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Vaheb S, Mokary Y, Ghoshouni H, Mirmosayyeb O, Moases Ghaffary E, Shaygannejad V, Yazdan Panah M. Onabotulinum toxin A improves neurogenic detrusor overactivity following spinal cord injury: a systematic review and meta-analysis. Spinal Cord 2024; 62:285-294. [PMID: 38637637 DOI: 10.1038/s41393-024-00992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES The current study aimed to assess the efficacy and safety of Onabotulinum toxin A (OBTX-A) treatment for neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients. SETTING Iran. METHODS All relevant articles of clinical trials and cohort studies indexed in PubMed/MEDLINE, Embase, Scopus, and Web of Science databases up to September 6, 2022, that addressed OBTX-A treatment for NDO following SCI were included. The quality of eligible studies was evaluated using Cochrane criteria. Also, the weighted mean difference (WMD) was measured with a random-effect model. RESULTS Regarding the overall efficacy after OBTX-A treatment in the short term, volume per void (VV) (WMD = 118.8, 95% CI: 90.9-146.7, p < 0.01), incontinence-quality of life (IQoL) (WMD = 24.3, 95% CI: 15.8-32.8, p < 0.01), and maximum cystometric capacity (MCC) (WMD = 144.5, 95% CI: 132.3 to 156.7, p < 0.01) significantly increased, while maximum detrusor pressure during storage (MDP) (WMD = -30.5, 95% CI: -35.9 to -25.1, p < 0.01) showed a significant decrease. Furthermore, compared to the placebo group at the 200-unit dose, there was a significant increase in MCC (WMD = 113.5, 95% CI: 84.7 to 142.3, p < 0.01) and a significant decrease in MDP (WMD = -27.2, 95% CI: -39.2 to -15.1, p < 0.01). Urinary tract infection (UTI), hematuria, and autonomic dysreflexia were the most common side effects, occurring at rates of 29.6%, 14.8%, and 13.4%, respectively. CONCLUSION Our findings highlighted the effectiveness and safety of OBTX-A as a promising treatment of NDO following SCI.
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Affiliation(s)
- Saeed Vaheb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Yousef Mokary
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Ghoshouni
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Omid Mirmosayyeb
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Moases Ghaffary
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Shaygannejad
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Yazdan Panah
- Students Research Committee, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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Werneburg GT, Stoffel JT. Bladder Compliance: How We Define It and Why It Is Important. Urol Clin North Am 2024; 51:209-220. [PMID: 38609193 DOI: 10.1016/j.ucl.2023.12.001] [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] [Indexed: 04/14/2024]
Abstract
Bladder compliance is the relationship between detrusor pressure and bladder storage volume. We discuss the definition of compliance, how it may be accurately measured, and its clinical relevance. Specifically, we discuss the association between low compliance and upper urinary tract deterioration. We discuss medical and surgical therapies that have been demonstrated to improve compliance and reduce upper tract risk. Finally, we propose a model, which not only considers compliance but also differential pressure between the bladder and ureters, and how this may also be an accurate predictor of upper tract deterioration. We call for further investigation to test this model.
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Affiliation(s)
- Glenn T Werneburg
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - John T Stoffel
- Department of Urology, Neurourology and Pelvic Reconstruction Division, University of Michigan, 3875 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Chen YC, Ou YC, Hu JC, Yang MH, Lin WY, Huang SW, Lin WY, Lin CC, Lin VC, Chuang YC, Kuo HC. Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury. J Clin Med 2022; 11:6850. [PMID: 36431327 PMCID: PMC9697498 DOI: 10.3390/jcm11226850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/08/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.
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Affiliation(s)
- Yu-Chen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Yin-Chien Ou
- Department of Urology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Ju-Chuan Hu
- Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Min-Hsin Yang
- Department of Urology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Wei-Yu Lin
- Department of Urology, Taipei Hospital, Ministry of Health and Welfare, New Taipei 242033, Taiwan
| | - Shi-Wei Huang
- Department of Urology, National Taiwan University Hospital Yun-Lin Branch, Douliou 640203, Taiwan
| | - Wei-Yu Lin
- Department of Urology, Chiayi Chang Gung Memorial Hospital, Chiayi 261363, Taiwan
| | - Chih-Chieh Lin
- Department of Urology, Taipei Veterans General Hospital, Taipei 112304, Taiwan
- Department of Urology, School of Medicine, College of Medicine, Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Victor C. Lin
- Department of Urology, E-Da Hospital, Kaohsiung 824, Taiwan
| | - Yao-Chi Chuang
- Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Kaohsiung 833401, 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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Chen H, Xie K, Jiang C. A single-blind randomized control trial of trigonal versus nontrigonal Botulinum toxin-A injections for patients with urinary incontinence and poor bladder compliance secondary to spinal cord injury. J Spinal Cord Med 2021; 44:757-764. [PMID: 32003644 PMCID: PMC8477943 DOI: 10.1080/10790268.2020.1712892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective: To evaluate the effect of trigonal Botulinum toxin-A (BTX-A) injections on patients with urinary incontinence (UI) and poor bladder compliance (BC) secondary to spinal cord injury (SCI).Design: A single-blind randomized control trial.Setting: Department of urology in three hospitals.Participants: SCI patients with UI and poor BC were randomly assigned to either the experimental group or the control group.Interventions: The experimental group received an injection of 240 U BTX-A into the detrusor plus 60 U BTX-A into the trigone, while the control group received 300 U BTX-A into the detrusor sparing the trigone.Outcome Measures: Video urodynamic outcomes, including vesicoureteric reflux (VUR), detrusor leak point pressure (DLPP), and detrusor leak point volume (DLPV), were measured at baseline and week 12. UI episodes, voiding volume, and Incontinence Quality of Life (I-QoL) were assessed at baseline, week 2, 4, 8 and 12.Results: No patient reported new-onset VUR. Compared with baseline data, a significant improvement was achieved in both groups, whereas compared with DLPP and DLPV, a significant difference was noted between the two groups 12 weeks after injection. In the experimental group, the improvement of mean weekly UI episodes, voiding volume, and I-QoL were significantly better than those in the control group at 4, 8, and 12 weeks, respectively (all P < 0.05). Systemic complications of BTX-A injection were not reported.Conclusion: Trigonal BTX-A injection is more effective and safer than nontrigonal BTX-A injection for SCI patients with UI secondary to neurogenic-poor BC and does not result in VUR.
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Affiliation(s)
- Hui Chen
- Department of Urology, Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, People’s Republic of China,Department of Urology, Qingyan City People's Hospital, Guangdong, People’s Republic of China,Correspondence to: Hui Chen, Department of Urology, Guangdong Provincial Work Injury Rehabilitation Hospital, 68 Qide Road, Baiyun District, Guangzhou, Guangdong, 510440, People’s Republic of China; Department of Urology, Qingyan City People's Hospital, Guangdong511500, People’s Republic of China.
| | - Keji Xie
- Department of Urology, Guangzhou First Municipal People’s Hospital, Guangzhou, People’s Republic of China
| | - Chonghe Jiang
- Department of Urology, Qingyan City People's Hospital, Guangdong, People’s Republic of China
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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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Jung IY, Mo KI, Leigh JH. Effect of intravesical botulinum toxin injection on symptoms of autonomic dysreflexia in a patient with chronic spinal cord injury: a case report. J Spinal Cord Med 2019; 42:806-809. [PMID: 28486884 PMCID: PMC6830299 DOI: 10.1080/10790268.2017.1322738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Context: There are few treatment options for managing autonomic dysreflexia in patients with chronic spinal cord injury (SCI). According to some studies, intravesical botulinum toxin for SCI patients with autonomic dysreflexia has a preventive effect on symptoms of autonomic dysreflexia. However, the usefulness of an intravesical botulinum toxin injection has never been reported for autonomic dysreflexia in an adult patient with chronic cervical SCI, although there has been for one pediatric patient.Findings: A 62-year-old man with chronic cervical SCI had neurogenic bladder due to C6-7 SCI since sustaining a fall in 1980. He presented with an intermittent headache and severe hypertension because of persistent autonomic dysreflexia. His symptoms did not improve with conservative management, and he could not undergo an operation to resect the lung cancer because of his uncontrolled blood pressure. To control his fluctuating blood pressure, he was taken to an operating room to receive an intravesical botulinum toxin injection for refractory bladder spasms. Subsequently, his blood pressure was controlled, and then the lung mass could be surgically removed. His improved condition lasted for more than 6 months.Conclusion: This case suggests that botulinum toxin is a logical treatment option for autonomic dysreflexia as well as neurogenic detrusor overactivity in patients with chronic SCI. Dedicated research is warranted to assess the efficacy of an intravesical botulinum toxin injection, as it was used successfully to stop the symptoms of autonomic dysreflexia in our patient.
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Affiliation(s)
- Il-Young Jung
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Kyo Ik Mo
- Department of Urology, Korea Workers’ Compensation and Welfare Service Incheon Hospital, Incheon, Republic of Korea
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea,Correspondence to: Ja-Ho Leigh, MD, Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon, 21458, Republic of Korea.
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Lucas E. Medical Management of Neurogenic Bladder for Children and Adults: A Review. Top Spinal Cord Inj Rehabil 2019; 25:195-204. [PMID: 31548786 PMCID: PMC6743750 DOI: 10.1310/sci2503-195] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurogenic bladder is a chronic condition affecting patients of all ages with significant medical and quality of life implications. Goals of treatment consist of protection of the upper urinary tract and promotion of reliable urinary continence. Successful management involves medications and most often bladder drainage via clean intermittent catheterization. This article reviews current literature on medical management to achieve goals of treatment.
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Efficacy and Safety of OnabotulinumtoxinA in Patients With Neurogenic Detrusor Overactivity Caused by Spinal Cord Injury: A Systematic Review and Meta-analysis. Int Neurourol J 2018; 22:275-286. [PMID: 30599499 PMCID: PMC6312972 DOI: 10.5213/inj.1836118.059] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/25/2018] [Indexed: 01/10/2023] Open
Abstract
Purpose OnabotulinumtoxinA (BoNT-A) is a promising therapy for treating neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI). This systematic review and meta-analysis aimed to carry out an in-depth review and to make an objective estimation of the efficacy and safety of BoNT-A on NDO after SCI. Methods The PubMed, Embase, and Cochrane databases were searched for all relevant articles published from 2001 to 2016 that referred to NDO, SCI, and BoNT-A or botulinum toxin A. All data were recorded in an Excel spreadsheet by 2 individual reviewers. Review Manager version 5.3 was used to carry out the meta-analysis. Results This analysis included 17 studies involving 1,455 patients. Compared with placebo and baseline, BoNT-A was effective in increasing maximum cystometric capacity, volume at first involuntary detrusor contraction, cystometric bladder capacity (all P<0.00001), compliance (P=0.001), and the number of patients with complete dryness (P=0.0003), and decreasing detrusor pressure, the number of patients with no involuntary detrusor contractions, the maximum flow rate, the incidence of detrusor overactivity (all P<0.00001), and the number of urinary incontinence episodes (P=0.001). There were no statistically significant differences between doses of 200 U and 300 U or between injections into the detrusor and submucosa. There were no life-threatening adverse events. Conclusions BoNT-A is effective and safe in treating NDO after SCI. There were no statistically significant differences between doses of 200 U and 300 U or between injecting into the detrusor and submucosa. However, more high-quality randomized controlled trials are still needed.
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Malde S, Fry C, Schurch B, Marcelissen T, Averbeck M, Digesu A, Sahai A. What is the exact working mechanism of botulinum toxin A and sacral nerve stimulation in the treatment of overactive bladder/detrusor overactivity? ICI-RS 2017. Neurourol Urodyn 2018; 37:S108-S116. [DOI: 10.1002/nau.23552] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/19/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Sachin Malde
- Department of Urology; Guy's Hospital; London United Kingdom
| | - Christopher Fry
- School of Physiology, Pharmacology & Neuroscience; University of Bristol; Bristol United Kingdom
| | - Brigitte Schurch
- Department of Clinical Neurosciences; Neuropsychology and Neurorehabilitation Service Vaudois University Hospital of Lausanne; Switzerland
| | - Tom Marcelissen
- Department of Urology; Maastricht University Medical Centre; Netherlands
| | | | - Alex Digesu
- Department of Urogynaecology; St. Mary's Hospital; United Kingdom
| | - Arun Sahai
- Department of Urology; Guy's Hospital; London United Kingdom
- King's College London; King's Health Partners; United Kingdom
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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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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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Hennessey DB, Hoag N, Gani J. Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence-a review. Transl Androl Urol 2017; 6:S103-S111. [PMID: 28791229 PMCID: PMC5522793 DOI: 10.21037/tau.2017.04.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.
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Affiliation(s)
- Derek B Hennessey
- Department of Urology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Nathan Hoag
- Department of Urology, Victoria General Hospital, Victoria, British Columbia, Canada
| | - Johan Gani
- Department of Urology, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Urology, Western Health, Footscray, Victoria, Australia
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Kamei J, Furuta A, Akiyama Y, Niimi A, Ichihara K, Fujimura T, Fukuhara H, Kume H, Homma Y, Igawa Y. Video-urodynamic effects of mirabegron, a β3 -adrenoceptor agonist, in patients with low-compliance bladder. Int J Urol 2015; 22:956-61. [PMID: 26177781 DOI: 10.1111/iju.12867] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 06/10/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To investigate video-urodynamic effects of mirabegron, a β3 -adrenoceptor agonist, on low-compliance bladder. METHODS We retrospectively reviewed nine patients (three men, six women, age 17-68 years) who had been diagnosed with lower urinary tract dysfunction with low-compliance bladder, and who underwent video-urodynamic study before and during administration of mirabegron 50 mg once daily. Urodynamic parameters were compared before and after treatment. RESULTS Mirabegron treatment significantly increased first desire to void and cystometric capacity with an average increment of 80 mL (P = 0.027) and 123 mL (P = 0.005), respectively. Bladder compliance also significantly increased (mean value 8.1 mL/cmH2 O before, 18.2 mL/cmH2 O after, P = 0.024). In the six patients who had been taking anticholinergic agents at baseline video-urodynamic study and then switched to mirabegron, mean cystometric capacity and bladder compliance were also increased significantly from 208.3 to 346.8 mL (P = 0.015) and from 7.2 to 17.5 mL/cmH2 O (P = 0.047), respectively. Vesicoureteral reflux grade was improved in three of the four patients who had shown vesicoureteral reflux on cystography before treatment. CONCLUSIONS Mirabegron improves cystometric capacity and bladder compliance, and it lowers vesicoureteral reflux grade in patients with low-compliance bladder. Thus, mirabegron might represent a good alternative drug for low-compliance bladder refractory to anticholinergic treatment.
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Affiliation(s)
- Jun Kamei
- Department of Continence Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Furuta
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Akiyama
- Department of Continence Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Aya Niimi
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Ichihara
- Department of Continence Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Fujimura
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukio Homma
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhiko Igawa
- Department of Continence Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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The Shifting Paradigm of Treating Neurogenic Bladder Patients After the Introduction of Neuromodulation. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-014-0282-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim SW, Choi JH, Lee YS, Han SW, Im YJ. Preoperative Urodynamic Factors Predicting Outcome of Botulinum Toxin-A Intradetrusor Injection in Children With Neurogenic Detrusor Overactivity. Urology 2014; 84:1480-4. [DOI: 10.1016/j.urology.2014.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 08/27/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
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Álvares RA, Araújo ID, Sanches MD. A pilot prospective study to evaluate whether the bladder morphology in cystography and/or urodynamic may help predict the response to botulinum toxin a injection in neurogenic bladder refractory to anticholinergics. BMC Urol 2014; 14:66. [PMID: 25123234 PMCID: PMC4139716 DOI: 10.1186/1471-2490-14-66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 08/11/2014] [Indexed: 11/24/2022] Open
Abstract
Background We have observed different clinical responses to botulinum toxin A (BTX-A) in patients who had similar urodynamic parameters before the procedure. Furthermore, some bladders evaluated by cystography and cystoscopy during the procedure had different characteristics that could influence the outcome of the treatment. The aim of this study was to assess whether cystography and urodynamic parameters could help predict which patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergics respond better to treatment with injection of BTX-A. Methods In total, 34 patients with spinal cord injury were prospectively evaluated. All patients emptied their bladder by clean intermittent catheterization (CIC) and had incontinence and NDO, despite using 40 mg or more of intravesical oxybutynin and undergoing detrusor injection of BTX-A (300 IU). Pretreatment evaluation included urodynamic, and cystography. Follow-up consisted of urodynamic and ambulatory visits four months after treatment. The cystography parameters used were bladder shape, capacity and presence of diverticula. Urodynamic parameters used for assessment were maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), compliance and reflex volume (RV). Results After injection of BTX-A, 70% of the patients had success, with 4 months or more of continence. Before the treatment, there were significant differences in most urodynamic parameters between those who responded successfully compared to those who did not. Patients who responded successfully had greater MCC (p = 0.019), higher RV (p = 0.041), and greater compliance (p = 0.043). There was no significant difference in the MDP (0.691). The cystography parameters were not significantly different between these groups bladder shape (p = 0.271), capacity (p > 0.720) and presence of diverticula (p > 0.999). Statistical analyses were performed using SPSS (version 20.0) and included Student’s t-test for two paired samples and Fisher’s exact test, with a significance threshold of 0.05. Conclusions This study suggests that the cystography parameters evaluated cannot be used to help predict the response to injection of BTX-A in the treatment of refractory NDO. However, the urodynamic parameters were significantly different in patients who responded to the treatment, with the exception of the MDP.
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Affiliation(s)
- Ronaldo Alvarenga Álvares
- SARAH Network of Rehabilitation Hospitals, Unit Belo Horizonte, Minas Gerais, Av Amazonas 5953, Gameleira 30510-000, Brazil.
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Harris CJ, Dmochowski R, Reynolds WS. Botox for the Neurogenic Bladder. CURRENT BLADDER DYSFUNCTION REPORTS 2013. [DOI: 10.1007/s11884-013-0201-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mehta S, Hill D, McIntyre A, Foley N, Hsieh J, Ethans K, Teasell RW, Loh E, Welk B, Wolfe D. Meta-Analysis of Botulinum Toxin A Detrusor Injections in the Treatment of Neurogenic Detrusor Overactivity After Spinal Cord Injury. Arch Phys Med Rehabil 2013; 94:1473-81. [DOI: 10.1016/j.apmr.2013.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 04/07/2013] [Indexed: 10/26/2022]
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Gaillet S, Bardot P, Bernuz B, Boissier R, Lenne-Aurier K, Thiry-Escudier I, Tournebise H, Lechevallier E, Karsenty G. Five years follow-up study and failures analysis of Botulinum toxin repeated injections to treat neurogenic detrusor overactivity. Prog Urol 2012. [DOI: 10.1016/j.purol.2012.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Repeated botulinum-a toxin injection in the treatment of neuropathic bladder dysfunction and poor bladder compliance in children with myelomeningocele. Neurourol Urodyn 2011; 30:1546-9. [DOI: 10.1002/nau.21124] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 03/10/2011] [Indexed: 11/07/2022]
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Herschorn S, Gajewski J, Ethans K, Corcos J, Carlson K, Bailly G, Bard R, Valiquette L, Baverstock R, Carr L, Radomski S. Efficacy of botulinum toxin A injection for neurogenic detrusor overactivity and urinary incontinence: a randomized, double-blind trial. J Urol 2011; 185:2229-35. [PMID: 21497851 DOI: 10.1016/j.juro.2011.02.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Indexed: 01/09/2023]
Abstract
PURPOSE We determined the efficacy of onabotulinumtoxinA for neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis. MATERIALS AND METHODS In a prospective, double-blind, multicenter study 57 patients 18 to 75 years old with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis and urinary incontinence (defined as 1 or more occurrences daily) despite current antimuscarinic treatment were randomized to onabotulinumtoxinA 300 U (28) or placebo (29) via cystoscopic injection at 30 intradetrusor sites, sparing the trigone. Patients were offered open label onabotulinumtoxinA 300 U at week 36 and followed a further 6 months while 24 each in the treatment and placebo groups received open label therapy. The primary efficacy parameter was daily urinary incontinence frequency on 3-day voiding diary at week 6. Secondary parameters were changes in the International Consultation on Incontinence Questionnaire and the urinary incontinence quality of life scale at week 6. Diary and quality of life evaluations were also done after open label treatment. RESULTS The mean daily frequency of urinary incontinence episodes was significantly lower for onabotulinumtoxinA than for placebo at week 6 (1.31 vs 4.76, p <0.0001), and for weeks 24 and 36. Improved urodynamic and quality of life parameters for treatment vs placebo were evident at week 6 and persisted to weeks 24 to 36. The most common adverse event in each group was urinary tract infection. CONCLUSIONS In adults with antimuscarinic refractory neurogenic detrusor overactivity and multiple sclerosis onabotulinumtoxinA is well tolerated and provides clinically beneficial improvement for up to 9 months.
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Affiliation(s)
- Sender Herschorn
- Division of Urology, University of Toronto, Sunnybrook Health Sciences Centre, Room A309, 2075 Bayview Ave., Toronto, Ontario M4N 3M5, Canada.
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Apostolidis A. Pharmacotherapy for overactive bladder: minimally invasive treatment – botulinum toxins. Expert Opin Pharmacother 2011; 12:1029-39. [DOI: 10.1517/14656566.2011.554398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Therapeutic effects of detrusor botulinum toxin A injection on neurogenic detrusor overactivity in patients with different levels of spinal cord injury and types of detrusor sphincter dyssynergia. Spinal Cord 2011; 49:659-64. [DOI: 10.1038/sc.2010.179] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Five-year cost analysis of intra-detrusor injection of botulinum toxin type A and augmentation cystoplasty for refractory neurogenic detrusor overactivity. World J Urol 2010; 29:51-7. [PMID: 21110030 DOI: 10.1007/s00345-010-0618-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Treatment options for antimuscarinic refractory neurogenic detrusor overactivity (NDO) are botulinum toxin type A injections (BTX-A) and augmentation cystoplasty (AC). We estimated initial and cumulative 5-year costs of these treatments. MATERIALS AND METHODS Base case is an individual with antimuscarinic refractory NDO and decreased bladder compliance. Primary analysis is from the health care payor perspective. Model probabilities and ranges were derived from literature and chart review. Reimbursements were derived from the average of insurance carriers. Complication cost calculations were based on standard practice. Decision-analysis model was made with TreeAge Pro Healthcare 2009 Software, Inc. and rolled back for cost calculation. One-way sensitivity analysis was performed on all variables, and two-way sensitivity analyses were based on these results. RESULTS Average reimbursement for one BTX-A injection and AC was $2,946.83 and $25,041.53, respectively. BTX-A treatment was less expensive over 5 years, costing $28,065. The model was only sensitive within a reasonable clinical range for Botox durability. BTX-A was more cost-effective over 5 years if the effect lasted for >5.1 months. The model was based on an AC complication rate of 40%. If the PAC complication rate<14%, AC was cheaper over 5 years. The model was sensitive to surgeons costs of BTX-A ($3,027) and facility costs of BTX-A ($1,004) and AC ($17,100). CONCLUSIONS This is the first cost analysis of BTX-A and AC. BTX-A is cheaper at durations>5.1 months and AC was cheaper when the cost of BTX-A increases or the AC complication rate dropped below 14%.
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Smaldone MC, Ristau BT, Leng WW. Botulinum Toxin Therapy for Neurogenic Detrusor Overactivity. Urol Clin North Am 2010; 37:567-80. [DOI: 10.1016/j.ucl.2010.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Grise P, Ruffion A, Denys P, Egon G, Chartier Kastler E. Efficacy and tolerability of botulinum toxin type A in patients with neurogenic detrusor overactivity and without concomitant anticholinergic therapy: comparison of two doses. Eur Urol 2010; 58:759-66. [PMID: 20674149 DOI: 10.1016/j.eururo.2010.06.035] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 06/22/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Botulinum toxin type A (BoNTA) has been reported to be effective for treatment of patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergic agents. However, in most of the studies, the efficacy was associated with concomitant use of anticholinergics. OBJECTIVE To evaluate the efficacy and tolerability of BoNTA and compare two different doses in patients with NDO without concomitant anticholinergics. DESIGN, SETTING, AND PARTICIPANTS Between 2004 and 2006, adults with NDO refractory to anticholinergics or discontinued anticholinergics due to adverse events or contraindications from four different French clinical centres were included in a prospective, randomised, double-blind, comparative trial. Inclusion criteria were urinary incontinence (UI) resulting from NDO that could not be managed with anticholinergics. Patients with bladder cancer, lithiasis, or urinary infection were excluded. INTERVENTION Patients were randomised to receive an intradetrusor injection of 500 U or 750 U of BoNTA. MEASUREMENTS The initial evaluation (ie, clinical and urodynamic variables and quality of life [QoL]) was repeated at days 30, 90, 180, and 360. Primary outcome was complete continence rate at day 30. Secondary outcomes were cumulative incontinence rate, reappearance of leakages, pad usage, urodynamics, and QoL. RESULTS AND LIMITATIONS Seventy-seven patients received 500 U (n=39) or 750 U (n=38) of BoNTA and were included in the full analysis set for efficacy analysis. Complete continence at day 30 was observed in 22 patients (56.4%) and 28 patients (73.7%) receiving 500 U or 750 U of BoNTA, respectively (p=0.056; one-sided χ(2) test to compare to α=0.025). The median delay in the reappearance of leakages was 168 d. Monotherapy of BoNTA significantly improved UI in patients with NDO. Although there was a trend towards a greater improvement with 750 U of BoNTA, no statistically significant differences in terms of clinical and urodynamic variables and QoL were found between the treatment groups. Tolerability was excellent and equivalent for both doses. CONCLUSIONS Monotherapy of BoNTA at Dysport (Ipsen, Brisbane, CA, USA) doses of 500 U or 750 U seems to be effective and well tolerated in patients with NDO.
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Affiliation(s)
- Philippe Grise
- Department of Urology, Rouen University Hospital, Rouen Cedex, France.
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Oeconomou A, Apostolidis A. Current Status of Botulinum Toxin for Neurogenic Bladder Dysfunction. CURRENT BLADDER DYSFUNCTION REPORTS 2010. [DOI: 10.1007/s11884-010-0051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Campbell JD, Gries KS, Watanabe JH, Ravelo A, Dmochowski RR, Sullivan SD. Treatment success for overactive bladder with urinary urge incontinence refractory to oral antimuscarinics: a review of published evidence. BMC Urol 2009; 9:18. [PMID: 19930578 PMCID: PMC2788579 DOI: 10.1186/1471-2490-9-18] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 11/20/2009] [Indexed: 11/10/2022] Open
Abstract
Background Treatment options for overactive bladder (OAB) with urinary urge incontinence (UUI) refractory to oral antimuscarinics include: botulinum toxin type A (BoNTA), sacral neuromodulation (SNM), and augmentation cystoplasty (AC). A standard treatment success metric that can be used in both clinical and economic evaluations of the above interventions has not emerged. Our objective was to conduct a literature review and synthesis of published measures of treatment success for OAB with UUI interventions and to identify a treatment success outcome. Methods We performed a literature review of primary studies that used a definition of treatment success in the OAB with UUI population receiving BoNTA, SNM, or AC. The recommended success outcome was compared to generic and disease-specific health-related quality-of-life (HRQoL) measures using data from a BoNTA treatment study of neurogenic incontinent patients. Results Across all interventions, success outcomes included: complete continence (n = 23, 44%), ≥ 50% improvement in incontinence episodes (n = 16, 31%), and subjective improvement (n = 13, 25%). We recommend the OAB with UUI treatment success outcome of ≥ 50% improvement in incontinence episodes from baseline. Using data from a neurogenic BoNTA treatment study, the average change in the Incontinence Quality of Life questionnaire was 8.8 (95% CI: -4.7, 22.3) higher for those that succeeded (N = 25) versus those that failed (N = 26). The average change in the SF-6D preference score was 0.07 (95% CI: 0.02, 0.12) higher for those that succeeded versus those that failed. Conclusion A treatment success definition that encompasses the many components of underlying OAB with UUI symptoms is currently not practical as a consequence of difficulties in measuring urgency. The treatment success outcome of ≥ 50% improvement in incontinence episodes was associated with a clinically meaningful improvement in disease-specific HRQoL for those with neurogenic OAB with UUI. The recommended success definition is less restrictive than a measure such as complete continence but includes patients who are satisfied with treatment and experience meaningful improvement in symptoms. A standardized measure of treatment success will be useful in clinical and health economic applications.
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Brin MF. Development of future indications for BOTOX®. Toxicon 2009; 54:668-74. [DOI: 10.1016/j.toxicon.2009.01.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 01/14/2009] [Indexed: 11/30/2022]
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Critères de décision et recommandations de bonne pratique clinique pour la première injection intradétrusorienne de toxine botulique A dans le traitement de l’hyperactivité neurogène du détrusor. Prog Urol 2009; 19:372-82. [DOI: 10.1016/j.purol.2009.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Accepted: 02/17/2009] [Indexed: 01/09/2023]
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Smith CP. Botulinum toxin in the treatment of OAB, BPH, and IC. Toxicon 2009; 54:639-46. [PMID: 19268490 DOI: 10.1016/j.toxicon.2009.02.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 01/27/2009] [Accepted: 02/02/2009] [Indexed: 11/16/2022]
Abstract
Botulinum neurotoxins (BoNTs) are well known for their ability to potently and selectively disrupt and modulate neurotransmission. BoNT is currently undergoing regulatory evaluation for urological disorders in the United States and the European Union and is not FDA approved for urologic use. Overactive bladder (OAB) and benign prostatic hyperplasia (BPH) are common urologic conditions characterized by urinary frequency, urgency, nocturia, urge incontinence and, in the case of BPH, decreased urine flow that are currently being evaluated in clinical trials with BoNT-A. Interstitial cystitis (IC) is a chronic condition in which patients describe urinary frequency, urgency and associated bladder/pelvic pain. In the two former conditions, BoNT-A is currently being evaluated in Phase II or Phase III clinical trials as a therapeutic agent. Evidence for BoNT in the treatment of IC is limited to small case series. The purpose of this article is to provide up to date clinical evidence regarding the use of BoNT to treat these three urologic problems. For the sake of clarity, BoNT-A describes the use of Botox unless otherwise specified. In addition, when describing OAB, two sub-populations exist: those with OAB of neurogenic origin (NDO) and those with OAB of unknown (idiopathic) origin (IDO).
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Affiliation(s)
- Christopher P Smith
- Scott Department of Urology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
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Apostolidis A, Dasgupta P, Denys P, Elneil S, Fowler CJ, Giannantoni A, Karsenty G, Schulte-Baukloh H, Schurch B, Wyndaele JJ. Recommendations on the Use of Botulinum Toxin in the Treatment of Lower Urinary Tract Disorders and Pelvic Floor Dysfunctions: A European Consensus Report. Eur Urol 2009; 55:100-19. [DOI: 10.1016/j.eururo.2008.09.009] [Citation(s) in RCA: 241] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 09/08/2008] [Indexed: 01/23/2023]
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Bentaleb Y, Castel-Lacanal E, Sallusto F, De Boissezon X, Malavaud B, Marque P, Rischmann P, Gamé X. [Prospective study of the clinical and urodynamic results of intradetrusor botulinum toxin injections for the treatment of neurogenic overactive bladder]. Prog Urol 2008; 18:449-55. [PMID: 18602606 DOI: 10.1016/j.purol.2008.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Accepted: 03/11/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the clinical and urodynamic efficacy and duration of efficacy of intradetrusor botulinum toxin A (BTA) injections in patients with neurogenic overactive bladder refractory to anticholinergic therapy. PATIENTS AND METHODS Between 2004 and 2005, 33 patients (19 men and 14 women), with neurogenic overactive bladder were treated by intradetrusor injections of 300 U of BTA (Botox) in 30 points. All patients were refractory to, intolerant of or presented contraindications to anticholinergic therapy. All patients voided by intermittent self-catheterization. RESULTS Six weeks after BTA injections, the success rate was 75.8%, with improvement in 12.1% of cases and failure in 9.1% of cases. The mean number of self-catheterizations per 24 h was significantly decreased (6.37 versus 5.2, P=0.02), the maximum voiding volume was increased (321.68 ml versus 536.25 ml, P=0.002), the mean number of episodes of incontinence per 24 h was decreased (7.39 versus 0.03, P<0.0001), the proportion of patients with incontinence was decreased (66.66% versus 6.04%, P<0.0001), the mean maximum cystomanometric capacity was increased (286.75 ml versus 554.16 ml, P=0.002) and the mean maximum intravesical pressure was decreased (54.8 cm H(2)O versus 5.3 cm H(2)O, P<0.0001). After BTA injections, 87.8 % of patients no longer experienced uninhibited contractions. The median duration of clinical efficacy was 7.03 months. At 12 months, injections were still effective clinically in 21.2 % of patients. CONCLUSION Intradetrusor BTA injections are an effective and well tolerated treatment for neurogenic overactive bladder. Their clinical efficacy persisted for more than 12 months in more than 20% of cases.
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Affiliation(s)
- Y Bentaleb
- Service d'Urologie, d'Andrologie et de Transplantation Rénale, CHU de Rangueil, Toulouse Cedex, France
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Silvaggi NR, Wilson D, Tzipori S, Allen KN. Catalytic features of the botulinum neurotoxin A light chain revealed by high resolution structure of an inhibitory peptide complex. Biochemistry 2008; 47:5736-45. [PMID: 18457419 DOI: 10.1021/bi8001067] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Clostridium botulinum neurotoxin serotype A light chain (BoNT/A-LC) is a Zn(II)-dependent metalloprotease that blocks the release of acetylcholine at the neuromuscular junction by cleaving SNAP-25, one of the SNARE proteins required for exocytosis. Because of the potential for use of the toxin in bioterrorism and the increasingly widespread application of the toxin in the medical field, there is significant interest in the development of small-molecule inhibitors of the metalloprotease. Efforts to design such inhibitors have not benefited from knowledge of how peptides bind to the active site since the enzyme-peptide structures available previously either were not occupied in the vicinity of the catalytic Zn(II) ion or did not represent the product of SNAP-25 substrate cleavage. Herein we report the 1.4 A-resolution X-ray crystal structure of a complex between the BoNT/A-LC and the inhibitory peptide N-Ac-CRATKML, the first structure of the light chain with an inhibitory peptide bound at the catalytic Zn(II) ion. The peptide is bound with the Cys S gamma atom coordinating the metal ion. Surprisingly, the cysteine sulfur is oxidized to the sulfenic acid form. Given the unstable nature of this species in solution, is it likely that oxidation occurs on the enzyme. In addition to the peptide-bound structure, we report two structures of the unliganded light chain with and without the Zn(II) cofactor bound at 1.25 and 1.20 A resolution, respectively. The two structures are nearly identical, confirming that the Zn(II) ion plays a purely catalytic role. Additionally, the structure of the Zn(II)-bound uncomplexed enzyme allows identification of the catalytic water molecule and a second water molecule that occupies the same position as the peptidic oxygen in the tetrahedral intermediate. This observation suggests that the enzyme active site is prearranged to stabilize the tetrahedral intermediate of the protease reaction.
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Affiliation(s)
- Nicholas R Silvaggi
- Department of Physiology and Biophysics, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Suivi des patients après injection de toxine botulique intradétrusorienne. ACTA ACUST UNITED AC 2008; 51:315-21. [DOI: 10.1016/j.annrmp.2008.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Accepted: 03/20/2008] [Indexed: 11/21/2022]
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Indications et résultats des injections intradétrusoriennes de toxine botulique type A chez l’enfant. Prog Urol 2008; 18:168-71. [DOI: 10.1016/j.purol.2007.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 10/01/2007] [Indexed: 11/21/2022]
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Botulinum Toxin A (Botox®) Intradetrusor Injections in Adults with Neurogenic Detrusor Overactivity/Neurogenic Overactive Bladder: A Systematic Literature Review. Eur Urol 2008; 53:275-87. [DOI: 10.1016/j.eururo.2007.10.013] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 10/05/2007] [Indexed: 01/20/2023]
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Elman LB, Houghton DJ, Wu GF, Hurtig HI, Markowitz CE, McCluskey L. Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis. J Palliat Med 2007; 10:433-57. [PMID: 17472516 DOI: 10.1089/jpm.2006.9978] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders. OBJECTIVES The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms. DESIGN The authors review current management and the supporting literature. CONCLUSIONS Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.
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Affiliation(s)
- Lauren B Elman
- ALS Association Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chenet A, Perrouin-Verbe B, Le Normand L, Labat JJ, Brunel P, Lefort M, Mathé JF. Efficacité des injections intradétrusoriennes répétées de toxine A dans l'hyperactivité vésicale d'origine neurologique. ACTA ACUST UNITED AC 2007; 50:651-60. [PMID: 17490775 DOI: 10.1016/j.annrmp.2007.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 03/21/2007] [Indexed: 01/07/2023]
Abstract
PURPOSE Toxin injections are an effective treatment for neurogenic detrusor overactivity. The efficacy of repeat injections is not well documented. The objective of this study was to evaluate the efficacy of repeat injections of toxin A to the detrusor in patients with neurogenic overactive bladders. MATERIALS AND METHODS Patients who had received 300-UI injections of Botox(R) were retrospectively studied. The clinical data included continence, duration of the absence of incontinence, changes in anticholinergic dosage or pad use and patient satisfaction. Urodynamic data analyzed were maximal cystometric capacity, bladder contraction and detrusor pressure during contraction. Data were analyzed by Wilcoxon and Kruskal-Wallis tests. RESULTS-DISCUSSION: Data for 42 patients (30 men, 12 women) were analysed. Pathologic features were trauma to the spinal cord, multiple sclerosis or varied causes of myelopathy. Patients received 1 to 6 injections of Botox(R). The mean duration of efficacy was 6 months. Efficacy did not differ among successive injections. Anticholinergic drugs were discontinued in 43% of patients and pad use in 48%. A total of 80% of the patients were satisfied with the treatment. Bladder contraction disappeared in 70% of patients. The mean maximal cystometric capacity increase was 144 ml. CONCLUSION Clinical and urodynamic data show that repeat injection of toxins to the detrusor remains an effective therapy for neurogenic bladder overactivity. Efficacy for continence is maintained during successive injections.
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Affiliation(s)
- A Chenet
- Service de médecine physique et réadaptation neurologique, hôpital Saint-Jacques, CHU de Nantes, 85, rue Saint-Jacques, 44093 Nantes cedex, France
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Abstract
In the past, renal failure was the leading cause of death after spinal cord injury (SCI). Today mortality from SCI has declined dramatically partly owing to the improved management of urologic dysfunction associated with SCI. The goals of bladder management in spinal cord injury patients are intended to (1) ensure social continence for reintegration into community, (2) allow low-pressure storage and efficient bladder emptying at low detrusor pressures, (3) avoid stretch injury from repeated overdistension, (4) prevent upper and lower urinary tracts complications from high intravesical pressures, and (5) prevent recurrent urinary tract infections. This article provides an overview of neurogenic bladder dysfunction associated with SCI and current management options.
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Affiliation(s)
- Gregory Samson
- Department of Rehabilitation Medicine, Leonard M. Miller School of Medicine, P.O. Box 016960 (D-461), Miami, FL 33101, USA
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Karsenty G, Corcos J, Schurch B, Ruffion A, Chartier-Kastler E. Chapitre C-l C - Traitement pharmacologique de l’hyperactivité détrusorienne neurologique : injections intra-détrusoriennes de toxine botulique A. Prog Urol 2007; 17:568-75. [PMID: 17622092 DOI: 10.1016/s1166-7087(07)92370-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Botulinum toxins are among the most powerful of all natural poisons. They are responsible for human botulism and constitute potential chemical weapons, but are nevertheless used as therapeutic agents in an increasing number of indications and medical specialties. Botulinum toxins were used for the first time in urology by intrasphincteric injection by Dykstra in 1988 to treat detrusor-sphincter dyssynergia in spinal cord injury patients. Schurch performed the first intradetrusor injections in 2000 to treat incontinence due to overactive bladder in adult spinal cord injury or multiple sclerosis patients. This review of the literature presents the results and level of proof for the use of botulinum toxin intradetrusor injection to treat neurogenic voiding disorders. Botulinum toxin A intradetrusor injections constitute a safe, conservative, reversible and short-term effective (6-12 months) alternative after failure of anticholinergic therapy for overactive bladder and its clinical consequences in adult spinal cord injury or multiple sclerosis patients (level 1b) and in children with neural tube defects (level 4). The efficacy of the first injection appears to be maintained at subsequent injections (up to 10 cycles) (level 4). Convergent and longer-term data are necessary to document and more clearly define the medium- and long-term efficacy profile of this approach, currently considered to be a major progress in neurourology.
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Affiliation(s)
- G Karsenty
- Service d'urologie, Centre hospitalo-universitaire de Marseille, France.
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Kim DK, Thomas CA, Smith C, Chancellor MB. The Case for Bladder Botulinum Toxin Application. Urol Clin North Am 2006; 33:503-10, ix. [PMID: 17011386 DOI: 10.1016/j.ucl.2006.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Botulinum toxin (BoNT) has been shown to be and effective agent in suppressing detrusor overactivity due to neurogenic causes. Recently, BoNT has been extended to patients who have idiopathic detrusor overactivity. This article reviews the use of BoNT to treat disorders of neurogenic detrusor overactivity and establishes BoNT as a therapeutic modality to treat idiopathic bladder overactivity. It is important to remember that the application of BoNT in the lower urinary tract is not approved by the regulatory agencies and caution should be applied until larger randomized clinical studies are completed.
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Affiliation(s)
- Dae Kyung Kim
- Department of Urology, Eulji University School of Medicine, 1306 Dunsandong Seogu, Daejeon, Korea
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45
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Casanova N, McGuire E, Fenner DE. Botulinum toxin: A potential alternative to current treatment of neurogenic and idiopathic urinary incontinence due to detrusor overactivity. Int J Gynaecol Obstet 2006; 95:305-11. [PMID: 17070528 DOI: 10.1016/j.ijgo.2006.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyze and report the current data on the treatment of both neurogenic and idiopathic detrusor overactivity with Botulinum toxin. METHODS Literature review using Pub-Med and Medline from 1990 until June 30, 2006. RESULTS Case series of patients with neurogenic detrusor dysfunction (NDD) and idiopathic detrusor overactivity (IDO) range from 15 to 200 patients with follow up from 12 to 36 weeks post-treatment. Significant improvements in cystometric bladder capacity, reflex volume at first urge to void, and bladder compliance are seen in nearly all patients. Approximately 50% of NDD patients achieved urinary continence and almost all had improvement in bladder control up to 36 weeks following treatment. Patients with IDO with urgency alone or with incontinence also had urodynamic as well as symptom improvement. Approximately 75% of patients with IDO and incontinence are dry at 12 weeks post-treatment. Urgency disappears on average in two thirds of patients. Quality of life scores also shows significant improvement for all groups. CONCLUSION Botulinum toxin-A has emerged as a promising option for the treatment of neurogenic and refractory idiopathic detrusor overactivity. Studies to date have shown that not only is this treatment effective at decreasing urinary symptoms and incontinence, as well as improving potentially dangerous urodynamic measures, but it is also minimally invasive, reversible and safe. Questions over proper dosing and dilution, number of injection sites, and re-injection rates remain to be answered.
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Affiliation(s)
- N Casanova
- University of Michigan, Department of Obstetrics and Gynecology, Ann Arbor, MI, USA
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Sahai A, Khan MS, Arya M, John J, Singh R, Patel HRH. The overactive bladder: review of current pharmacotherapy in adults. Part 2: treatment options in cases refractory to anticholinergics. Expert Opin Pharmacother 2006; 7:529-38. [PMID: 16553568 DOI: 10.1517/14656566.7.5.529] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the first part of this review the potential pathophysiological factors involved in the overactive bladder were outlined, and the wide range of first-line anticholinergic pharmacotherapies available for such patients were reviewed. The second part will focus on the intravesical instillation of resiniferatoxin and injections of botulinum toxin into the bladder to treat overactive bladder and detrusor overactivity. Resiniferatoxin has been shown to increase bladder capacity and improve incontinence in patients with neurogenic and non-neurogenic detrusor overactivity. Botulinum toxin has successfully been used to treat neurogenic and idiopathic detrusor overactivity, with improvements observed in bladder capacity, decreases in detrusor pressures on filling and voiding, and increased volumes at first contraction. Further validation is required for both treatments, in the form of large randomised controlled trials, before their use can be considered routine, with particular focus on dosing required.
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Affiliation(s)
- Arun Sahai
- Urology Department, Guy's Hospital, London, UK
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Affiliation(s)
- M Ramachandran
- The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
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48
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Schurch B, Schulte-Baukloh H. Botulinum Toxin in the Treatment of Neurogenic Bladder in Adults and Children. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.eursup.2006.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
This review highlights a recent innovation in the medical treatment of detrusor overactivity (DO). Anticholinergics are usually the gold standard to treat bladder overactivity. Adverse effects and lack of efficacy are the two main causes for considering alternative treatments. Until recently, invasive surgery (mainly bladder augmentation) was the only available treatment option for patients with intractable DO. This article considers botulinum toxin type A (BTX-A) injection as an alternative treatment to surgery in patients with DO who do not respond to anticholinergic therapy. To identify papers for inclusion in this review, we searched PubMed with the keywords 'botulinum toxin', 'overactive bladder', 'urinary incontinence' and 'neurogenic bladder' for the years 2000-5. Review articles were not included. Abstracts were cited only if they contained important new information. Experimental animal studies and articles or book chapters related to the use of botulinum toxin for other indications (such as achalasia and cervical dystonia) were analysed with regard to the mechanisms of action of botulinum toxin. From this review, it appears that BTX-A injection into the detrusor muscle is a very effective method for treating urinary incontinence secondary to neurogenic detrusor overactivity (NDO), as well as urinary incontinence due to idiopathic overactive bladder (IDO). In both conditions, the duration of effect seems to be at least 6 months. Overall success rates seem to be similar in both patient populations. For NDO, only one evidence-based medicine level 1 study is available, whereas for IDO, only evidence-based medicine level 3 or 4 studies have been published. Particularly in this latter indication, injection technique and outcome parameters vary from study to study and need to be standardised. Without randomised controlled studies aimed at comparing different techniques and dosages, it remains difficult to decide what technique is optimal for treating patients with IDO who are not willing to perform clean intermittent self-catheterisation (CISC). Therefore, studies that compare different dosages and techniques with the risk of needing CISC in regard to the duration of the effect are mandatory. As more studies of repeated injections have been published, it appears that, at least at medium follow-up, the toxin remains as effective as after the first injection, and there is no evidence of change in bladder compliance or detrusor fibrosis. However, long-term observational studies are necessary to assess these last points. Finally, the commonly reported dose appears to be well tolerated, since few adverse effects have been reported.
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Affiliation(s)
- Brigitte Schurch
- Neuro-Urology, Swiss Paraplegic Center, Balgrist University Hospital, Zurich, Switzerland.
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