Effects of Botulinum Toxin Type A in the Bladder Wall of Children With Neurogenic Bladder Dysfunction: A Comparison of Histological Features Before and After Injections

Abstract

Conclusion: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair. Postoperative urethral fistula formation was more likely in children who received caudal epidural. Editorial CommentThis is a prospective randomized controlled trial comparing penile block with a caudal block for children undergoing hypospadias repair. They had 27 children in each group. Their patient population was older than most contemporary series with ages ranging from 4-12 years. Penile measurements were taken before and 10 minutes after the block in both groups. Breakthrough fentanyl was given for patients with increase in mean arterial pressure (MAP) or heart rate greater than 15% from baseline. Visual analogue scores were measured at various intervals over the course of 4 days. The authors found that pain scores were significantly worse in the group receiving the caudal block. In addition, changes in MAP and heart rate were significantly higher in the caudal group. This resulted in increased use of narcotics for the caudal block group. Five patients developed urethrocutaneous fistula. All of these patients were in the caudal group. The authors speculated that this may be due to the increase in penile volume that was seen in the caudal group but not observed in the penile block group.Both penile and caudal blocks are used routinely for hypospadias repair. There is very limited data comparing the two in a prospective fashion as these authors have done. The decision of which type of regional anesthesia to perform is often based on the preference of the surgeon or anesthesiologist involved and over time a particular type of block simply becomes part of the culture of each individual institution. The authors only included patients with midshaft to distal hypospadias. Their fistula rate of nearly 20% seems high for a primary repair in such patients. It is interesting that all of these fistulas occurred in the caudal group. More prospective studies with greater numbers of patients would be helpful to improve our care for a common procedure. Dr. M. Chad Wallis Division of Pediatric UrologyUniversity of Utah Salt Lake City, Utah, USA E-mail: chad.wallis@hsc.utah.edu Effects of botulinum toxin type a in the bladder wall of children with neurogenic bladder dysfunction: a comparison of histological features before and after injections Pascali MP, Mosiello G, Boldrini R, Salsano ML, Castelli E, De Gennaro M Department of Nephro-Urology, Bambino Gesù Pediatric and Research Hospital, Piazza S. Onofrio 4, Rome, Italy J Urol. 2011; 185(6 Suppl): 2552-7 Purpose: Botulinum toxin type A has gained popularity in urology. Most reported studies have been in adults at urology centers and most have addressed long-term safety. Since botulinum toxin type A treatment for neurogenic bladder dysfunction requires repeat injections, verifying that such treatment does not induce fibrosis in children seems essential.

The management of overactive bladder symptom complex

“…Efficacy of selected anticholinergic drugs compared with placebo in overactive bladder: meta-analysis results 8 prescriber.co.uk sidered very safe and histological studies have failed to show any long-term adverse effects on the bladder such as tissue fibrosis. 16 In the largest randomised trial to date, Botox 100 units significantly decreased the number of urinary incontinence episodes per day at 12 weeks, with a mean decrease from baseline of 2.95 and 1.03 in the Botox and placebo groups respectively (p<0.001). Significant reductions from baseline compared with placebo in all other OAB symptoms were also observed at week 12 following Botox treatment.…”

Long‐term outcomes and risks factors for failure of intradetrusor onabotulinumtoxin A injections for the treatment of refractory neurogenic detrusor overactivity

“…Indeed, less bladder fibrosis has been described following Botox® injections. 17 However, some studies reported no difference in terms of inflammation, fibrosis or edema before and after one or several Botox® injections. 18 They neither noticed any histological differences between responders and non-responders to Botox®.…”

Pharmacotherapy in Pediatric Neurogenic Bladder Intravesical Botulinum Toxin Type A

“…At present, there are no comparative studies published that analyze this aspect of injection. There is, however, evidence of an intention to simplify the injection technique, for instance with the use of different devices, such as endoinjector needle systems, with curved needles that can reach difficult endovesical sites, like lateral walls or bladder roof and trabecular region [20, 21]. …”

“…Botulinum toxin, in blocking the release of acetylcholine, diminishes muscular contraction and the nerve growth factor. It also inhibits release of inflammatory mediators which induce fibrosis [20, 21]. …”