Which Preparation of Botulinum Toxin A Should Be Used, Where Should It Be Injected, and How Should Its Efficacy Be Assessed?

Abstract

In 1988, Dyktra et al. described the use of botulinum toxin (BoNT) in themanagement of lower urinary tract symptoms (LUTS) by treating detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury [1]. Subsequently, Schurch and coworkers reported success with the use of BoNT in the management of neurogenic detrusor overactivity (NDO) [2]. There are seven serotypes of BoNT, from BoNT type A (BoNTA) to type G. Themost commonly used serotype in the management of LUTS is BoNTA; occasionally, BoNT type B has been used in cases resistant to BoNTA. A recent systematic review reported 37 articles that concerned outcomes for adults with NDO, 28 articles for idiopathic detrusor overactivity (IDO), 8 articles for DSD, 10 articles for bladder outlet obstruction, and 9 articles for painful bladder syndrome/interstitial cystitis [3]. In this comprehensive review, all articles were included except those reporting <10 cases. From this review it can be seen that besides applications in NDO and IDO, the evidence for the other potential applications for BoNT is still at an investigational stage. It is also prudent to note that BoNT therapy is currently used without approval of the licensing authorities for all urologic applications except NDO (applications either granted or in progress). A number of proprietary BoNTA preparations are commercially available. They are produced by very different isolation, extraction, purification, and formulation processes. These proprietary BoNTA preparations are marketed under different trade names: Botox (Allergan Pharmaceuticals, Irvine, CA, USA), Dysport (Ipsen Biopharm Ltd., Slough, UK), Xeomin (Merz Pharmaceuticals UK Ltd., Herts, UK), Prosigne (Lanzhou Biologic Products, Lanzhou, China), and PurTox (Mentor Corp., Madison, WI, USA). They all contain completely different fragments of BoNTA being isolated. Although all BoNTA products have the same