Repeated injections of botulinum toxin-A for idiopathic detrusor overactivity

Intravesical Injection of Botulinum Toxin Type A in Men without Bladder Outlet Obstruction and Post-Deobstructive Prostate Surgery

Purpose: A significant proportion of men without bladder outlet obstruction (BOO) have been reported to have overactive bladders (OAB). This article aimed to review the specific group of reports on the use of botulinum toxin type A (BTX-A) injections into the bladder wall. Materials and methods: Original articles reporting men with small prostates without BOO were identified through a literature search using the PubMed and EMBASE databases. Finally, we included 18 articles that reviewed the efficacy and adverse effects of BTX-A injections in men. Results: Of the 18 articles screened, 13 demonstrated the therapeutic efficacy and adverse effects of BTX-A injections in men. Three studies compared BTX-A injection response between patients without prior prostate surgery and those undergoing prior prostate surgery, including transurethral resection of the prostate and radical prostatectomy (RP). Patients with prior RP experienced better efficacy and had a low risk of side effects. Two studies focused on patients who had undergone prior surgery for stress urinary incontinence, including male sling and artificial urethral sphincter surgery. The BTX-A injection was a safe and effective procedure for this specific group. OAB in men was found to have a different pathophysiology mechanism from that in female patients, which may decrease the efficacy of BTX-A injection in men. However, patients with small prostates and low prostate-specific antigen levels demonstrated better efficacy and tolerability after BTX-A injection. Conclusions: Although intravesical injection of BTX-A was a good option for controlling refractory OAB in men, the evidence-based guidelines are still limited. Further research is necessary to better understand the role of BTX-A injections on various aspects and histories. Therefore, treating patients using strategies tailored to their individual conditions is important.

An indirect comparison meta-analysis of noninvasive intravesical instillation and intravesical injection of botulinum toxin-A in bladder disorders

BACKGROUND

Botulinum toxin type A (BTX-A) intravesical instillation and BTX-A intravesical injection are both effective treatments or overactive bladder (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS), but direct comparative studies of the two treatments are lacking.

METHODS

We conducted a pairs-comparison meta-analysis and an adjusted indirect comparison meta-analysis extracting published data from randomized controlled trials in literature databases from the inception of each database to Aug. 31, 2021, evaluating efficacy and safety of BTX-A intravesical instillation and BTX-A intravesical injection. We also carried out a subgroup analysis.

RESULTS

We identified 24 trials in 21 studies were included in our study, of which 18 trials in 17 studies were BTX-A intravesical injections, 6 trials in 4 studies were BTX-A intravesical instillation. Compared with the normal saline injection, BTX-A intravesical injections for patients with OAB and IC/ BPS can obviously improve the symptoms of urinary frequency, urgency episode, UI and UUI, but BTX-A significantly increased the rate of urinary retention and urinary tract infection and increased PVR (p < 0.05). Adjusted indirect comparison meta-analysis showed that BTX-A intravesical injections was more effective than BTX-A intravesical instillation (p > 0.05). Surprisingly, BTX-A intravesical instillation had fewer side effects than BTX-A intravesical injections (p < 0.05).

CONCLUSIONS

Although BTX-A intravesical injections of OAB and IC/BPS has been significantly superior the BTX-A intravesical instillation, it has major side effects, but this needs to be confirmed by more large-scale, multicenter, direct comparison randomized controlled trials.

Botulinum Toxin A: A Review of Potential Uses in Treatment of Female Urogenital and Pelvic Floor Disorders

Background: Botulinum toxin is an injectable neuromodulator that inhibits transmission between peripheral nerve endings and muscle fibers, resulting in muscle paralysis. Botulinum toxin type A is the most common form of botulinum toxin used in clinical practice.

Methods: In this review, we examine the mechanism of action, formulations, common clinical use in the genital-urinary tract, and potential clinical use in pelvic floor disorders of botulinum toxin type A.

Results: Several aspects of botulinum toxin A make it a favorable therapeutic tool, including its accessibility, its longevity, and its impermanence and reversibility of resultant chemodenervation in a relatively short and safe manner. Although botulinum toxin A has well-established efficacy in treating refractory overactive bladder and neurogenic detrusor overactivity, its use in pelvic floor disorders is still in its infancy.

Conclusion: The efficacy of botulinum toxin A for treating pelvic pain, voiding dysfunction, muscle pain and dysfunction, and certain colorectal-related pain issues shows promise but requires additional rigorous evaluation.

Transcutaneous tibial nerve stimulation for the treatment of bladder storage symptoms in people with multiple sclerosis: Protocol of a single-arm feasibility study

Background: Neurogenic lower urinary tract dysfunction (NLUTD) is common among people with multiple sclerosis (MS) with a pooled prevalence of 68.41% using self-report measures and 63.95% using urodynamic studies. Transcutaneous tibial nerve stimulation (TTNS) is a non-invasive option to manage bladder storage symptoms; however, the potential efficacy of TTNS among people with MS is based on a small number of studies with the absence of high-quality evidence relating to efficacy, and lack of clarity of the optimal electrical stimulation parameters and frequency, duration and number of treatment sessions. This study aims to assess whether TTNS is feasible and acceptable as a treatment for bladder storage symptoms in people with MS. Methods: We will use a single-arm experimental study to explore the feasibility and acceptability of TTNS in the treatment of bladder storage symptoms in MS. The CONSORT extension for pilot and feasibility studies will be followed to standardise the conduct and reporting of the study. The recruitment plan is twofold: 1) Open recruitment for people with MS through MS Ireland's communication channels; 2) recruitment from a convenience sample of people with MS who have previously participated in a qualitative interview study of urinary symptoms. We will assess recruitment/retention rates, the urinary symptoms changes and the effect on quality of life pre and post intervention using ICIQ-OAB, 3-day bladder diary, King's Health Questionnaire and collect self-reported data on adherence and adverse events. Acceptability of using TTNS will be evaluated at the end of intervention. This study has been reviewed and approved by the Education and Health Science's Faculty Research Ethics Committee, University of Limerick [2020_06_07_EHS].  Conclusion: It is anticipated that assessing the feasibility and acceptability of TTNS for storage bladder symptoms in MS will inform the development of a definitive randomised trial. Trial registration: ClinicalTrials.gov NCT04528784 27/08/2020.

Selective bladder denervation for overactive bladder (OAB) syndrome: From concept to healing outcomes using the ovine model

Aims:

We evaluated a Selective Bladder Denervation (SBD) device, which uses radiofrequency ablation, for the treatment of overactive bladder syndrome in terms of its nerve denervation, ablation characteristics, and post-treatment healing.

Methods:

Using the SBD device, eight fresh extirpated ovine bladder trigones were treated (90°C set point for 60 s) and nitroblue tetrazolium viability stained to characterize the ablation. In addition, 12 trigones were treated in vivo with three adjacent ablations and divided into survival cohorts: Day 7, Day 30, and Day 90 to assess the ablations and their associated healing.

Results:

The ex vivo single trigone ablations had a 7.9 ± 0.9 mm width and 5.7 ± 1.0 mm thickness that involved the submucosa, detrusor muscle, adventitia, and vagina. Microscopic viability staining confirmed complete nerve necrosis within the targeted tissue. The in vivo Day 7 trigones supported the ex vivo ablation characteristics and showed up to minimal inflammation, granulation tissue, and collagen fibrosis. Day 30 trigones had essentially absent inflammation and granulation tissue with evolving collagen fibrosis at the ablation's periphery. Day 90 trigones had essentially absent acute inflammation, minimal chronic inflammation, essentially absent granulation tissue, and up to mild collagen fibrosis. No ureteral/urethral alterations, vesico-vaginal fistulas, or other complications were identified.

Conclusions:

The SBD device provided a targeted trigone ablation with resultant denervation. The tissue healing timeline followed that expected for a hyperthermic ablation and was characterized by a fibroproliferative healing response with limited inflammation and granulation tissue. The ablations did not impact the overlying bladder mucosal surface.

Sacral nerve stimulation versus intravesical botulinum toxin injections for medically refractory overactive bladder: A contemporary review of UK treatment from both clinician and patients’ perspectives

Introduction:

In the UK, 10,000 refractory overactive bladder patients per year receive intravesical onabotulinum toxin A treatment and 300 receive sacral nerve stimulation implants. Current National Institute for Health and Care Excellence guidelines propose using onabotulinum toxin A before sacral nerve stimulation whilst the European Association of Urology (EAU) and American Urological Association (AUA) suggests both be offered with equipoise. The aim of this study was to ascertain both patients and clinician views regarding these two treatments.

Subjects/methods:

Fifty consecutive overactive bladder patients who were refractory to behavioural and medical therapy anonymously completed a structured questionnaire about their treatment preferences. Additionally, 100 UK consultant urologists anonymously completed a separate questionnaire about their treatment preferences and which treatment modalities they had available for use in their Trusts.

Results:

Of patients, 60% preferred sacral nerve stimulation over onabotulinum toxin A, of whom 80% would happily randomise into a trial between the two treatments. Ninety-seven per cent of 100 consultant urologists in the UK have access to onabotulinum toxin A in their hospitals, but only 39% have access to sacral nerve stimulation. Of clinicians given access to all available options, 71% would use onabotulinum toxin A as their first choice treatment for refractory overactive bladder.

Conclusion:

There appears to be a significant disparity between current UK overactive bladder guidance, National Health Service accessibility to onabotulinum toxin A and sacral nerve stimulation therapies, the views of clinicians, and patient preferences for treatment.

Level of evidence:

5

Pharmacotherapy for Pediatric Neurogenic Bladder

Neurogenic bladder (NB) is a nonspecific term that may describe conditions ranging from areflectic noncontractile bladder to detrusor overactivity. The most common cause of NB in children is the presence of dysraphic malformations. Urodynamic evaluations make it possible to describe bladder dysfunctions and to plan a therapeutic strategy for each patient. In a child with NB there are two major dangerous functional problems seen in urodynamic investigations: high intravesical pressure in the storage phase and high pressure during urination. The basic goals of urologic treatment for a child with NB are the protection of the urinary tract from complications and improvement of continence. Treatment for a child with NB is usually conservative, and focuses on achieving safe bladder pressures during storage with reliable emptying, via voiding or catheterization. The two most important forms of conservative treatment are clean intermittent catheterization and pharmacological treatment of functional disorders. Some drugs are used in the treatment of functional disorders in children with NB, but none of the drugs are officially approved for small children and babies.

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

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

OnabotulinumtoxinA for the treatment of idiopathic overactive bladder is effective and safe for repeated use

INTRODUCTION

The objective of this study was to compare efficacy and safety outcomes between patients receiving onabotulinum-toxinA (OnabotA) for the first time and those receiving a repeat injection.

METHODS

Data collected before and after OnabotA injection were extracted from a clinical registry. Patients were classified into either first or repeat injection subgroups. Efficacy was measured by the change in use of oral bladder medications, the number of voids per day or night, the frequency of urinary incontinence (UI) episodes, and patient-reported outcomes. Safety was measured by the number of self-reported complications. Differences in safety measures between the subgroups were tested.

RESULTS

The analysis included complete data from 81 patients; 30 (37%) receiving OnabotA for the first time, 51 (63%) receiving a repeat injection. Both subgroups reported significant reductions in the use of anticholinergics, more tolerable bladder symptoms, and improvements in patient-reported outcomes. Dry rates were similarly high in both groups (50% and 43%, respectively). There were no statistically significant differences between the subgroups in terms of their safety outcomes.

CONCLUSIONS

OnabotA is equally as efficacious and safe for patients with overactive bladder receiving a repeat injection as it is for those receiving their first injection.

Medium- to long-term outcomes of botulinum toxin A for idiopathic overactive bladder

Botulinum toxin A (BoNT-A) has become an important therapeutic tool in the management of refractory overactive bladder (OAB). Over the last decade, there have been growing numbers of patients receiving repeat injections and these outcomes have begun to be reported in large, high-quality cohorts. This article reviews the current evidence for the medium- to long-term use of BoNT-A in adults with idiopathic detrusor overactivity (IDO) receiving repeat injections. We find that medium-term outcomes are encouraging but long-term outcomes are not as extensively reported. There is high-quality evidence that efficacy following the first injection persists across multiple treatment cycles. There are no additional safety concerns from repeat injections up to six treatment cycles. However, there is a need for further data to confirm the efficacy and safety of BoNT-A beyond the follow-up period in the current literature.

OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial

Importance

Women with refractory urgency urinary incontinence are treated with sacral neuromodulation and onabotulinumtoxinA with limited comparative information.

Objective

To assess whether onabotulinumtoxinA is superior to sacral neuromodulation in controlling refractory episodes of urgency urinary incontinence.

Design, Setting, and Participants

Multicenter open-label randomized trial (February 2012-January 2015) at 9 US medical centers involving 381 women with refractory urgency urinary incontinence.

Interventions

Cystoscopic intradetrusor injection of 200 U of onabotulinumtoxinA (n = 192) or sacral neuromodulation (n = 189).

Main Outcomes and Measures

Primary outcome, change from baseline mean number of daily urgency urinary incontinence episodes over 6 months, was measured with monthly 3-day diaries. Secondary outcomes included change from baseline in urinary symptom scores in the Overactive Bladder Questionnaire Short Form (SF); range, 0-100, higher scores indicating worse symptoms; Overactive Bladder Satisfaction questionnaire; range, 0-100; includes 5 subscales, higher scores indicating better satisfaction; and adverse events.

Results

Of the 364 women (mean [SD] age, 63.0 [11.6] years) in the intention-to-treat population, 190 women in the onabotulinumtoxinA group had a greater reduction in 6-month mean number of episodes of urgency incontinence per day than did the 174 in the sacral neuromodulation group (-3.9 vs -3.3 episodes per day; mean difference, 0.63; 95% CI, 0.13 to 1.14; P = .01). Participants treated with onabotulinumtoxinA showed greater improvement in the Overactive Bladder Questionnaire SF for symptom bother (-46.7 vs -38.6; mean difference, 8.1; 95% CI, 3.0 to 13.3; P = .002); treatment satisfaction (67.7 vs 59.8; mean difference, 7.8; 95% CI, 1.6 to 14.1; P = .01) and treatment endorsement (78.1 vs 67.6; mean difference; 10.4, 95% CI, 4.3 to 16.5; P < .001) than treatment with sacral neuromodulation. There were no differences in convenience (67.6 vs 70.2; mean difference, -2.5; 95% CI, -8.1 to 3.0; P = .36), adverse effects (88.4 vs 85.1; mean difference, 3.3; 95% CI, -1.9 to 8.5; P = .22), and treatment preference (92.% vs 89%; risk difference, -3%; 95% CI, -16% to 10%; P = .49). Urinary tract infections were more frequent in the onabotulinumtoxinA group (35% vs 11%; risk difference, -23%; 95% CI, -33% to -13%; P < .001). The need for self-catheterization was 8% and 2% at 1 and 6 months in the onabotulinumtoxinA group. Neuromodulation device revisions and removals occurred in 3%.

Conclusions and Relevance

Among women with refractory urgency urinary incontinence, treatment with onabotulinumtoxinA compared with sacral neuromodulation resulted in a small daily improvement in episodes that although statistically significant is of uncertain clinical importance. In addition, it resulted in a higher risk of urinary tract infections and need for transient self-catheterizations.

Comparison of the effectiveness of repeated injections of onabotulinum toxin A for refractory idiopathic detrusor overactivity: analysis of an open label extension of a randomized trial (the RELAX study)

AIMS

To assess effects of repeat treatment with onabotulinumtoxin A (onaBoNT-A) in women with refractory idiopathic detrusor overactivity (DO).

METHODS

Analysis of an open-label extension study of a large randomized placebo controlled trial of onaBoNT-A. Participants had been randomized to receive 200 IU onaBoNTA or placebo and were offered up to two further onaBoNTA injections over a 5-year period. For this analysis, the primary outcome was duration of treatment effect by patient-reported symptom return. Weibull proportional hazards regression models were fitted in a Bayesian framework to estimate missing times. Multivariable hazard regression analysis (hazard ratio, 95% credible intervals (HR, 95% CrI) compared repeated injections adjusting for differences in baseline symptom severity. Secondary outcomes included inter-injection interval, incontinence, urgency, and voiding episodes 6 weeks after injection.

RESULTS

Four hundred and forty-two active injections were administered: 228 patients had one, 155 had two, and 59 had three injections. Time to symptom return for injection number 1 and 2 was 84 (95%CI: 63, 112) and 180 (95%CI: 135, 223) days, respectively. Median inter-injection intervals for receiving second and third injection were 266 days (range: 130, 1400) and 372 days (range: 134, 1283). No statistically significant differences in symptom outcomes or time to symptom return (HR 0.88, 95% CrI 0.37, 2.07 for injection 2, HR 0.33, 95% CrI 0.09, 1.03 for injection 3) were observed.

CONCLUSIONS

Repeated onaBoNT-A injections have consistent efficacy and duration of action. There appears to be long-term placebo effects in both groups of randomized patients, with implications for open-label extension studies.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Eight-Year Experience With Botulinum Toxin Type-A Injections for the Treatment of Nonneurogenic Overactive Bladder: Are Repeated Injections Worthwhile?

Purpose:

To investigate the efficacy and safety of repeated botulinum toxin type-A (BTX-A) injections for patients with drug-refractory nonneurogenic overactive bladder (NNOAB) and explore factors predictive of outcome.

Methods:

Data were collected from all patients receiving repeated BTX-A injections for drug-refractory NNOAB between 2004 and 2012. Trigone-sparing injections were administered under sedation with antibiotic prophylaxis. Patient characteristics including age, sex, preoperative urodynamics, injection number, BTX-A dose, complications, and patient global impression of improvement (PGI-I) scores were collected. Correlations between patient factors and outcomes were assessed by using Pearson’s chi-square tests.

Results:

Fifty-two patients with a mean age of 67.4 years (range, 26–93 years) received 140 BTX-A injections in total; 33 (64%), 15 (29%), and 4 patients (7%) received 2, 3 to 4, and 5 to 8 injections, respectively. Mean follow-up time was 49 months (range, 9–101 months). Nine patients developed urinary tract infection; additionally, 3 patients experienced transient urinary retention. Median PGI-I score was 2 out of 7 (interquartile range [IQR], 2). For 46 patients, the PGI-I score remained stable with the administration of each injection. Pearson chi-square tests revealed that male patients or reduced bladder compliance was associated with a higher (worse) PGI-I score. Median PGI-I scores for men and women were 3 (IQR, 1) and 2 (IQR, 1), respectively; additionally, median PGI-I scores for those with normal bladder compliance and those with reduced bladder compliance were 2 (IQR, 2) and 4.5 (IQR, 1), respectively. Median PGI-I scores and complication rates were the same in the older patient (≥70 years) and younger (<70 years) patient cohorts.

Conclusions:

Efficacy is maintained with repeated BTX-A injections. Patients including the elderly show a good degree of tolerability with a low complication rate. Male patients or reduced bladder compliance is associated with poorer outcomes.

Overactive bladder - 18 years - Part II

Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics - pillars of the overactive bladder pharmacotherapy - started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning - as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder - 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

[Idiopathic overactive bladder and BOTOX(®): Literature review]

AIM

Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence.

RESULTS

Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL.

CONCLUSION

Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB.

Patient experience and satisfaction with Onabotulinumtoxin A for refractory overactive bladder

OBJECTIVE

To evaluate the patient experience of our dedicated botulinum toxin A (BTX-A) service using a validated patient-reported experience measure (PREM) and assess patient-reported satisfaction with treatment.

MATERIALS AND METHODS

The first 100 patients who underwent BTX-A treatment for refractory idiopathic detrusor overactivity (IDO) in our institution were contacted for telephone interview. They had all been assessed, injected and followed up in a dedicated BTX-A clinic. Patients were asked to complete a validated PREM - the Client Satisfaction Questionnaire (CSQ-8) - as well as a questionnaire developed in our department to assess satisfaction with the results of the treatment. Most patients received 200 U OnabotulinumtoxinA (Botox(®) ) via an outpatient local anaesthetic flexible cystoscopy technique.

RESULTS

Complete data was available for 72 patients. In all, 49 patients were continuing to receive BTX-A treatment while 23 had opted for no further injections. The overall mean (sd) CSQ-8 satisfaction score was 38.3 (3.3), indicating a high level of patient satisfaction with the service offered in our institution. There was a significant difference in total satisfaction scores between those still receiving BTX-A (mean score 29.8) and those who have discontinued treatment (mean score 25.1) (P < 0.01). Overall patient satisfaction with the result of the treatment was high with an overall mean (sd) score of 8.6 (2.0) on a visual analogue scale. Of those who had discontinued BTX-A, most were either using conservative measures only (44%) or had recommenced anticholinergic medications.

CONCLUSION

Overall patient satisfaction with the dedicated BTX-A service offered in our institution is high and can result in a positive patient experience. The use of PREMs are advocated in order to fully capture the patient's views of the quality of services and treatments they receive.

OnabotulinumtoxinA for the treatment of overactive bladder

OnabotulinumtoxinA injection is a safe and effective treatment for adults with refractory overactive bladder. There is sufficient level 1 evidence to support offering onabotulinumtoxinA injections as a second-line treatment to patients who have failed behavioral therapy and oral medications such as antimuscarinics and β3 agonists. An intradetrusor injection of 100 U of onabotulinumtoxinA is likely the optimal dose to balance risks and benefits, and this is the dose approved by the US Food and Drug Administration. Improvement in urgency urinary incontinence episodes, as well as symptom scores and quality of life, were seen in around 60%-65% of patients, and were significantly improved compared with those on placebo. Most studies have reported a duration of symptom relief ranging from 6 to 12 months, with repeat injections being safe and efficacious. Overall, the risk of urinary retention was around 6% across the study populations.

The Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment: ROSETTA trial

We present the rationale for and design of a randomized, open-label, active-control trial comparing the effectiveness of 200 units of onabotulinum toxin A (Botox A®) versus sacral neuromodulation (InterStim®) therapy for refractory urgency urinary incontinence (UUI). The Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial compares changes in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms, adverse events and cost effectiveness in women receiving these two therapies. Eligible participants had previously attempted treatment with at least 2 medications and behavioral therapy. We discuss the importance of evaluating two very different interventions, the challenges related to recruitment, ethical considerations for two treatments with significantly different costs, follow-up assessments and cost effectiveness. The ROSETTA trial will provide information to healthcare providers regarding the technical attributes of these interventions as well as the efficacy and safety of these two interventions on other lower urinary tract and pelvic floor symptoms. Enrollment began in March, 2012 with anticipated end to recruitment in mid 2014.

Discontinuation rates and inter-injection interval for repeated intravesical botulinum toxin type A injections for detrusor overactivity

OBJECTIVE

To report discontinuation rates, inter-injection interval and complication rates after repeated intravesical botulinum toxin type A for the treatment of detrusor overactivity.

METHOD

Patients with urodyamically proven detrusor overactivity who had two or more botulinum toxin type A injections in the period 2004-2011 at Freeman Hospital, Newcastle Upon Tyne, UK, were considered for the present study. Discontinuation rates, complication rates and interval between botulinum toxin type A treatments were retrospectively analyzed.

RESULTS

Overall, 125 patients (median age 53 years, range 19-83 years) were included in the analysis. The female-to-male ratio was 2.4:1 and median follow up was 38 months. A total of 96 patients had idiopathic detrusor overactivity, whereas 29 had neurogenic detrusor overactivity. A total of 667 injections were carried out, with 125 patients receiving two injections, 60 receiving three injections, 28 receiving four injections, 14 receiving five injections, three receiving six injections, three receiving seven injections and two receiving eight injections. The mean interval (±standard deviation) between the first and second injection (n = 125) was 17.6 months (±10.4), between the second and third (n = 60) was 15.7 ± 7.4 months, between the third and fourth (n = 28) was 15.4 ± 8.6 months, and between the fourth and subsequent injections (n = 22) was 11.6 ± 4.5 months. A total of 26% required intermittent catheterization, and 18% developed recurrent urinary tract infections. There was a discontinuation rate of 25% at 60 months.

CONCLUSION

Repeated botulinum toxin type A injections represent a safe and effective method for managing patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity. We have shown that the inter-injection interval remains unchanged up to five injections.

The use of botulinum toxin for the treatment of overactive bladder syndrome

Over the last 50 years, botulinum toxin has been transformed from a cause of life-threatening disease to an effective medical therapy. It has been used in a variety of specialties for different indications, significantly improving patient quality of life. A recent growing body of evidence suggests that intra-detrusor injection of botulinum toxin may have beneficial effects in patients with medication refractory detrusor overactivity and may offer a new minimally invasive alternative to patients with severe overactive bladder symptoms. To review current data regarding the effects of botulinum toxin in patients with overactive bladder, a MEDLINE^®/PubMed^® literature search was carried out. The mechanism of action, clinical usage, adverse effects, and treatment efficacy were reviewed and the results are presented in this paper.

Botulinum toxin-A for the treatment of overactive bladder: UK contributions

Background:

Botulinum toxin-A (BoNT/A) is now established second-line management for refractory overactive bladder (OAB) and recognised in many incontinence guidelines and pathways. For those with neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis, the toxin is currently licensed in certain parts of the world, including the UK. It is an effective treatment in those in whom antimuscarinics and conservative measures have failed who have symptoms of OAB and or detrusor overactivity (DO).

Methods:

Treatment can be given in an outpatient setting and can be administered under local anaesthesia. Its efficacy lasts for between six and 12 months.

Results:

It has an acceptable safety profile with the biggest risk being urinary tract infection and difficulty emptying the bladder, necessitating clean intermittent self-catheterisation (CISC). Medium-term follow-up suggests repeated injections are also safe and efficacious.

Conclusions:

The mechanism of action of the toxin is more complicated than originally thought, and it seems likely that it affects motor and sensory nerves of the bladder. In the last 10 years much of the progress of this treatment from early experimental trials to mainstream clinical use, and a better understanding of how it works in the bladder, are as a result of research conducted in the UK. This review summarises the significant and substantial evidence for BoNT/A to treat refractory OAB from UK centres.

Intradetrusor injection of botulinum toxin for the management of refractory overactive bladder syndrome: an update

Overactive bladder (OAB) is a common syndrome that has a negative impact on daily activities and quality of life. The first-line treatment to manage this condition includes behavioral modifications, physical treatment, and oral pharmacotherapy with antimuscarinics. Botulinum toxin has emerged as an alternative and second-line treatment option for patients with OAB who are refractory to first-line treatment modalities when injected into the detrusor muscle. Although its application in the management of OAB remains off label, studies have shown its efficacy both subjectively and objectively. It is considered as a minimally invasive and reversible alternative. Adequate dosage of the toxin, number of injection sites, and reinjection rates are yet to be determined. This review attempts to provide an update on the current position of botulinum toxin in managing refractory OAB addressing contemporary data on the mechanism of action, technique, safety, complications, and clinical results.

OnabotulinumtoxinA in the treatment of neurogenic bladder

This review examines the evidence for use of onabotulinumtoxinA in the treatment of neurogenic lower urinary tract dysfunction. Since its first use in 1988 to treat detrusor sphincter dyssynergia, use of botulinum toxin has increased in this group of patients. We discuss the mechanism of action, patient selection, dosing, efficacy, and side effect profile of this now licensed treatment option.

New and emerging indications of botulinum toxin therapy

Botulinum neurotoxin (BoNT) is composed of the heavy chain with the receptor-binding site and the translocation domain and the light chain with endopeptidase activity that cleaves the SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein receptor) complex, an essential molecule for membrane fusion. Its extraordinarily high toxicity depends on the affinity of the receptor-binding site to the receptor located inside the synaptosome. The membrane fusion mechanism is important not only in neurotransmitter release at the nerve terminals but also in the expression of pain receptors on the cell surface. Based on these mechanisms, BoNT is increasingly used for varieties of conditions including cosmetic uses, muscle hyperactivity, hyperhydrosis, pain, overactive bladder and epilepsy. It will become a major arm of neuromodulating treatments for neurological diseases. A part of this toxin, such as the heavy chain, may become a novel drug-delivery system for neurodegenerative diseases.

Botulinum toxin injection for lower urinary tract dysfunction

Botulinum toxin has been recently accepted as a novel treatment for lower urinary tract dysfunctions refractory to conventional treatment. Review of the clinical trials in recent years, botulinum toxin type A has been widely used in the urethra or urinary bladder to treat voiding dysfunction due to detrusor sphincter dyssynergia, incontinence due to neurogenic or idiopathic detrusor overactivity, sensory disorders such as bladder hypersensitivity, overactive bladder, and interstitial cystitis/painful bladder syndrome. Intravesical botulinum toxin type A injection is effective in treatment of urinary incontinence due to detrusor overactivity in men and women, as well as in children. Currently botulinum toxin type A has also been applied to treat lower urinary tract symptoms due to benign prostatic hyperplasia in patients not suitable for surgery. This article reviewed the recent advances of botulinum toxin type A on lower urinary tract dysfunction.

Overactive bladder: diagnosis and management

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. Whilst a number of women may be managed based on a clinical diagnosis alone urodynamic studies may be useful in those women with complex or refractory symptoms. In the first instance all women will benefit from a conservative approach using bladder retraining although a number will require antimuscarinic therapy. For those women with persistent symptoms following medical therapy alternative treatment modalities such as intravesical Botulinum Toxin, neuromodulation or reconstructive surgery may be considered. This review, whilst giving an overview of the syndrome, will focus on a practical clinical approach to managing women with symptoms of overactive bladder (OAB).

Antibodies after botulinum toxin A injection into musculus detrusor vesicae: incidence and clinical relevance

OBJECTIVES

Botulinum toxin A (BTX-A) injection into the detrusor muscle has changed therapy options for patients with overactive bladder (OAB). However, in some patients, therapy fails or the effects of BTX-A decrease. The aim of this prospective study was to evaluate the incidence of BTX-A antibodies (BTX-A Abs) after injection of BTX-A and its clinical relevance.

METHODS

31 patients (27 women, 4 men) were treated with BTX-A for OAB between January 2009 and August 2010. Eleven patients were treated once, 16 patients were treated twice and 4 patients were treated three times. Blood was collected before and 3 months after the BTX-A injection and BTX-A Abs were determined.

RESULTS

In 5 patients (16%) BTX-A Abs were detectable after the BTX-A injection. The BTX-A Ab titer was clearly positive in 1 patient (3.2%). This patient showed complete failure of BTX-A therapy. In 4 patients (13%) BTX-A Abs were slightly positive after the first BTX-A injection. The second BTX-A injection showed no positive effects in only 1 patient with borderline BTX-A Ab titers; the second BTX-A injection was successful in 2 patients.

CONCLUSIONS

The incidence of BTX-A Abs should be verified in nonresponders. More data are necessary to check the clinical relevance and risk of BTX-A Ab formation, especially in long-term follow-up, to optimize patient selection for this minimally invasive treatment option in OAB.

Role of botulinum toxin-A in refractory idiopathic overactive bladder patients without detrusor overactivity

BACKGROUND

To evaluate the efficacy of intradetrusor botulinum toxin-A (BTX-A) in idiopathic overactive bladder patients (OAB) refractory to anti-muscarinic therapy, without detrusor overactivity (DOA) on urodynamics.

METHODS

Patients with refractory idiopathic OAB without DOA on urodynamics were prospectively enrolled. Subjects completed a 3-day voiding diary (3-VD), urogenital distress inventory-6 questionnaire (UDI-6) and graded their quality of life on a 10-cm visual analog scale (VAS) prior to study enrollment and at week 12 postinjection. All patients underwent multichannel urodynamics at study enrollment and 12 weeks postinjection. Improvement was analyzed based on 3-VD, UDI-6 questionnaire, VAS scores, and urodynamic parameters at week 12 postinjection compared to study enrollment.

RESULTS

The study included 32 patients. Mean ± SD age was 56 ± 16. There were 27 women and 5 men. Nineteen patients had OAB without incontinence (OAB-dry) and 13 patients had OAB with incontinence (OAB-wet). In OAB-dry patients, mean ± SD urinary frequency dropped from 24 ± 11 to 10 ± 4 by week 12. In OAB-wet patients, mean ± SD urge incontinence episodes dropped from 7.9 ± 5 to 0 ± 2.6 by week 12. Mean UDI-6 and VAS scores improved significantly in both groups by week 12 (P = 0.0001). On comparing urodynamic parameters, OAB-wet patients showed significant decrease in maximum detrusor pressure during the voiding phase at week 12 compared to baseline values (P = 0.02).

CONCLUSIONS

Refractory idiopathic OAB patients without DOA on urodynamics may benefit from intradetrusor BTX-A.

Repeat botulinum toxin-A injections for treatment of adult detrusor overactivity

Intravesical injections of botulinum toxin-A have become established as an effective therapy in the management of neurogenic and idiopathic detrusor overactivity that is refractory to treatment with anticholinergic medication. The effects of the toxin are finite and repeated injections are required to sustain the beneficial therapeutic effects. The available data suggest a reproducible and sustained improvement in symptoms as well as urodynamic parameters following repeated injections of botulinum toxin-A. The reported incidence of adverse events is low and resistance to the toxin is uncommon. The timing of repeat injections within the published data is variable, reflecting differing practise among clinicians, but is typically 6-12 months. Larger scale studies are still required to clarify the usefulness of botulinum toxin-A as a long-term treatment in the management of detrusor overactivity.