Simplified Bladder Botulinum-Toxin Delivery Technique Using Flexible Cystoscope and 10 Sites of Injection

Anatomical location and number of injection sites of intravesical OnabotulinumtoxinA for females with refractory idiopathic overactive bladder: A scoping review

AIMS

The negative impact on quality of life and the economic-related burden to the patient and the health care system associated with idiopathic overactive bladder (iOAB) is well-documented. Intradetrusor OnabotulinumtoxinA (BTN/A) injections are a well-used treatment modality for the management of overactive detrusor refractory to medical management, with well-documented efficacy and safety profiles. There is currently no best practice guideline for the administration of BTN/A for this procedure and historically the trigone of the bladder has been excluded from the injection paradigm given the risk of vesicoureteral reflux (VUR).

METHODS

A scoping review methodology was employed to assess available literature to evaluate current techniques used. There is emerging literature that the inclusion of the trigone may increase the efficacy of the procedure, while maintaining a similar adverse effect profile. Similar results could also be obtained by decreasing the number of injection sites. A scoping review was completed with systematic methodology using the Preferred Systematic Reviews and Meta Analyses extension for Scoping Review checklist. The search strategy looked to evaluate BTN/A and number of injection sites and the inclusion of the trigone in female patients with iOAB. Studies with male or neurogenic bladder only were excluded. Mixed studies were included. A specialist research librarian was engaged, with supervision from a functional urologist using a combination of MeSH and natural language terms. Two investigators independently reviewed the titles and abstracts.

RESULTS

Twelve articles were included and were published between 2005 and 2021. There was no evidence of VUR in any of the results. All but one study reported similar if not improved efficacy of trigone-inclusion. Lower number of injection sites had similar efficacy profiles to higher numbers of intradetrusor injections.

CONCLUSIONS

Further high-quality randomized control trials of trigone inclusion and reduction of injection sites are required. It is hoped that with further exploration of intraoperative methods for BTN/A injections, the development of universally accepted guidelines may optimize management and experiences for patients with iOAB.

Injection site number and outcomes of intradetrusor onabotulinumtoxinA for refractory overactive bladder syndrome: a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

The optimal number of onabotulinumtoxinA injections for the treatment of refractory overactive bladder syndrome is unknown. Our primary objective was to determine whether 10-injections sites with 100 units of onabotulinumtoxinA each were associated with less pain than 20-injections sites.

METHODS

In a single-blinded randomized trial, 100 units of onabotulinumtoxinA was administered, either as 10 × 1 ml or as 20 × 0.5 ml injections following the instillation of 30 ml of bupivacaine and 5 ml of NaHCO3 solution for 15 min. The primary outcome was procedural pain, as measured on an 11-point Numerical Pain Rating Scale (NPRS) immediately following the procedure. A power calculation estimated that 16 subjects in each arm were needed to detect a mean difference of 1 with a standard deviation of 1, on the NPRS score between the two treatment groups, with α 0.05 and power 80%. To adjust for an estimated 20% dropout rate, the final sample size was planned for 20 patients per group.

RESULTS

From October 2020 to November 2022, a total of 56 patients were approached and 40 were enrolled and randomized to two groups (21 in the 10-injections group and 19 in 20-injections group). The difference in the median pain score between the group was not statistically significant (4 [1.5-5] for 10 injections vs 3 [1-4] for 20 injections, p=0.823).

CONCLUSION

Patients' perception of pain, efficacy, and adverse events did not significantly differ between patients receiving 10 and those receiving 20 injections of 100 units of onabotulinumtoxinA.

Use of Botulinum Toxin A in the Treatment of Lower Urinary Tract Disorders: A Review of the Literature

Botulinum neurotoxin (BoNT) is used to treat a variety of ailments, and its therapeutic application in lower urinary tract disorders (LUTDs) is well studied. Robust evidence supporting the efficacy and tolerability of BoNT in the treatment of neurogenic detrusor overactivity (NDO) and non-neurogenic overactive bladder (OAB) has led to regulatory approval for these conditions. Use of BoNT in the treatment of interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and detrusor sphincter dyssynergia has demonstrated some promise, but is still evolving and off-label for these indications. Trials to date do not support the use of BoNT for benign prostatic hyperplasia. This comprehensive review outlines the mechanisms of BoNT in the treatment of LUTDs in adults and presents background and updated data examining the efficacy and adverse events associated with the use of BoNT in common urologic applications.

Efficacy and safety of two administration modes of an intra-detrusor injection of 750 units dysport® (abobotulinumtoxinA) in patients suffering from refractory neurogenic detrusor overactivity (NDO): A randomised placebo-controlled phase IIa study

AIMS

Assess the efficacy and safety of abobotulinumtoxinA (Dysport®) in adult patients with neurogenic detrusor overactivity (NDO).

METHODS

This Phase IIa, international, multicentre, double-blind, randomised, placebo controlled, pilot study enrolled 47 patients with NDO and urinary incontinence resulting from spinal cord injury (SCI) or multiple sclerosis (MS). Patients were treated with 15 intra-detrusor injections of Dysport 750 U or the equivalent placebo (n = 16 and 7) or 30 injections of Dysport 750 U or the equivalent placebo (n = 17 and 7). Primary endpoint was change from baseline in mean number of daily incontinence episode frequency (IEF) at day 84. Secondary endpoints included change from baseline in urodynamic parameters and quality of life (QOL). A safety assessment was also conducted.

RESULTS

Adjusted mean changes from baseline in IEF were -3.2 (-76%) and -1.7 (-15%) for 15 injections Dysport and placebo groups, respectively, (P = 0.1103) and -3.2 (-88%) and -2.6 (-73%) for 30 injections Dysport and placebo groups, respectively, (P = 0.0686). Statistically significant improvements in maximum cystometric capacity, maximum detrusor pressure and volume at first contraction were reported in the Dysport groups compared with placebo (P < 0.05). Improvements in QOL were reported. Three muscle weakness episodes were reported as serious adverse events in two tetraplegic and one paraplegic patient, all in the 15 injections Dysport group.

CONCLUSIONS

Both 15 and 30 injections administration modes of Dysport decreased daily IEF and resulted in significant improvements in urodynamic parameters in NDO patients with MS or SCI. Reduction to 15 injection sites did not appear to be associated with any impact on efficacy. Neurourol. Urodynam. 36:457-462, 2017. © 2016 Wiley Periodicals, Inc.

Results of intravesical botulinum toxin A in men with idiopathic overactive bladder symptoms

Objective:

The objective of this article is to determine treatment outcomes and risk factors for urinary retention in men with idiopathic overactive bladder (OAB) symptoms treated with intravesical botulinum toxin A (BTXA).

Patients and methods:

All men undergoing intravesical BTXA treatment from 2009 to 2013 at the Royal Berkshire Hospital were identified. Pre-treatment urodynamics and outcomes of treatment were determined.

Results:

A total of 35/43 men were deemed to have idiopathic OAB. Symptomatic improvement was seen in six of 13 (46%) dry OAB and 12/22 (55%) wet OAB irrespective of proven detrusor overactivity. Catheterisation rates were dose dependent with an overall rate of 16/35 (46%). Four of nine (44%) with bladder outflow obstruction required catheterisation, as did eight of 17 (47%) without. Twelve of 25 (48%) men with a Bladder Contractility Index (BCI) ⩽120 required catheterisation, as did four of 10 (40%) with a BCI >120.

Conclusion:

BTXA is a successful treatment in males with idiopathic wet and dry OAB, irrespective of detrusor overactivity. One hundred units is an appropriate dose at which to begin treatment. Surprisingly, presence of bladder outflow obstruction and weak bladder contractility did not demonstrate an increased risk for catheterisation although further study should be conducted with larger numbers of patients.

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.

The safety and efficacy of botulinum toxin-A in the management of bladder oversensitivity: a randomised double-blind placebo-controlled trial

OBJECTIVE

To assess the safety and efficacy of botulinum toxin-A (botn-A) in the management of patients with bladder oversensitivity (BO).

PATIENTS AND METHODS

Twenty-three consecutive patients with a diagnosis of BO refractory to anticholinergics were enrolled in this randomised, double blind, placebo-controlled trial. Patients were randomly allocated to receive intradetrusor injections of either botn-A (100 U Botox) or saline (placebo) via a flexible cystoscopic approach. The study was designed to have 90% power to detect a change in the maximum cystometric capacity (MCC) of 30%. It was calculated that a total cohort of 58 patients would be required. Urodynamic assessment (UDS), voiding diaries (VD) and quality of life (QoL) were assessed at baseline and at 4 and 12 weeks following intervention.

RESULTS

An interim analysis was performed and the trial halted after recruitment of 23 patients as a result of poorly perceived patient benefit. Data were analysed for 21 patients (10 botn-A; 11 placebo). In the treatment arm, there was a significant increase in MCC (mean rise 105 ml; p = 0.009). However, storage symptoms remained statistically unchanged following botn-A. Three patients in the treatment arm were required to perform clean intermittent self-catheterisation with no clinical improvement. The limitations of this trial include the small sample size and the unplanned interim analysis.

CONCLUSIONS

This is the first randomised, double blind, placebo-controlled trial examining the effects of botn-A exclusively in patients with BO. A significant increase in MCC was observed but this did not translate to clinical benefit with no change observed in the symptoms and quality of life for the majority of patients.

Trigonal injection of botulinum toxin-A does not cause vesicoureteral reflux in neurogenic patients

AIMS

We evaluated the effect of botulinum toxin type A (BTX-A) injections in the trigone on the antireflux mechanism and evaluated its short-term efficacy.

MATERIALS AND METHODS

Between April and December 2006, 21 patients (10 men and 11 women) were prospectively evaluated. All were incontinent due to refractory NDO and underwent detrusor injection of 300 units of BTX-A, including 50 units into the trigone. Baseline and postoperative evaluation after eight weeks included cystogram, urinary tract ultrasound and urodynamics.

RESULTS

At baseline, 20 patients had no vesicoureteral (VUR) and one had grade II unilateral VUR. Postoperative evaluation revealed no cases of de novo VUR and the patient with preinjection VUR had complete resolution of the reflux. Ultrasound showed 5 (23.8%) patients with hydronephrosis before BTX-A injection and only one (4.8%) at the followup evaluation (p=0.066). After treatment, 9 (42.8%) patients became dry, 11 (52.4%) were improved and one (4.8%) had no improvement. Improved patients received antimuscarinic treatment and 8 (38.1%) became dry, with a final total continence rate of 80.1%. Cystometric capacity increased from 271+/-92 to 390+/-189 ml (p=0.002), reflex volume varied from 241+/-96 to 323+/-201 ml (p=0.020) and maximum detrusor pressure reduced from 66+/-39 to 38+/-37 cm H(2)O (p<0.001).

CONCLUSIONS

Our results confirm the safety of trigone injections of BTX-A in terms of development of VUR and upper urinary tract damage. Whether they are beneficial for patients with NDO or other causes of voiding dysfunction will need further studies.

Repeated botulinum toxin injection for idiopathic overactive bladder: will chemodenervation become a long-term solution?

Botulinum toxin A (BTX-A) has emerged as a novel treatment option for idiopathic overactive bladder (OAB) refractory to antimuscarinic agents. The clinical needs of refractory OAB patients have been recently met by sacral neuromodulation and augmentation enterocystoplasty. Important features of BTX-A should include safety, efficacy, and ease of delivery during long-term repeated usage. This article reviews the role of repeated BTX-A injections in the treatment of idiopathic OAB.

Botulinum toxin for detrusor overactivity and symptoms of overactive bladder: where we are now and where we are going

Botulinum toxin (BTX) treatment for overactive bladder and detrusor overactivity is becoming increasingly recognized as an excellent therapeutic option for treating patients refractory to anticholinergic agents. Results from open-label studies have suggested that this therapy is effective in neurogenic and idiopathic detrusor overactivity, yet validating evidence from randomized, placebo-controlled trials has been unavailable. The exact mechanism of action of BTX in the bladder is controversial, although evidence suggests that apart from preventing the presynaptic release of acetylcholine from the parasympathetic innervation to the bladder, it might have an effect on sensory mechanisms. The latter hypothesis could in part explain its effect on symptoms such as urgency. The purpose of this Review is to present the results of randomized, placebo-controlled trials in which BTX treatment for detrusor overactivity was investigated. Also the evidence supporting its potential dual mechanism of action in the bladder will be considered. In addition, the various techniques of administration of BTX are discussed and avenues for further research suggested.

Safety and Tolerability of Sedation-Free Flexible Cystoscopy for Intradetrusor Botulinum Toxin-A Injection

PURPOSE

Intradetrusor botulinum toxin-A injection is a promising emerging therapy for neurogenic and idiopathic overactive bladder that is refractory to current antimuscarinic agents. We evaluated a sedation-free procedure using flexible endoscopy to perform intradetrusor botulinum toxin-A injection using a validated pain score to assess the tolerability of this technique.

MATERIALS AND METHODS

Five men and 22 women with idiopathic overactive bladder refractory to antimuscarinics were prospectively evaluated and randomized to 100 U (14) or 150 U botulinum toxin-A (13). Subjects underwent BTA injection with intravesical lidocaine using a 14Fr Olympus flexible cystoscope, which accommodates a 27 gauge flexible Olympus injection needle. Patients were evaluated with the visual analog scale to evaluate discomfort during and 15 minutes after the procedure. Procedure time was recorded.

RESULTS

In 22 female patients the mean pain score was 3.1 (range 0 to 10) during the procedure and 0.7 (range 0 to 7) 15 minutes after the procedure. In 5 male patients the mean pain score was 1.6 (range 0 to 3.5) during the procedure and 0.0 with all reporting no pain 15 minutes after the procedure. Mean procedure time was 4.5 minutes (range 4 to 6). Only 1 of the 27 patients requested sedation before any subsequent injections.

CONCLUSIONS

Sedation-free intradetrusor botulinum toxin-A injection using intravesical lidocaine and flexible endoscopy is a well tolerated and safe procedure to perform in an office setting.

Refractory overactive bladder in men: update on novel therapies

Overactive bladder (OAB) in men is an entity that may be challenging to diagnose and treat, especially in the presence of bladder outlet obstruction. The application of oral medical treatments of lower urinary tract symptoms attributed to benign prostatic hyperplasia has traditionally utilized alpha-adrenergic blockers and 5alpha-reductase inhibitors. After failure of oral medical therapies, surgical options are traditionally offered. Even after surgical options are successful, lower urinary tract symptoms that are secondary to OAB persist. These patients merit a trial of antimuscarinic drugs. Additionally, certain patients with concomitant bladder outlet obstruction who have not been surgically relieved can still merit a trial of antimuscarinic drugs without significant risk of developing urinary retention. When these oral antimuscarinic drugs fail, options still remain for treating men with refractory OAB. Successful application of various diagnostic approaches and the initiation of conservative options as well as other options, such as neuromodulation for refractory urgency and urge incontinence, can help the patient. Finally, emerging data support the use of intradetrusor injections of botulinum toxin for refractory OAB.

Improving the global management of the neurogenic bladder patient: part II. Future treatment strategies

BACKGROUND

Patients with neurogenic bladder represent a small fraction of the total overactive bladder population. As a consequence, development of new therapies in this area has largely focused on idiopathic urinary incontinence. The absence of data for patients with neurological disease has far-reaching implications, affecting reimbursement and physicians' willingness to prescribe therapies, and limiting access of potential valuable treatments to patients whose lives are significantly impaired by inadequately managed bladder symptoms.

SCOPE

The range of new therapies is increasing. Although many reviews of the overall safety, efficacy and mode of action of such treatments are available, there is limited information on how these treatments will best be used in clinical practice. We considered the current benefits and limitations of the various new licensed and unlicensed therapies and what role each would have in the future management of neurogenic urinary incontinence.

CONCLUSIONS

A wide range of new treatments have been investigated for the management of overactive bladder; few, however, have been evaluated extensively in neurogenic urinary incontinence. Further studies are required to determine the optimal dosing regimes and formulations for individual sub-populations of neurogenic bladder patients and to determine the cost-effectiveness of these interventions. With the current experience available, two treatment algorithms for a subset of patients with neurological disease have also been proposed, which suggest at which stage of management and in which patients individual therapies for neurogenic urinary incontinence could be used.

Botulinum Toxin for the Management of Bladder Dysfunction

This review highlights a recent innovation in the medical treatment of detrusor overactivity (DO). Anticholinergics are usually the gold standard to treat bladder overactivity. Adverse effects and lack of efficacy are the two main causes for considering alternative treatments. Until recently, invasive surgery (mainly bladder augmentation) was the only available treatment option for patients with intractable DO. This article considers botulinum toxin type A (BTX-A) injection as an alternative treatment to surgery in patients with DO who do not respond to anticholinergic therapy. To identify papers for inclusion in this review, we searched PubMed with the keywords 'botulinum toxin', 'overactive bladder', 'urinary incontinence' and 'neurogenic bladder' for the years 2000-5. Review articles were not included. Abstracts were cited only if they contained important new information. Experimental animal studies and articles or book chapters related to the use of botulinum toxin for other indications (such as achalasia and cervical dystonia) were analysed with regard to the mechanisms of action of botulinum toxin. From this review, it appears that BTX-A injection into the detrusor muscle is a very effective method for treating urinary incontinence secondary to neurogenic detrusor overactivity (NDO), as well as urinary incontinence due to idiopathic overactive bladder (IDO). In both conditions, the duration of effect seems to be at least 6 months. Overall success rates seem to be similar in both patient populations. For NDO, only one evidence-based medicine level 1 study is available, whereas for IDO, only evidence-based medicine level 3 or 4 studies have been published. Particularly in this latter indication, injection technique and outcome parameters vary from study to study and need to be standardised. Without randomised controlled studies aimed at comparing different techniques and dosages, it remains difficult to decide what technique is optimal for treating patients with IDO who are not willing to perform clean intermittent self-catheterisation (CISC). Therefore, studies that compare different dosages and techniques with the risk of needing CISC in regard to the duration of the effect are mandatory. As more studies of repeated injections have been published, it appears that, at least at medium follow-up, the toxin remains as effective as after the first injection, and there is no evidence of change in bladder compliance or detrusor fibrosis. However, long-term observational studies are necessary to assess these last points. Finally, the commonly reported dose appears to be well tolerated, since few adverse effects have been reported.