Onabotulinumtoxin A for Treating Overactive/Poor Compliant Bladders in Children and Adolescents with Neurogenic Bladder Secondary to Myelomeningocele

Abstract

This retrospective study was performed to verify the efficacy and safety of Onabotulinumtoxin A (BTX-A) in treating children with neurogenic bladder (NB) secondary to myelomeningocele (MMC) with detrusor overactivity/low compliance. From January 2002 to June 2011, 47 patients out of 68 with neuropathic bladder were selected (22 females, 25 males, age range 5–17 years; mean age 10.7 years at first injection). They presented overactive/poor compliant neurogenic bladders on clean intermittent catheterization, and were resistant or non compliant to pharmacological therapy. Ten patients presented second to fourth grade concomitant monolateral/bilateral vesicoureteral reflux (VUR). All patients were incontinent despite catheterization. In the majority of patients Botulinum-A toxin was administered under general/local anesthesia by the injection of 200 IU of toxin, without exceeding the dosage of 12IU/kg body weight, diluted in 20 cc of saline solution in 20 sites, except in the periureteral areas. Follow-up included clinical and ultrasound examination, urodynamics performed at 6, 12 and 24 weeks, and annually thereafter. Seven patients remained stable, 21 patients required a second injection after 6–9 months and 19 a third injection. VUR was corrected, when necessary, in the same session after the BT-A injection, by 1–3 cc of subureteral Deflux®. Urodynamic parameters considered were leak point pressure (LPP), leak point volume (LPV) and specific volume at 20 cm H2O pressure. The results were analyzed using the Wilcoxon test. All patients experienced a significant 66.45% average increase of LPV (Wilcoxon paired rank test = 7169 × 10 −10) and a significant 118.57% average increase of SC 20 (Wilcoxon paired rank test = 2.466 × 10 −12). The difference between preoperative and postoperative LPP resulted not significant (Wilcoxon paired rank test = 0.8858) No patient presented severe systemic complications; 38/47 patients presented slight hematuria for 2–3 days. Two patients had postoperative urinary tract infection. All patients were hospitalized for 24 h with catheterization. Thirty-eight out of 47 patients achieved dryness between CIC; nine patients improved their incontinence but still need pads. Ten patients have resumed anticholinergic agents. Our results suggest that the use of BTX-A is safe and effective in patients with MMC with a positive effect on their dryness and quality of life.

Outcomes of intra‐detrusor injections of botulinum toxin in patients with spina bifida: A systematic review

“…There were no perioperative urinary tract infections in six studies . Three studies reported post‐injections urinary tract infections, rates ranging from 4% to 29% . No other significant complications were noted, especially no muscular weakness or fatigue.…”

“…Following evaluation of the full text of the remaining 15 papers, three more studies were excluded as they were overlapping series. The remaining 12 articles, published between 2002 and 2015, were included in this systematic review (n = 261 patients) and fully analyzed …”

“…The total number of injections ranged from one to six per patient . Mean interval between injections varied from 6 months to 16 months .…”

Urological Results after Fetal Myelomeningocele Repair in Pre-MOMS Trial Patients at the Children's Hospital of Philadelphia

“…The use of clean intermittent catheterization and anticholinergics [3], urethral dilation [4] and overnight catheter drainage [5] - and recently the use of onabotulinumtoxinA [6,7,8,9] - have all been introduced to optimize bladder storage and/or bladder emptying. The identification of an infant with detrusor sphincter dyssynergy is critical, since the developing bladder and kidneys are most vulnerable during the first several years of life.…”

Video-urodynamic Improvement of Trigonal BTX-A Injection for Patients with Poor Bladder Compliance Secondary to Spinal Cord Injury

“…Botulinum toxin A (Botox ® , Allergan, Irvine, Calif.) is recommended as the second-line treatment for those patients who have an inadequate response to or are intolerant to anticholinergic medication [4,5]. In the past ten years, intradetrusor injection of BTX-A was performed while avoiding the trigone to prevent VUR.…”