Comparing a transrectal ultrasound-guided with a cystoscopy-guided botulinum toxin a injection in treating detrusor external sphincter dyssynergia in spinal cord injury

The Efficacy and Safety of Intrasphincteric Botulinum Toxin-A Injections in Patients with Non-Spinal Cord Injury-Related Detrusor Sphincter Dyssynergia: A Retrospective Study

Botulinum toxin-A (BoNT-A) injections into the external urethral sphincter are an established therapeutic procedure for reducing bladder outlet obstruction in patients with detrusor sphincter dyssynergia (DSD) due to spinal cord injury (SCI). Given the paucity of data on patients with DSD but without SCI, we aimed to assess the efficacy of intrasphincteric BoNT-A injections in this cohort. For this retrospective study, we screened all patients who underwent their first intrasphincteric BoNT-A injection at our institution between 2015 and 2021. The inclusion criteria were patients aged 18 years or older with neurogenic detrusor overactivity (NDO) and DSD with a maximum detrusor pressure (Pdetmax) of >40 cmH2O, confirmed via video-urodynamic studies (VUDS). The primary outcome was a reduction in Pdetmax and detrusor overactivity leak point pressure (DOLPP) during NDO-associated urinary incontinence posttreatment. The secondary outcome was a reduction in patients relying on indwelling urinary catheters posttreatment. We included 13 eligible patients (all male, median age 31 years, with different underlying neurological disorders, except SCI). All underwent intrasphincteric BoNT-A injections with either 100 (n = 7) or 150 (n = 6) units, respectively. Pdetmax during voiding was significantly reduced posttreatment (median 105 vs. 54 cmH2O, p = 0.006), whereas DOLPP remained unchanged (i.e., median 50 cmH2O). While seven patients relied on indwelling urinary catheters pre-treatment, all were catheter-free posttreatment. Intrasphincteric BoNT-A injections in patients with non-SCI related DSD appear feasible for reducing bladder outlet obstruction to a certain degree in this cohort and subsequently for reducing the rate of indwelling catheters.

Satisfaction with Surgical Procedures and Bladder Management of Chronic Spinal Cord Injured Patients with Voiding Dysfunction Who Desire Spontaneous Voiding

We aimed to investigate treatment outcome and satisfaction with bladder outlet surgeries and bladder management in patients with spinal cord injury (SCI), voiding dysfunction, and to seek a spontaneous voiding or reflex voiding program. A total of 261 patients were included in this retrospective study. The mean age at surgical procedure was 49.2 ± 15.9 years; the median follow-up period was 11 (IQR 6, 17) years; 119 received a urethral Botox injection, 41 underwent transurethral incision of the bladder neck (TUI-BN), 77 underwent transurethral incision or resection of the prostate (TUI-P or TUR-P), and 24 had an external sphincterotomy. Satisfactory surgical outcome was reported by 80.5% of patients undergoing TUI-BN, 70.8% undergoing external sphincterotomy, 64.9% receiving TUI-P or TUR-P, and 59.7% receiving the urethral Botox injection. Persistent dysuria was the most common reason for dissatisfaction after the urethral Botox injection (73.1%) and TUI-BN (58.5%). Recurrent urinary tract infection continued in most patients after any type of surgery (all >75%). Most patients with SCI were satisfied with their initial bladder outlet operation in facilitating spontaneous voiding. However, repeat, or multiple surgical interventions were needed in 65.5% of SCI patients to achieve satisfactory voiding. A correct diagnosis is very important before every intervention and bladder management to reach the best satisfaction. VUDS is suggested before surgical procedures to ensure efficacy, even in patients with the same level of SCI.

[Efficacy of botulinum toxin A injections in the urethral sphincter in patients with difficulties to perform self-intermittent catherization]

PURPOSE

To evaluate safety and efficacy of botulinum toxin A injections in the urethral striated sphincter in patients with difficulties to perform self-intermittent catherization.

METHODS

In this prospective study, 12 patients suffering from upper motor neuron diseases (8 multiple sclerosis, 2 myelitis, 1 brain injury, 1 multi system atrophy) and with difficulties to perform self-intermittent catherization, defined by a ICDQ score>1 (Intermittent Catheterization Difficulty Questionnaire) have had injections of 100U BOTOX^® under EMG guidance in the urethral striated sphincter, for a total of 15 injections. Evaluations consisted of two questionnaires (ICDQ and PGI-A, Patient Global Improvement) 30 days after the injection.

RESULTS

30 days after the injection, ICDQ was improved with a mean decrease of the total score of 7.8 (SD=5.9, P<0,001). In the same manner, all the patients were improved with a mean PGI-A score of 2.3. In 73.3 % of cases, the PGI-A score was equal to 2 (improvement=much better), and in 20 % it was equal to 3 (improvement=a little better).

CONCLUSIONS

Botulinum toxin A injections in the urethral striated sphincter in patients with difficulties to perform self-intermittent catherization seem to safe and effective.

LEVEL OF EVIDENCE

4.

Use of botulinum toxin for voiding dysfunction

The use of botulinum toxin A (BoNT-A) has expanded across a range of lower urinary tract conditions. This review provides an overview of the current indications for BoNT-A in the lower urinary tract and critically evaluates the published evidence within each area. The classic application of BoNT-A has been in the management of refractory neurogenic detrusor overactivity (NDO) and overactive bladder (OAB). There is a large volume of high-quality evidence, including numerous randomized placebo-controlled trials, which demonstrate the efficacy of BoNT-A over a long follow-up period. The culmination of this robust evidence-base has led to onabotulinumtoxin A (onaBoNT-A) receiving regulatory approval as a second-line treatment for NDO at a dose of 200 U and OAB at dose of 100 U. Other applications for BoNT-A are used on an off-license basis and include interstitial cystitis/bladder pain syndrome (IC/BPS), benign prostatic hyperplasia (BPH), and detrusor sphincter dyssynergia (DSD). These applications are associated with a less mature evidence-base although the literature is rapidly evolving. At present, the results for painful bladder syndrome (PBS) are promising and BoNT-A injections are recommended as a fourth line option in recent international guidelines, although larger randomized study with longer follow-up are required to confirm the initial findings. As a treatment for DSD, BoNT-A injections have shown potential but only in a small number of trials of limited quality. No definite recommendation can be made based on the current evidence. Finally, the results for the treatment of BPH have been variable and recent high quality randomized controlled trials (RCTs) have suggested no benefit over placebo so at present it cannot be recommended for routine clinical practice. Future advances of BoNT-A include liposome encapsulated formulations which are being developed as an alternative to intravesical injections.

Predictors of outcome for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia in men with spinal cord injury

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

The objective of this study was to determine outcome predictors for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury.

METHODS

Botulinum toxin type A (100 Units Botox, Allergan) was injected into the external urethral sphincter using a transperineal approach under EMG guidance. Treatment was indicated if DSD was found on urodynamic testing with a post-void residual volume (PVR) above 100 ml. Urodynamic tests and cystourethrograms were performed at baseline. Dysuria (scale of 1-5) and PVR (48- h bladder diary) were evaluated at baseline and 1 month. The outcome was deemed excellent when PVR was equal to or <100 ml and 20%, and dysuria rated <3.

RESULTS

Seventy-two men with tetraplegia and 27 with paraplegia were included. There were significant reductions in PVR (from 227 to 97 ml and 63% to 27%) and dysuria (from 4.3 to 2.3). Excellent outcomes were found in 48 patients (48%), and the duration of effectiveness was 6.5 months. The need for catheterisation was decreased or eliminated in 18 patients. Vesicoureteral reflux disappeared in some patients. Poor outcome was significantly related to the presence of bladder neck dyssynergia and the absence of detrusor contraction in standard cystometry. Outcome was also related to the severity of DSD, with a strong correlation between PVR before and after injection (r=0.58). Injections were repeated in 36 patients and yielded similar outcomes in most cases (89%).

CONCLUSIONS

Detrusor contractions (odds ratio=8.6) and normal bladder neck activity (odds ratio=7.1) are strong predictors of excellent outcome.

Management and rehabilitation of neurologic patients with lower urinary tract dysfunction

Diverse lower urinary tract problems arise in neurologic disease, caused by dysfunctions of the bladder and outlet, both during urine storage and voiding. Most neurologic diseases cause some lower urinary tract dysfunction (LUTD), and the type of dysfunction is related to the location of the nervous system lesion. Clinical evaluation requires identification of risk factors for major morbidity, particularly renal dysfunction, and mechanisms underlying symptoms. A holistic approach is needed to cover influential aspects (e.g., cognitive function, mobility, and urinary tract infections) and related issues (e.g., sexual function, bowel function, and autonomic dysreflexia), requiring a multidisciplinary team. Comprehensive history and examination are supported by a bladder diary, urinalysis, and renal assessment, supplemented by urodynamic tests. The simplest classification of neurogenic LUTD describes both bladder and sphincter function, cataloging each structure as normal, overactive, or underactive. Treatment aims to protect life expectancy and improve quality of life, noting the possibility of neurologic disease progression and comorbid disorders. Conservative measures include fluid advice and assessment of suitable containment products. Urine storage can be improved with antimuscarinic medications, bladder injections with botulinum neurotoxin A, and less established methods such as nerve stimulation, intravesical instillations, and beta-3 agonist. For severe storage dysfunction, sacral neuromodulation or surgery to improve reservoir function, increase outlet resistance, or divert the urinary tract may be needed. Voiding is usually replaced by intermittent or indwelling catheterization, which has largely superseded triggered reflex voiding, bladder expression, or sphincterotomy. Treatment selection is hampered by a limited, low-quality evidence base.

Treatment of detrusor external sphincter dyssynergia using ultrasound-guided trocar catheter transurethral botulinum toxin a injection in men with spinal cord injury

OBJECTIVE

To evaluate the effects of transrectal ultrasound-guided trocar catheter transurethral botulinum toxin A (BTX-A) injection into the external urethral sphincter (EUS) for treating detrusor external sphincter dyssynergia (DESD) in men with spinal cord injury (SCI).

DESIGN

Descriptive study.

SETTING

Hospital rehabilitation department.

PARTICIPANTS

Patients (N=15; mean age, 40.5y; range, 22-64y) with suprasacral SCI with confirmed DESD determined by urodynamic study.

INTERVENTIONS

A single dose of 100U BTX-A was injected into the EUS via transrectal ultrasound-guided trocar catheter transurethral injection.

MAIN OUTCOME MEASURES

Maximal detrusor pressure, detrusor leak point pressure, maximal pressure on static urethral pressure profilometry, postvoid residual volume, and maximal flow rate.

RESULTS

After BTX-A transurethral injection, 4 (28.5%) patients showed an excellent result and 7 (46.7%) patients showed an improved result, whereas 4 (28.5%) patients experienced treatment failure. The overall success rate was 75.2%. We observed a significant decrease in static urethral pressure (P<.05) and detrusor leak point pressure after treatment (P<.05), but not in detrusor pressure. The postvoid residual volume were significantly decreased in the fourth week after treatment (P<.05).

CONCLUSIONS

Transrectal ultrasound-guided trocar catheter transurethral BTX-A injection into the EUS effectively suppresses or ameliorates DESD. A potential advantage of the method is that ultrasound guidance may not be necessary in the next injection.

[Botulinum A toxin and detrusor sphincter dyssynergia: retrospective study of 47 patients]

INTRODUCTION

To assess the efficacy of injections of botulinum toxin type A (BT-A) in the urethral sphincter for treating detrusor sphincter dyssynergia (DSD).

PATIENTS AND METHODS

Retrospective observational study of patients with confirmed urodynamic DSD (neurological and non-neurological etiologies) treated at our center from 2002 to 2010. All patients received 300 IU of DYSPORT® injected transperineally under electromyographic control. Using a visual analog scale (VAS) for mictional disorders and the measure of the post-void residual (PVR) as criteria of efficacy, results were classified as "non-satisfactory" (decrease in the VAS<2 or decrease in the PVR<20%), "intermediate" (decrease in the VAS≥2 or decrease in the PVR≥20%) or "satisfactory" (decrease in the VAS>3 or decrease in the PVR>40%).

RESULTS

Records of 47 patients (7 women and 40 men) were studied. Mean follow-up was 14.2 months. At the end of follow-up, there were 23.4% (11) of "satisfactory" results, 19.1% (9) of "intermediate" results, 42.6% (20) of "non-satisfactory" results and 14.9% (7) of patients lost for follow-up. The mean decrease in PVR was 60 mL (from an average of 212 to an average of 152 mL). No side effect was observed.

CONCLUSION

In this small series reporting the results of the injection of BT-A in the urethral sphincter for DSD, we observed 42.5% of satisfactory or intermediate results without associated side effects.