Carolinas Medical Center, Charlotte, NC

Objective: This is a prospective study analyzing the effects of repeated botulinum toxin-A (BTA) injections on several urodynamic parameters in patients suffering from neurogenic detrusor overactivity

Methods: Between 2001 and 2006, patients with neurogenic incontinence refractory to high-dose anticholinergic medications were selected for prospective treatment. All patients emptied their bladder via intermittent catheterization and had severe detrusor hyperreflexia. Evaluation included a complete medical history, review of voiding diaries, physical examination, and cystometrogram on anticholinergic agents before BTA injection. A total of 300 units (30 mL) of BTA were injected cystoscopically at 30 detrusor muscle sites sparing the trigone. All patients were informed to taper off anticholinergic medications 1 week after BTA treatment. Cystometrograms were performed at baseline, 6 weeks following all BTA treatments and when the patients reported return of incontinence. Repeat BTA injections were allowed when cystometrogram documented return of detrusor hyperreflexia. Outcome parameters that were measured included continence level, maximum cystometric capacity, detrusor compliance, maximum detrusor pressure, and the presence of detrusor hyperreflexia. Clinical and urodynamic follow-up was obtained at 6 weeks, 24 weeks and yearly after treatment. Statistical significance was determined using the paired t test with significance set at p < .05. For non-parametric data, a Wilcoxon signed rank test was used with significance set at p < .05.

Results: Thirty-three patients (16 males, 17 females) with a mean age of 42.9 (range of 23-73 years) participated in our study. In our series 100% (33/33), 61% (20/33), 27% (9/33), 15% (5/33), and 12% (4/33) of patients received 2, 3, 4, 5, and 6 BTA treatments respectively. The median time between BTA injections was 287 days (range 133-1750 days) with a median of 294 days, 343 days, 266 days, 364 days and 251 days between first through sixth treatments respectively. Six weeks after BTA injections, 69.8% (p < .05), 88.9% (p=<.05), and 100% (p=<.05) of patients were continent following the first, second, and third injections respectively. Maximum cystometric capacity was increased following the first 3 BTA treatments by 154.64 mL (±132.39 mL), 188.73 mL (±140.93 mL) and 268.67mL (±87.76 mL) respectively (p < .05). Detrusor compliance significantly increased following the first 2 BTA treatments. Detrusor hyperreflexia resolved in 75%, 67%, 89%, 60%, 25% and 66% of patients after the first through sixth BTA injection respectively. There were no adverse events related to BTA injections.

Conclusions: In our series BTA injections appears to be a safe, minimally invasive and effective treatment option for patients with refractory neurogenic detrusor activity. Repeated BTA treatments significantly improved clinical and urodynamic outcomes that did not seem to decrease over time. Further long-term studies are needed to validate our preliminary findings.

UroToday.com Coverage of SUFU 2007

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