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Chow PM, Trump T, Goldman HB. Outcomes of sequential third-line therapies in patients with refractory overactive bladder. Int J Urol 2024. [PMID: 38693892 DOI: 10.1111/iju.15463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/01/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Sacral neuromodulation (SNM) and onabotulinumtoxinA (BoNTA) injection are third-line therapies for overactive bladder (OAB). Although the efficacy of each third-line treatment has been well established in clinical trials, there is far less information about performing one third-line therapy after the other. Our aim is thus to investigate the outcomes of post-SNM BoNTA and post-BoNTA SNM as "second" third-line treatments. METHODS We retrospectively reviewed all OAB patients who had both SNM and BoNTA between 2013 and 2022. The primary endpoint was the response rates (>50% improvements) of the second third-line treatments. Secondary endpoints were the proportion of the patients who achieved total dry, the duration of treatments of patients who had significant responses, and risk factors that are associated with treatment response or duration of treatments. RESULTS A total of 172 patients had two third-line therapies. There were 104 patients who had post-SNM BoNTA and 68 patients who had post-BoNTA SNM. In the post-SNM BoNTA group, 62.5% (65/104) had significant responses after BoNTA treatment. In the post-BoNTA SNM group, 61.8% (44/68) had significant responses after SNM treatment. The proportions of patients who became dry were 21.2% and 23.5%, respectively. In the post-SNM BoNTA group, spinal pathology is associated with a lower probability of a significant response (48.9% vs. 73.7%, p-value = 0.0105). CONCLUSIONS BoNTA or SNM remains a viable option for refractory OAB after patients fail from one another. Spinal pathology is associated with a poorer response of post-SNM BoNTA.
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Affiliation(s)
- Po-Ming Chow
- Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
- National Taiwan University Hospital Hsin-Chu Branch, Zhubei City, Taiwan
| | - Tyler Trump
- Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Howard B Goldman
- Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Nitti V, Haag-Molkenteller C, Kennelly M, Chancellor M, Jenkins B, Schurch B. Treatment of neurogenic detrusor overactivity and overactive bladder with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32377. [PMID: 37499088 PMCID: PMC10374192 DOI: 10.1097/md.0000000000032377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
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.
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Affiliation(s)
- Victor Nitti
- Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Urology and Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Michael Kennelly
- Urology, Urogynecology, Female Pelvic Medicine and Reconstructive Surgery, Atrium Health, Charlotte, NC, USA
| | | | | | - Brigitte Schurch
- Neurourology Unit Department of Neurosciences, Centre Hospitalier Universitaire Vaudois, Université de Lausanne, Lausanne, Switzerland
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Solifenacin Treatment After Intradetrusor Injections With Botulinum Toxin in Patients With Neurogenic Detrusor Overactivity. Am J Ther 2022; 29:e507-e511. [PMID: 35731251 DOI: 10.1097/mjt.0000000000001531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neurogenic detrusor overactivity (NDO) is treated with antimuscarinics as first-line treatment. For patients with contraindications or unresponsive, intradetrusor injections with botulinum toxin (BoNT) are a safe and effective but expensive option. STUDY QUESTION Our study evaluated whether adding solifenacin to the intradetrusor injection of BoNT A could boost the effect of BoNT in patients with NDO due to multiple sclerosis or spinal cord injury refractory to antimuscarinics alone and/or lead to less frequent injections. STUDY DESIGN We performed a prospective study on 49 patients assigned alternatively to group A, undergoing BoNT injections, and group B, adding solifenacin. MEASURES AND OUTCOMES We gathered data from urodynamic testing and questionnaire assessments before and 3 months after injections and reinjections. We analyzed 39 patients who achieved total continence and a minimum 24-month follow-up period. RESULTS After treatment, both groups had statistically significant improvement of overactive bladder questionnaire (OABq) score, post void residue (PVR), and peak detrusor pressure (Pdet). Reinjection was needed after a mean 8.2 months for group A and 11.7 months for group B. We analyzed the improvement rate of parameters compared between the 2 groups-group B had greater OABq score improvement (A = 17.25 ± 5.07, B = 20.44 ± 4.51, P = 0.0485), as well as for maximum bladder capacity (A = 11.05 ± 7.04 mL, B = 19.39 ± 6.43 mL, P = 0.0005); differences in Pdet change (A = 51.72 ± 16.57 cmH 2 O, B = 50.80 ± 16.33 cmH 2 O, P = 0.7635) and PVR change (A = 17.67 ± 12.63 mL, B = 12.30 ± 8.32 mL, P = 0.126) were not statistically significant. CONCLUSIONS Our study shows that adding solifenacin improves patient satisfaction, increases the interval between reinjections, thus lowering costs, and improves maximum bladder capacity. Pdet was kept in safe ranges, but no statistically significant conclusions could be drawn regarding Pdet and PVR decrease related to adding solifenacin. Although our study is limited by the small series of patients and lack of randomization and placebo control group, the BoNT-solifenacin combination could be considered in NDO in terms of cost-effectiveness. Further studies would be beneficial.
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Video-Urodynamic Characteristics and Predictors of Switching from Botulinum Neurotoxin a Injection to Augmentation Enterocystoplasty in Spinal Cord Injury Patients. Toxins (Basel) 2022; 14:toxins14010047. [PMID: 35051024 PMCID: PMC8777902 DOI: 10.3390/toxins14010047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 01/27/2023] Open
Abstract
Botulinum neurotoxin type A (BoNT-A) injection and augmentation enterocystoplasty (AE) are alternative and effective management strategies for neurogenic detrusor overactivity (NDO) refractory to pharmacotherapy. A great majority of patients with spinal cord injury (SCI) may, however, prefer BoNT-A injections to AE, due to the less invasive characteristics. In this study we evaluated the influence of various video-urodynamic study (VUDS) parameters in SCI patients who continuously received repeat BoNT-A detrusor injections or switched to AE to improve their bladder conditions. We compared the changes in the urodynamic parameters before and after each mode of treatment. In this retrospective study, all SCI patients with refractory NDO who had received at least one BoNT-A injection were enrolled. VUDS was performed before and after both BoNT-A injection and AE. All of the urodynamic parameters of the storage and micturition-including the bladder capacity of every sensation, maximal flow rate (Qmax), post-voiding residual volume, detrusor pressure at Qmax, and bladder contractility index-were recorded. A total of 126 patients, including 46 women and 80 men, with a mean age of 41.8 ± 13.1 years, were recruited for this study. All of the patients receiving either BoNT-A injection or AE had a statistically significant increase of bladder capacity at every time-point during filling and a decrease in detrusor pressure at Qmax during voiding. Patients who switched from BoNT-A to AE had greater improvements in their urodynamic parameters when compared with those who continued with BoNT-A injections. Accordingly, SCI patients receiving BoNT-A injections but experiencing few improvements in their urodynamic parameters should consider switching to AE to achieve a better storage function and bladder capacity.
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Satisfaction with Detrusor OnabotulinumtoxinA Injections and Conversion to Other Bladder Management in Patients with Chronic Spinal Cord Injury. Toxins (Basel) 2022; 14:toxins14010035. [PMID: 35051012 PMCID: PMC8779816 DOI: 10.3390/toxins14010035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022] Open
Abstract
This study investigated the satisfaction with continued detrusor Botox injections for urinary incontinence and conversion to other surgical procedures and bladder management procedures for neurogenic detrusor overactivity (NDO) in patients with chronic spinal cord injury (SCI). A total of 223 patients with chronic SCI underwent detrusor Botox 200U for urodynamically confirmed NDO and urinary incontinence. After initial detrusor Botox injections, patients opted to either continue detrusor Botox injections every six to nine months and on clean intermittent catheterization (CIC), switch to other bladder management procedures, or receive surgical procedures to improve their urinary incontinence, correct emergent complications, or have better voiding conditions without CIC. Urinary incontinence improvement rates and satisfaction with bladder management were assessed and compared between different subgroups, urodynamic parameters, and bladder management procedures. Finally, a total of 154 male and 69 female patients were included, among whom 56 (25.1%), 81 (36.3%), 51 (22.9%), and 35 (15.7%) showed a marked, moderate, mild, and no reduction in urinary incontinence, respectively. However, only 48.4% of the patients continued detrusor Botox injections over the mean follow-up period of seven years. Patients with cervical or thoracic SCI had fair incontinence improvement rates. The presence of high detrusor pressure and higher-grade bladder outlet resistance also predicted a decrease in incontinence. Although more than 50% of the patients switched to other bladder management procedures or received surgical treatment, 69.1% expressed satisfaction with their current status. This large cohort of patients with chronic SCI who received initial detrusor Botox injections revealed that only 48.4% continued with Botox injections. Those who received surgical procedures due to urological complications or demanded change in bladder management could achieve high satisfaction rates.
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Giuliano F, Joussain C, Denys P. Long Term Effectiveness and Safety of Intracavernosal Botulinum Toxin A as an Add-on Therapy to Phosphosdiesterase Type 5 Inhibitors or Prostaglandin E1 Injections for Erectile Dysfunction. J Sex Med 2022; 19:83-89. [PMID: 34937674 DOI: 10.1016/j.jsxm.2021.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Some evidence suggests that intracavernosal botulinum toxin A (BTX-A IC) injections administered in addition to phosphodiesterase type 5 inhibitors (PDE5-Is) or prostaglandin E1 intracavernosal injections (PGE1 ICI) could effectively treat erectile dysfunction (ED) in non-responders, or insufficient responders to these pharmacologic treatments. AIM To determine the long-term effectiveness and safety of combined treatment involving a single injection of BTX-A IC as an add on therapy to PDE5-Is or PGE1-ICI for the treatment of ED of different etiologies. METHODS A retrospective, uncontrolled, single center study was conducted. Data from 123 consecutive patients with ED who were insufficient responders to PDE5-Is or PGE1-ICI and who received onabotulinumtoxinA 100 U, abobotulinumtoxinA 250 U or 500 U IC as an add on to their current pharmacologic treatment were analyzed. All analyses were exploratory. Qualitative data were compared using the Fisher's exact test. Univariate and multivariate analysis were performed using logistic regression with Odds Ratios (OR). Only variables with P < .05 in the univariate analysis were selected for multivariate analysis. RESULTS The minimally clinically important difference (relative to baseline severity of ED) in the International Index of Erectile Function-Erectile function domain (IIEF-EF) score was achieved in 50% of patients at 34 (27-42) days and in 41% at 5.9 (3.9 - 8.1) months following BTX-A IC in combination with PDE5-Is or PGE1 ICI. The severity of ED influenced response to BTX-A IC according to the multivariate analysis (OR = 0.3, IC(95%]) = (0.16 - 0.56). Neither being post prostatectomy nor the type of BTX-A affected the response. Effectiveness tended to decrease more over time with abobotulinumtoxinA 250 U than 500 U.The only side-effects were mild penile pain on injection (n = 1) and mild penile pain for 3 days following injection (n = 1); no systemic effects were reported. CLINICAL IMPLICATIONS BTX-A IC (all types) administered as an add on to registered pharmacologic treatments improved erectile function for at least 6 months in 41% of patients with ED of varying etiologies, and was safe. STRENGTHS & LIMITATIONS A relatively large cohort of patients with ED was included, with a long follow-up period, however the study was retrospective, and uncontrolled. CONCLUSION This study provides preliminary evidence that BTX-A IC administered as an add-on therapy for ED that is insufficiently responsive to standard therapy is effective for at least 6 months, and is safe. Randomized clinical trials are now needed to fully confirm these results.
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Affiliation(s)
- Francois Giuliano
- Neuro-Uro-Andrology R.Poincare academic hospital, Garches, France
- Faculty of Medicine, U1179 Inserm / Versailles Saint Quentin University, Montigny le Bretonneux, Paris Saclay, France
| | - Charles Joussain
- Neuro-Uro-Andrology R.Poincare academic hospital, Garches, France
- Faculty of Medicine, U1179 Inserm / Versailles Saint Quentin University, Montigny le Bretonneux, Paris Saclay, France
| | - Pierre Denys
- Neuro-Uro-Andrology R.Poincare academic hospital, Garches, France
- Faculty of Medicine, U1179 Inserm / Versailles Saint Quentin University, Montigny le Bretonneux, Paris Saclay, France
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Tiburtius C, Böthig R, Kowald B, Hirschfeld S, Thietje R. Can clinical and urodynamic parameters predict the occurrence of neutralizing antibodies in therapy failure of intradetrusor onabotulinumtoxin A injections in patients with spinal cord injury? BMC Urol 2020; 20:113. [PMID: 32741365 PMCID: PMC7397590 DOI: 10.1186/s12894-020-00683-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/23/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The aim of the study was to clarify whether clinical and/or urodynamic parameters could be used to infer the probability of neutralizing antibody (NAb) formation as a possible cause of therapy failure (non-response, NR) in patients with neurogenic detrusor overactivity (NDO) due to acquired spinal cord injury/disease (SCI/D) treated with intradetrusor botulinum neurotoxin A (BoNT-A) injections. METHODS A retrospective chart review was performed of all patients with SCI/D who underwent both intradetrusor onabotulinumtoxin A injections and the determination of neutralizing antibodies against BoNT-A between January 1, 2002, and December 31, 2018. NR was defined as urodynamically confirmed persistent or reappearing NDO. RESULTS A total of 2700 BoNT-A injections in 414 patients were ascertained. In 69 patients with primary NR after the first BoNT-A injection (n = 6) or with secondary NR after more than one BoNT-A injection (n = 63), an antibody analysis was performed. Antibody examination showed 36 (52.2%) negative, 5 (7.2%) borderline and 14 (each 20.3%) each of positive and highly positive values. Subgroup analysis indicated a correlation between NAb formation and the duration of BoNT-A therapy (p = 0.015), the mean number of BoNT-A injections (p = 0.011) and the time interval between BoNT-A applications (< 7 months, p = 0.022). Urodynamic data analysis indicate significant differences with cut-off values of MCC (< 225 ml, p = 0.038) and MDP (> 45 cmH2O, p = 0.040). However, in the regression analysis models, the predictive value for the occurrence of NAb was too low (MCC: ROC AUC 0.62, MDP: ROC AUC 0.52) to distinguish with sufficient certainty between NAb-positive and NAb-negative NR patients. CONCLUSIONS Despite significant correlations, clinical and urodynamic parameters are only partially suitable for predicting antibody formation against BoNT-A.
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Affiliation(s)
- Christian Tiburtius
- Centre for Spinal Injuries, Department Neuro-Urology, BG Trauma Hospital Hamburg, Bergedorfer Str. 10 Germany, 21033, Hamburg, Germany.
| | - Ralf Böthig
- Centre for Spinal Injuries, Department Neuro-Urology, BG Trauma Hospital Hamburg, Bergedorfer Str. 10 Germany, 21033, Hamburg, Germany
| | - Birgitt Kowald
- Biomechanical Laboratory, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Sven Hirschfeld
- Centre for Spinal Injuries, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Roland Thietje
- Centre for Spinal Injuries, BG Trauma Hospital Hamburg, Hamburg, Germany
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Are 200 units of onabotulinumtoxin A sufficient for the suppression of neurogenic detrusor overactivity in individuals with established 300-unit botulinum toxin treatment? A retrospective cohort study. World J Urol 2020; 39:543-547. [PMID: 32322995 DOI: 10.1007/s00345-020-03211-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To investigate the effects of 200-unit onabotulinumtoxin A detrusor injections on neurogenic detrusor overactivity (NDO) in patients who have previously been treated with 300-unit injections. SETTING Tertiary urologic referral center in Switzerland. METHODS The patient database was screened for patients with NDO as a result of chronic (≥ 12 months) spinal cord injury (SCI), who had been treated with 300- followed by 200-unit onabotulinumtoxin A detrusor injections. Patient characteristics, bladder management data and concurrent bladder medication as well as urodynamic data were collected. The percent changes in the urodynamic parameters from the 300- to the 200-unit treatment phase were calculated to test for non-inferiority of the 200-unit treatment. RESULTS The data of 61 individuals with a mean age of 44 ± 15 years (range 18-73 years) and a mean 13.2 ± 9.5 years (range 2-43 years) since SCI were analyzed. The 200-unit treatment was not inferior regarding the urodynamic parameters compared to the 300-unit treatment. Furthermore, the proportion of patients with urinary incontinence was similar for both doses. There was no significant difference in the number of daily bladder evacuations (p = 0.13) or used incontinence pads (p = 0.43) between the two dosage phases. Moreover, there was no significant (p = 0.19) increase in the use of concurrent NDO medication (antimuscarinics or mirabegron) during the 200-unit treatment. CONCLUSIONS The treatment of NDO with 200 units of onabotulinumtoxin A was not inferior to a 300-unit treatment regarding urodynamic parameters in patients with chronic SCI.
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Onabotulinumtoxina Re-Injection for Refractory Detrusor Overactivity Using 3-4 Injection Sites: Results of a Pilot Study. Urology 2020; 137:50-54. [DOI: 10.1016/j.urology.2019.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/21/2022]
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Dimitrova R, James L, Liu C, Orejudos A, Yushmanova I, Brin MF. Safety of OnabotulinumtoxinA with Concomitant Antithrombotic Therapy in Patients with Muscle Spasticity: A Retrospective Pooled Analysis of Randomized Double-Blind Studies. CNS Drugs 2020; 34:433-445. [PMID: 32170665 PMCID: PMC7125063 DOI: 10.1007/s40263-020-00709-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND OnabotulinumtoxinA is approved as a treatment across multiple indications. For the treatment of spasticity, onabotulinumtoxinA is injected directly into affected muscles. Intramuscular injections may result in local bleeding and related complications, especially in patients receiving anticoagulant therapy. Despite anticoagulants being commonly used, there is limited information in the medical literature regarding the safety of intramuscular medications in patients receiving oral anticoagulants. This retrospective analysis included pooled safety data from Allergan-sponsored studies evaluating onabotulinumtoxinA for the treatment of patients with muscle spasticity. OBJECTIVE The objective of this study was to determine the risk of bleeding complications in patients with post-stroke spasticity receiving antithrombotic therapy and intramuscular onabotulinumtoxinA. METHODS We conducted a retrospective analysis of pooled safety data from 16 randomized, double-blind, placebo-controlled Allergan-sponsored studies of onabotulinumtoxinA for the treatment of post-stroke upper or lower limb muscle spasticity, including adult patients with at least moderate upper or lower limb spasticity and receiving at least one dose of the study drug. Bleeding-related adverse events starting within 4 weeks of study treatment were assessed. The incidence rates of bleeding complications were compared for patients receiving classes of antithrombotic therapy vs those not receiving antithrombotic therapy and for those receiving onabotulinumtoxinA vs placebo (with or without antithrombotic therapy). RESULTS Of 1877 patients, 1182 received antithrombotic therapy. The overall incidence of bleeding complications was < 2%. In those receiving any antithrombotic therapy, the incidence of bleeding was 1.0% vs 1.4% (no antithrombotic therapy); after onabotulinumtoxinA, it was 0.9% for those receiving antithrombotic therapy vs 1.4% (no antithrombotic therapy), and for placebo 1.2% vs 1.4%, respectively. Subgroup results were similar. CONCLUSIONS No apparent increased risk of bleeding complications was observed following administration of onabotulinumtoxinA to patients receiving antithrombotic therapy. Nonetheless, patient education and careful observation of the injection site in patients receiving antithrombotic therapy remains warranted.
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Affiliation(s)
| | - Lynn James
- Allergan plc, 2525 Dupont Drive; T1-1B, Irvine, CA 92623-9534 USA
| | | | | | - Irina Yushmanova
- Allergan plc, 2525 Dupont Drive; T1-1B, Irvine, CA 92623-9534 USA
| | - Mitchell F. Brin
- Allergan plc, 2525 Dupont Drive; T1-1B, Irvine, CA 92623-9534 USA ,grid.266093.80000 0001 0668 7243University of California, Irvine, CA USA
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Dominique I, Tremblais B, Charvier K, Nogueira MCS, Paparel P, Journel NM, Ruffion A. How long does the effect of botulinum toxin in neurogenic patients last? An analysis of the subset of "good responders". Low Urin Tract Symptoms 2019; 12:155-161. [PMID: 31856406 DOI: 10.1111/luts.12297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/14/2019] [Accepted: 10/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to assess long-term efficacity of botulinum neurotoxin A (BoNT-A) in the treatment of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS This was a retrospective monocentric study in a reference center. We included patients who received intradetrusor BoNT-A for NDO between 2001 and 2015. The focus of our analysis was on patients defined as "good responders" (≥ 5 injections of intradetrusor BoNT-A over a period of ≥5 years). The primary endpoint was the evaluation of long-term efficacity of BoNT-A. Recurrent NDO was monitored by the use of cystomanometry before the first injection and 1 month after each injection. The secondary objective was to assess the influence of NDO's etiology, age, and sex on the long-term efficacity of the treatment. RESULTS A total of 107 patients were included (60.7% with spinal cord injury [SCI] and 36.4% with multiple sclerosis [MS]). The mean follow-up period was 83.7 months (66; 120). The mean number of injections was of 8.9 (5; 21). A total of 67.3% (n = 72) of patients were still controlled by treatment at the end of their follow-up period. Therapeutic failure occurred in 30 patients (26.1%) with a cessation of BoNT-A treatment at 76 months on average (median: 82.5 months). There was no significant impact of age (P = .42), sex (P = .35), or NDO's etiology (MS vs SCI; P = .54) on long-term efficacy of BoNT-A treatment. CONCLUSION The results of our study indicate that the application of BoNT-A seems to be an effective and durable treatment in a large number of neurogenic patients after more than 10 years of follow-up. However, botulinum toxin tolerance occurred in approximately 25% of patients.
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Affiliation(s)
- Inès Dominique
- Lyon Sud-Pierre Bénite Teaching Hospital, Pierre-Bénite, France
| | | | | | | | | | | | - Alain Ruffion
- Lyon Sud-Pierre Bénite Teaching Hospital, Pierre-Bénite, France
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The Botulinum Treatment of Neurogenic Detrusor Overactivity: The Double-Face of the Neurotoxin. Toxins (Basel) 2019; 11:toxins11110614. [PMID: 31652991 PMCID: PMC6891665 DOI: 10.3390/toxins11110614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/18/2019] [Accepted: 10/20/2019] [Indexed: 12/13/2022] Open
Abstract
Botulinum neurotoxin (BoNT) can counteract the highly frequent involuntary muscle contractions and the uncontrolled micturition events that characterize the neurogenic detrusor overactivity (NDO) due to supra-sacral spinal cord lesions. The ability of the toxin to block the neurotransmitter vesicular release causes the reduction of contractions and improves the compliance of the muscle and the bladder filling. BoNT is the second-choice treatment for NDO once the anti-muscarinic drugs have lost their effects. However, the toxin shows a time-dependent efficacy reduction up to a complete loss of activity. The cellular mechanisms responsible for BoNT effects exhaustion are not yet completely defined. Similarly, also the sites of its action are still under identification. A growing amount of data suggest that BoNT, beyond the effects on the efferent terminals, would act on the sensory system recently described in the bladder mucosa. The specimens from NDO patients no longer responding to BoNT treatment displayed a significant increase of the afferent terminals, likely excitatory, and signs of a chronic neurogenic inflammation in the mucosa. In summary, beyond the undoubted benefits in ameliorating the NDO symptomatology, BoNT treatment might bring to alterations in the bladder sensory system able to shorten its own effectiveness.
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Peyronnet B, Gamé X, Vurture G, Nitti VW, Brucker BM. Botulinum Toxin Use in Neurourology. Rev Urol 2018; 20:84-93. [PMID: 30288145 DOI: 10.3903/riu0792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The use of botulinum toxin A (BTX-A) has revolutionized the treatment of neurogenic lower urinary tract dysfunction (NLUTD) over the past three decades. Initially, it was used as a sphincteric injection for detrusor sphincter dyssynergia but now is used mostly as intradetrusor injection to treat neurogenic detrusor overactivity (NDO). Its use is supported by high-level-of-evidence studies and it has become the gold-standard treatment for patients with NDO refractory to anticholinergics. Several novelties have emerged in the use of BTX-A in neurourology over the past few years. Although onabotulinumtoxinA (BOTOX®, Allergan, Inc., Irvine, CA) remains the only BTX-A for which use is supported by large, multicenter, randomized, controlled trials (RCT), and is therefore the only one to be licensed in the United States and Europe, a second BTX-A, abobotulinumtoxinA (Dysport®, Ipsen Biopharmaceuticals, Basking Ridge, NJ), is also supported by high-level-of-evidence studies. Other innovations in the use of BTX-A in neurourology during the past few years include the BTX switch (from abobotulinumtoxinA to onabotulinumtoxinA or the opposite) as a rescue option for primary or secondary failures of intradetrusor BTX-A injection and refinements in intradetrusor injection techniques (number of injection sites, injection into the trigone). There is also a growing interest in long-term failure of BTX-A for NDO and their management, and a possible new indication for urethral sphincter injections.
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Affiliation(s)
- Benoit Peyronnet
- Department of Urology, University of Rennes Rennes, France.,Department of Urology, New York University New York, NY
| | - Xavier Gamé
- Department of Urology, University of Toulouse Toulouse, France
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Prakash NS, Lopategui DM, Gomez C. Changes in Management of Poorly Compliant Bladder in Botulinum Toxin A Era. Curr Urol Rep 2018; 18:64. [PMID: 28689244 DOI: 10.1007/s11934-017-0707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bladder compliance is a measure of distensibility. Maladies such as myelodysplasia, myelomeningocele, spinal cord injury, multiple sclerosis and obstructive uropathy are known to decrease bladder compliance. Decrease in bladder compliance is a characteristic of neurogenic bladders. The pathophysiology of bladder compliance is complex but ultimately leads to high pressure during filling and storage phases. These high pressures lead to renal impairment, incontinence, and recurrent urinary tract infections. This review presents management of poorly compliant bladders with onabotulinumtoxinA.
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Affiliation(s)
| | - Diana M Lopategui
- Department of Urology, Miller School of Medicine University of Miami, Miami, FL, USA
| | - Christopher Gomez
- Department of Urology, Miller School of Medicine University of Miami, Miami, FL, USA.
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Aisen CM, Chung DE. Intravesical Botulinum Toxin for Neurogenic Bladder—Can We Just Irrigate the Bladder with Botulinumtoxin? CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0446-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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16
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González-Ruiz de León C, Pérez-Haro ML, Jalón-Monzón A, García-Rodríguez J. [Female urinary incontinence: An update]. Semergen 2017; 43:578-584. [PMID: 28318909 DOI: 10.1016/j.semerg.2017.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/01/2017] [Accepted: 01/10/2017] [Indexed: 10/19/2022]
Abstract
The urinary incontinence is a highly prevalent symptom in the adult female population. It has important psychosocial and economic connotations, and affects the quality of life of these patients. As it is an under-diagnosed problem due to patients not always consulting for it, it is very important to keep this in mind and to provide an opportunistic screening from Primary Health Care. It is difficult to determine the costs of this, but it is estimated to be the 2% of the health budget. Because of all of this, it is very important to know how to make a correct diagnose of this condition, to determine the different types of incontinence, possible causes, and treatments available. The purpose of this review is to show the different diagnostic and therapeutic tools available, to show the Primary Health Care role in this condition, and when to refer to specialist care.
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Affiliation(s)
| | - M L Pérez-Haro
- Servicio de Urología, Hospital Universitario Central de Asturias, Oviedo, España
| | - A Jalón-Monzón
- Servicio de Urología, Hospital Universitario Central de Asturias, Oviedo, España
| | - J García-Rodríguez
- Servicio de Urología, Hospital Universitario Central de Asturias, Oviedo, España
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Koschorke M, Leitner L, Sadri H, Knüpfer SC, Mehnert U, Kessler TM. Intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity incontinence: do we need urodynamic investigation for outcome assessment? BJU Int 2017; 120:848-854. [DOI: 10.1111/bju.13976] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Miriam Koschorke
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
- Department of Urology; University Hospital Pedro Ernesto; Rio de Janeiro Brazil
| | - Lorenz Leitner
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
- Department of Urology; University Hospital Basel; Basel Switzerland
| | - Helen Sadri
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
| | - Stephanie C. Knüpfer
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
| | - Ulrich Mehnert
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
| | - Thomas M. Kessler
- Neuro-Urology; Spinal Cord Injury Center and Research; University of Zürich; Balgrist University Hospital; Zürich Switzerland
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Kaviani A, Khavari R. Disease-Specific Outcomes of Botulinum Toxin Injections for Neurogenic Detrusor Overactivity. Urol Clin North Am 2017; 44:463-474. [PMID: 28716326 PMCID: PMC5604875 DOI: 10.1016/j.ucl.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Intradetrusor injection of botulinum toxin A (BTX-A) is an effective option for managing patients with neurogenic detrusor overactivity (NDO) who do not respond to or tolerate oral pharmacologic agents. There is level I evidence that intradetrusor injection of onabotulinumtoxinA for refractory NDO in patients with multiple sclerosis and spinal cord injury is associated with a significantly greater achievement of goals and improved performance in urodynamic studies than placebo. Pilot studies or small case series support BTX-A for NDO in patients with Parkinson's disease and cerebrovascular accident. BTX-A seems to be effective in children with myelomeningocele. However, no adult data exists.
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Affiliation(s)
- Aaron Kaviani
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX 77030, USA
| | - Rose Khavari
- Department of Urology, Houston Methodist Hospital, 6560 Fannin Street, Suite 2100, Houston, TX 77030, USA.
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Ni J, Wang X, Cao N, Si J, Gu B. Is repeat Botulinum Toxin A injection valuable for neurogenic detrusor overactivity-A systematic review and meta-analysis. Neurourol Urodyn 2017; 37:542-553. [PMID: 28745818 DOI: 10.1002/nau.23354] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/31/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Jianshu Ni
- Department of Urology; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai People's Republic of China
| | - Xiaohu Wang
- Department of Urology; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai People's Republic of China
| | - Nailong Cao
- Department of Urology; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai People's Republic of China
| | - Jiemin Si
- Department of Urology; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai People's Republic of China
| | - Baojun Gu
- Department of Urology; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai People's Republic of China
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Onem K, Bayrak O, Demirtas A, Coskun B, Dincer M, Kocak I, Onur R. Efficacy and safety of onabotulinumtoxinA injection in patients with refractory overactive bladder: First multicentric study in Turkish population. Neurourol Urodyn 2017; 37:263-268. [PMID: 28407394 DOI: 10.1002/nau.23286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/19/2017] [Indexed: 11/07/2022]
Abstract
AIMS To investigate the efficacy and safety of intradetrusor onabotulinumtoxinA (onaBoNT-A) injection in patients with overactive bladder (OAB) refractory to antimuscarinic treatment. METHODS A total of 80 patients with OAB symptoms were enrolled in this prospective multicenter study and received 100 U intradetrusor onaBoNT-A injection.The changes from baseline in the frequency of voiding, urge urinary incontinence (UI) and urge episodes, mean and maximum bladder capacities, uroflowmetry, post-void residual urine volume (PVR), quality of life score, and treatment benefit scale score were assessed. The need for a second injection,and treatment-related adverse events were also examined postoperatively. RESULTS OnaBoNT-A injection significantly decreased the UI episodes(P = 0.0001), the mean voiding frequency (P = 0.0001), and the urgency episodes (P = 0.0001) in the third month compared to baseline. Similarly, the mean bladder capacity, and maximal bladder capacity were increased (P < 0,05). The quality of life scores improved by 57.1% compared to the pre-treatment rate (P = 0,0001). No significant change was observed in the PVR or maximum flow rate. Urinary retention developed in 3 (3.75%) patients and urinary infection and transient hematuria were observed in five patients (6.25%) each. The UI episodes, voiding frequency and urgency episodes were significantly lower at the 9th month than at baseline (all P = 0.0001). Overall 67% of the patients continued to experience benefits from the injection. Sixteen patients (20%) required a second injection in the third month. Eight patients were lost to follow-up at the last visit in the 9th month, and 34 of the remaining 56 patients required a second injection at the 9th month. Cumulatively, 50 (63%) patients needed re-injections. CONCLUSIONS Our results demonstrated that the onaBoNT-A injection produced significant improvement in all OAB symptoms with a low incidence of treatment related adverse events.
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Affiliation(s)
- Kadir Onem
- Faculty of Medicine, Department of Urology, University of Ondokuz Mayis, Samsun, Turkey
| | - Omer Bayrak
- Faculty of Medicine, Department of Urology, University of Gaziantep, Gaziantep, Turkey
| | - Abdullah Demirtas
- Faculty of Medicine, Department of Urology, University of Erciyes, Kayseri, Turkey
| | - Burhan Coskun
- Faculty of Medicine, Department of Urology, University of Uludag, Bursa, Turkey
| | - Murat Dincer
- Faculty of Medicine, Department of Urology, University of Health Sciences, Bagcilar Branch, Istanbul, Turkey
| | - Izzet Kocak
- Faculty of Medicine, Department of Urology, University of Adnan Menderes, Aydin, Turkey
| | - Rahmi Onur
- Faculty of Medicine, Department of Urology, University of Marmara, Istanbul, Turkey
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Hoffman D, Ferrante KL. Urinary Tract Infection Rates and Mechanisms After OnabotulinumtoxinA Bladder Injection: a Review. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0404-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bayrak O, Sadioglu E, Sen H, Dogan K, Erturhan S, Seckiner I. Efficacy of onabotulinum toxin A injection in pediatric patients with non-neurogenic detrusor overactivity. Neurourol Urodyn 2017; 36:2078-2082. [DOI: 10.1002/nau.23240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 12/28/2016] [Accepted: 01/24/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Omer Bayrak
- Department of Urology; University of Gaziantep; Gaziantep Turkey
| | - Erkan Sadioglu
- Department of Urology; University of Gaziantep; Gaziantep Turkey
| | - Haluk Sen
- Department of Urology; University of Gaziantep; Gaziantep Turkey
| | - Kazim Dogan
- Department of Urology; University of Gaziantep; Gaziantep Turkey
| | - Sakip Erturhan
- Department of Urology; University of Gaziantep; Gaziantep Turkey
| | - Ilker Seckiner
- Department of Urology; University of Gaziantep; Gaziantep Turkey
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OnabotulinumtoxinA for Overactive Bladder and Urinary Incontinence. J Urol 2016; 197:S224-S225. [PMID: 28010976 DOI: 10.1016/j.juro.2016.11.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 11/21/2022]
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Tracey JM, Stoffel JT. Secondary and tertiary treatments for multiple sclerosis patients with urinary symptoms. Investig Clin Urol 2016; 57:377-383. [PMID: 27847911 PMCID: PMC5109793 DOI: 10.4111/icu.2016.57.6.377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/09/2016] [Indexed: 01/23/2023] Open
Abstract
Multiple sclerosis patients with refractory urinary symptoms after treatment with behavioral therapy and medications still have treatment options. Prior to starting treatments, baseline symptoms should be assessed and treatment goals thoroughly discussed. Catheterization, botulinum toxin, and reconstructive surgery all can play a role in improving both safety and quality of life for these patients. Newer modalities, such as neuromodulation, may also have an increasing role in the future as more data develop regarding efficacy. Risks need to be weighed against any perceived benefit and disease status before more aggressive therapy is initiated.
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Affiliation(s)
- James M Tracey
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - John T Stoffel
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Smith JA. This Month in Adult Urology. J Urol 2016. [DOI: 10.1016/j.juro.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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