Botulinum-A toxin for treating detrusor hyperreflexia in spinal cord injured patients: a new alternative to anticholinergic drugs? Preliminary results

Response to Treatment with Botulinum Neurotoxin A (BoNT-A) in Children and Adolescents with Neurogenic Lower Urinary Tract Dysfunction and Idiopathic Overactive Bladder: A Systematic Review and Meta-Analysis

INTRODUCTION

Botulinum neurotoxin A (BoNT-A) is a treatment option for neurogenic lower urinary tract dysfunctions (NLUTD) and idiopathic overactive bladder (OAB) in adults. Recently, its use has gained popularity in paediatric urology. Transitional urology deals with adolescents affected by congenital urological issues, who mature into adulthood. The aim of this systematic review was to update the current knowledge on the use of BoNT-A in children and adolescents.

METHODS

A comprehensive search in PubMed, Scopus, and Web of Science databases was performed from articles published up to September 2024. Both prospective and retrospective single-cohort or comparative studies evaluating outcomes of interest were included. These consisted of the amelioration of urinary incontinence (UI), continence rates, improvement of urodynamic parameters (maximum detrusor pressure during voiding, maximum bladder capacity, and bladder compliance), and type and prevalence of adverse/side effects. Qualitative and quantitative data syntheses were provided. Moderators and meta-regression analyses were carried out as well.

RESULTS

Forty-one full-text manuscripts were selected of which 26 focused on children with NLUTD, 13 on idiopathic OAB, and two on both conditions. Overall, 1521 patients were included of whom 715 were male, 646 female, and 160 of unknown sex. Mean age varied between 5.6 and 15.6 years. No studies specifically focused on transitional urology, despite patients up to at least 17 years of age being included. Several differences existed in design, type, dose, way of administration, outcomes measured and follow-up time; however, all studies independently showed an improvement of UI and urodynamic parameters with no major side/adverse events. Pooled analysis showed a mean rate of improvement in UI scores/episodes of 75.87% within a period of 3-6 months following BoNT-A treatment. Meta-regression analyses demonstrated a significant correlation between dryness rate and both patients' age (negative) and bladder compliance (positive).

CONCLUSIONS

Several uncontrolled or comparative studies provided significative evidence of the clinical benefit and safety of BoNT-A administration in children in terms of UI relief and improvement of urodynamic parameters, with neurogenic aetiologies being the most investigated conditions. A reduced bladder compliance was identified as one of the potential predictors of poor response to BoNT-A. Moreover, the earlier the treatment was started the higher the success rate that was reached in terms of dryness/urinary continence achievement.

Adverse Effects of Intravesical OnabotulinumtoxinA Injection in Patients with Idiopathic Overactive Bladder or Neurogenic Detrusor Overactivity: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Despite the efficacy of onabotulinumtoxinA, its safety profile remains a concern. This meta-analysis reviewed the major adverse events (AEs) associated with intravesical onabotulinumtoxinA treatment in patients with neurogenic detrusor overactivity (NDO) and idiopathic overactive bladder (iOAB). Randomized controlled trials (RCTs) conducted between January 2000 and December 2022 were searched for adult patients administered different onabotulinumtoxinA dosages or onabotulinumtoxinA vs. placebo. Quality assessment was performed using the Cochrane Collaboration tool, and statistical analysis was performed using Review Manager version 5.3. A total of 26 RCTs were included in the analysis, including 8 on NDO and 18 on iOAB. OnabotulinumtoxinA vs. placebo significantly increased the urinary tract infection (UTI) incidence in patients with NDO (relative risk, or RR, 1.54) and iOAB (RR, 2.53). No difference in the RR with different onabotulinumtoxinA dosages was noted. Urinary retention was frequent with onabotulinumtoxinA use in the NDO (RR, 6.56) and iOAB (RR, 7.32) groups. Similar observations were made regarding the risks of de novo clean intermittent catheterization (CIC). The risk of voiding difficulty increased with onabotulinumtoxinA use in patients with iOAB. Systemic AEs of onabotulinumtoxinA, including muscle weakness (RR, 2.79) and nausea (RR, 3.15), were noted in patients with NDO; most systemic AEs had a low incidence and were sporadic.

Clinical efficacy and safety analysis of type A botulinum toxin in the treatment of adolescents with refractory overactive bladder

The objective of this study was to assess the clinical effectiveness and safety of type A botulinum toxin in the treatment of refractory overactive bladder in adolescents. We conducted a retrospective analysis of 37 adolescent patients with refractory overactive bladder who were treated at the Urology Department of Hangzhou Third People's Hospital between January 2018 and August 2023. These patients received intravesical injections of type A botulinum toxin at a concentration of 10 U/mL, with an average of 20 injection points. We recorded changes in urination diaries and urodynamic parameters both before and 1 month after treatment. After 1 month of treatment, significant improvements were observed in several parameters, when compared to the pretreatment values. These included daytime frequency of urination (11.13 ± 6.45), average single void volume (173.24 ± 36.48) mL, nighttime frequency of urination (2.43 ± 0.31), urgency episodes (3.12 ± 0.27), initial bladder capacity (149.82 ± 41.34) mL, and maximum bladder capacity (340.25 ± 57.12) mL (all P < .001). After the first treatment, 5 patients had mild hematuria, 4 patients had urinary tract infection, and 1 patient had urinary retention, which was relieved after catheterization. No serious complications or adverse reactions were observed in other patients. The follow-up period ranged from 6 to 18 months, and the duration of efficacy varied from 2 to 8 months. Eight patients who initially had treatment failure achieved symptom relief after reinjection. In adolescents with refractory overactive bladder who do not respond well to conventional drug therapy, type A botulinum toxin can be administered safely and effectively. It significantly improves lower urinary tract symptoms and enhances the quality of life for these patients.

Onabotulinum toxin A improves neurogenic detrusor overactivity following spinal cord injury: a systematic review and meta-analysis

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.

How to define failure of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity

INTRODUCTION

Neurogenic detrusor overactivity (NDO) has a major impact on patients' quality of life and can lead to upper urinary tract complications. Intradetrusor botulinum toxin type A injections are administered as second-line treatment to these patients following the failure of anticholinergic agents. The aim of the DETOX 2 study is to propose a consensus definition of the failure of intradetrusor botulinum toxin injections for NDO in patients presenting spinal cord injury, spina bifida, or multiple sclerosis (MS) with self-catheterization.

METHOD

This study followed the method adopted by the French National Authority for Health for recommendations by consensus. Based on a review of the literature and a preliminary survey, a steering committee compiled a questionnaire and selected a rating group comprising 16 experts from the Neuro-Urology Committee of the French Urology Association (cnuAFU) and Genulf. The experts were asked to complete the online questionnaire. At the end of the first round, all participants came together to discuss any disagreements and a second-round online questionnaire was completed to reach a consensus.

RESULTS

Thirteen of the 16 experts approached completed both rounds of questionnaires. A strong consensus was reached for two proposals (median score = 9/10) which were therefore included in the definition from the first round: at least one repeat injection of the same botulinum toxin at the same dose must be given to rule out failure on technical grounds and a duration of efficacy <3 months must be considered a failure. At the end of round 2, a relative consensus was reached regarding the clinical criterion defining failure (median score = 7/10) and the urodynamic criterion of failure (median score = 8/10). An additional proposal was selected during this second round on the need for a voiding diary (median score = 8/10).

CONCLUSION

The first consensus definition of failure of an intradetrusor injection of TB-A for NDO has been achieved with this study: persistence of detrusor overactivity with maximum detrusor pressures >40 cm H2O and/or a compliance issue and/or persistence of urinary incontinence and/or urgency and/or a number of daily self-catheterizations >8/day and/or efficacy <3 months. This study will help to standardize research on the failure of the intradetrusor botulinum toxin for NDO in clinical practice and clinical research.

From Toxin to Treatment: A Narrative Review on the Use of Botulinum Toxin for Autonomic Dysfunction

Since its regulatory approval over a half-century ago, botulinum toxin has evolved from one of the most potent neurotoxins known to becoming routinely adopted in clinical practice. Botulinum toxin, a highly potent neurotoxin produced by Clostridium botulinum, can cause botulism illness, characterized by widespread muscle weakness due to inhibition of acetylcholine transmission at neuromuscular junctions. The observation of botulinum toxin's anticholinergic properties led to the investigation of its potential benefits for conditions with an underlying etiology of cholinergic transmission, including autonomic nervous system dysfunction. These conditions range from disorders of the integument to gastrointestinal and urinary systems. Several formulations of botulinum toxin have been developed and tested over time, significantly increasing the availability of this treatment for appropriate clinical use. Despite the accelerated and expanded use of botulinum toxin, there lacks an updated comprehensive review on its therapeutic use, particularly to treat autonomic dysfunction. This narrative review provides an overview of the effect of botulinum toxin in the treatment of autonomic dysfunction and summarizes the different formulations and dosages most widely studied, while highlighting reported outcomes and the occurrence of any adverse events.

Intravesical injection of botulinum toxin type a may be an effective treatment option for autonomic dysreflexia in patients with high-level spinal cord injury

OBJECTIVE

To evaluate the efficacy of intravesical injection of botulinum toxin type A (BTX-A) for neurogenic detrusor overactivity (DO) in reducing the frequency and severity of autonomic dysreflexia (AD).

DESIGN

A cross-sectional nonrandomized trial with before (baseline) and after (follow-up) assessments.

SETTING

A single spinal cord injury (SCI) rehabilitation center in China.

PARTICIPANTS

Twenty-five patients with SCI at or above T6 and a history of AD who underwent urodynamic studies (UDS) before and 3 months after BTX-A injection.

INTERVENTIONS

Received bladder injection treatment wtih 200 U BTX-A.

OUTCOME MEASURES

The maximum detrusor pressure(Pdetmax) and voume at first DO(VFIDC), baseline and overall maximum systolic blood pressure (SBP) during UDS, and scores of Incontinence Specific Quality of Life Instrument (IQoL) were recorded before and 3 months after the injection. The change in SBP (ΔSBP) from baseline to maximum SBP during UDS was calculated to assess the severity. The frequency of AD was recorded using ambulatory blood pressure monitoring during a 24 h period before and 3 months after the injection.

RESULTS

BTX-A injection decreased the Pdetmax and increased the VFIDC and mean urine volume per catheterization increased. The maximum SBP and the ΔSBP during UDS decreased significantly decreased after the injection (151.44 ± 13.92 vs 133.32 ± 9.20 mmHg and 49.44 ± 12.81 vs 33.08 ± 9.11 mmHg respectively, P < 0.05). The frequency of bladder-related ADs (i.e. performed a clean intermittent catheterization or leakage) during a 24-h period significantly decreased from 11.04 ± 1.81-7.88 ± 2.15 (P < 0.001).

CONCLUSIONS

BTX-A decreases the severity of SBP increase and the number of AD episodes 3 months after intravesical injection.

Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): Development, insights, and impact

Neurogenic detrusor overactivity (NDO) is a complication of multiple sclerosis, spinal cord injury (SCI), stroke, head injury, and other conditions characterized by damage to the upper motor neuronal system. NDO often leads to high bladder pressure that may cause upper urinary tract damage and urinary incontinence (UI). Prior to the use of onabotulinumtoxinA, oral anticholinergics and surgical augmentation cystoplasty were the treatment options. Overactive bladder (OAB) is non-neurogenic and affects a much larger population than NDO. Both NDO and OAB negatively impact patients' quality of life (QOL) and confer high health care utilization burdens. Early positive results from pioneering investigators who injected onabotulinumtoxinA into the detrusor of patients with SCI caught the interest of Allergan, which then initiated collaborative clinical trials that resulted in FDA approval of onabotulinumtoxinA 200U in 2011 for NDO and 100U in 2013 for patients with OAB who inadequately respond to or are intolerant of an anticholinergic. These randomized, double-blind, placebo-controlled trials for NDO showed significant improvements in UI episodes, urodynamic parameters, and QOL; the most frequent adverse events were urinary tract infection (UTI) and urinary retention. Similarly, randomized, double-blind, placebo-controlled trials of onabotulinumtoxinA 100U for OAB found significant improvements in UI episodes, treatment benefit, and QOL; UTI and dysuria were the most common adverse events. Long-term studies in NDO and OAB showed sustained effectiveness and safety with repeat injections of onabotulinumtoxinA, the use of which has profoundly improved the QOL of patients failing anticholinergic therapy and has expanded the utilization of onabotulinumtoxinA into smooth muscle.

Treating Neurogenic Lower Urinary Tract Dysfunction in Chronic Spinal Cord Injury Patients-When Intravesical Botox Injection or Urethral Botox Injection Are Indicated

Lower urinary tract symptoms (LUTS), such as urgency, urinary incontinence, and/or difficulty voiding, hamper the quality of life (QoL) of patients with spinal cord injury (SCI). If not managed adequately, urological complications, such as urinary tract infection or renal function deterioration, may further deteriorate the patient's QoL. Botulinum toxin A (BoNT-A) injection within the detrusor muscle or urethral sphincter yields satisfactory therapeutic effects for treating urinary incontinence or facilitating efficient voiding; however, adverse effects inevitably follow its therapeutic efficacy. It is important to weigh the merits and demerits of BoNT-A injection for LUTS and provide an optimal management strategy for SCI patients. This paper summarizes different aspects of the application of BoNT-A injection for lower urinary tract dysfunctions in SCI patients and provides an overview of the benefits and drawbacks of this treatment.

Patient perceived improvement and medication resumption rates after intradetrusor onabotulinumtoxina for idiopathic urgency urinary incontinence

INTRODUCTION AND HYPOTHESIS

Intradetrusor onabotulinumtoxinA (BTX-A) is a third-line therapy for overactive bladder (OAB), however several gaps exist in periprocedural care. Prior studies have demonstrated BTX-A efficacy at 2-3 weeks, but there are limited data documenting when patients should begin to note symptom improvement. The primary aim of this study was to evaluate patient-reported temporal improvement in symptoms, with secondary aim to evaluate medication resumption rates, following initial BTX-A injection.

METHODS

A prospective, single-arm cohort study of patients with non-neurogenic urgency incontinence undergoing initial BTX-A injection was performed. Intradetrusor 100 units BTX-A was administered in standard 20-site template. Patients discontinued OAB medication(s) at BTX-A injection and completed a daily Patient Global Impression of Improvement (PGI-I) diary for 3 weeks. Data were collected at 1 month, including final satisfaction score, medication resumption rates, and adverse outcomes.

RESULTS

Fifty-one patients were included, with 25 patients (49%) actively taking an OAB medication. Median time to first improvement was 3 days, at least "much better" (PGI-I <2) was 5 days, and maximal improvement was 7 days. Twenty of 25 patients (80%) opted to remain off OAB medications at 1 month based on symptomatic improvement following injection. Adverse outcomes included urinary tract infection in three patients (6%) and symptomatic incomplete emptying requiring temporary intermittent catheterization in two patients (4%).

CONCLUSIONS

Median time to first and maximal improvement was 3 and 7 days, respectively, following initial 100 units BTX-A. Eighty percent of patients on medications opted to remain off at 1 month. These data may help further counsel patient expectations following initial BTX-A therapy.

Neurotoxins Acting at Synaptic Sites: A Brief Review on Mechanisms and Clinical Applications

Neurotoxins generally inhibit or promote the release of neurotransmitters or bind to receptors that are located in the pre- or post-synaptic membranes, thereby affecting physiological functions of synapses and affecting biological processes. With more and more research on the toxins of various origins, many neurotoxins are now widely used in clinical treatment and have demonstrated good therapeutic outcomes. This review summarizes the structural properties and potential pharmacological effects of neurotoxins acting on different components of the synapse, as well as their important clinical applications, thus could be a useful reference for researchers and clinicians in the study of neurotoxins.

Experiencia con el uso de toxina botulínica en niños con vejiga hiperactiva neurogénica: Una serie de casos

Objetivo Describir la experiencia con la administración de inyección de toxina botulínica en niños con vejiga hiperactiva neurogénica refractaria a manejo de primera línea.

Materiales y Métodos Estudio observacional descriptivo (serie de casos) que incluyó a 14 niños con diagnóstico de vejiga hiperactiva neurogénica refractarios a tratamiento de primera línea sometidos a administración intravesical de toxina botulínica entre 2015 y 2021; se realizó el seguimiento teniendo en cuenta las variables clínicas, con evaluación de la respuesta y de los eventos adversos. Se reportaron frecuencias absolutas y porcentajes para las variables cualitativas; para las variables cuantitativas, se reportaron medidas de tendencia central y dispersión.

Resultados Se incluyeron 6 niños y 8 niñas, con una media de edad 10,1 (desviación estándar [DE]: ± 4,4) años. Todos los pacientes fueron tratados previamente con anticolinérgico y cateterismos limpios intermitentes, con una media de uso de 2,8 (DE: ± 1.0) pañales al día; 11 (78,5%) pacientes tenían antecedente de infección urinaria, 13 (92,8%), estreñimiento, y 2 (15,3%), incontinencia fecal. En la ecografía, 7 (50,0%) pacientes presentaban engrosamiento de las paredes vesicales, y 6 (42,8%), hidronefrosis. Tras el procedimiento, 1 paciente presentó infección urinaria como complicación, 6 presentaron una respuesta completa, 7, respuesta parcial, y 1 paciente no obtuvo respuesta con la primera inyección, con un tiempo promedio efectivo de la terapia 8 (DE: ± 6,3) meses. Una segunda inyección fue necesaria en 6 (42.8%) pacientes, y, de estos, 3 (50%) requirieron una tercera inyección.

Conclusión La inyección de toxina botulinica intravesical como terapia de segunda línea de manejo para vejiga hiperactiva neurogénica tiene buenos resultados, con bajas tasas de complicaciones.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

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.

The translational implications of the science behind the overactive bladder and the role of OnabotulinumtoxinA

Urinary incontinence (UI) is a very common condition that can affect patients of all ages and the commonest cause is an overactive bladder (OAB). Most patients with OAB were treated with pharmacotherapy and major surgery. Over 25 years ago, Dasgupta, Fowler et al. studied the presence and role of C fibres in the human bladder which are highly sensitive to capsaicin, the active ingredient of chillies. When capsaicin was instilled into patients' bladders as a synthetic solution, it was found to be highly effective in some patients. Capsaicin was later replaced by Resiniferatoxin. Both toxins desensitised C-fibres through the capsaicin receptor, TRPV1, without any lasting damage to the bladder itself. The discovery of botulinum toxin and its use in the treatment of OAB represents a major breakthrough, in the treatment of OAB. Another key innovation was the development of technique to administer the drug under local anaesthesia which allowed numerous patients to benefit from treatment who would otherwise have been precluded because of the need for injection under general anaesthetic. After extensive trials over many years Botox (OnabotulinumtoxinA) is now licensed for use in OAB. Compared to other treatments for overactive bladder, OnabotulinumtoxinA is more cost-effective and less invasive. It is thought to have changed the quality of life of an estimated 5 million patients worldwide.

A Feasibility Study to Evaluate Changes in Urinary Metabolites after OnabotulinumtoxinA Injection for Refractory Overactive Bladder

Metabolomics analysis of urine before and after overactive bladder (OAB) treatment may demonstrate a unique molecular profile, allowing predictions of responses to treatment. This feasibility study aimed to correlate changes in urinary metabolome with changes in OAB symptoms after intravesical onabotulinumtoxinA (BTX-A) injections for refractory OAB. Women 18 years or older with non-neurogenic refractory OAB were recruited to complete OAB-V8 questionnaires and submit urine samples before and after 100 units intravesical BTX-A injection. Samples were submitted to CE-TOFMS metabolomics profiling. Data were expressed as percent of change from pre-treatment and were correlated with OAB-V8 score improvement. Urinary metabolite changes in the OAB-V8 groups were compared using the Kruskal–Wallis test, and associations between metabolites and OAB-V8 scores were examined using quantile regression analysis. Of 61 urinary metabolites commonly detected before and after BTX-A, there was a statistically significant decrease in adenosine and an increase in N8-acetylspermidine and guanidinoacetic acid levels associated with OAB score improvement, suggesting that intravesical BTX-A injection modifies the urinary metabolome. These urinary metabolites could provide insight into OAB pathophysiology and help identify patients who would benefit most from chemodenervation.

Intravesical botulinum-A toxin in children with refractory non-neurogenic overactive bladder

INTRODUCTION

Overactive bladder (OAB) with urinary incontinence poses a potentially significant impact on daily activities and quality of life. OAB can be unresponsive to specific urotherapy and antispasmodic medication. Due to its successful outcomes in the treatment of neurogenic bladder, intravesical botulinum-A toxin (BTX-A) became a possible solution for children refractory to treatment.

OBJECTIVE

To analyse the outcomes of intravesical BTX-A injections on bladder volume and incontinence in children with refractory OAB.

STUDY DESIGN

The charts of children diagnosed with refractory non-neurogenic OAB who underwent BTX-A treatment in our centre since 2011 were retrospectively analysed. The functional bladder volume (FBV) is expressed as a percentage of the expected bladder capacity (EBC) for age. Dependent variables were compared using the Wilcoxon Signed Rank test. A multivariate logistic regression was used to identify predictors of the response on urinary incontinence.

RESULTS

Fifty children (41 boys) with a median age of 9.9 years were included. In the short term, there was a significant increase in FBV after initial BTX-A treatment from a median of 52.9%-70% (p = 0.000). In the short (<6 months) and long term (6-12 months) 72% and 46% showed improvement of continence, respectively. Male gender and small baseline FBV predict a positive outcome on continence in the long term. The most prevalent complications were urinary tract infections occurring in five cases (10%).

DISCUSSION

Although BTX-A injections serve as an effective therapy to increase bladder volume in non-neurogenic OAB children, the outcomes on urinary incontinence are highly variable. This may be a consequence of the multifactorial aspects of this condition. BTX-A will enable children to inhibit their bladder urgency. The effectiveness of post-BTX-A urotherapy training will therefore most probably be higher. We believe that BTX-A injections should be reserved for children refractory to both specific urotherapy and medication. An appropriate population seems to be children with severe OAB symptoms, confirmed detrusor overactivity in urodynamic study and reduced bladder volume.

CONCLUSION

In refractory OAB children, BTX-A injections are safe and effective in enlarging bladder volume and reducing OAB symptoms, particularly in the first six months after injection.

Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in children

INTRODUCTION

Treatment options for refractory neurogenic detrusor overactivity (NDO) in children include botulinum toxin type A (BTX-A) and augmentation cystoplasty (AC). Although BTX-A is accepted in contemporary pediatric urologic practice, cost and long-term outcomes data for BTX-A are limited relative to the gold standard, AC. The purpose of this study was to compare the projected 10-year costs of AC versus BTX-A.

METHODS

We performed a cost analysis from the payer perspective by computationally modeling treatment sequences by a Markov model. In the model, we used probabilities derived from published sources, and costs obtained at a tertiary medical center. The base case was a pediatric patient with refractory NDO. In the model, we assumed biannual BTX-A treatments. Treatment costs over 10 years were compared between immediate AC versus bridging therapy with BTX-A. Using the computational model, we simulated 100,000 instances of 10-year treatment cost for each of the two treatment modalities. The costs for the two treatment approaches were then compared using t-test and Wilcoxon test.

RESULTS

The projected median and mean 10-year cost of immediately AC were $51,798.72 (95% CI [$51,798.72, $327,483.80]) and $123,473.4 (SD: $98,085.23) respectfully, while the projected median and mean 10-year cost of bridging therapy with BTX-A prior to proceeding to AC as needed were $74,552.46 (95% CI [$53,188.56, $309,913.07]) and $124,858.80 (SD: $84,495.35) (p < 0.001).

CONCLUSIONS

For a typical index pediatric patient with NDO, bridging therapy with intravesical BTX-A is associated with an increased cost compared to immediate AC over a ten-year period.

Interventional management and surgery of neurogenic lower urinary tract dysfunction in patients with chronic spinal cord injury: A urologist's perspective

Neurogenic lower urinary tract dysfunction (NLUTD) caused by spinal cord injury (SCI) is challenging for urologists. NLUTD not only affects the quality of life but also endangers the upper urinary tract of patients with chronic SCI. Considering that the bladder and urethral function change with time, regular follow-up of NLUTD is necessary, and any complication should be adequately treated. The first priority of bladder management in patients with chronic SCI manifesting NLUTD should be renal function preservation, followed by the normalization of lower urinary tract function. The quality of life should also be assessed. Patients who have a high risk for impaired renal function should be more frequently identified and investigated. Conservative treatment and pharmacological therapy should be started as early as possible. Intravesical or urethral injections of botulinum toxin A is an alternative treatment for refractory NLUTD. When surgical intervention is necessary, less invasive and reversible procedures should be considered first. Improving patients' quality of life and willingness to undergo bladder management is the most important aspect of treatment.

BoNT/A1 Secondary Failure for the Treatment of Neurogenic Detrusor Overactivity: An Ex Vivo Functional Study

Management of neurogenic detrusor overactivity (NDO) remains a clinical priority to improve patients’ quality of life and prevent dramatic urological complications. Intradetrusor injection of onabotulinumtoxinA (BoNT/A1, botulinum neurotoxin A1) is approved as second therapeutic line in these patients, demonstrating a good efficacy. However, a loss of its efficacy over time has been described, with no clear understanding of the underlying mechanisms. This paper aims at shedding new light on BoNT/A1 secondary failure in NDO through functional and structural analysis. Three groups of patients (either non-NDO, NDO with no toxin history or toxin secondary failure) were investigated using an ex vivo bladder strip assay. Detrusor strips were tensed in organ baths and submitted to electrical field stimulation to generate contractions. Recombinant BoNT/A1 was then added at various concentrations and contractions recorded for 4 h. Histology exploring BoNT/A1 targets, fibrosis and neuronal markers was also used. Detrusor strips from patients with BoNT/A1 secondary failure displayed a smaller sensitivity to toxin ex vivo at 3 nM compared to the other groups. Histological evaluation demonstrated the presence of cleaved Synaptosomal-Associated Protein, 25 kDa (c-SNAP25) in the detrusor from the toxin-secondary failure population, indicating some remaining in vivo sensitivity to BoNT/A1 despite the therapeutic escape. Moreover, residual c-SNAP25 did not affect parasympathetic-driven contractions observed ex vivo. This study confirms the slightly lower efficacy of BoNT/A1 in the BoNT/A1 secondary failure NDO group, suggesting that the escape from BoNT/A1 efficacy in NDO occurs at least at the parasympathetic level and could imply compensatory mechanisms for detrusor contraction.

BoNT/A in the Urinary Bladder-More to the Story than Silencing of Cholinergic Nerves

Botulinum neurotoxin (BoNT/A) is an FDA and NICE approved second-line treatment for overactive bladder (OAB) in patients either not responsive or intolerant to anti-cholinergic drugs. BoNT/A acts to weaken muscle contraction by blocking release of the neurotransmitter acetyl choline (ACh) at neuromuscular junctions. However, this biological activity does not easily explain all the observed effects in clinical and non-clinical studies. There are also conflicting reports of expression of the BoNT/A protein receptor, SV2, and intracellular target protein, SNAP-25, in the urothelium and bladder. This review presents the current evidence of BoNT/A's effect on bladder sensation, potential mechanisms by which it might exert these effects and discusses recent advances in understanding the action of BoNT in bladder tissue.

Botulinum Toxin Injection for Medically Refractory Neurogenic Bladder in Children: A Systematic Review

The objective was to evaluate the use of botulinum toxin A (BTX-A) injection in children with medically refractory neurogenic bladder. A systematic review of the literature was conducted using three databases (Medline via PubMed, Cochrane, and EMBASE). Articles evaluating BTX-A in children with neurogenic bladder were collected. The clinical and urodynamic parameters were reviewed for the safety and efficacy evaluation. Sixteen studies were selected into this study and a total of 455 children with medical refractory neurogenic bladder were evaluated. All of the patients had received traditional conservative medications such as antimuscarinics and intermittent catheterization as previous treatment. The duration of treatments ranged from 2 months to 5.7 years. Improvements in incontinence and vesicoureteral reflux were the most common clinical outcomes. The detrusor pressure, bladder capacity and bladder compliance improvement were the most common urodynamic parameters which had been reported. However, patient satisfaction with the procedure remained controversial. There was only a minimal risk of minor adverse effects. In all of the studies, BTX-A injection was well tolerated. In conclusion, BTX-A injection appears to be a safe and effective treatment in the management of medically unresponsive neurogenic bladder in children. There is currently no evidence that the use of BTX-A injection could be used as a first-line therapy for neurogenic bladder in children.

Beyond botulinum neurotoxin A for chemodenervation of the bladder

PURPOSE OF REVIEW

Botulinum neurotoxin A (BoNT/A), or Botox, is a popular option for overactive bladder (OAB) and neurogenic bladder (NGB) with or without incontinence. This review aims to discuss the clinical outcomes of BoNT in adult and pediatric bladder conditions, and introduces the potential benefit of novel, engineered neurotoxins beyond BoNT/A.

RECENT FINDINGS

A large volume of evidence supports the use of Botox for OAB (to reduce urgency, frequency and incontinence episodes), and for NGB (to decrease incontinence and improve bladder capacity and detrusor pressures). Botox is now also Food & Drug Administration (FDA)-approved for pediatric neurogenic detrusor overactivity. However, urinary retention, diminished response over time and treatment failures are prevalent issues with Botox. Modifying natural BoNTs or forming chimeric toxins are alternatives to BoNT/A that may have higher efficacy and lower side-effect profile. One example is BoNT/BMY-WW. This novel engineered toxin binds to a more commonly expressed synaptotagmin receptor, with potentially more potent paralytic effect and less capacity for systemic diffusion.

SUMMARY

Novel engineered neurotoxins may be the next frontier in OAB and NGB therapy.

Frontiers in the Clinical Applications of Botulinum Toxin A as Treatment for Neurogenic Lower Urinary Tract Dysfunction

Patients with neurogenic lower urinary tract dysfunction (NLUTD) experience urinary incontinence with or without difficult urination, which might promote recurrent urinary tract infection (UTI) and exacerbate upper urinary tract function. Nonetheless, appropriate bladder management has been shown to reduce urological complications and improve quality of life. In addition to pharmacological therapy and surgical intervention, botulinum toxin A (BoNT-A) has been widely utilized in NLUTD. The therapeutic efficacy of detrusor BoNT-A injections for neurogenic detrusor overactivity due to spinal cord injury (SCI), multiple sclerosis, or other central nervous system lesions, such as cerebrovascular accident, Parkinson disease, early dementia, and pediatric NLUTD due to myelomeningocele, has been well established, with repeated BoNT-A injections every 6 to 9 months being necessary to maintain its therapeutic effects. Urethral BoNT-A injection can decrease urethral sphincter resistance and facilitate efficient voiding in patients with NLUTD who wish to preserve self-voiding. Detrusor BoNT-A injection can also decrease the occurrence of autonomic dysreflexia in patients with SCI, even after failed augmentation enterocystoplasty, with additional benefits including reduced UTI episodes and preserved renal function with repeated injections. However, this treatment does have some side effects. Complete informed consent for BoNT-A injection therapy with full disclosure of its potential complications should therefore be obtained before this procedure is undertaken.

Bladder and Bowel Management in Dogs With Spinal Cord Injury

Spinal cord injury in companion dogs can lead to urinary and fecal incontinence or retention, depending on the severity, and localization of the lesion along the canine nervous system. The bladder and gastrointestinal dysfunction caused by lesions of the autonomic system can be difficult to recognize, interpret and are easily overlooked. Nevertheless, it is crucial to maintain a high degree of awareness of the impact of micturition and defecation disturbances on the animal's condition, welfare and on the owner. The management of these disabilities is all the more challenging that the autonomic nervous system physiology is a complex topic. In this review, we propose to briefly remind the reader the physiology of micturition and defecation in dogs. We then present the bladder and gastrointestinal clinical signs associated with sacral lesions (i.e., the L7-S3 spinal cord segments and nerves) and supra-sacral lesions (i.e., cranial to the L7 spinal cord segment), largely in the context of intervertebral disc herniation. We summarize what is known about the natural recovery of urinary and fecal continence in dogs after spinal cord injury. In particular we review the incidence of urinary tract infection after injury. We finally explore the past and recent literature describing management of urinary and fecal dysfunction in the acute and chronic phase of spinal cord injury. This comprises medical therapies but importantly a number of surgical options, some known for decades such as sacral nerve stimulation, that might spark some interest in the field of spinal cord injury in companion dogs.

Neurogenic Bladder: Epidemiology, Diagnosis, and Management

Lower urinary tract dysfunction is a common sequel of neurological disease resulting in symptoms that significantly impacts quality of life. The site of the neurological lesion and its nature influence the pattern of dysfunction. The risk for developing upper urinary tract damage and renal failure is considerably lower in patients with slowly progressive nontraumatic neurological disorders, compared with those with spinal cord injury or spina bifida. This acknowledged difference in morbidity is considered when developing appropriate management algorithms. The preliminary evaluation consists of history taking, and a bladder diary and may be supplemented by tests such as uroflowmetry, post-void residual measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the clinical indications. Incomplete bladder emptying is most often managed by intermittent catheterization, and storage dysfunction is managed by antimuscarinic medications. Intra-detrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. In select patients, reconstructive urological surgery may become necessary. An individualized, patient-tailored approach is required for the management of lower urinary tract dysfunction in this special population.

Efficacy and safety of Mirabegron as adjuvant treatment in children with refractory neurogenic bladder dysfunction

INTRODUCTION

When patients with neurogenic bladder become refractory, there are different alternatives, such as the use of β3-adreceptor agonists. The aim of the present study is to evaluate efficacy and safety of Mirabegron as adjuvant treatment.

MATERIAL AND METHODS

37 patients under 18 years of age who underwent Mirabegron were retrospectively studied. The inclusion criteria were: cases with neurogenic bladder who were under clean intermittent catheterization (CIC) programs and refractory to oral oxybutynin (Group A) and/or onabotulinumtoxinA (Group B). Once refractory neurogenic bladder was confirmed by clinical and/or urodynamic studies, Mirabegron 25 mg/day was indicated and evaluation was performed in the third month without stopping therapy. Systolic/diastolic blood pressure and transaminases were monitored. Paired t test and Pearson's chi - squared test were used.

RESULTS

Maximum cystometric capacity increased significantly by 125 mL, from 322 to 446 ml (p < 0.0001). End-filling detrusor pressure decreased significantly by 12 cm H₂O, from 44 to 31 cm H₂O (p < 0.0001). The variation in both parameters was significant in Groups A and B. The presence of detrusor overactivity increased globally from 21 to 32% after starting Mirabegron, but the intensity of contractions was reduced in 20 cm H₂O. Of the 18 patients who were incontinent before, 13 cases (72%) remained dry after initiating therapy with Mirabegron. None of the patients stated having suffered any adverse effects. Blood pressure and transaminases showed no significant difference. None of the patients discontinued treatment due to intolerance to Mirabegron (Summary Table).

DISCUSSION

In our study the treatment with Mirabegron improved significantly the clinical and urodynamic parameters. A significant increase in bladder capacity and a significant decrease in end-filling detrusor pressure were observed in both groups. The intensity of overactivity was attenuated. According to the records of the voiding diary, over 70% of the incontinent patients became dry after the administration of Mirabegron. We did not observe any adverse effects. The most important limitations of the present study are its retrospective design, the small size of the sample population and of each group, and the use of only one dose of Mirabegron.

CONCLUSIONS

Mirabegron as adjuvant treatment in children with refractory neurogenic bladder increased bladder capacity, reduced intravesical pressure and helped achieve continence in more than two thirds of the sample population. Mirabegron was safe and well tolerated by children.

Clinical Efficacy of Transurethral Resection of the Prostate Combined with Oral Anticholinergics or Botulinum Toxin - A Injection to Treat Benign Prostatic Hyperplasia with Overactive Bladder: A Case-Control Study

Introduction

Recent investigations showed that anticholinergic drugs could use for the management of storage symptoms after transurethral resection of the prostate (TURP). The use of intravesical botulinum toxin-A (BTX-A) for the management of overactive bladder is rapidly increasing. In this research, we assess the efficacy of BTX-A vs solifenacin in men suffering from bladder outlet obstruction–over active bladder (BOO-OAB) managed with TURP.

Methods

In this case–control study, 50 men with BOO-OAB randomized into two groups. The control group (A) underwent TURP and subsequently managed by solifenacin 5 mg daily, and the case group (B) underwent TURP and BTX-A injection in the bladder wall in the same session. Treatment success was the primary outcome and defined as post-injection improvement in the storage score of the International Prostate Symptom Score (IPSS) from baseline.

Results

The IPSS, post-void residual volume, frequency, incomplete emptying, nocturia and urgency subscores considerably ameliorated after 12 weeks and 36 weeks for both groups, but it was more significant in the case arm. The quality of life (QoL) scores significantly improved after the treatments in both groups. Intervention group showed significant reductions regarding urgency incontinence compared with the solifenacin group at 12th and 36th weeks.

Conclusion

BTX-A is an effective and well-tolerated treatment in patients with benign prostatic hyperplasia (BPH) who are candidates of TURP and simultaneously suffer from OAB symptoms.

Botulinum Toxin Type A Therapy: Intravesical Injection or Electromotive Drug Administration

OBJECTIVES

To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC).

MATERIALS AND METHODS

A total of 26 children with MMC (11 boys, 15 girls) who had urinary incontinence secondary to NDO were retrospectively enrolled in the study. Patients in EMDA group (n = 14), using an electrode-catheter, 10 IU/kg of BoNTA were inserted into the bladder for EMDA without anesthesia and on an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and 2 dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. Patients in injection group (n = 12) were received interavesical injection of 10 IU/kg of BoNTA via rigid cystoscope on an inpatient basis. All patients had been evaluated by a voiding diary, urodynamic study, renal, and bladder ultrasounds before, 6 months and 1 year after the treatment.

RESULTS

Six months after the treatment, 12 of 14 (85.7 %) and 8 of 12 (66.6%) patients in EMDA and injection groups respectively became completely dry between 2 consecutive clean intermittent catheterizations, which maintained in 11 of 14 (78.5%) of patients in EMDA group compared to 6 of 12 (50%) of patients in injection group, 1 year after the treatment.

CONCLUSION

Patients in both groups improved after the treatment; however improvement in EMDA group was more prominent with better sustained effects. BoNTA/EMDA is a feasible, reproducible, cost benefit, and pain free method as an outpatient basis and no need for anesthesia.

Intravesical Loss of OnabotulinumtoxinA During Endoscopic Intradetrusor Injection - A Multicenter Experience

Purpose

To evaluate intravesical loss of onabolunumtoxinA (onaBTA) during endoscopic injection into the bladder wall for treatment of neurogenic detrusor overactivity (NDO). The intraluminal loss of onaBTA cannot be determined directly, therefore we added methylene blue (MB) to reconstitute onaBTA. Subsequently we used spectrophotometry to determine the total amount of MB in the irrigation fluid, which allowed us to calculate total intraluminal loss of onaBTA.

Methods

The study population was consisted of 48 patients with NDO. The mean age was 36.6±8.9 years. Forty-two patients suffered from NDO due to spinal cord injury and 6 patients suffered from multiple sclerosis. Each patient received 200 units of onaBTA administered by 30 endoscopic injections (1 mL per injection) using a 23-G needle. The entire volume of irrigation fluid was collected and spectrophotometry was used to determine the MB concentration. The total amount of injected onaBTA, total amount of irrigation solution and the known amount of MB used during reconstitution, allowed for the determination of intravesical loss of onaBTA.

Results

Forty-five patients were included in the final analysis. The mean volume of irrigation fluid was 603.33±400.14 mL. The mean absorbance was 0.14±0.12 with the mean MB concentration 0.19±0.18 mg/L. The mean calculated loss of onaBTA was 4.14±4.11 units.

Conclusions

The endoscopic injection of onaBTA marked by MB into the bladder wall is associated with minimal intravesical loss of the agent, representing less than 3% of the administered dose of MB. This may reflect the amount of the onaBTA detected in the irrigation fluid.

Mechanism of Action of Botulinum Toxin A in Treatment of Functional Urological Disorders

Intravesical botulinum toxin (BoNT) injection is effective in reducing urgency and urinary incontinence. It temporarily inhibits the detrusor muscle contraction by blocking the release of acetylcholine (Ach) from the preganglionic and postganglionic nerves in the efferent nerves. BoNT-A also blocks ATP release from purinergic efferent nerves in the detrusor muscle. In afferent nerves, BoNT-A injection markedly reduces the urothelial ATP release and increases nitric oxide (NO) release from the urothelium. BoNT-A injection in the urethra or bladder has been developed in the past few decades as the treatment method for detrusor sphincter dyssyndergia, incontinence due to neurogenic or idiopathic detrusor overactivity, sensory disorders, including bladder hypersensitivity, overactive bladder, and interstitial cystitis/chronic pelvic pain syndrome. Although the FDA only approved BoNT-A injection treatment for neurogenic detrusor overactivity and for refractory overactive bladder, emerging clinical trials have demonstrated the benefits of BoNT-A treatment in functional urological disorders. Cautious selection of patients and urodynamic evaluation for confirmation of diagnosis are crucial to maximize the successful outcomes of BoNT-A treatment.

Effect of Botulinum Toxin A on Bladder Pain-Molecular Evidence and Animal Studies

Botulinum toxin A (BTX-A) is a powerful neurotoxin with long-lasting activity that blocks muscle contractions. In addition to effects on neuromuscular junctions, BTX-A also plays a role in sensory feedback loops, suggesting the potentiality for pain relief. Although the only approved indications for BTX-A in the bladder are neurogenic detrusor overactivity and refractory overactive bladder, BTX-A injections to treat bladder pain refractory to conventional therapies are also recommended. The mechanism of BTX-A activity in bladder pain is complex, with several hypotheses proposed in recent studies. Here we comprehensively reviewed properties of BTX-A in peripheral afferent and efferent nerves, the inhibition of nociceptive neurotransmitter release, the reduction of stretch-related visceral pain, and its anti-inflammatory effects on the bladder urothelium. Studies have also revealed possible effects of BTX-A in the human brain. However, further basic and clinical studies are warranted to provide solid evidence-based support in using BTX-A to treat bladder pain.

Long term continuation with repeated Botulinum toxin A injections in people with neurogenic detrusor overactivity after spinal cord injury

STUDY DESIGN

Retrospective chart study.

OBJECTIVES

The aim was to examine continuation of treatment of individuals with spinal cord injury including myelomeningocele and neurogenic detrusor overactivity, treated with repeated intra-detrusor Botulinum toxin A injections, and to investigate factors associated with discontinuation of treatment.

SETTING

Rigshospitalet, Denmark METHODS: This study included 128 individuals with spinal cord injury and neurogenic detrusor overactivity, who were offered repeated Botulinum toxin A injections between 2001 and 2018. Continuation rates of the treatment were estimated using Kaplan Meier analysis. A Cox proportional hazard analysis was used to investigate factors predictive of discontinuation.

RESULTS

A total of 1156 treatments were performed. The median number of treatments was six (IQR 9, range 1-51), and median follow-up was 10.6 years (IQR 8.5, range 0-16.9). All urodynamic parameters changed significantly after the first treatment (p < 0.001). The continuation group had significantly higher mean maximum bladder capacity after the first injections compared with the discontinuation group, with a mean difference between the groups of 84.5 mL (95% CI 4.7-164.2) (p = 0.038). The probability of continuing treatments after 5 years was 59% (95% CI 50.0-67.8) and 50% (95% CI 40.1-59.3) after 10 years. Individuals aged 31-50 years were more likely to continue treatment compared with those aged >50 years (95% CI 0.21‒0.79) (p = 0.008). No other factors predicted discontinuation.

CONCLUSIONS

This long-term follow-up study showed that 50% of people with spinal cord injury starting intra-detrusor Botulinum toxin A for neurogenic detrusor overactivity are still receiving injections after 10 years.

Clinical application of intravesical botulinum toxin type A for overactive bladder and interstitial cystitis

After decades of clinical and basic science research, the clinical application of botulinum toxin A (Botox) in urology has been extended to neurogenic detrusor overactivity (NDO), idiopathic detrusor overactivity, refractory overactive bladder (OAB), interstitial cystitis/bladder pain syndrome (IC/BPS), lower urinary tract symptoms, benign prostatic hyperplasia, and neurogenic or non-neurogenic lower urinary tract dysfunction in children. Botox selectively disrupts and modulates neurotransmission, suppresses detrusor overactivity, and modulates sensory function, inflammation, and glandular function. In addition to motor effects, Botox has been found to have sensory inhibitory effects and anti-inflammatory effects; therefore, it has been used to treat IC/BPS and OAB. Currently, Botox has been approved for the treatment of NDO and OAB. Recent clinical trials on Botox for the treatment of IC/BPS have reported promising therapeutic effects, including reduced bladder pain. Additionally, the therapeutic duration was found to be longer with repeated Botox injections than with a single injection. However, the use of Botox for IC/BPS has not been approved. This paper reviews the recent advances in intravesical Botox treatment for OAB and IC/BPS.

Effect of intravesical botulinum toxin injection on symptoms of autonomic dysreflexia in a patient with chronic spinal cord injury: a case report

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.

Promise and the Pharmacological Mechanism of Botulinum Toxin A in Chronic Prostatitis Syndrome

Chronic prostatitis/chronic pelvic pain syndrome (CP/ CPPS) has a negative impact on the quality of life, and its etiology still remains unknown. Although many treatment protocols have been evaluated in CP/CPPS, the outcomes have usually been disappointing. Botulinum neurotoxin A (BoNT-A), produced from Clostridium botulinum, has been widely used to lower urinary tract dysfunctions such as detrusor sphincter dyssynergia, refractory overactive bladder, interstitial cystitis/bladder pain syndromes, benign prostatic hyperplasia, and CP/ CPPS in urology. Here, we review the published evidence from animal models to clinical studies for inferring the mechanism of action underlying the therapeutic efficacy of BoNT in CP/CPPS. Animal studies demonstrated that BoNT-A, a potent inhibitor of neuroexocytosis, impacts the release of sensory neurotransmitters and inflammatory mediators. This pharmacological action of BoNT-A showed promise of relieving the pain of CP/CPPS in placebo-controlled and open-label BoNT-A and has the potential to serve as an adjunct treatment for achieving better treatment outcomes in CP/CPPS patients.

Clinical outcomes of botulinum toxin A management for neurogenic detrusor overactivity: meta-analysis

The aim of this work was to evaluate the efficacy and safety of botulinum toxin A (BTX-A) treatment in patients with neurogenic detrusor overactivity. PUBMED, EMBASE, and Cochrane Library were identified on 13 May 2017 to identify relevant randomized controlled trials. All data obtained were analyzed using Stata 12.0. Five randomized controlled trials were included in this study. Compared to placebo, the BTX-A groups had significantly fewer urinary incontinence (UI) episodes per day and per week (BTX-A with 300 U for frequency of UI per day at week 2, mean difference (MD): −1.13, 95% confidence interval (CI): −1.89 to −0.37; 200 U; BTX-A with 300 U for frequency of UI per week at week 6, MD: −11.42, 95% CI: −13.91 to −8.93; BTX-A with 200 U for frequency of UI per week at week 6, MD: −10.72, 95% CI: −13.40 to −8.04), increased in maximum cystometric capacity at week 6 (BTX-A with 300 U, MD: 154.88, 95% CI: 133.92–175.84; BTX-A with 200 U, MD: 141.30, 95% CI: 121.28–161.33), decreased maximum detrusor pressure at week 6 (BTX-A with 300 U, MD: −31.72, 95% CI: −37.69 to −25.75; BTX-A with 200 U, MD: −33.47, 95% CI: −39.20 to −27.73). For adverse effects, BTX-A was often associated with more complications and urinary tract infections (BTX-A with 300 U: relative risk (RR):1.42, 95% CI: 1.15–1.76; BTX-A with 200 U: RR: 1.42, 95% CI: 1.11–1.82). This meta-analysis suggests that treatment with BTX-A is effective and safe for neurogenic detrusor overactivity, and recommends using BTX-A with 300 U or with 200 U, as suitable dosage.

Safety of Intradetrusor OnabotulinumtoxinA (BTX-A) Injection in the Asymptomatic Patient With a Positive Urine Dip

OBJECTIVE

To evaluate differences in adverse events (AE) in asymptomatic patients with a positive urine dip (UD) at time of intradetrusor onabotulinumtoxinA (BTX-A) injection vsthose with a defined negative UD.

MATERIALS AND METHODS

All intradetrusor BTX-A injections were retrospectively reviewed at a single institution between 2016 and 2018. Exclusion criteria included an indwelling catheter, recent positive urine culture, recent antibiotic course, or absence of UD on the day of injection. A positive UD was defined using 7 different definitions with varying combinations of any level of positive blood, leukocyte esterase, or nitrite. Negative UDs were defined those excluded from the positive UD group. We compared multiple positive UD-defined groups to their respective negative UD cohorts with regards to outcomes and demographics.

RESULTS

A total of 212 patients underwent 335 cycles of BTX-A injections over a 2-year period. The average age was 65 years (range: 21-90). The majority received 100 units (73%) of BTX-A for a non-neurogenic diagnosis (73%). The overall rate of AEs, urinary tract infection, and urinary retention was 14.6%, 9%, and 3%, respectively. In all groups, the most common AE was urinary tract infection followed by urinary retention. There were no major Clavien-Dindo-defined complications. There was no statistically significant difference in the total or categorical AE rates between positive and negative UD groups using all 7 definitions of a positive UD (P = .05-1.0).

CONCLUSION

These data do not support the practice of obtaining a preprocedure UD in asymptomatic patients undergoing intradetrusor BTX-A injection for any indication; test results are unable to predict outcomes or AEs.

Central pattern generators in the brainstem and spinal cord: an overview of basic principles, similarities and differences

Central pattern generators (CPGs) are generally defined as networks of neurons capable of enabling the production of central commands, specifically controlling stereotyped, rhythmic motor behaviors. Several CPGs localized in brainstem and spinal cord areas have been shown to underlie the expression of complex behaviors such as deglutition, mastication, respiration, defecation, micturition, ejaculation, and locomotion. Their pivotal roles have clearly been demonstrated although their organization and cellular properties remain incompletely characterized. In recent years, insightful findings about CPGs have been made mainly because (1) several complementary animal models were developed; (2) these models enabled a wide variety of techniques to be used and, hence, a plethora of characteristics to be discovered; and (3) organizations, functions, and cell properties across all models and species studied thus far were generally found to be well-preserved phylogenetically. This article aims at providing an overview for non-experts of the most important findings made on CPGs in in vivo animal models, in vitro preparations from invertebrate and vertebrate species as well as in primates. Data about CPG functions, adaptation, organization, and cellular properties will be summarized with a special attention paid to the network for locomotion given its advanced level of characterization compared with some of the other CPGs. Similarities and differences between these networks will also be highlighted.

Outcome of Botulinum Toxin-A intraprostatic injection for benign prostatic hyperplasia induced lower urinary tract symptoms: A prospective multicenter study

INTRODUCTION

Our aim was to determine the factors predicting the outcome of intraprostatic injection of Botulinum Toxin-A (BTX-A) in the treatment of benign prostatic hyperplasia (BPH)-induced lower urinary tract symptoms (LUTS) and to evaluate its efficacy and safety.

METHODS

Between September 2016 and May 2018, 45 Egyptian patients, with BPH-induced LUTS were included; the indication was a failure of medical treatment, unfit, or refusing surgical intervention. Measurements of prostate size by TRUS, total PSA level before and 12 weeks after injection. IPSS, uroflow, and postvoiding residual urine (PVR) were measured before injection, 2, 4, 8 and 12 weeks postinjection. 100 U BTX-A vial was diluted with 10 mL of saline then injected into the transition zone at base and midzone of the prostate by TRUS.

RESULTS

The mean patients' age was 64.4 ± 6.6 years. Mean baseline IPSS 24.06 decreased to 18.75 at 2 weeks and progressively decreased to 16.37 at 12 weeks (P < 0.001), Q _max of 9.08 mL/s. increased to 10.44 at 2 weeks and 11.44 at 12 weeks (P < 0.001), mean prostate volume was 67.44cc; decreased to 66.06cc (P < 0.001) at 12 weeks and mean residual urine was 82.62 mL and decreased to 57.66 mL at 12 weeks.

DISCUSSION

Intraprostatic injection of BTX-A as modality treatment of LUTS/BPH significantly improve IPSS, Q _max , PVR, and decrease prostate volume. We can suspect better results with this line of treatment in patients with IPSS ≤ 22 and Q _max  ≤ 10 mL/min and prostate volume ≤ 56.5cc.

Intradetrusor injection of botulinum toxin A in children: a 10-year single centre experience

PURPOSE

We evaluated the efficacy and safety outcomes of endoscopic intradetrusor botulinum toxin A (BTA) injections for the treatment of children with neuropathic bladder (NB) and non-neuropathic bladder (NNB) with or without detrusor overactivity in a single centre with a retrospective analysis.

METHODS

For the period 2006-2015, children who received BTA in our hospital were analysed. They were divided into group 1, those with underlying NB and group 2, those without a clear neuropathic cause of symptoms (NNB). Data are given as percentages or medians (interquartile range).

RESULTS

Over the study period, 52 children (28 boys, 54%) received BTA, 28 in group 1 (54%; 17 (61%) boys) and 24 in group 2 (46%; 11 (46%) boys). Age at first injection was 11.8 (9.5-14.4) years. After initial injection, 40 (77%) reported symptomatic improvement, 17 (43%) becoming dry. There was no significant difference in response to initial injection between groups (p = 0.11). Duration of improvement after first injection was 7 (5.8-14) months. Twenty-five (48%) had further injections, of whom 3 (12%) were initial non-responders. Ongoing improvement was reported in 20 (80%), 11 (44%) of whom were dry. There was no significant difference in overall response to injections between groups (p = 0.11). Of the 11 non-responders, none (0/3) improved after subsequent injection and 3 (27%) subsequently underwent major urological surgery. Of the 40 who responded, 2 (5%) underwent major surgery.

CONCLUSION

BTA injection produced symptomatic improvement in 77% of our study population, with no significant differences in response between NB and NNB groups. In 95% of those who improved, major urinary tract procedures were avoided during the period studied. None of the initial non-responders improved after subsequent BTA injection. BTA injection is effective and reliable in the management of children with NB and NNB refractory to medical therapy.

The protection of acute spinal cord injury by subarachnoid space injection of Danshen in animal models

CONTEXT/OBJECTIVE

Following acute spinal cord injury (ASCI) in rabbits, subarachnoid space injection of Danshen was performed to protect the neurological damage. In this study, we established rabbit models of spinal cord injury using a modified Allen's method.

DESIGN

After the operation introducing the injuries, the rabbits were randomized into two different groups, control group (normal saline, NS) and Danshen, a component extracted from Chinese herb, treatment group. Each rabbit was supplied with either the drug or placebo at 0.3 ml/kg each day through subarachnoid cavity.

SETTING

Rabbit model of acute spinal cord injury were used for the response to Danshen treatment.

PARTICIPANTS

Total 48 Chinese rabbits aged four∼ five months old provided by Experimental Animal Center of Hubei Province were used for this study.

INTERVENTIONS

Danshen drug or placebo was administered via a silicon tube embedded under the spinal dura mater to administer the drugs into subarachnoid cavity.

OUTCOME MEASURES

After the treatment, damage indicators including cell apoptosis, morphological changes and oxidative damages were assessed.

RESULTS

We found out that cell apoptosis was decreased after Danshen injection as determined by downregulation of apoptosis index (AI) by TUNEL analysis as well as propidium iodide (PI) percentage by FACS analysis. In the meanwhile, we observed cells after the treatment have increased numbers of BCL-2 positive cells, this indicated the antiapoptotic gene expression is increased after Danshen treatment. When we check the oxidative damage indicators, we found superoxide dismutase (SOD) was increased and malondiadehyde (MDA) levels were decreased after the treatment.

CONCLUSION

Danshen can protect ASCI through inhibition of oxidative damage in the injured cells and thus reduce the subsequent cell apoptosis in the spinal.

Citation analysis of the most influential articles on traumatic spinal cord injury

Objective: We conducted a citation analysis in order to catalog and pay tribute to the 100 most influential clinical research articles in traumatic spinal cord injury.Design: The Thomson Reuters Web of Science was searched in a two-step process without time period limitations. Review articles were excluded. In the first stage of data extraction, a Boolean query was used to identify the top 100 most cited clinical papers on traumatic spinal cord injury. One hundred and seven keywords were manually chosen and extracted from titles and abstracts. A second Boolean query used these keywords to broaden search results. The top 100 articles from this second stage search comprised the final list.Outcome Measures: For each article, measures evaluated were number of citations, average number of citations per year, time elapsed before first citation, and time elapsed until the year in which each article received its respective highest number of citations in a one-year period.Results: 119,991 articles were found in the second stage search. The top 100 most cited articles meeting inclusion criteria were identified within the first 2,104 results. Archives of Physical Medicine and Rehabilitation was the most represented journal, with 20 of the top 100 articles. The top 100 list averaged 255 citations per article. The most highly cited article was the NASCIS 2 trial by Bracken et al., cited 1500 times, which investigated the efficacy of methylprednisolone or naloxone for spinal cord injury.Conclusion: Clinical research in traumatic spinal cord injury has grown over time, expanding to encompass rehabilitation and experimental therapies in addition to acute management trials. The list may serve as an archive and reference for further studies in this field.

Medical Management of Neurogenic Bladder for Children and Adults: A Review

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.

Female Pelvic Medicine & Reconstructive Surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 2: management of urinary incontinence in a neurogenic patient

Discussion and management of incontinence in a patient with spina bifida by four international experts followed by a literature review.

Quo Vadis Botulinum Toxin: Normative Constraints and Quality of Life for Patients With Idiopathic OAB?

Background: Idiopathic overactive bladder (iOAB), with or without urge incontinence (UI), has significant psychosocial effects on patients' quality of life (QoL). The first choice of treatment for iOAB is anticholinergics and, alternatively, the β-3-adrenoceptor agonist mirabegron. However, systemic side effects and contraindications should be considered for both medications.

Objective: We report the efficacy, safety and effects on QoL of botulinum toxin therapy (onabotulinum toxin type A, BOTOX®, Allergan) among patients with iOAB ± UI.

Patients and Methods: Between 2005 and 2013, 51 patients were treated with onabotulinum toxin A (100 units). The inclusion criteria were the presence of confirmed iOAB ± UI with previous use of anticholinergic medication. Micturition frequency, pad count, postvoid residual volume and QoL were evaluated using two validated questionnaires [the Client Satisfaction Questionnaire-8 (CSQ-8) and the King's Health Questionnaire (KHQ)]. Statistical analysis was performed with SPSS 24.0 (p < 0.05).

Results: After botulinum toxin injection, a significant improvement in iOAB ± UI symptoms was observed. The micturition frequency decreased from 10.4 ± 0.5 to 5.2 ± 0.4 micturitions per day (p = 0.026), and the pad count decreased from 3.6 ± 1.0 to 1.2 ± 0.3 pads per day (p = 0.033). Anticholinergics were not used during the administration of botulinum toxin therapy. Complications and postoperative need for intermittent self-catheterization (ISC) were not observed. Overall, 72 and 24% of patients reported being “satisfied” or “very satisfied” with the treatment. Additionally, 66% of patients would choose botulinum toxin again for the treatment of iOAB.

Conclusion: Botulinum toxin therapy is an efficient, safe, and life-improving treatment for iOAB.

Ancillary benefits of bladder chemodenervation for SCI neurogenic bladder

Study design

Case series.

Objective

Bladder chemodenervation is effective in treating neurogenic detrusor overactivity (NDO) in patients with neurogenic bladder due to spinal cord injury. Anecdotal reports also describe the improvement of non-bladder symptoms, specifically those related to autonomic dysreflexia (AD) and muscle spasticity. We conducted a study to further investigate this phenomenon.

Setting

USA, Urban Tertiary Care Center.

Methods

Twenty-one persons with SCI completed the study between March and December 2015. Mean age was 45 years (range 21-69). All were scheduled to undergo bladder chemodenervation with onabotulinumtoxinA 200 units to treat bothersome NDO refractory to oral medications. Each completed a questionnaire detailing symptoms unrelated to NDO immediately prior to the procedure, and again between 6 and 12 weeks after.

Results

All patients reported improvement in NDO symptoms following chemodenervation. Ten patients with prior symptoms of AD reported improvement in AD symptoms after injection. Seventeen patients reported skeletal muscle spasticity in the 3-month period before chemodenervation. In the follow up period, only 14 patients reported having muscle spasticity. In aggregate, 12 of 21 patients reported improvement of non-bladder symptomatology following chemodenervation.

Conclusions

Chemodenervation of the bladder in patients with SCI can provide ancillary benefits in addition to mitigation of lower urinary symptoms. The mechanism may be related to dampening the bladder's ability to initiate noxious reflex responses.

TRPs in Tox: Involvement of Transient Receptor Potential-Channels in Chemical-Induced Organ Toxicity-A Structured Review

Chemicals can exhibit significant toxic properties. While for most compounds, unspecific cell damaging processes are assumed, a plethora of chemicals exhibit characteristic odors, suggesting a more specific interaction with the human body. During the last few years, G-protein-coupled receptors and especially chemosensory ion channels of the transient receptor potential family (TRP channels) were identified as defined targets for several chemicals. In some cases, TRP channels were suggested as being causal for toxicity. Therefore, these channels have moved into the spotlight of toxicological research. In this review, we screened available literature in PubMed that deals with the role of chemical-sensing TRP channels in specific organ systems. TRPA1, TRPM and TRPV channels were identified as essential chemosensors in the nervous system, the upper and lower airways, colon, pancreas, bladder, skin, the cardiovascular system, and the eyes. Regarding TRP channel subtypes, A1, M8, and V1 were found most frequently associated with toxicity. They are followed by V4, while other TRP channels (C1, C4, M5) are only less abundantly expressed in this context. Moreover, TRPA1, M8, V1 are co-expressed in most organs. This review summarizes organ-specific toxicological roles of TRP channels.