Evaluation and Management of Failed Bladder Augment

Outcomes of Intradetrusor OnabotulinumtoxinA Injection in Adults with Congenital Spinal Dysraphism in Tertiary Transitional Urology Clinic

Purpose

Published data regarding intradetrusor injection of onabotulinumtoxinA in adults with congenital spinal dysraphism are scarce. In this study, we retrospectively investigated the outcomes of intradetrusor injection of onabotulinumtoxinA in this setting.

Materials and Methods

Billing codes were used to identify 149 patients who underwent onabotulinumtoxinA injection between 2012-2016 at our tertiary transitional urology clinic. Charts were then reviewed to identify patients with congenital spinal dysraphism.

Results

A total of 18 patients with the mean age of 20.76 (±3.03) years at the time of 1st onabotulinumtoxinA injection were identified. All patients had urinary incontinence. Urinary incontinence improved by injection of 200 or 300 U of onabotulinumtoxinA in 81.2% of patients and 63.6% of them became dry (p= 0.023). Mean glomerular filtration rate before and 13.3 (±9) months after treatment was 100.2 (±17.2) and 120.1 (±16.6) mL/min/1.73 m2 respectively (p= 0.41). Baseline hydronephrosis improved in 3 of 4 patients. Repeat urodynamic study after injection was done in 11 patients who did not clinically improve or who had loss of bladder compliance at baseline (29.3 Vs. 67.2 ml/cmH2O). Mean maximum cystometric capacity before and after injection was 310.1 and 380.2 mL (p= 0.045). Mean bladder compliance before and after treatment was 29.2 and 28.7 ml/cmH2O respectively (p= 0.48) in this high risk group.

Conclusions

Intradetrusor onabotulinumtoxinA injection may improve refractory urinary incontinence in selected adults with spinal dysraphism. However, despite improvement in maximum cystometric capacity, bladder compliance does not improve following therapy in patients who had loss of compliance at baseline.

Indications for Augmentation Cystoplasty in the Era of OnabotulinumtoxinA

Overactive bladder (OAB) with or without a neurogenic etiology that is refractory to conventional first-, second-, and third-line therapies is a challenging condition that typically leaves the physician and the patient with few options. Historically, treatment for patients who did not respond to any of the few pharmacologic choices focused on more invasive surgical options--specifically, augmentation cystoplasty (AC). In 2011 and 2013, the Food and Drug Administration (FDA) approved intradetrusor injection of onabotulinumtoxinA for the treatment of neurogenic detrusor overactivity (NDO) and idiopathic detrusor overactivity (IDO), respectively. Since then, a dramatic decline in the use of AC has called into question its utility in the treatment algorithm of this difficult patient population. The purpose of this paper is to review the current body of literature in order to outline the circumstances in which AC is still a relevant therapeutic option.