Intraoperative Onabotulinumtoxin-A Reduces Postoperative Narcotic and Anticholinergic Requirements After Continent Bladder Reconstruction

Is Onabotulinum Toxin-A Combined Injection in the Bowel Patch and the Bladder Remnant a Safe Alternative to Bladder Re-Augmentation?

OBJECTIVE

To assess both the safety and efficacy, in terms of symptomatic improvement, of botulinum toxin injections distributed in the bowel patch and the bladder remnant of failed augmented bladders.

MATERIALS AND METHODS

A retrospective study was performed on patients with augmented bladders who had presented with clinical and/or urodynamic failure and had received an onabotulinum¹ toxin-A (BTX-A) injection at both the bowel and the bladder level due to refractoriness to oral treatment. The primary variable tested was safety, which was assessed by analysing the adverse effects according to the Clavien-Dindo classification. Subjective improvement was assessed by means of the Treatment Benefit Scale (TBS) as a secondary variable.

RESULTS

Eight patients who underwent a total of 23 procedures were analysed. The mean age at first injection was 23 years. The mean interval between bladder augmentation and first BTX-A injection was 65.11 months. The mean interval between BTX-A injections was 11.6 months. No adverse effects due to systemic absorption were recorded. The only postoperative complication was an afebrile urinary infection (Clavien-Dindo 2) in 2 out of 23 procedures (8.7%). Eighty-six percent (19/22) of the procedures yielded a symptomatic benefit (TBS 1 and 2).

CONCLUSION

Injection of onabotulinum toxin-A in both the bowel patch and the bladder remnant appears to be a safe and efficient technique for the symptomatic treatment of patients with bladder augmentation who have shown clinical and/or urodynamic failure in response to a conservative treatment. This procedure allows bladder re-augmentation to be delayed or even avoided.

Robotics in Pediatric Urology

Robotic surgery has been slow to be fully accepted in the world of pediatric urology largely because of its initial application directed towards adult use and because of the inherent high cost associated with it. However, as previously shown, it has now become the gold standard for adolescent pyeloplasty in The United States. As the adoption of robotic surgery in children has become more widespread, its use has been applied to a broader spectrum of procedures with similar success rates to standard laparoscopy. These procedures include nephrectomy, heminephrectomy, ureteral reimplantation, and ureteroureterostomy. However, it has also shown feasibility and comparable success when compared to open surgery in procedures that were previously deemed too complex to be done by standard laparoscopy. For example, bladder neck reconstruction with Mitrofanoff and Malone procedure as well as bladder augmentation. This review objective is to provide an overview of robotic surgery in pediatric urology, with a focus on the more common cases such as pyeloplasty and reimplantation as well as more complex bladder reconstruction procedures.