MP80-14 BOTULINUM TOXIN A: THE SHIFT TO A MINIMALLY INVASIVE MANAGEMENT OF NEUROGENIC BLADDER

Abstract

INTRODUCTION AND OBJECTIVES: The key in management of neurogenic dysfunction of the lower urinary tract is the maintenance of low storage pressures. First line treatment is anticholinergic therapy with intermittent catheterization. Once patients are refractory to anticholinergic therapy, augmentation cystoplasty (AC) has traditionally been used to create a high capacity, low-pressure reservoir. Yet, this procedure is associated with a high complication rate. The FDA approved Botulinum toxin A (BTX-A) in August of 2011 for the treatment of neurogenic detrusor over activity (NDO). Multiple studies have shown its effectiveness in neurogenic bladders with associated improvements in incontinence episodes and urodynamic parameters. Our study reviews how the advent of BTX-A has changed modern treatment of NDO. METHODS: We performed a retrospective chart review from 2003-2013 of patients seen in our Urology practice with anticholinergic refractory NDO that underwent AC or cystectomy with urinary diversion. We analyzed their charts and testing data to see how many patients would have met the indication for BTX-A. Furthermore, we compared our practice since the incorporation of BTX-A to see how our treatment of NDO has changed. RESULTS: 59 patients met inclusion criteria for our study. 34 patients underwent reconstructive surgery for NDO. The remaining 25 patients have been managed with BTX-A detrusor injections (available since August 2011). Review of the 34 patients that underwent open surgery revealed 21 (62%) would have met indication for BTX-A injections. Additionally, 30 of the 34 patients that underwent reconstructive surgery had surgery in the first 8 years of the study resulting in nearly 4 open surgeries for NDO per year. After BTX-A was introduced in 2011 the number of open reconstructive surgeries at our institution was reduced to less than 2 per year. During that same time period an average of 12 patients per year were managed with BTX-A. Of the 34 reconstructive patients, 14 (41%) had a complication with 10 (29%) requiring a repeat procedure. Conversely, only one BTX-A patient (4%) had a complication for which further intervention was not required. CONCLUSIONS: Anticholinergic refractory NDO is a complex disorder that impairs quality of life and often threatens the upper urinary tracts. Although it is not the answer for every patient, BTX-A has become an effective minimally invasive alternative to urinary reconstruction. This study demonstrates how the addition of BTX-A is evolving the care of NDO patients.