabotulinumtoxinA into the detrusor of patients with SCI caught the interest of Allergan, which then initiated collaborative clinical trials that resulted in FDA approval of onabotulinumtoxinA 200U in 2011 for NDO and 100U in 2013 for patients with OAB who inadequately respond to or are intolerant of an anticholinergic. These randomized, double-blind, placebo-controlled trials for NDO showed significant improvements in UI episodes, urodynamic parameters, and QOL; the most frequent adverse events were urinary tract infection (UTI) and urinary retention. Similarly, randomized, double-blind, placebo-controlled trials of onabotulinumtoxinA 100U for OAB found significant improvements in UI episodes, treatment benefit, and QOL; UTI and dysuria were the most common adverse events. Long-term studies in NDO and OAB showed sustained effectiveness and safety with repeat injections of onabotulinumtoxinA, the use of which has profoundly improved the QOL of patients failing anticholinergic therapy and has expanded the utilization of onabotulinumtoxinA into smooth muscle.
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Affiliation(s)
- Victor Nitti
- Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Urology and Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Michael Kennelly
- Urology, Urogynecology, Female Pelvic Medicine and Reconstructive Surgery, Atrium Health, Charlotte, NC, USA
| | | | | | - Brigitte Schurch
- Neurourology Unit Department of Neurosciences, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
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Chen Y, Peng L, Zhang C, Chen J, Chen J, Shen H, Luo D. The effectiveness and safety of oral medications, onabotulinumtoxinA (three doses) and transcutaneous tibial nerve stimulation as non or minimally invasive treatment for the management of neurogenic detrusor overactivity in adults: a systematic review and network meta-analysis. Int J Surg 2023; 109:1430-1438. [PMID: 36974676 PMCID: PMC10389548 DOI: 10.1097/js9.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Oral medications, onabotulinumtoxinA injections, and transcutaneous tibial nerve stimulation (TTNS) are recommended by the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines as non or minimally invasive treatments for patients with neurogenic detrusor overactivity (NDO) without treatment hierarchy. OBJECTIVE The objective was to compare and rank the effectiveness and safety of oral medications, three doses of onabotulinumtoxinA, and TTNS on improving urodynamic outcomes in patient-reported outcomes and safety outcomes in patients with NDO. METHODS The authors searched PubMed, EMBASE, MEDLINE, Cochrane Library, Medicine, and clinicaltrials.gov, from their inception to October 2022 and included randomized controlled studies on the drug, onabotulinumtoxinA, and TTNS for the treatment of patients with NDO. Outcomes included urodynamic parameters, voiding diary, quality of life changes, adverse event rate and postvoid residual. RESULTS A total of 26 articles and 2938 patients were included in the statistics. Regarding effectiveness, all interventions except TTNS and α-blockers were statistically different for the placebo group. The urodynamic outcome and patient-reported outcome suggested that onabotulinumtoxinA injection (urodynamic outcome: onabotulinumtoxinA 200 U, the mean surface under the cumulative ranking curve (SUCRA): 87.4; patient-reported outcome: onabotulinumtoxinA 100 U, mean SUCRA: 89.8) was the most effective treatment, and the safety outcome suggested that TTNS (SUCRA: 83.3) was the safest. Cluster analysis found that antimuscarinics and β3-adrenoceptor-agonists possessed good effectiveness and safety. CONCLUSION OnabotulinumtoxinA injection is probably the most effective way to treat patients with NDO, with increasing effectiveness but decreasing safety as the dose rises. The effectiveness of α-blockers and TTNS was not statistically different from the placebo group. Antimuscarinics and β3-adrenoceptor-agonists have good effectiveness and safety.
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Affiliation(s)
| | | | | | | | | | | | - Deyi Luo
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
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Chen PC, Lee KH, Lee WC, Yeh TC, Kuo YC, Chiang BJ, Liao CH, Meng E, Kao YL, Lee YC, Kuo HC. Treating Neurogenic Lower Urinary Tract Dysfunction in Chronic Spinal Cord Injury Patients-When Intravesical Botox Injection or Urethral Botox Injection Are Indicated. Toxins (Basel) 2023; 15:toxins15040288. [PMID: 37104226 PMCID: PMC10145925 DOI: 10.3390/toxins15040288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/01/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023] Open
Abstract
Lower urinary tract symptoms (LUTS), such as urgency, urinary incontinence, and/or difficulty voiding, hamper the quality of life (QoL) of patients with spinal cord injury (SCI). If not managed adequately, urological complications, such as urinary tract infection or renal function deterioration, may further deteriorate the patient's QoL. Botulinum toxin A (BoNT-A) injection within the detrusor muscle or urethral sphincter yields satisfactory therapeutic effects for treating urinary incontinence or facilitating efficient voiding; however, adverse effects inevitably follow its therapeutic efficacy. It is important to weigh the merits and demerits of BoNT-A injection for LUTS and provide an optimal management strategy for SCI patients. This paper summarizes different aspects of the application of BoNT-A injection for lower urinary tract dysfunctions in SCI patients and provides an overview of the benefits and drawbacks of this treatment.
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Affiliation(s)
- Po-Cheng Chen
- Urologic Department, En Chu Kong Hospital, New Taipei City 237414, Taiwan
| | - Kau-Han Lee
- Division of Urology, Department of Surgery, Chi Mei Medical Center, Tainan 71004, Taiwan
| | - Wei-Chia Lee
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Ting-Chun Yeh
- Division of Urology, Department of Surgery, Taiwan Adventist Hospital, Taipei City 10556, Taiwan
| | - Yuh-Chen Kuo
- Department of Urology, Yangming Branch of Taipei City Hospital, Taipei 11146, Taiwan
- Department of Exercise and Health Sciences, University of Taipei, Taipei 111036, Taiwan
| | - Bing-Juin Chiang
- College of Medicine, Fu-Jen Catholic University, New Taipei City 24205, Taiwan
- Department of Urology, Cardinal Tien Hospital, New Taipei City 23148, Taiwan
| | - Chun-Hou Liao
- Divisions of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City 23148, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - En Meng
- Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yao-Lin Kao
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Yung-Chin Lee
- Department of Urology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung 812, Taiwan
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien 97004, Taiwan
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Xu R, Yang TX, Fang KW, Wang G, Li P. Efficacy, according to urodynamics, of OnabotulinumtoxinA compared with antimuscarinic drugs, for neurogenic detrusor overactivity: a systematic review and network meta-analysis. Sci Rep 2022; 12:17905. [PMID: 36289427 PMCID: PMC9606369 DOI: 10.1038/s41598-022-22765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/19/2022] [Indexed: 01/20/2023] Open
Abstract
To summarize the differences in urodynamic outcomes between oral antimuscarinic drugs and OnabotulinumtoxinA, and finding a therapy that maintains good urodynamics in neurogenic detrusor overactivity (NDO). We conducted a literature search of EMBASE and PubMed, with the language limited to English. In the analysis, all of the published randomized trials of OnabotulinumtoxinA or antimuscarinic drugs used to treat NDO were found and the results were finally obtained through Bayesian model analysis. A total of 12 RCTs and 2208 patients were included. OnabotulinumtoxinA 300U was superior to other drugs in terms of MCC, volume at IDC, and Pdetmax endpoints. OnabotulinumtoxinA 200U was more effective on the urodynamic endpoint of BC than other drugs or doses of OnabotulinumtoxinA. According to the MCC urodynamic results, oxybutynin, solifenacin 10 mg, and tolterodine 4 mg also had positive effects. OnabotulinumtoxinA 300U, 200U and 100U were better in improving the urodynamic results of NDO, and the current evidence also shows that selective injection of onabotulinumtoxinA can effectively improve the urodynamic results.
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Affiliation(s)
- Rui Xu
- grid.415444.40000 0004 1800 0367The Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan People’s Republic of China
| | - Tong-Xin Yang
- grid.415444.40000 0004 1800 0367The Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan People’s Republic of China
| | - Ke-Wei Fang
- grid.415444.40000 0004 1800 0367The Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan People’s Republic of China
| | - Guang Wang
- grid.415444.40000 0004 1800 0367The Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan People’s Republic of China
| | - Pei Li
- grid.415444.40000 0004 1800 0367The Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan People’s Republic of China
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The translational implications of the science behind the overactive bladder and the role of OnabotulinumtoxinA. Surgeon 2022; 21:e126-e132. [PMID: 37162132 DOI: 10.1016/j.surge.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
Urinary incontinence (UI) is a very common condition that can affect patients of all ages and the commonest cause is an overactive bladder (OAB). Most patients with OAB were treated with pharmacotherapy and major surgery. Over 25 years ago, Dasgupta, Fowler et al. studied the presence and role of C fibres in the human bladder which are highly sensitive to capsaicin, the active ingredient of chillies. When capsaicin was instilled into patients' bladders as a synthetic solution, it was found to be highly effective in some patients. Capsaicin was later replaced by Resiniferatoxin. Both toxins desensitised C-fibres through the capsaicin receptor, TRPV1, without any lasting damage to the bladder itself. The discovery of botulinum toxin and its use in the treatment of OAB represents a major breakthrough, in the treatment of OAB. Another key innovation was the development of technique to administer the drug under local anaesthesia which allowed numerous patients to benefit from treatment who would otherwise have been precluded because of the need for injection under general anaesthetic. After extensive trials over many years Botox (OnabotulinumtoxinA) is now licensed for use in OAB. Compared to other treatments for overactive bladder, OnabotulinumtoxinA is more cost-effective and less invasive. It is thought to have changed the quality of life of an estimated 5 million patients worldwide.
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Solifenacin Treatment After Intradetrusor Injections With Botulinum Toxin in Patients With Neurogenic Detrusor Overactivity. Am J Ther 2022; 29:e507-e511. [PMID: 35731251 DOI: 10.1097/mjt.0000000000001531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neurogenic detrusor overactivity (NDO) is treated with antimuscarinics as first-line treatment. For patients with contraindications or unresponsive, intradetrusor injections with botulinum toxin (BoNT) are a safe and effective but expensive option. STUDY QUESTION Our study evaluated whether adding solifenacin to the intradetrusor injection of BoNT A could boost the effect of BoNT in patients with NDO due to multiple sclerosis or spinal cord injury refractory to antimuscarinics alone and/or lead to less frequent injections. STUDY DESIGN We performed a prospective study on 49 patients assigned alternatively to group A, undergoing BoNT injections, and group B, adding solifenacin. MEASURES AND OUTCOMES We gathered data from urodynamic testing and questionnaire assessments before and 3 months after injections and reinjections. We analyzed 39 patients who achieved total continence and a minimum 24-month follow-up period. RESULTS After treatment, both groups had statistically significant improvement of overactive bladder questionnaire (OABq) score, post void residue (PVR), and peak detrusor pressure (Pdet). Reinjection was needed after a mean 8.2 months for group A and 11.7 months for group B. We analyzed the improvement rate of parameters compared between the 2 groups-group B had greater OABq score improvement (A = 17.25 ± 5.07, B = 20.44 ± 4.51, P = 0.0485), as well as for maximum bladder capacity (A = 11.05 ± 7.04 mL, B = 19.39 ± 6.43 mL, P = 0.0005); differences in Pdet change (A = 51.72 ± 16.57 cmH 2 O, B = 50.80 ± 16.33 cmH 2 O, P = 0.7635) and PVR change (A = 17.67 ± 12.63 mL, B = 12.30 ± 8.32 mL, P = 0.126) were not statistically significant. CONCLUSIONS Our study shows that adding solifenacin improves patient satisfaction, increases the interval between reinjections, thus lowering costs, and improves maximum bladder capacity. Pdet was kept in safe ranges, but no statistically significant conclusions could be drawn regarding Pdet and PVR decrease related to adding solifenacin. Although our study is limited by the small series of patients and lack of randomization and placebo control group, the BoNT-solifenacin combination could be considered in NDO in terms of cost-effectiveness. Further studies would be beneficial.
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Sartori AM, Padilla-Fernández B, 't Hoen L, Blok BFM, Castro-Díaz DM, Del Popolo G, Musco S, Hamid R, Ecclestone H, Groen J, Karsenty G, Phé V, Kessler TM, Pannek J. Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review. Eur Urol Focus 2022; 8:1386-1398. [PMID: 34404618 DOI: 10.1016/j.euf.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group. OBJECTIVE To present all used definitions of UTIs in neurourological patients. EVIDENCE ACQUISITION This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated. EVIDENCE SYNTHESIS After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low. CONCLUSIONS Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed. PATIENT SUMMARY Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.
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Affiliation(s)
- Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain.
| | - Lisette 't Hoen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David M Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Giulio Del Popolo
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Stefania Musco
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Rizwan Hamid
- Department of Neuro-urology, London Spinal Injuries Centre, Stanmore, UK
| | - Hazel Ecclestone
- Department of Neuro-urology, London Spinal Injuries Centre, Stanmore, UK
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Veronique Phé
- Department of Urology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Academic Hospital, Sorbonne University, Paris, France
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
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Wang CC, Chou ECL, Chuang YC, Lin CC, Hsu YC, Liao CH, Kuo HC. Effectiveness and Safety of Intradetrusor OnabotulinumtoxinA Injection for Neurogenic Detrusor Overactivity and Overactive Bladder Patients in Taiwan-A Phase IV Prospective, Interventional, Multiple-Center Study (Restore Study). Toxins (Basel) 2021; 13:toxins13120911. [PMID: 34941748 PMCID: PMC8707051 DOI: 10.3390/toxins13120911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/26/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
We conducted a phase IV, pre/post multi-center study to evaluate the efficacy and safety of intradetrusor onabotulinumtoxinA injection in patients with neurogenic detrusor overactivity (NDO, n = 119) or overactive bladder (OAB, n = 215). Patients received either 200U (i.e., NDO) and 100U (i.e., OAB) of onabotulinumtoxinA injection into the bladder, respectively. The primary endpoint for all patients was the change in the PPBC questionnaire score at week 4 and week 12 post-treatment compared with baseline. The secondary endpoints were the changes in subjective measures (i.e., questionnaires: NBSS for patients with NDO and OABSS for those with OAB) at week 4 and week 12 post-treatment compared with baseline. Adverse events included symptomatic UTI, de novo AUR, gross hematuria and PVR > 350mL were recorded. The results showed that compared with baseline, PPBC (3.4 versus 2.4 and 2.1, p < 0.001) and NBSS (35.4 versus 20.4 and 18.1, p < 0.001) were significantly improved at 4 weeks and 12 weeks in NDO patients. In addition, compared with baseline, PPBC (3.5 versus 2.3 and 2.0, p < 0.001) and OABSS (9.1 versus 6.2 and 5.7, p < 0.001) were significantly improved at 4 weeks and 12 weeks in OAB patients. Eight (6.7%) had symptomatic UTI and 5 (4.2%) had de novo AUR in NDO patients. Twenty (9.3%) had symptomatic UTI but no de novo AUR in OAB patients. In conclusion, we found that intradetrusor onabotulinumtoxinA injections were safe and improved subjective measures related to NDO or OAB in our cohort.
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Affiliation(s)
- Chung-Cheng Wang
- Department of Urology, En Chu Kong Hospital, New Taipei City 237414, Taiwan;
- Department of Biomedical Engineering, Chung Yuan Christian University, Chungli 320314, Taiwan
| | - Eric Chieh-Lung Chou
- Department of Urology, China Medical University Hospital, School of Medicine, China Medical University, Taichung 406040, Taiwan;
| | - Yao-Chi Chuang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833401, Taiwan;
| | - Chih-Chieh Lin
- Shu-Tien Urological Research Center, Department of Urology, Taipei Veterans General Hospital, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan;
| | - Yu-Chao Hsu
- Department of Urology, Linko Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyung 333323, Taiwan;
| | - Chun-Hou Liao
- Department of Urology, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City 242062, Taiwan;
| | - Hann-Chorng Kuo
- Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Buddhist Tzu Chi University, Hualiang 970374, Taiwan
- Correspondence:
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Frontiers in the Clinical Applications of Botulinum Toxin A as Treatment for Neurogenic Lower Urinary Tract Dysfunction. Int Neurourol J 2021; 24:301-312. [PMID: 33401351 PMCID: PMC7788334 DOI: 10.5213/inj.2040354.177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022] Open
Abstract
Patients with neurogenic lower urinary tract dysfunction (NLUTD) experience urinary incontinence with or without difficult urination, which might promote recurrent urinary tract infection (UTI) and exacerbate upper urinary tract function. Nonetheless, appropriate bladder management has been shown to reduce urological complications and improve quality of life. In addition to pharmacological therapy and surgical intervention, botulinum toxin A (BoNT-A) has been widely utilized in NLUTD. The therapeutic efficacy of detrusor BoNT-A injections for neurogenic detrusor overactivity due to spinal cord injury (SCI), multiple sclerosis, or other central nervous system lesions, such as cerebrovascular accident, Parkinson disease, early dementia, and pediatric NLUTD due to myelomeningocele, has been well established, with repeated BoNT-A injections every 6 to 9 months being necessary to maintain its therapeutic effects. Urethral BoNT-A injection can decrease urethral sphincter resistance and facilitate efficient voiding in patients with NLUTD who wish to preserve self-voiding. Detrusor BoNT-A injection can also decrease the occurrence of autonomic dysreflexia in patients with SCI, even after failed augmentation enterocystoplasty, with additional benefits including reduced UTI episodes and preserved renal function with repeated injections. However, this treatment does have some side effects. Complete informed consent for BoNT-A injection therapy with full disclosure of its potential complications should therefore be obtained before this procedure is undertaken.
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Declemy A, Chesnel C, Charlanes A, Le Breton F, Sheikh Ismael S, Amarenco G. Short-term reproducibility of cystometry in multiple sclerosis patients. Prog Urol 2020; 31:169-174. [PMID: 33309471 DOI: 10.1016/j.purol.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To assess the reproducibility of detrusor activity cystometric pattern in multiple sclerosis (MS) patients, which is poorly documented in the medical literature, by means of successive filling. METHODS We conducted a prospective study in MS patients; cystometry was repeated twice at 5minutes of interval if a detrusor overactivity before 300mL of filling was observed. Thus, 3 successive cystometries were analysed. The following characteristics were recorded: detrusor maximum pressure (Pmax), volume at the first involuntary detrusor contraction (IDC), maximum cystometric capacity (MCC), pressure at the first IDC, the existence of an overactive detrusor classified as phasic or terminal. RESULTS We included 31 patients (19 women and 12 men); only 6 patients were naïve-treatment, the mean EDSS was: 5.3 (±1.6) and the mean age was 48.4 (±12.5) years. All the patients had an overactive detrusor for each cystometry. The reproducibility was good for all the parameters (range ICC between 0.7 and 0.83). CONCLUSION Quantitative and qualitative cystometric data have a good reproducibility in MS patients with detrusor overactivity before 300mL of filling. LEVEL OF PROOF 3.
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Affiliation(s)
- A Declemy
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France.
| | - C Chesnel
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France
| | - A Charlanes
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France
| | - F Le Breton
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France
| | - S Sheikh Ismael
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France
| | - G Amarenco
- Sorbonne université, GRC 01, GREEN - groupe de recherche clinique en neuro-urologie, AP-HP, hôpital Tenon, 75020 Paris, France; Department of neuro-urology, Tenon hospital, AP-HP, 75020 Paris, France
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12
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Austin PF, Franco I, Dobremez E, Kroll P, Titanji W, Geib T, Jenkins B, Hoebeke PB. OnabotulinumtoxinA for the treatment of neurogenic detrusor overactivity in children. Neurourol Urodyn 2020; 40:493-501. [PMID: 33305474 PMCID: PMC7839517 DOI: 10.1002/nau.24588] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/29/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
AIMS This study evaluated whether one (or more) of three doses of onabotulinumtoxinA were safe and effective to treat neurogenic detrusor overactivity (NDO) in children. METHODS This was a 48-week prospective, multicenter, randomized, double-blind study in children (aged 5-17 years) with NDO and urinary incontinence (UI) receiving one onabotulinumtoxinA treatment (50, 100, or 200 U; not to exceed 6 U/kg). Primary endpoint: change from baseline in daytime UI episodes. Secondary endpoints: change from baseline in urine volume at first morning catheterization, urodynamic measures, and positive response on the treatment benefit scale. Safety was also assessed. RESULTS There was a similar reduction in urinary incontinence from baseline to Week 6 for all doses (-1.3 episodes/day). Most patients reported positive responses on the treatment benefit scale (75.0%-80.5%). From baseline to Week 6, increases were observed in urine volume at first morning clean intermittent catheterization (50 U, 21.9 ml; 100 U, 34.9 ml; 200 U, 87.5 ml; p = 0.0055, 200 U vs. 50 U) and in maximum cystometric capacity (range 48.6-63.6 ml) and decreases in maximum detrusor pressure during the storage phase (50 U, -12.9; 100 U, -20.1; 200 U, -27.3 cmH2 O; p = 0.0157, 200 U vs. 50 U). The proportion of patients experiencing involuntary detrusor contractions dropped from baseline (50 U, 94.4%; 100 U, 88.1%; 200 U, 92.6%) to Week 6 (50 U, 61.8%; 100 U, 44.7%; 200 U, 46.4%). Safety was similar across doses; urinary tract infection was most frequent. CONCLUSIONS OnabotulinumtoxinA was well tolerated and effective for the treatment of NDO in children; 200 U showed greater efficacy in reducing bladder pressure and increasing bladder capacity.
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Affiliation(s)
- Paul F Austin
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Israel Franco
- Yale New Haven Children's Hospital, New Haven, Connecticut, USA
| | | | - Pawel Kroll
- Neuro-urology Unit, Paediatric Urology Clinic, Poznań, Poland
| | | | - Till Geib
- Allergan, an AbbVie company, Irvine, California, USA
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13
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O'Connor RC, Johnson DP, Guralnick ML. Intradetrusor botulinum toxin injections (300 units) for the treatment of poorly compliant bladders in patients with adult neurogenic lower urinary tract dysfunction. Neurourol Urodyn 2020; 39:2322-2328. [PMID: 32866304 DOI: 10.1002/nau.24490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/10/2022]
Abstract
AIMS To evaluate the therapeutic effects of intradetrusor onabotulinum toxin A (BTX) injections in patients with adult neurogenic lower urinary tract dysfunction (ANLUTD) and medically refractory poorly compliant bladders. METHODS We retrospectively evaluated patients with urodynamic studies (UDS)-proven, medically refractory impaired bladder compliance (≤20 mL/cm H2 O) secondary to spinal myelopathy treated with 300 units of BTX cystoscopically injected into the detrusor muscle. Objective improvement in compliance was defined as an increase ≥5 mL/cm H2 O on repeat urodynamics. Characteristics were compared between patients who demonstrated symptomatic and objective improvement following treatment versus those without. RESULTS Seventy-one individuals were included in the final analysis. Mean patient age was 37.2 years (range: 18-78) and ANLUTD duration was 14.5 years (range: 1-34). Average pre-injection bladder compliance was 9.2 mL/cm H2 O (range: 3.0-16.7). After treatment with BTX, 37 of 71 (52%) patients reported subjective reductions in lower urinary tract symptoms. Repeat UDS demonstrated objective bladder compliance improvements in 22 of 71 (31%). Individuals with shorter time intervals since neurologic injury responded better to BTX than those with longer durations (P = .032). CONCLUSION BTX injections significantly improved symptoms and bladder compliance in 31% of ANLUTD patients with medical refractory poorly compliant bladders.
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Affiliation(s)
- R Corey O'Connor
- Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dane P Johnson
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri
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14
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Gong QQ, Xu YQ, Xu J, Ding XY, Guo C. Meta-Analysis of Randomized Controlled Trials Using Botulinum Toxin A at Different Dosages for Urinary Incontinence in Patients With Overactive Bladder. Front Pharmacol 2020; 10:1618. [PMID: 32009968 PMCID: PMC6974921 DOI: 10.3389/fphar.2019.01618] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 12/11/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Urinary incontinence (UI) is a common and refractory complication for patients with neurogenic detrusor overactivity (NDO) or idiopathic overactive bladder (IOAB). Objectives: To evaluate the effect of Botulinum toxin A (BTX-A) based on different dosages strategy for UI. Method: The MEDLINE, Ovid EMbase, The Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Internet (CNKI), and WanFang database were searched for relevant published randomized controlled trials (RCTs) between 1969 to September 31, 2018. All database were searched to identify relevant randomized controlled trials (RCTs) that investigated the clinical benefit of BTX-A for management of UI in patients with NDO and IOAB. Results: This meta-analysis involved 19 original studies. The BTX-A was superior to placebo in reducing episodes of UI for NDO patients in all subgroups of different dosages for different durations, and also reduced maximum detrusor pressure in all kinds of 200U and 300U at 6 weeks. However, it increased post void residual in different dosages of 200U at 2 weeks. For IOAB patients, compared to placebo, BTX-A increased detrusor compliance for different dosages of 200U and 300U at 12 and 36 weeks, but it increased risk of urinary tract infections at other dosages. Conclusions: This meta-analysis indicated that BTX-A 200U and 300U are more effective than placebo in the treatment of NDO, with minimal, local, and manageable adverse events. Furthermore, BTX-A 300U and 200U could also improve detrusor compliance of IOAB. However, more RCTs would still be necessary to explore the effect of BTX-A on management of UI in NDO and IOAB patients.
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Affiliation(s)
- Qin-Qin Gong
- Center for Women's Healthcare Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yu-Qiong Xu
- Department of Gynaecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Jun Xu
- Center for Gynaecology and Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiao-Yan Ding
- Center for Gynaecology and Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chong Guo
- Center for Women's Healthcare Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Center for Gynaecology and Obstetrics, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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15
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Averbeck MA, Iacovelli V, Panicker J, Schurch B, Finazzi Agrò E. Urodynamics in patients with multiple sclerosis: A consensus statement from a urodynamic experts working group. Neurourol Urodyn 2019; 39:73-82. [PMID: 31746485 DOI: 10.1002/nau.24230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 11/12/2022]
Abstract
AIMS Urodynamics (UDS) is often indicated for multiple sclerosis (MS) patients either at presentation to specialized medical centers or after failure of conservative management of lower urinary tract dysfunction (LUTD). However, the ideal moment and context to indicate this exam in this group of patients remain controversial. We aimed to establish a consensus panel to address the role of UDS in MS patients. METHODS A panel representing urology, rehabilitation medicine, and neurology skilled in neuro-urology participated in a consensus-forming project using a Delphi method to reach consensus on the role of UDS in MS patients. RESULTS In total, five 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 Florence in September 2017 and then with a follow-up teleconference in March 2018. By the end of the Delphi process, formal consensus was achieved for 100% of the items and an algorithm was then developed in a face-to-face meeting in Philadelphia in August 2018. The final expert opinion recommendations were approved by the unanimous consensus of the panel. CONCLUSIONS UDS represents an important diagnostic tool for MS patients and is particularly useful to evaluate the pattern of LUT dysfunction in high-risk patients. There is a lack of high-evidence level studies to support an optimal urodynamic long-term follow-up protocol.
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Affiliation(s)
- M A Averbeck
- Department of Urology, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | - V Iacovelli
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy.,Urology Unit, San Carlo di Nancy General Hospital - GVM Care and Research, Rome, Italy
| | - J Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, UCL Queen Square Institute of Neurology, London, UK
| | - B Schurch
- Neurourology Unit, Department of Clinical Neurosciences, University Hospital of Lausanne, Lausanne, Switzerland
| | - E Finazzi Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
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16
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Wu SJ, Xu YQ, Gao ZY, Wang ZP, Zhao F, Liu L, Wang S. Clinical outcomes of botulinum toxin A management for neurogenic detrusor overactivity: meta-analysis. Ren Fail 2019; 41:937-945. [PMID: 31599184 PMCID: PMC6807649 DOI: 10.1080/0886022x.2019.1655448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The aim of this work was to evaluate the efficacy and safety of botulinum toxin A (BTX-A) treatment in patients with neurogenic detrusor overactivity. PUBMED, EMBASE, and Cochrane Library were identified on 13 May 2017 to identify relevant randomized controlled trials. All data obtained were analyzed using Stata 12.0. Five randomized controlled trials were included in this study. Compared to placebo, the BTX-A groups had significantly fewer urinary incontinence (UI) episodes per day and per week (BTX-A with 300 U for frequency of UI per day at week 2, mean difference (MD): −1.13, 95% confidence interval (CI): −1.89 to −0.37; 200 U; BTX-A with 300 U for frequency of UI per week at week 6, MD: −11.42, 95% CI: −13.91 to −8.93; BTX-A with 200 U for frequency of UI per week at week 6, MD: −10.72, 95% CI: −13.40 to −8.04), increased in maximum cystometric capacity at week 6 (BTX-A with 300 U, MD: 154.88, 95% CI: 133.92–175.84; BTX-A with 200 U, MD: 141.30, 95% CI: 121.28–161.33), decreased maximum detrusor pressure at week 6 (BTX-A with 300 U, MD: −31.72, 95% CI: −37.69 to −25.75; BTX-A with 200 U, MD: −33.47, 95% CI: −39.20 to −27.73). For adverse effects, BTX-A was often associated with more complications and urinary tract infections (BTX-A with 300 U: relative risk (RR):1.42, 95% CI: 1.15–1.76; BTX-A with 200 U: RR: 1.42, 95% CI: 1.11–1.82). This meta-analysis suggests that treatment with BTX-A is effective and safe for neurogenic detrusor overactivity, and recommends using BTX-A with 300 U or with 200 U, as suitable dosage.
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Affiliation(s)
- Shang-Jun Wu
- Department of Urology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University , Huangshi , China
| | - Yu-Qiong Xu
- Peking University Shenzhen Hospital , Shenzhen , China
| | - Zheng-Yan Gao
- Department of Urology, The Sixth People's Hospital of Yancheng City , Yancheng , China
| | - Zhi-Peng Wang
- Department of Urinary Surgery, Linzi District People's Hospital, Binzhou Medical University , Yantai , China
| | - Feng Zhao
- Department of Transfusion Medicine, Linzi District People's Hospital, Binzhou Medical University , Yantai , China
| | - Lin Liu
- Department of Biotherapy, Linzi District People's Hospital, Binzhou Medical University , Yantai , China
| | - Sheng Wang
- Medical Intensive Care Unit, PKUCare Luzhong Hospital , Zibo , China
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17
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Kroll P. The Current Role of Botox in a Pediatric Neurogenic Bladder Condition. CURRENT BLADDER DYSFUNCTION REPORTS 2019. [DOI: 10.1007/s11884-019-00516-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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18
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Gabay B, Maucort-Boulch D, Ruffion A, Scheiber Nogueira MC, Terrier JE. [Long-term outcomes of intradetrusor botulinum toxin A in multiple sclerosis patients]. Prog Urol 2019; 29:156-165. [PMID: 30880066 DOI: 10.1016/j.purol.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/24/2018] [Accepted: 02/01/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this study was to analyze the long-term efficiency and tolerance of TB in the management of anticholinergic refractory hyperactive bladder in patients with MS. MATERIAL AND METHOD Retrospective mono-centric cohort study of all patients with MS who had a TB injection for anticholinergic refractory hyperactivity from 2005 to 2015. The primary endpoint was clinical efficiency based on the frequency of urinary leakage and symptomatic urinary tract infections. RESULTS One hundred and nineteen patients received the first injection. Median follow-up was 26.5 months. After an injection, there was a significant decrease in the number of leaks, with 69.7% of patients without leaks and 93.3% of patients without urinary tract infections. After 7 injections 44% of the patients were still dry and 62.07% had no symptomatic urinary tract infections. The failure rate was 24.37%, the average duration before discharge was 34.7 months. 19 (66%) patients stop treatment for loss of efficacy, 9 (31%) for disease progression and 1 (3%) for cessation of treatment without cause. Of the 774 injections performed, there were complications for 26 of them (3.35%). CONCLUSION Botulinum toxin remains the second-line reference treatment for detrusor overactivity of neurological origin. There is, at least in the short term, a good answer in a large number of cases. This response can be maintained for many years, especially if patients use intermittent catheterization, with excellent tolerance. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- B Gabay
- Service d'urologie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69310 Pierre Bénites, France; Université Claude-Bernard-Lyon 1, 69000 Lyon, France.
| | - D Maucort-Boulch
- Université Claude-Bernard-Lyon 1, 69000 Lyon, France; Service de biostatistique et bioinformatique, hospices civils de Lyon, 69003 Lyon, France.
| | - A Ruffion
- Service d'urologie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69310 Pierre Bénites, France; Université Claude-Bernard-Lyon 1, 69000 Lyon, France.
| | | | - J E Terrier
- Service d'urologie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69310 Pierre Bénites, France; Université Claude-Bernard-Lyon 1, 69000 Lyon, France.
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19
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Khavari R, Elias SN, Pande R, Wu KM, Boone TB, Karmonik C. Higher Neural Correlates in Patients with Multiple Sclerosis and Neurogenic Overactive Bladder Following Treatment with Intradetrusor Injection of OnabotulinumtoxinA. J Urol 2019; 201:135-140. [PMID: 30076906 DOI: 10.1016/j.juro.2018.07.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OnabotulinumtoxinA is a well described treatment of neurogenic overactive bladder. While motor effects on the detrusor muscle have been extensively studied, the sensory effects have not. The aim of this study was to evaluate the impact of intradetrusor onabotulinumtoxinA injection on brain activity in female patients with multiple sclerosis and neurogenic overactive bladder. MATERIALS AND METHODS We prospectively studied 12 women with stable multiple sclerosis and neurogenic overactive bladder using concurrent functional magnetic resonance imaging and urodynamic studies prior to and 6 to 10 weeks following onabotulinumtoxinA injection. Individual functional magnetic resonance imaging activation maps at the time of strong urgency were averaged before and after onabotulinumtoxinA injection where areas of significant activation were identified. RESULTS After onabotulinumtoxinA injection functional magnetic resonance imaging activation increased in the right cingulate body (p = 0.0012), the left posterior cingulate (p = 0.02), the left anterior cingulate (p = 0.0015), the right prefrontal cortex (p = 0.0015), the insula (p = 0.0138) and the pons micturition center (p = 0.05). Sparse areas showed decreased activity, including the left cerebellum (p = 0.001), the left fusiform gyrus (p = 0.065) and the bilateral lentiform nucleus (p = 0.026). CONCLUSIONS Intradetrusor injection of onabotulinumtoxinA appeared to increase the activity of most brain regions known to be involved in the sensation and process of urinary urgency in female patients with multiple sclerosis and neurogenic overactive bladder. To our knowledge this is the first study of its kind to evaluate the possible effects of onabotulinumtoxinA at the human brain level where sensory awareness is located. This activation pattern may be used to further phenotype patients to optimize therapy or determine the sensory effects of onabotulinumtoxinA beyond the bladder.
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Affiliation(s)
- Rose Khavari
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Saba N Elias
- MRI Core, Houston Methodist Research Institute, Houston, Texas
| | - Rashmi Pande
- Department of Urology, Houston Methodist Hospital, Houston, Texas
| | - Katherine M Wu
- MRI Core, Houston Methodist Research Institute, Houston, Texas
| | - Timothy B Boone
- Department of Urology, Houston Methodist Hospital, Houston, Texas
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20
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Peyronnet B, Gamé X, Vurture G, Nitti VW, Brucker BM. Botulinum Toxin Use in Neurourology. Rev Urol 2018; 20:84-93. [PMID: 30288145 DOI: 10.3903/riu0792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The use of botulinum toxin A (BTX-A) has revolutionized the treatment of neurogenic lower urinary tract dysfunction (NLUTD) over the past three decades. Initially, it was used as a sphincteric injection for detrusor sphincter dyssynergia but now is used mostly as intradetrusor injection to treat neurogenic detrusor overactivity (NDO). Its use is supported by high-level-of-evidence studies and it has become the gold-standard treatment for patients with NDO refractory to anticholinergics. Several novelties have emerged in the use of BTX-A in neurourology over the past few years. Although onabotulinumtoxinA (BOTOX®, Allergan, Inc., Irvine, CA) remains the only BTX-A for which use is supported by large, multicenter, randomized, controlled trials (RCT), and is therefore the only one to be licensed in the United States and Europe, a second BTX-A, abobotulinumtoxinA (Dysport®, Ipsen Biopharmaceuticals, Basking Ridge, NJ), is also supported by high-level-of-evidence studies. Other innovations in the use of BTX-A in neurourology during the past few years include the BTX switch (from abobotulinumtoxinA to onabotulinumtoxinA or the opposite) as a rescue option for primary or secondary failures of intradetrusor BTX-A injection and refinements in intradetrusor injection techniques (number of injection sites, injection into the trigone). There is also a growing interest in long-term failure of BTX-A for NDO and their management, and a possible new indication for urethral sphincter injections.
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Affiliation(s)
- Benoit Peyronnet
- Department of Urology, University of Rennes Rennes, France.,Department of Urology, New York University New York, NY
| | - Xavier Gamé
- Department of Urology, University of Toulouse Toulouse, France
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21
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Haynes BM, Osbun NC, Yang CC. Ancillary benefits of bladder chemodenervation for SCI neurogenic bladder. Spinal Cord Ser Cases 2018; 4:83. [PMID: 30245851 DOI: 10.1038/s41394-018-0116-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 07/02/2018] [Accepted: 07/31/2018] [Indexed: 11/09/2022] Open
Abstract
Study design Case series. Objective Bladder chemodenervation is effective in treating neurogenic detrusor overactivity (NDO) in patients with neurogenic bladder due to spinal cord injury. Anecdotal reports also describe the improvement of non-bladder symptoms, specifically those related to autonomic dysreflexia (AD) and muscle spasticity. We conducted a study to further investigate this phenomenon. Setting USA, Urban Tertiary Care Center. Methods Twenty-one persons with SCI completed the study between March and December 2015. Mean age was 45 years (range 21-69). All were scheduled to undergo bladder chemodenervation with onabotulinumtoxinA 200 units to treat bothersome NDO refractory to oral medications. Each completed a questionnaire detailing symptoms unrelated to NDO immediately prior to the procedure, and again between 6 and 12 weeks after. Results All patients reported improvement in NDO symptoms following chemodenervation. Ten patients with prior symptoms of AD reported improvement in AD symptoms after injection. Seventeen patients reported skeletal muscle spasticity in the 3-month period before chemodenervation. In the follow up period, only 14 patients reported having muscle spasticity. In aggregate, 12 of 21 patients reported improvement of non-bladder symptomatology following chemodenervation. Conclusions Chemodenervation of the bladder in patients with SCI can provide ancillary benefits in addition to mitigation of lower urinary symptoms. The mechanism may be related to dampening the bladder's ability to initiate noxious reflex responses.
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Affiliation(s)
- Brandon M Haynes
- Department of Urology, University of Washington, Seattle, WA USA
| | - Nathan C Osbun
- Department of Urology, University of Washington, Seattle, WA USA
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, WA USA
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22
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Doherty A, Hennessey DB, Onggo JR, Ranasinghe W, Gani J. Modifications to Botulinum toxin A delivery in the management of detrusor overactivity recalcitrant to initial injections: a review. World J Urol 2018; 37:891-898. [PMID: 30140945 DOI: 10.1007/s00345-018-2456-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/16/2018] [Indexed: 01/11/2023] Open
Abstract
PURPOSE One quarter of patients will not respond to initial intra-detrusor Botulinum toxin A (BTX) injections for detrusor overactivity. Alternative treatment options include long-term catheterization, sacral neuromodulation, urinary diversion or bladder augmentation. Some of these procedures are invasive. This review explores modifications to BTX delivery that can improve outcome. METHODS A search of Medline, Embase and Cochrane Library to December 2017 was performed according to Preferred Reporting Items for Systematic Review and Metaanalysis (PRISMA) guidelines. Search criteria included, dose escalation, increasing injection site number, trigone injection, switching preparation and alternative methods of BTX delivery. RESULTS Several modifications to BTX delivery may improve response. There is moderate evidence that increasing the dose from 100 U to 200 U results in statistically better symptom control. Trigone-including injections were associated with significantly improved patient-reported symptom scores, as well as superior results in urodynamic outcomes without risking urinary retention and vesico-ureteric reflux. Switching from onabotulinum (OTA) or abobotulinum (ATA) or vice versa may also improve response in over 50% of patients as shown in limited studies. Increasing the number of injection sites is not beneficial. Indeed, decreasing the number of injections to as low as three sites does not result in decreased clinical outcomes. Injection-free delivery is associated with lower efficacy compared to conventional intradetrusor injections. CONCLUSION Before contemplating alternative treatments, practitioners can try to improve on BTX delivery. Firstly, the dose can be increased to 200 U; the trigone included in the injection sites and switching brands may also be helpful.
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Affiliation(s)
- A Doherty
- Department of Urology, Craigavon Area Hospital, Portadown, UK.
| | - D B Hennessey
- Department of Urology, Craigavon Area Hospital, Portadown, UK
| | - J R Onggo
- Department of Urology, Austin Health, Melbourne, Australia
| | - W Ranasinghe
- Department of Urology, Austin Health, Melbourne, Australia
| | - J Gani
- Department of Urology, Austin Health, Melbourne, Australia.,Department of Urology, Western Health, University of Melbourne, Melbourne, Australia
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Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is the most frequent neuroinflammatory disease of the central nervous system and is commonly associated with lower urinary tract (LUT) dysfunction. As a consequence, health-related quality of life is often impaired and the upper urinary tract might be at risk for damage. The aim of this review is to give an overview of current treatment options for LUT dysfunction in patients with MS. RECENT FINDINGS The treatment is tailored to the type of dysfunction-storage or voiding dysfunction-beginning with conservative treatment options and ending with invasive therapies and surgery. Additionally, alternative options, e.g., different intravesical therapies or cannabinoids, have been evaluated in recent years with promising results. Current available therapies offer different possible treatments for LUT dysfunction in patients with MS. They address either voiding or storage dysfunction and therefore ameliorate LUT symptoms improve quality of life and protect the upper urinary tract.
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Affiliation(s)
- Jure Tornic
- Department of Uro-Neurology, The National Hospital For Neurology and Neurosurgery and UCL Institute for Neurology, Queen Square, London, WC1N 3BG, UK.
| | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital For Neurology and Neurosurgery and UCL Institute for Neurology, Queen Square, London, WC1N 3BG, UK
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24
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Dray E, Cameron AP, Clemens JQ, Qin Y, Covalschi D, Stoffel J. Does Post-Void Residual Volume Predict Worsening Urological Symptoms in Patients with Multiple Sclerosis? J Urol 2018; 200:868-874. [PMID: 29702098 DOI: 10.1016/j.juro.2018.04.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Our goal was to examine how post-void residual urine volume relates to urinary symptoms in patients with multiple sclerosis. MATERIALS AND METHODS We retrospectively reviewed the records of patients with multiple sclerosis who had lower urinary tract symptoms and presented to a tertiary neurourology clinic. Patients for whom post-void residual volume was recorded at the initial urological assessment were included in our analysis. Results of the AUA (American Urological Association) SI (Symptom Index) and the M-ISI (Michigan Incontinence Symptom Index) completed at this visit were analyzed to assess the severity of lower urinary tract symptoms and incontinence. A chart review was performed to obtain information on demographics and documented urinary tract infections. RESULTS Between 2014 and 2017, 110 patients diagnosed with multiple sclerosis underwent post-void residual volume measurement at our clinic. Average post-void residual volume was 123.4 cc (range 0 to 650 cc). The mean AUA symptom score was 19.1 with an average bother score of 4.1. Analysis of post-void residual volume as a continuous variable did not show an association between increasing post-void residual volume and an increasing AUA SI or bother score (p = 0.53 and 0.44, respectively). When evaluated by post-void residual volume tertile, no relationship was found between post-void residual volume, and the AUA SI and the M-ISI (p = 0.54 and 0.57, respectively). No correlation was also found between increasing post-void residual volume and a recent history of recurrent urinary tract infections (p = 0.27). CONCLUSIONS Post-void residual volume was not associated with worsening obstructive lower urinary tract symptoms as assessed by the AUA SI, worsening incontinence as measured by the M-ISI score or an increased risk of recurrent urinary tract infections in select patients with multiple sclerosis and lower urinary tract symptoms.
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25
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Prakash NS, Lopategui DM, Gomez C. Changes in Management of Poorly Compliant Bladder in Botulinum Toxin A Era. Curr Urol Rep 2018; 18:64. [PMID: 28689244 DOI: 10.1007/s11934-017-0707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bladder compliance is a measure of distensibility. Maladies such as myelodysplasia, myelomeningocele, spinal cord injury, multiple sclerosis and obstructive uropathy are known to decrease bladder compliance. Decrease in bladder compliance is a characteristic of neurogenic bladders. The pathophysiology of bladder compliance is complex but ultimately leads to high pressure during filling and storage phases. These high pressures lead to renal impairment, incontinence, and recurrent urinary tract infections. This review presents management of poorly compliant bladders with onabotulinumtoxinA.
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Affiliation(s)
| | - Diana M Lopategui
- Department of Urology, Miller School of Medicine University of Miami, Miami, FL, USA
| | - Christopher Gomez
- Department of Urology, Miller School of Medicine University of Miami, Miami, FL, USA.
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26
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Lombardi G, Musco S, Bacci G, Celso M, Bellio V, Del Popolo G. Long-term response of different Botulinum toxins in refractory neurogenic detrusor overactivity due to spinal cord injury. Int Braz J Urol 2017; 43:721-729. [PMID: 28537692 PMCID: PMC5557449 DOI: 10.1590/s1677-5538.ibju.2016.0584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 12/03/2016] [Indexed: 11/29/2022] Open
Abstract
Purpose To assess the response in spinal cord injured patients alternatively treated with different types and dosages of Botulinum neurotoxin type A (BoNT/A) over 15 years. Material and methods Patients who underwent first BoNT/A from 1999-2001 and practiced intermittent catheterization were included. Baseline 3-day bladder diary (BD) and urodynamics were collected. BoNT/A failure was defined when patients asked for re-injection ≤ 3 months post-treatment. Criteria for re-injection was at least one daily episode of urinary incontinence at BD. Before re-injection, patients were asked if they had reached 6 months of dryness without antimuscarinics (YES response). Results Overall, 32/60 (53.4%) “No failure” (NF) group; 16 (26.6%) “occasional failure” (OF) and 12 (20%) “consecutive failure” (CF) were included. A total of 822 BoNT/A infiltrations were performed. The mean interval from previous injection to treatment re-scheduling was 8 months. No significant differences between treatments were found within the three groups (p>0.05). The percentage of YES responses increased from 19% (AboBoNT/A 500IU) to 29 % (OnaBoNT/A 300IU) in NF, and from 18% (AboBoNT/A 500IU) to 25% (OnaBoNT/A 300IU) for OF. Five NF cases (15.6%) maintained 6 months of dryness after each injection. Among the baseline variables, only low compliance (< 20mL/cmH2O) was found as predictor for failure (p=0.006). Conclusions Long term BoNT/A for NDO did not increase failures, independent of the types of treatments and switching. Definition of failure and other criteria for continuing repetitive BoNT/A treatment is mandatory. CF was predictable for no response in earlier follow-up.
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Affiliation(s)
- Giuseppe Lombardi
- Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Stefania Musco
- Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Giovanni Bacci
- Department of Biology, Universita Degli Studi di Firenze, Toscana, Italy
| | - Maria Celso
- Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Valerio Bellio
- Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Giulio Del Popolo
- Department of Neuro-Urology, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
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27
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Peyronnet B, Gamé X. Failures and long-term discontinuations of intradetrusor botulinum toxin injections for neurogenic detrusor overactivity: A new challenge in neurourology. Neurourol Urodyn 2017; 37:1182-1183. [PMID: 28991395 DOI: 10.1002/nau.23424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/17/2017] [Indexed: 11/06/2022]
Affiliation(s)
| | - Xavier Gamé
- Department of Urology, University of Toulouse, Toulouse, France
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28
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Dielubanza E, Vasavada S. An important counseling tool for urologists managing patients with neurogenic detrusor overactivity. BJU Int 2017; 120:E1-E2. [DOI: 10.1111/bju.13898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Elodi Dielubanza
- Glickman Urological Institute; Cleveland Clinic; Cleveland OH USA
| | - Sandip Vasavada
- Glickman Urological Institute; Cleveland Clinic; Cleveland OH USA
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29
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Gu HY, Song JK, Zhang WJ, Xie J, Yao QS, Zeng WJ, Zhang C, Niu YM. A systematic review and meta-analysis of effectiveness and safety of therapy for overactive bladder using botulinum toxin A at different dosages. Oncotarget 2017; 8:90338-90350. [PMID: 29163833 PMCID: PMC5685754 DOI: 10.18632/oncotarget.20056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 07/25/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose To assess the effectiveness and safety of botulinum toxin A (BTX-A) at different dosages for overactive bladder (OAB). Materials and Methods The MEDLINE, EMBASE, and Cochrane Controlled Trials Register databases were searched through November 3, 2016 to identify relevant randomized controlled trials (RCTs). Results Eleven studies were identified in this meta-analysis. Compared with placebo, the urinary incontinence (UI) episodes per week as the primary outcomes, urodynamic parameters including maximum cystometric capacity (MCC), and maximum detrusor pressure (MDP) for neurogenic detrusor overactivity (NDO) at 6 weeks, and for idiopathic detrusor overactivity (IDO) at 36 weeks were evaluated. These and other outcomes for effectiveness of BTX-A at different dosages in two observation periods indicate that a dose greater than 50 U is significantly more effective for certain symptoms of OAB compared with placebo. However, there were no significant differences between some dosages. Compared with placebo, the outcomes of total adverse events for NDO and for IDO show that doses of 300 U and 200 U for NDO are associated with more complications. Conclusions In consideration that the treatments of BTX-A were with minimal, local, and manageable adverse effects, this meta-analysis demonstrates that BTX-A 200 U is recommended for management of NDO for short-term treatment for there was no significant difference from the larger dose of 300U. The short-term efficacies of BTX-A for IDO remain to be investigated.
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Affiliation(s)
- Hui-Yun Gu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Ju-Kun Song
- Department of Oral and Maxillary Surgery, Guizhou Provincial People's Hospital, Guiyang 550002, China
| | - Wen-Jun Zhang
- Department of Ultrasound, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Jin Xie
- Administrative Office, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Qi-Sheng Yao
- Department of Urinary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Wen-Jing Zeng
- Department of Anesthesiology, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Yu-Ming Niu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China.,Department of Urinary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
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30
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Kaviani A, Khavari R. Disease-Specific Outcomes of Botulinum Toxin Injections for Neurogenic Detrusor Overactivity. Urol Clin North Am 2017; 44:463-474. [PMID: 28716326 PMCID: PMC5604875 DOI: 10.1016/j.ucl.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Intradetrusor injection of botulinum toxin A (BTX-A) is an effective option for managing patients with neurogenic detrusor overactivity (NDO) who do not respond to or tolerate oral pharmacologic agents. There is level I evidence that intradetrusor injection of onabotulinumtoxinA for refractory NDO in patients with multiple sclerosis and spinal cord injury is associated with a significantly greater achievement of goals and improved performance in urodynamic studies than placebo. Pilot studies or small case series support BTX-A for NDO in patients with Parkinson's disease and cerebrovascular accident. BTX-A seems to be effective in children with myelomeningocele. However, no adult data exists.
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Affiliation(s)
- Aaron Kaviani
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX 77030, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX 77030, USA.
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31
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Eldred-Evans D, Dasgupta P. Use of botulinum toxin for voiding dysfunction. Transl Androl Urol 2017; 6:234-251. [PMID: 28540231 PMCID: PMC5422676 DOI: 10.21037/tau.2016.12.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 10/11/2016] [Indexed: 01/23/2023] Open
Abstract
The use of botulinum toxin A (BoNT-A) has expanded across a range of lower urinary tract conditions. This review provides an overview of the current indications for BoNT-A in the lower urinary tract and critically evaluates the published evidence within each area. The classic application of BoNT-A has been in the management of refractory neurogenic detrusor overactivity (NDO) and overactive bladder (OAB). There is a large volume of high-quality evidence, including numerous randomized placebo-controlled trials, which demonstrate the efficacy of BoNT-A over a long follow-up period. The culmination of this robust evidence-base has led to onabotulinumtoxin A (onaBoNT-A) receiving regulatory approval as a second-line treatment for NDO at a dose of 200 U and OAB at dose of 100 U. Other applications for BoNT-A are used on an off-license basis and include interstitial cystitis/bladder pain syndrome (IC/BPS), benign prostatic hyperplasia (BPH), and detrusor sphincter dyssynergia (DSD). These applications are associated with a less mature evidence-base although the literature is rapidly evolving. At present, the results for painful bladder syndrome (PBS) are promising and BoNT-A injections are recommended as a fourth line option in recent international guidelines, although larger randomized study with longer follow-up are required to confirm the initial findings. As a treatment for DSD, BoNT-A injections have shown potential but only in a small number of trials of limited quality. No definite recommendation can be made based on the current evidence. Finally, the results for the treatment of BPH have been variable and recent high quality randomized controlled trials (RCTs) have suggested no benefit over placebo so at present it cannot be recommended for routine clinical practice. Future advances of BoNT-A include liposome encapsulated formulations which are being developed as an alternative to intravesical injections.
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Affiliation(s)
- David Eldred-Evans
- Department of Urology, Medical Research Council (MRC) Centre for Transplantation, King's College London, Guy's Hospital, London, UK
| | - Prokar Dasgupta
- Department of Urology, Medical Research Council (MRC) Centre for Transplantation, King's College London, Guy's Hospital, London, UK
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32
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Denys P, Dmochowski R, Aliotta P, Castro-Diaz D, Blok B, Ethans K, Aboushwareb T, Magyar A, Kennelly M. Positive outcomes with first onabotulinumtoxinA treatment persist in the long term with repeat treatments in patients with neurogenic detrusor overactivity. BJU Int 2017; 119:926-932. [PMID: 28139068 DOI: 10.1111/bju.13795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To examine whether response to first treatment with onabotulinumtoxinA is predictive of long-term treatment outcome in patients with neurogenic detrusor overactivity (NDO). PATIENTS AND METHODS Patients with NDO who were enrolled in a 3-year extension study (after a 52-week phase III study) received onabotulinumtoxinA 'as needed', based on fulfilment of prespecified retreatment criteria. This post hoc analysis included patients who received only the 200-U dose during the phase III and extension studies. Data on mean percent reduction from baseline in urinary incontinence (UI) episodes at week 6 after the first treatment were analysed, and the patients were stratified into three response groups: <50% (group 1; n = 33), 50-74% (group 2; n = 23), and 75-100% (group 3; n = 139). The following were assessed: change from baseline in mean percent UI reduction; proportions of patients who achieved ≥50% and 100% UI reduction after each subsequent treatment, and patients who achieved ≥50% UI reduction after all subsequent treatments; change from baseline in Incontinence Quality of Life (I-QOL) total summary score; and the proportion of patients who achieved or exceeded the minimally important difference (MID; +11 points) in I-QOL score. Adverse events (AEs) were also assessed. RESULTS The majority of the patients (83.1%; 162/195) experienced a ≥50% UI reduction after onabotulinumtoxinA treatment 1. Baseline characteristics were largely similar across the groups. After treatment 1, the mean percent reduction in UI remained consistent in subsequent treatments 2-6 for patients in response group 2 (range: 64.5-83.5%) and group 3 (range: 79.4-88.0%), but increased for those in the low response group (range: 36.3-60.3%). After treatment 1, the proportion of patients who achieved ≥50% reduction in UI episodes was consistent with subsequent treatments 2-6 in group 2 (range: 75.0-100%) and group 3 (range: 87.3-97.1%), but increased in the low response group (range: 48.3-72.7%). Even among those who achieved a low response after treatment 1, 37.9% of patients achieved ≥50% UI reduction in all subsequent treatments. Improvements in I-QOL scores in groups 2 and 3 were consistently 2-3 times the MID. In the low response group, at least 50% of the patients achieved or exceeded the MID with treatments 2-6. AEs were similar across all response groups and consistent across repeated treatments. CONCLUSION Patients with NDO with a ≥50% UI reduction after their first onabotulinumtoxinA treatment continued to experience consistent improvements in UI and quality of life with subsequent treatments over the duration of 4 years. A <50% UI reduction after first treatment did not necessarily predict low response with subsequent treatments. Thus, these results underscore the importance of attempting at least a second treatment with onabotulinumtoxinA before deeming patients unsuitable for onabotulinumtoxinA therapy.
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Affiliation(s)
| | | | - Philip Aliotta
- Western New York Urology Associates, LLC, Cheektowaga, NY, USA
| | - David Castro-Diaz
- Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Bertil Blok
- Erasmus Medical Centre, Rotterdam, The Netherlands
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33
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Cheng T, Shuang WB, Jia DD, Zhang M, Tong XN, Yang WD, Jia XM, Li S. Efficacy and Safety of OnabotulinumtoxinA in Patients with Neurogenic Detrusor Overactivity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS One 2016; 11:e0159307. [PMID: 27463810 PMCID: PMC4963110 DOI: 10.1371/journal.pone.0159307] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/30/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neurogenic detrusor overactivity (NDO) affects the quality of life (QoL) of millions of individuals worldwide. The purpose of this study was to assess the efficacy and safety of onabotulinumtoxinA in patients with NDO using a network meta-analytic approach, which can also quantify and compare the efficacy of onabotulinumtoxinA across different dosages. METHODS PubMed, EMBASE, and the Controlled Trials Register were searched to identify randomized controlled trials comparing onabotulinumtoxinA to a control for NDO in adult patients. The primary outcome was the mean number of urinary incontinence (UI) episodes per week. Urodynamic parameters included the maximum cystometric capacity (MCC) and the maximum detrusor pressure (MDP). The safety of onabotulinumtoxinA was determined by the incidence of various frequent adverse events (AEs). Two authors extracted data independently, and the statistical analyses were performed using RevMan 5.1.0 software. RESULTS A total of 1,915 patients from six randomized controlled trials were included in this meta-analysis. The onabotulinumtoxinA-treated groups had a significantly decreased mean number of urinary incontinence episodes per week (at week 6) (onabotulinumtoxinA200U: MD: -10.72, 95% CI: -13.4 to -8.04, P<0.00001; 300 U: MD: -11.42, 95% CI: -13.91 to -8.93, P<0.00001), MDP (200 U: MD: -33.46, 95% CI: -39.74 to -27.18, P<0.00001; 300 U: MD: -31.72, 95% CI: -37.69 to -25.75, P<0.00001), and greater increased MCC (200 U: MD: 141.30, 95% CI: 121.28 to 161.32, P<0.00001; 300 U: MD: 151.39, 95% CI: 130.43 to 172.34, P<0.00001) compared to the placebo-treated groups. However, there were no significant differences between the onabotulinumtoxinA-treated groups for the number of weekly UI episodes at 6 weeks (MD: 0.08, 95% CI: -2.57 to 2.73, P = 0.95). Similarly, we also observed that there were no significant differences in MCC (MD: -9.97, 95% CI: -33.15 to 13.20, P = 0.40) and MDP (MD: -1.86, 95% CI: -8.09 to 4.37, P = 0.56). Considering the AEs, the onabotulinumtoxinA-treated groups were often associated with more complications, including urinary tract infections (UTIs) (RR: 1.47, 95% CI: 1.29 to 1.67, P<0.00001), urinary retention (RR: 5.58, 95% CI: 3.53 to 8.83, P<0.00001), hematuria (RR: 1.70, 95% CI: 1.01 to 2.85, P = 0.05), and muscle weakness (RR: 2.59, 95% CI: 1.36 to 4.91, P = 0.004). CONCLUSIONS OnabotulinumtoxinA can significantly reduce the frequency of urge urinary incontinence and improve urodynamic parameters (MCC and MDP) in patients with NDO at 6 weeks after treatment. This meta-analysis indicates that onabotulinumtoxinA is effective and safe for treating patients with NDO compared to placebo. Additionally, we did not observe any statistical or clinical differences in efficacy between 300 and 200 U dosages.
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Affiliation(s)
- Tao Cheng
- The First Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wei-bing Shuang
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- * E-mail:
| | | | - Min Zhang
- The First Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xu-nan Tong
- The First Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wei-dong Yang
- Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Xu-ming Jia
- ShanXi Hospital of Integrated Traditional and Western Medicine, Taiyuan, Shanxi, China
| | - Shuo Li
- The First Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, China
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Clinical Efficacy and Changes of Urothelial Dysfunction after Repeated Detrusor Botulinum Toxin A Injections in Chronic Spinal Cord-Injured Bladder. Toxins (Basel) 2016; 8:toxins8060164. [PMID: 27249005 PMCID: PMC4926131 DOI: 10.3390/toxins8060164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/08/2016] [Accepted: 05/18/2016] [Indexed: 11/18/2022] Open
Abstract
Chornic spinal cord injury (SCI) will induce bladder urothelium dysfunction. This study investigated the therapeutic effects on urothelial dysfunction after repeated detrusor injections of onabotulinumtoxinA (BoNT-A) in SCI patients with neurogenic detrusor overactivity (NDO). Twenty chronic suprasacral SCI patients with NDO were enrolled. The patients received 300 U BoNT-A injection into the detrusor every six months. The urothelium was assessed by cystoscopic biopsy at baseline and six months after each BoNT-A treatment. Immunofluorescence staining for urothelial dysfunction, including E-cadherin, zonula occludens-1 (ZO-1), tryptase for mast cell activity, and urothelial apoptosis were investigated. The outcome of urothelial dysfunction parameters after BoNT-A injection were compared between baseline and six months after each treatment. Repeated 300 U BoNT-A injections showed a sustained decrease of detrusor pressure compared with baseline. After three repeated BoNT-A detrusor injections, significantly greater distributions of E-cadherin (p = 0.042) and ZO-1 (p = 0.003) expressions, but no significant changes, of urothelial apoptosis and mast cell activation were found after repeated BoNT-A therapy. Urothelial dysfunction, such as adhesive and junction protein concentrations in SCI patients’ bladders, recovered after three repeated cycles of BoNT-A treatment. The therapeutic effects sustained. However, urothelial inflammation and apoptosis after SCI were not significantly improved after three repeated BoNT-A injections.
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35
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Hascoet J, Manunta A, Brochard C, Arnaud A, Damphousse M, Menard H, Kerdraon J, Journel H, Bonan I, Odent S, Fremond B, Siproudhis L, Gamé X, Peyronnet B. Outcomes of intra-detrusor injections of botulinum toxin in patients with spina bifida: A systematic review. Neurourol Urodyn 2016; 36:557-564. [PMID: 27187872 DOI: 10.1002/nau.23025] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/30/2016] [Indexed: 12/11/2022]
Abstract
CONTEXT Bladder management in spina bifida patients relies on clean intermittent catheterization and oral antimuscarinics with a significant failure rate. The efficacy of intradetrusor injections of botulinum toxin has been confirmed in patients with spinal cord injury or multiple sclerosis but not in patients with myelomeningocele. OBJECTIVE To conduct a systematic review of current evidence regarding the efficacy of intra-detrusor injections of Botulinum Toxin A (BTX-A) in spina bifida patients with neurogenic detrusor overactivity (NDO) refractory to antimuscarinics. METHODS A research has been conducted on Medline and Embase using the keywords: ("spina bifida" OR "myelomeningocele" OR "dysraphism") AND "toxin." The search strategy and studies selection were performed using the PICOS method according to the PRISMA statement. RESULT Twelve published series were included (n = 293 patients). All patients were <18 years old. There was no randomized study comparing BTX-A versus placebo and most studies had no control group. Most studies reported a clinical and urodynamic improvement with resolution of incontinence in 32-100% of patients, a decrease in maximum detrusor pressure from 32 to 54%, an increase of maximum cystometric capacity from 27 to 162%, and an improvement in bladder compliance of 28-176%. Two studies suggested lower efficacy in patients with low compliance bladder compared to those with isolated detrusor overactivity. CONCLUSION Intradetrusor injections of BTX-A could be effective in children with spina bifida but this assumption is not supported by high level of evidence studies. There is no data available in adult patients. Neurourol. Urodynam. 36:557-564, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Andrea Manunta
- Service d'urologie, CHU Rennes, Rennes, France.,Centre de référence spina bifida, CHU Rennes, Rennes, France
| | - Charlène Brochard
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Service de Gastro-Entérologie, CHU Rennes, Rennes, France.,Equipe thématique INPHY CIC 1414 et INSERM UMR 991, CHU Rennes, Rennes, France
| | - Alexis Arnaud
- Service de chirurgie pédiatrique, CHU Rennes, Rennes, France
| | - Mireille Damphousse
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Service de médecine physique et réadaptation, CHU Rennes, Rennes, France
| | - Hélène Menard
- Centre de référence spina bifida, CHU Rennes, Rennes, France
| | - Jacques Kerdraon
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Centre de rééducation de Kerpape, Ploemeur, France
| | - Hubert Journel
- Centre de référence spina bifida, CHU Rennes, Rennes, France
| | - Isabelle Bonan
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Service de médecine physique et réadaptation, CHU Rennes, Rennes, France
| | - Sylvie Odent
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Service de génétique, CHU Rennes, Rennes, France
| | - Benjamin Fremond
- Service de chirurgie pédiatrique, CHU Rennes, Rennes, France.,Centre de référence spina bifida, CHU Rennes, Rennes, France
| | - Laurent Siproudhis
- Centre de référence spina bifida, CHU Rennes, Rennes, France.,Service de Gastro-Entérologie, CHU Rennes, Rennes, France.,Equipe thématique INPHY CIC 1414 et INSERM UMR 991, CHU Rennes, Rennes, France
| | - Xavier Gamé
- Département d'Urologie, Transplantation Rénale et Andrologie, CHU Rangueil, Toulouse, France
| | - Benoit Peyronnet
- Service d'urologie, CHU Rennes, Rennes, France.,Centre de référence spina bifida, CHU Rennes, Rennes, France.,Equipe thématique INPHY CIC 1414 et INSERM UMR 991, CHU Rennes, Rennes, France
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36
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Giarenis I, Zacchè M, Robinson D, Cardozo L. Is there any association between urodynamic variables and severity of overactive bladder in women with idiopathic detrusor overactivity? Neurourol Urodyn 2016; 36:780-783. [DOI: 10.1002/nau.23023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 04/03/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Ilias Giarenis
- Department of Urogynaecology; King's College Hospital; London United Kingdom
| | - Martino Zacchè
- Department of Urogynaecology; King's College Hospital; London United Kingdom
| | - Dudley Robinson
- Department of Urogynaecology; King's College Hospital; London United Kingdom
| | - Linda Cardozo
- Department of Urogynaecology; King's College Hospital; London United Kingdom
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37
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Sadiq A, Brucker BM. Management of neurogenic lower urinary tract dysfunction in multiple sclerosis patients. Curr Urol Rep 2016; 16:44. [PMID: 26025495 DOI: 10.1007/s11934-015-0519-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple sclerosis (MS) can be a debilitating neurological condition that attributes significant morbidity to bladder dysfunction. Although many effective treatment options exist, symptomatic patients are often underdiagnosed and undertreated. The purpose of this article is to give an overview of the current literature including new screening tools to identify symptomatic patients and updates on treatment options including medications, botulinum toxin, and neuromodulation.
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Affiliation(s)
- Areeba Sadiq
- Department of Urology, New York University Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY, 10016, USA,
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38
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Chen SF, Chang CH, Kuo HC. Effect of detrusor botulinum toxin a injection on urothelial dysfunction in patients with chronic spinal cord injury: a clinical and immunohistochemistry study before and after treatment. Spinal Cord 2016; 54:889-894. [PMID: 26832760 DOI: 10.1038/sc.2015.241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 11/22/2015] [Accepted: 12/14/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of this study is to investigate the changes of urothelial junction proteins, apoptosis and suburothelial inflammation after detrusor injection of botulinum toxin A (BoNT-A) in patients with spinal cord injury (SCI) and neurogenic detrusor overactivity (NDO). METHODS A total of 26 patients with chronic suprasacral SCI and NDO were enroled. The urothelium was assessed by cystoscopic biopsy at baseline, 3 and 6 months after a single treatment of 300 U BoNT-A into the detrusor. Immunofluorescence staining of E-cadherin, zonula occludens-1 (ZO-1) and tryptase for mast cell activity were performed. Urothelial apoptosis was also evaluated. The differences in urothelial dysfunction were compared between baseline and 3 and 6 months after treatment. Bladder biopsies from patients undergoing anti-incontinence surgery served as controls. RESULTS A single 300-U BoNT-A injection into the detrusor significantly decreased detrusor pressure and increased bladder compliance at 3 and 6 months after treatment. Significantly lower E-cadherin and ZO-1 expressions and increased mast cell and apoptotic cell counts were noted in SCI bladders compared with controls (all P<0.001). Significantly greater distributions of E-cadherin (P<0.001) and ZO-1 (P=0.05) expressions were noted 3 months after BoNT-A injection. However, these changes had declined by 6 months after treatment. Activated mast cells and urothelial apoptosis showed no significant differences between baseline and 3 or 6 months. CONCLUSION Urothelial dysfunction and adhesive and junction protein concentrations in SCI patients' bladders recovered after BoNT-A treatment. However, this effect decreased with time. Thus, neurogenic inflammation after SCI was not adequately improved after a single BoNT-A injection.
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Affiliation(s)
- S-F Chen
- Department of Urology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
| | - C-H Chang
- Department of Urology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
| | - H-C Kuo
- Department of Urology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
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39
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Chermansky CJ, Chancellor MB. Use of Botulinum Toxin in Urologic Diseases. Urology 2016; 91:21-32. [PMID: 26777748 DOI: 10.1016/j.urology.2015.12.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/18/2015] [Accepted: 12/30/2015] [Indexed: 01/23/2023]
Abstract
OnabotulinumtoxinA (onaBoNTA) is approved by the US Food and Drug Administration for the treatment of urinary incontinence due to neurogenic detrusor overactivity and for the treatment of refractory overactive bladder. As a treatment for benign prostatic hyperplasia, onaBoNTA showed no difference over placebo in recently published studies. In contrast, treating interstitial cystitis/bladder pain syndrome with onaBoNTA has shown efficacy, and the current American Urological Association guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome lists onaBoNTA as fourth-line treatment. This comprehensive review will present all studied applications of onaBoNTA within the lower urinary tract.
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Affiliation(s)
| | - Michael B Chancellor
- Department of Urology, Beaumont Health and Oakland University William Beaumont School of Medicine, Royal Oak, MI.
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Does Reduction of Number of Intradetrusor Injection Sites of aboBoNTA (Dysport®) Impact Efficacy and Safety in a Rat Model of Neurogenic Detrusor Overactivity? Toxins (Basel) 2015; 7:5462-71. [PMID: 26694464 PMCID: PMC4690145 DOI: 10.3390/toxins7124896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/03/2015] [Accepted: 12/10/2015] [Indexed: 11/27/2022] Open
Abstract
Intradetrusor injections of Botulinum toxin A—currently onabotulinumtoxinA—is registered as a second-line treatment to treat neurogenic detrusor overactivity (NDO). The common clinical practice is 30 × 1 mL injections in the detrusor; however, protocols remain variable and standardization is warranted. The effect of reducing the number of injection sites of Dysport® abobotulinumtoxinA (aboBoNTA) was assessed in the spinal cord-injured rat (SCI). Nineteen days post-spinalization, female rats received intradetrusor injections of saline or aboBoNTA 22.5 U distributed among four or eight sites. Two days after injection, continuous cystometry was performed in conscious rats. Efficacy of aboBoNTA 22.5 U was assessed versus aggregated saline groups on clinically-relevant parameters: maximal pressure, bladder capacity, compliance, voiding efficiency, as well as amplitude, frequency, and volume threshold for nonvoiding contractions (NVC). AboBoNTA 22.5 U significantly decreased maximal pressure, without affecting voiding efficiency. Injected in four sites, aboBoNTA significantly increased bladder capacity and compliance while only the latter when in eight sites. AboBoNTA significantly reduced NVC frequency and amplitude. This preclinical investigation showed similar inhibiting effects of aboBoNTA despite the number of sites reduction. Further studies are warranted to optimize dosing schemes to improve the risk-benefit ratio of BoNTA-based treatment modalities for NDO and further idiopathic overactive bladder.
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41
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OnabotulinumtoxinA (Botox A) for Neurogenic Detrusor; Evidence for 200 U vs. 300 U. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Panicker JN, Fowler CJ, Kessler TM. Lower urinary tract dysfunction in the neurological patient: clinical assessment and management. Lancet Neurol 2015; 14:720-32. [PMID: 26067125 DOI: 10.1016/s1474-4422(15)00070-8] [Citation(s) in RCA: 262] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/27/2015] [Accepted: 04/27/2015] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, UK.
| | - Clare J Fowler
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, London, UK
| | - Thomas M Kessler
- Neuro-Urology, Spinal Cord Injury Center, University of Zürich, Balgrist University Hospital, Zürich, Switzerland
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Abstract
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.
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OnabotulinumtoxinA intradetrusorial injections improve sexual function in female patients affected by multiple sclerosis: preliminary results. World J Urol 2015; 33:2095-101. [PMID: 25966660 DOI: 10.1007/s00345-015-1578-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/26/2015] [Indexed: 10/23/2022] Open
Abstract
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.
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45
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Chartier-Kastler E, Rovner E, Hepp Z, Khalaf K, Ni Q, Chancellor M. Patient-reported goal achievement following onabotulinumtoxinA treatment in patients with neurogenic detrusor overactivity. Neurourol Urodyn 2015; 35:595-600. [PMID: 25846869 DOI: 10.1002/nau.22757] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 01/30/2015] [Indexed: 11/11/2022]
Abstract
AIMS To identify the self-reported treatment goals of patients with urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO), determine whether patients achieved their goals following onabotulinumtoxinA treatment, and assess impact of neurogenic disease (multiple sclerosis or spinal cord injury) and/or clean intermittent catheterization (CIC) on goal achievement. METHODS Data from two Phase III studies of onabotulinumtoxinA 200U (n = 227) or placebo (n = 241) in NDO patients (≥14 UI episodes/week; inadequately managed by anticholinergics) were pooled for analysis. At baseline, patients listed their top two qualitative treatment goals, which were distributed into eight subcategories. Six weeks post-treatment, patients rated whether they achieved their goals (5-point Likert scale). The frequency distribution of goals, the proportion of patients who achieved their goals, and goal achievement by etiology and use/non-use of CIC were assessed. RESULTS At baseline, the most common goals were "be dry" (37.9%), "reduce other urinary symptoms" (26.4%), and "improve quality of life/sleep/emotions" (21.4%). Significantly higher proportions of onabotulinumtoxinA-treated patients achieved their overall goals versus placebo (62.0% vs. 17.2%; P < 0.001). OnabotulinumtoxinA treatment resulted in higher goal achievement in all goal categories, regardless of etiology. CIC use did not negatively impact patients' overall goal achievement; significantly higher proportions of onabotulinumtoxinA-treated patients versus placebo achieved their goals regardless of baseline catheterization use or de novo CIC during the first 6 weeks of the study. CONCLUSIONS The majority of patients with UI due to NDO achieved their self-determined treatment goals following onabotulinumtoxinA 200U therapy, regardless of etiology or CIC use. Neurourol. Urodynam. 35:595-600, 2016. © 2015 The Authors. Neurourology and Urodynamics, published by Wiley Periodicals, Inc.
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Affiliation(s)
| | - Eric Rovner
- Department of Urology, Medical University of South Carolina, Charleston, South Carolina
| | - Zsolt Hepp
- Global Health Outcomes Strategy and Research, Allergan, Inc., Irvine, California
| | - Kristin Khalaf
- Global Health Outcomes Strategy and Research, Allergan, Inc., Irvine, California.,Department of Pharmaceutical Sciences, University of Arizona, Phoenix, Arizona
| | - Quanhong Ni
- Global Health Outcomes Strategy and Research, Allergan, Inc., Irvine, California
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46
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Rademakers KLJ, Drossaerts JMAFL, Rahnama'i MS, van Koeveringe GA. Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring. Int J Urol 2015; 22:503-7. [PMID: 25711671 DOI: 10.1111/iju.12723] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/24/2014] [Accepted: 12/29/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms. METHODS This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics. RESULTS A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence. CONCLUSIONS Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome.
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Affiliation(s)
- Kevin L J Rademakers
- Department of Urology, Maastricht University Medical Center, Maastricht, The Netherlands
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48
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OnabotulinumtoxinA (Botox®): A Review of its Use in the Treatment of Urinary Incontinence in Patients with Multiple Sclerosis or Subcervical Spinal Cord Injury. Drugs 2014; 74:1659-72. [DOI: 10.1007/s40265-014-0271-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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49
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Cruz F, Nitti V. Chapter 5: Clinical data in neurogenic detrusor overactivity (NDO) and overactive bladder (OAB). Neurourol Urodyn 2014; 33 Suppl 3:S26-31. [DOI: 10.1002/nau.22630] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/18/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Francisco Cruz
- Hospital São João; IBMC & Faculty of Medicine do Porto; Porto Portugal
| | - Victor Nitti
- Department of Urology; New York University School of Medicine; New York USA
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50
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Ethans KD, Casey AR, Bard RJ, Namaka MP. Neurogenic overactive bladder in spinal cord injury and multiple sclerosis: role of onabotulinumtoxinA. Degener Neurol Neuromuscul Dis 2014; 4:65-75. [PMID: 32669901 PMCID: PMC7337250 DOI: 10.2147/dnnd.s40349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/23/2014] [Indexed: 11/23/2022] Open
Abstract
People with neurogenic overactive bladder from either multiple sclerosis or spinal cord injury often suffer significant morbidity and decreased quality of life. Here we review the pathophysiology of neurogenic overactive bladder and the impact it can have on people with multiple sclerosis or spinal cord injury. We also address the various traditional treatment options and focus on the use of botulinum toxin A (specifically onabotulinumtoxinA) for this condition.
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Affiliation(s)
- K D Ethans
- University of Manitoba.,Section of Physical Medicine and Rehabilitation, Health Sciences Centre
| | - A R Casey
- University of Manitoba.,Section of Physical Medicine and Rehabilitation, Health Sciences Centre
| | - R J Bard
- University of Manitoba.,Section of Urology, Health Sciences Centre, Winnipeg, Manitoba, Canada
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