Long-term real life efficacy of onabotulinum toxin A for the treatment of neurogenic detrusor overactivity in a population using intermittent self-catheterization

Abstract

Intradetrusor injection of onabotulinum toxin A (IDIBA) is the third-line therapy for patients with neurogenic detrusor overactivity (NDO). There is few evidence of long-term efficacy but no study assessed reasons for failure or abandonment of IDIBA and CISC (clean intermittent self-catheterization) combined strategy. We aimed to assess its long-term outcome in NDO management, and analyze failure and discontinuation. We retrospectively reviewed medical records of patients admitted in our neurourology department between 2001 and 2013. Inclusion criteria were: age > 18, NDO secondary to spinal cord injury (SCI), multiple sclerosis (MS) or myelomeningocele, NDO management associating IDIBA and CISC, failure of a 3-month combination of two anticholinergics and a 3 year follow-up minimum. Patients with bladder surgery were excluded. Clinical, urodynamic and radiologic data before the first injection, six weeks after the first and last injections were analyzed. Primary endpoints were failure (defined by clinical or urodynamic criteria) and abandonment rates at 3, 5 and 7 years. We secondarily analyzed risk factors for failure and discontinuation. During selected period, 292 patients were included, with mean age 40 ± 13.6 years, 58.2% males and mean duration of NDO 10.8 years. Etiologies for NDO were SCI (84.6%), MS (10.6%) and myelomeningocele (3.4%). After 3 years, 219 patients (80.6%) were still treated, 128 (71.1%) and 58 (60.8%) after 5 and 7 years respectively. Failure rates were 12.6%, 22.2% and 28.9% after 3, 5 and 7 years respectively. Discontinuation rate after 7 years was 11.3%. Reasons were: difficulties related to CISC (3.8%), personal convenience (2.7%), pseudobotulism (2.4%), pregnancy (1.03%), pain (1.03%) and prostatic cancer (0.3%). Clinical, urodynamic and radiologic severity criteria of NDO before IDIBA initiation were major risk factors for treatment failure. This is the first long-term follow-up study of patients with NDO treated by IDIBA and CISC. Less than two third of patients were still treated after 7 years. The main reason for abandonment was difficulties with CISC. Choosing the best time for IDIBA initiation could improve the management of these patients. Further studies are needed to determine the impact of initiation timing, and prior oral anti-muscarinics use on long-term efficiency.