Intradetrusor Botulinum Toxin Injections Research Articles

Значение видео-уродинамического исследования в выборе метода лечения детей с нейрогенными дисфункциями мочевого пузыря

Video urodynamics is the standard for assessment of the lower urinary tract in children with neurogenic urinary disorders aiming to provide more information about the condition of the lower urinary tract v. retrograde urethrocystography. Video urodynamics parameters are used as possible indicators for choosing various surgical treatment options, however, all work is focused on adult patients, and data for the pediatric cohort were not available as yet. The purpose of this research was the evaluation of the role of video urodynamics and retrograde urethrocystography in the selection of effective conservative and surgical treatment of neurogenic urinary disorders in children. Materials and methods used: 112 patients aged 1,8 to 18 y/o with neurogenic urinary disorders were included in the study, of whom 101 were those who had been proven effectively treated with conservative M-cholinoblockers or had successfully undergone minimally invasive surgery as follows: intradetrusor injection of botulinum toxin (n=21), transurethral correction of VUR (n=17), simultaneous execution of two of these interventions (n=22). Based on the results of video urodynamic and cystographic examination of these patients with the CHAID technique, the classification trees were built in order to evaluate the effective treatment (conservative/surgical). Results: the median age of patients was 9,0 years [7,8-12,0]. The first classification tree containing the parameter “presence of VUR according to the results of retrograde cystography.” The sensitivity of the obtained model for the effectiveness of surgical treatment was 83,3% v. 73,2% for conservative treatment. The accuracy was 79,2%. The ROC-AUC value was 0,783. The second classification tree contained the maximum Pves value according to the results of the video urodynamics, presence of hyperactivity, presence of VUR. The sensitivity of the obtained model for the effectiveness of surgical treatment was 93,3% v. 97,6% for conservative treatment. The accuracy was 95,0%. The ROC-AUC value was 0,972. Comparison of ROC-AUC values by the Delong test revealed statistically significant differences between these binary classification metrics (p<0.001). Conclusion: the parameters of video urodynamics have greater diagnostic accuracy in effective prediction of both conservative and surgical treatment methods compared to the retrograde urethrocystography.

Intradetrusor botox injection and augmentation cystoplasty trends among spina bifida patients at US freestanding children's hospitals

Intra-detrusor botulinum toxin (Botox) injection is a minimally invasive alternative to augmentation cystoplasty in patients with refractory neurogenic bladder. Botox was first used for neurogenic bladder children two decades ago. However, there are no existing guidelines on indications or use among patients with spina bifida. Furthermore, there are little data regarding its use relative to bladder augmentation and patient volume on a national scale. We sought to investigate the contemporary trends of intra-detrusor Botox injection and augment cystoplasty in free-standing children's hospitals. We queried the Pediatric Health Information System database to identify spina bifida patients from 2016 to 2019 who underwent intra-detrusor Botox injection and augment cystoplasty based on CPT and ICD-10 codes. Total spina bifida population under care in the free-standing children's hospitals was estimated by all inpatient and ambulatory surgery encounters as denominators to calculate frequency by time for both intra-detrusor Botox injections and augmentation cystoplasty. In total, we included 1924 intra-detrusor Botox injections and 842 augmentation cystoplasties. 1413 (51.1%) patients were female. Median age at surgery was 10.0 (interquartile range 6.98-13.5) years. There was a significant increase in intra-detrusor Botox injection frequency (p<0.001). While there was an overall decreasing, but not significant, trend for augmentation cystoplasty, there was a significant increase in this procedure during the summer months compared to the rest of the year (p<0.001, Figure1). Sensitivity analysis using only first intra-detrusor Botox injection per patient demonstrated similarly significant increasing trend. Use of intra-detrusor Botox injection for the management of neurogenic bladder has significantly increased among patients with spina bifida while augmentation cystoplasty has slightly decreased, but not significantly. Over time, practice patterns for the treatments of neurogenic bladder among spina bifida children have favored minimally invasive Botox injections while augmentation cystoplasty use has not significantly changed.

The Efficacy and Safety of Intradetrusor Botulinum Toxin Injection in Urinary Incontinence in Geriatric Patients

The Efficacy and Safety of Intradetrusor Botulinum Toxin Injection in Urinary Incontinence in Geriatric Patients

Percutaneous Tibial Nerve Stimulation in the Treatment of Refractory Idiopathic Overactive Bladder Syndrome: A Retrospective Cohort Study.

Overactive bladder (OAB) is a syndrome defined as urinary urgency, accompanied by increased frequency and nocturia with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology. The standard therapies are anticholinergic agents, selective beta-3 adrenoreceptor agonists, or intradetrusor injections of botulinum toxin (BTX-A). For patients with contraindications for BTX-A or drug therapies, percutaneous tibial nerve stimulation (PTNS) may be used. PTNS shows fewer side effects than anticholinergic drugs and costs less than BTX-A. The primary outcome of this study was to assess the efficacy of PTNS in women with refractory OAB. Women with refractory OAB undergoing PTNS at our tertiary referral center from 2017 to 2019 were included. The validated German Female Pelvic Floor Questionnaire and a micturition protocol were filled out before and after PTNS. PTNS was applied weekly for 12 weeks. Improvements in OAB symptoms were seen in daily micturition frequency, urgency, and urgency incontinence from pre- to post-PTNS (p < 0.006). Impairments to quality of daily life were significantly (p < 0.0002) less severe after PTNS. There was a significant reduction in daytime voiding frequency from a median of nine to five (p < 0.0001). Substantial reductions in OAB symptoms, daily micturition frequency, urgency, and urgency incontinence were found in patients with refractory OAB after PTNS.

Bladder augmentation in the era of botulinum toxin: Indications and results

To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection. We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context. We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%). In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team. Weak.

Long-term beneficial effects of mirabegron in pediatric patients with therapy-refractory neurogenic lower urinary tract dysfunction

Neurogenic lower urinary tract dysfunction (NLUTD) in children can cause renal failure and urinary incontinence if not treated sufficiently. Antimuscarinics (AM) and intradetrusor botulinum toxin injections (BoNT-A) with clean intermittent catheterization (CIC) are widely used treatment options for children with NLUTD. However, a considerable number will become refractory to these treatment options. This study aimed to evaluate the efficacy and long-term outcomes of mirabegron in children with NLUTD as an add-on and as a stand-alone treatment. Patients under 18 years of age with NLUTD who were refractory to AM and/or BoNT-A and were treated with mirabegron 50mg were retrospectively studied. Mirabegron was either used as monotherapy or in addition to AM and/or BoNT-A. Video-urodynamic studies (VUDSs) were performed before and after treatment with mirabegron. Changes in video-urodynamic parameters, the need for other NLUTD therapy during follow-up, patient-reported side effects, and urinary incontinence were outcomes of interest. A total of 34 patients with NLUTD were included. All patients were on CIC and the median age was 13.1 years (IQR 15.9-10.3). Median follow-up was 31.4 months (IQR 57.4-11.4). Bladder compliance improved by 89.9%, from 14.9 to 28.3ml/cm H2O (p-value<0.001). Maximum cystometric capacity, end-filling detrusor pressure, volume at first detrusor overactivity, vesicoureteral reflux, and urinary incontinence significantly improved after mirabegron. The add-on therapy group showed more significant improvements in video-urodynamic outcomes compared to the monotherapy group. The median time of requiring other NLUTD therapy was 25.5 months (IQR 39.8-14.8). None of the included patients reported side effects. Mirabegron is an effective treatment for children with therapy-refractory NLUTD with an average efficacy of 2 years after which additional therapy is required. Despite the retrospective character of this study, our results confirm the beneficial effect of mirabegron in children with therapy-refractory NLUTD, in particular when mirabegron is used as add-on therapy in those with low-compliance bladders.

Ultrasound-assisted intravesical botulinum toxin A delivery attenuates acetic acid-induced bladder hyperactivity in rats.

Background: Intradetrusor injection of botulinum toxin A (BTX-A) is an effective treatment for overactive bladder (OAB). However, the occurrence of adverse events associated with BTX-A injection therapy hinders its acceptance among patients and its clinical promotion. Intravesical instillation of BTX-A offers a promising alternative to injection therapy for treating OAB. Nevertheless, due to the presence of the bladder permeability barrier (BPB) and the high molecular weight of BTX-A, direct instillation is unable to penetrate the bladder urothelium. Purpose: This study aims to investigate the safety and feasibility of ultrasound-assisted intravesical delivery of BTX-A and its potential benefits in a rat model of bladder hyperactivity induced by acetic acid instillation. Methods: Hengli BTX-A and microbubbles (MB) were mixed and prepared as a novel complex. The size distribution and zeta potentials of the complex were measured. On day 1, rats' bladders were instilled with 1mL of saline, BTX-A (20U in 1mL), MB, or MB-BTX-A (20U in 1mL) complex with or without ultrasound (US) exposure (1MHz, 1.5W/cm2, 50% duty cycle, sonication for 10s with a 10-s pause for a total of 10min). The instillations were maintained for 30min. After 7days, cystometry was performed by filling the bladder with saline and 0.3% acetic acid (AA). Bladders were collected, weighed, and processed for immunoblotting, enzyme-linked immunosorbent assay (ELISA), histologic, and immunofluorescence analyses. Expression and distribution of SNAP-25 and SNAP-23 were assessed using Western blot and immunofluorescence. Calcitonin gene-related peptide (CGRP) in the bladder was detected using ELISA. Results: Intercontraction intervals (ICI) decreased by 72.99%, 76.16%, and 73.96% in rats pretreated with saline, BTX-A, and US + MB, respectively. However, rats treated with US + MB + BTX-A showed a significantly reduced response to AA instillation (57.31% decrease in ICI) without affecting amplitude, baseline pressure, or threshold pressure. Rats treated with US + MB + BTX-A exhibited increased cleavage of SNAP-25 and CGRP expression compared to the control group. Conclusion: Ultrasound-assisted intravesical delivery of BTX-A, with the assistance of MB cavitation, led to cleavage of SNAP-25, inhibition of calcitonin gene-related peptide release from afferent nerve terminals, and amelioration of acetic acid-induced bladder hyperactivity. These results support ultrasound-assisted intravesical delivery as an efficient non-injection method for administering BTX-A.

Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism

The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism. A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent). Fifteen children (ten boys, five girls, mean age of 7.6years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients. Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.

This Month in Pediatric Urology.

You have accessJournal of UrologyThis Month in Pediatric Urology1 Apr 2023This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003184AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Naturally occurring substances being adapted to medicinal use is part of the lore of biomedical science. Penicillin was once just a term referring to secretion from the mold, Penicillium notatum. In 1928, Alexander Fleming fortuitously recognized the presence and importance of the bactericidal band around the mold that had contaminated a culture plate of Staphylococcus aureus.1 This finding along with the work being done on sulfonamides ushered in the antibiotic era. In a similar fashion, botulinum toxin found its way into therapeutic use. Botulism is an uncommon but potentially fatal condition resulting typically from the ingestion of botulinum toxin produced by Clostridium botulinum bacteria.2 One of the characteristic symptoms is weakness of the eye muscles with drooping eyelids. Among infants, it creates so-called floppy baby syndrome and led to a recommendation of avoiding feeding honey to infants under age 1 year due to it acting as a reservoir of C botulinum spores. This early clinical presentation in eye muscles and muscle weakness led to interest in using the purified toxin (onabotulinumtoxin A) to treat strabismus.3 Success there led to applications elsewhere including the treatment of dysfunctional bladders and has led to calls for wider use in pediatric urology.4 Franco et al (page 774) in a multi-institutional study report on the long-term safety and tolerance of repeated cystoscopic intradetrusor injections of botulinum toxin in the treatment of children with neurogenic bladder overactivity.5 They found that the injections were well tolerated and there were few serious treatment-related adverse events; notably the development of urinary tract infection was similar to the rate seen prior to injection. These findings confirm what many pediatric urologists have already known when using botulinum toxin in this manner but may serve as an important step in adding it formally to the available treatment options. The data may help garner regulatory approval, thereby broadening acceptance with third-party payers, and allow wider access and use. REFERENCES 1. . New light on the history of penicillin. Med Hist. 1982; 26(1):1-24. Crossref, Medline, Google Scholar 2. . Clostridium botulinum and the clinical laboratorian: a detailed review of botulism, including biological warfare ramifications of botulinum toxin. Arch Pathol Lab Med. 2004; 128(6):653-662. Crossref, Medline, Google Scholar 3. . Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology. 1980; 87(10):1044-1049. Crossref, Medline, Google Scholar 4. . It is time to liberalize the administration of botulinum toxin in the pediatric urology clinic!. J Urol. 2022; 208(3):534-535. Link, Google Scholar 5. . Long-term safety and tolerability of repeated treatments with onabotulinumtoxinA in children with neurogenic detrusor overactivity. J Urol. 2023; 209(4):774-784. Link, Google Scholar © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue 4April 2023Page: 655-655 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Julian Wan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Efficacy of botulinum toxin in a patient with neurogenic detrusor overactivity

Neurogenic detrusor overactivity is a dangerin terms of the formation of vesicoureteralreflux, pyelonephritis, and chronic kidney disease. The standard treatment for neurogenic detrusor overactivity is intermittent catheterization of the bladder in combination with M-cholinoblockers, which is not always sufficient. In the article, the authors briefly outlined the physiological basis of intradetrusor injections of botulinum toxin in neurogenic detrusor overactivity in patients with myelodysplasia who underwent surgery for spinal hernias, tumors of the spinal canal, as well as patients with spinal trauma. The technology of intradetrusor injections of botulinum toxin is shown, possible complications are described. The effectiveness of intradetrusor injections of botulinum toxin is shown by a specific clinical example — a description of the medical history of a child who has a history of surgical treatment for a spinal hernia in the newborn period. After the operation, neurogenic detrusor overactivity was revealed, insensitive to treatment with M-cholinoblockers. Complications were vesicoureteral reflux and recurrent pyelonephritis. The results of cystometry before and after double administration of botulinum toxin are shown. Detrusor hypertension was stopped, pyelonephritis remission was achieved, trabecularity of the bladder mucosa was stopped. Simultaneously with the introduction of botulinum toxin, endoscopic correction of vesicoureteral reflux was performed.

Perspectives on the urological care in Parkinson's disease patients.

Parkinson's disease (PD) is recognized as the most common neurodegenerative disorder after Alzheimer's disease. Lower urinary tract symptoms are common in patients with PD, either storage symptoms (overactive bladder symptoms or OAB) or voiding symptoms. The most important diagnostic clues for urinary disturbances are provided by the patient's medical history. Urodynamic evaluation allows the determination of the underlying bladder disorder and may help in the treatment selection. Pharmacologic interventions especially anticholinergic medications are the first-line option for treating OAB in patients with PD. However, it is important to balance the therapeutic benefits of these drugs with their potential adverse effects. Intra-detrusor Botulinum toxin injections, electrical stimulation were also used to treat OAB in those patients with variable efficacy. Mirabegron is a β3-agonist that can also be used for OAB with superior tolerability to anticholinergics. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Deep brain stimulation (DBS) surgery is effective in improving urinary functions in PD patients. Sexual dysfunction is also common in PD. Phosphodiesterase type 5 inhibitors are first-line therapies for PD-associated erectile dysfunction (ED). Treatment with apomorphine sublingually is another therapeutic option for PD patients with ED. Pathologic hypersexuality has occasionally been reported in patients with PD, linked to dopaminergic agonists. The first step of treatment of hypersexuality consists of reducing the dose of dopaminergic medication. This review summarizes the epidemiology, pathogenesis, risk factors, genetic, clinical manifestations, diagnostic test, and management of PD. Lastly, the urologic outcomes and therapies are reviewed.

Comment on: “Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory Neurogenic Detrusor Overactivity in Children”

To assess the outcome of treatment for a chronic ailment in pediatric patients is a very complex task. In the case of neurogenic bladder secondary to spinal dysraphism there is one major fundamental endpoint and that is preservation of kidney function. The next important goal is improvement of quality of life by achieving continence and acceptable regular bladder emptying. Two treatment modalities are widely used, augmentation cystoplasty (AC) and intravesical injections of Botulinum toxin A (BTX-A). In many instances the latter is used preceding the augmentation if kidney function is preserved to postpone the more invasive and more definitive augmentation. However, there is no international consensus about when of these modalities may be used or when diversion should be instituted. But in any case, both regimens include lifelong monitoring and frequent new interventions. Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in childrenJournal of Pediatric UrologyVol. 18Issue 3PreviewTreatment options for refractory neurogenic detrusor overactivity (NDO) in children include botulinum toxin type A (BTX-A) and augmentation cystoplasty (AC). Although BTX-A is accepted in contemporary pediatric urologic practice, cost and long-term outcomes data for BTX-A are limited relative to the gold standard, AC. The purpose of this study was to compare the projected 10-year costs of AC versus BTX-A. Full-Text PDF

Commentary on “cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in children"

The authors have created a Markov model to evaluate the cost of bridging treatment to augmentation cystoplasty (AC) with bi-annual botulinum toxin type A (BTX-A) versus an initial AC [1]. The model assumes that all patients will eventually require an AC. I'm not certain this is a valid assumption. As the authors mention in the introduction, there is an escalating treatment plan, with initial anticholinergic medication followed by treatment with BTX-A. If all these fail, then there is an escalation to AC.

Cost comparison of intra-detrusor injection of botulinum toxin versus augmentation cystoplasty for refractory neurogenic detrusor overactivity in children

Treatment options for refractory neurogenic detrusor overactivity (NDO) in children include botulinum toxin type A (BTX-A) and augmentation cystoplasty (AC). Although BTX-A is accepted in contemporary pediatric urologic practice, cost and long-term outcomes data for BTX-A are limited relative to the gold standard, AC. The purpose of this study was to compare the projected 10-year costs of AC versus BTX-A. We performed a cost analysis from the payer perspective by computationally modeling treatment sequences by a Markov model. In the model, we used probabilities derived from published sources, and costs obtained at a tertiary medical center. The base case was a pediatric patient with refractory NDO. In the model, we assumed biannual BTX-A treatments. Treatment costs over 10 years were compared between immediate AC versus bridging therapy with BTX-A. Using the computational model, we simulated 100,000 instances of 10-year treatment cost for each of the two treatment modalities. The costs for the two treatment approaches were then compared using t-test and Wilcoxon test. The projected median and mean 10-year cost of immediately AC were $51,798.72 (95% CI [$51,798.72, $327,483.80]) and $123,473.4 (SD: $98,085.23) respectfully, while the projected median and mean 10-year cost of bridging therapy with BTX-A prior to proceeding to AC as needed were $74,552.46 (95% CI [$53,188.56, $309,913.07]) and $124,858.80 (SD: $84,495.35) (p<0.001). For a typical index pediatric patient with NDO, bridging therapy with intravesical BTX-A is associated with an increased cost compared to immediate AC over a ten-year period.

Learning Curve of Botulinum Toxin Bladder Injection for the Treatment of Refractory Overactive Bladder.

PurposeIntradetrusor botulinum toxin injections is an established second-line treatment for patients with refractory overactive bladder syndrome (OAB). We aimed to evaluate the learning curve of intradetrusor injections with botulinum toxin for the treatment of refractory OAB.Patients and MethodsThis retrospective study analyzed all women with idiopathic and refractory OAB who underwent botulinum toxin bladder injections performed by residents with no previous experience with operative cystoscopy under consultant supervision. Baseline International Consultation on Incontinence Questionnaire-Short Form questionnaire (ICIQ-SF) and Euroqol (EQ-5D) questionnaires were collected. Procedural data (operative time, number of valid injections, complications, subjective easiness, perceived tolerability) and patients’ outcomes (Patients Global Impression of Improvement (PGI-I), ΔICIQ-SF, ΔEQ-5D, need for self intermittent catheterization, duration of efficacy) were considered as markers to evaluate learning curves for each resident.ResultsTwenty-seven patients underwent intravesical injection of botulinum toxin performed by residents. Only a grade 1 Clavien-Dindo complication occurred, and none of the patients had urinary retention. PGI-I was very satisfactory, scoring 1.4 ± 0.9. Both ICIQ-SF and EQ-5D 2–2 were statistically improved (p < 0.00001 and p = 0.04, respectively). The mean duration of efficacy resulted to be 8.0±4.3 months. A positive effect of the learning curve was observed only for operative time, subjective easiness, and perceived tolerability.ConclusionIntradetrusor botulinum toxin injection for the treatment of refractory OAB is characterized by high efficacy and very low complications even at the very beginning of the learning curve when performed under proper mentorship.

Urodynamic studies and features of anaesthesia during intradetrusor botulinum therapy in the context of the COVID-19 pandemic (literature review)

The coronavirus pandemic has had a severe impact on the health care system. It is also changing the appointment and conduct of diagnostic procedures, emergency and routine medical care. According to the medical guidelines of the European Society of Urology (EAU) for the provision of urological care during the current epidemic situation, various levels of urgency have been proposed for diagnostic and therapeutic measures depending on the type of disease. Urodynamic studies refer to studies with a priority level from P2 (for neurogenic dysfunction of the urinary tract) to P4 (for lower urinary tract dysfunction without the risk of damage to the upper urinary tract). The question arises regarding the safety of these studies, both for patients and medical staff, and possible measures to reduce the risk of infection in a viral pandemic. Because of the increased workload of hospitals that have not been redesigned for the fight against coronavirus infection and provide routine and emergency urological care, an even greater need has arisen to find effective and safe methods of local anaesthesia for performing urodynamic studies and intradetrusive injections of botulinum toxin type A under local anesthesia in outpatient and outpatient settings (for example, in a short-term hospital). This article presents a literature review on the principles and features of performing urodynamic studies in the context of the Covid-19 pandemic and the effectiveness and safety of using various methods of local anaesthesia when performing intradetrusor injections of botulinum toxin with detrusor hyperactivity of a neurogenic and non-neurogenic nature. There were evaluated forms of local anaesthesia such as intradetrusor instillation of lidocaine, electrophoresis, and the use of alternative solutions for urinary bladder irrigation (for example, Ringer’s solution).

Efficacy and safety of intradetrusor botulinum toxin injections for idiopathic overactive bladder syndrome in patients with an artificial urinary sphincter.

To assess the efficacy and safety of intradetrusor botulinum toxin type A injections (IBTI) for idiopathic overactive bladder (iOAB) in non-neurological adults with an artificial urinary sphincter (AUS). We retrospectively selected, in the 11 French centers, members of a collaborative network (GENULF (Groupe d'étude de neuro-urologie de langue francaise)), the patients who had had an artificial urinary sphincter implantation and who had subsequently developed iOAB requiring IBTI. This study was approved by the French association of urology ethics committee (no 2018012). Between 2006 and 2020, 33 patients were included from 5 French centers. Mean follow-up after the first IBTI was 47months. The average age of the studied population was 68years, with 70% of females. A complete resolution of symptoms at optimal IBTI dose was experienced by 21 (64%) patients. Seven (21%) patients had partial improvement. Five non-responder patients (15%) had no improvement at all. Maximum cystometric bladder capacity was 240ml pre-IBTI and 335ml post IBTI. Discontinuation free survival at 60months was 50%. Two erosions occurred during the 6months following an IBTI both in male patients with a perineal implantation. There were four AUS balloon perforations that occurred during the 6months following an IBTI, all of them in female patients. IBTI has a good efficacy for the treatment of iOAB in patients with an AUS. However, both patients and practicians must be aware of the risk of rare and usually mild complications.

A 30-Month Complete Urinary Obstruction Resulting from Trapped and Incarcerated Uterus: A Case Report

Uterine incarceration is rare, but it can cause serious complications, in which the uterus is trapped in the pelvic cavity behind the sacral promontory. Fibroid uterus can cause urinary frequency and retention, which can result from compression of the urinary bladder with an enlarged fibroid uterus and the compression of the bladder neck or urethra, respectively. To our knowledge, there is no report on prolonged complete urinary obstruction because of an incarcerated uterus in nonpregnant women to date. A 51-year-old woman was referred for uterine myomas. She could not void for 30 months after she received an intradetrusor injection of botulinum toxin for urinary frequency management at the urology department of another hospital. She underwent clean intermittent catheterization for 30 months. She was referred to the gynecologic department for the evaluation of uterine myoma found on using abdominopelvic computed tomography. On physical examination, the uterine cervix was extremely displaced in the upward direction and was not exposed on speculum examination. Sonography and magnetic resonance imaging revealed that the urethra and the bladder neck were compressed by an extremely retroflexed fibroid uterus. Manual reduction of the incarcerated uterus failed; hence, we performed robot-assisted laparoscopic total hysterectomy with left salpingo-oophorectomy. She immediately urinated immediately after the operation and had normal urination at 1- and 48-month follow-up visits. Uterine incarceration by a fibroid uterus can cause complete urinary obstruction, as in this case. Uterine incarceration should be considered in women with urinary frequency or retention to avoid prolonged, serious complications.

A retrospective review of the long term clinical outcomes of patients with neurogenic lower urinary tract dysfunction following transverse myelitis.

Transverse myelitis (TM) is an inflammation of the spinal cord which causes neurological deficit in motor, sensory, and autonomic pathways. Persistent neurogenic lower urinary tract dysfunction (NLUTD) is common even where motor and sensory impairment is recovered. Long term follow-up is required to ensure optimal bladder management and protection of the upper tracts. We describe the clinical outcomes for a cohort of patients with TM who have received neurourological follow-up in a specialist center. A retrospective review of TM patient records was performed. Current pharmaceutical and surgical management, upper tract status, and patient reported symptoms are reported. Changes in urodynamic parameters and bladder emptying technique between current and baseline were analyzed. Sixty patients with NLUTD following TM were identified. The mean age at onset of NLUTD was 29 years (0-77 years). The mean follow-up was 13 years. 55% of patients were taking antimuscarinic medication, 53% of patients had intradetrusor botulinum toxin injections and 5% had bladder augmentation surgery. Forty-one patients had a baseline and recent urodynamic study which could be compared. Fifty-three of fifty-eight patients with a recent renal ultrasound had normal renal appearance. Four had mild hydronephrosis and one more extensive hydronephrosis. TM can have a persistent effect on lower urinary tract function. There is potential for upper tract damage if bladder management is not optimized. We have demonstrated that in a specialist neurourology unit within a tertiary center, one can provide acceptable long term outcomes following international guidelines.

Impact of intradetrusor botulinum toxin A injections on serum and urinary concentrations of nerve growth factor and brain-derived neurotrophic factor in patients with multiple sclerosis and neurogenic detrusor overactivity.

To evaluate the practical relevance of changes in serum and urinary neurotrophins levels in patients with multiple sclerosis (MS) and neurogenic lower urinary tract dysfunction (NLUTD) after intradetrusor injections of botulinum toxin A (BoNTA). The study included 36 patients with MS and NLUTD and 20 controls. The patients with NLUTD received intradetrusor injection of BoNTA (200 U). The nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) levels were measured in serum and urine at baseline and then at 1, 3, and 6 months by enzyme-linked immunosorbent assay. Urinary NGF and BDNF were normalized to creatinine (NGF/Cr, BDNF/Cr). Patients' assessment included urodynamic examination and Neurogenic Bladder Symptom Score (NBSS). After BoNTA injections, no significant changes were observed in the serum NGF and BDNF or the urinary BDNF/Cr. The urinary NGF/Cr was significantly higher in MS patients (1.23 ± 0.34) at baseline compared with controls (0.084 ± 0.02; p = .021). The urinary NGF/Cr decreased to 0.51 ± 0.12 (p = .001) and 0.53 ± 0.32 (p = .005) at 1 and 3 months, increasing to 1.12 ± 0.49 (p = .003) at 6 months. The urinary NGF/Cr level at baseline demonstrated a low diagnostic accuracy in predicting a better response to the BoNTA treatment (area under the curve = 0.661; p = .047) and no correlation with the urodynamic parameters. The urinary NGF/Cr at baseline or its reduction at the first month following treatment does not serve as a predictor for the response to the BoNTA injections or for urodynamic changes.