Therapeutic Effects Of Botulinum Toxin Research Articles

Smartphone and custom-made software to assess the effect of botulinum toxin in essential blepharospasm: Initial results.

It is challenging to assess essential blepharospasm (EB) patients objectively because they exhibit chaotic patterns of abnormal eyelid movements. Previously employed objective approaches used systems with low levels of accuracy systems or were too complex to be applied in routine clinical practice. We aimed to develop a practical tool using a smartphone camera and custom-made software to objectively assess the therapeutic effects of botulinum toxin in blepharospasm patients. Thirty-four patients with EB were evaluated before and 15 days after receiving onabotulinumtoxinA injections. The control group was composed of 19 age-matched healthy individuals. A smartphone (iPhone 6 S; Apple) was used to record spontaneous eyelid movements for 3min, after which eyelid movement frequency was analysed using custom-made software. Before treatment, eyelid movement frequency was significantly higher in the EB group (21.55 ± 13.30 movements/min) compared to the control group (8.26 ± 8.89 eyelid movements/min; p< 0.001). The frequency of spontaneous eyelid movements was significantly reduced after treatment in the EB patients (8.46 ± 6.32 eyelid movements/min; p< 0.001). After treatment, no statistically significant difference in eyelid movement rate was observed between the EB patients and the control group (p= 0.32). Assessment of the spontaneous eyelid movements obtained with the smartphone camera and analysed with the custom-made software enabled us to objectively measure the therapeutic effects of botulinum toxin in patients with blepharospasm. Further refinement of this system could enable customized and fine adjustments to botulinum toxin doses based on each patient's needs.

How does botulinum toxin really work?

Over the past 30 years, Botulinum toxin (BoNT) has emerged as an effective and safe therapeutic tool for a number of neurological conditions, including dystonia. To date, the exact mechanism of action of BoNT in dystonia is not fully understood. Although it is well known that BoNT mainly acts on the neuromuscular junction, a growing body of evidence suggests that the therapeutic effect of BoNT in dystonia may also depend on its ability to modulate peripheral sensory feedback from muscle spindles. Animal models also suggest a retrograde and anterograde BoNT transportation from the site of injection to central nervous system structures. In humans, however, BoNT central effects seem to depend on the modulation of afferent input rather than on BoNT transportation. In this chapter, we aimed to report and discuss research evidence providing information on the possible mechanisms of action of BoNT in relation to treatment of dystonia.

Impact of Scalene Muscle Botulinum Toxin Injection with and without Surgery in Neurogenic Thoracic Outlet Syndrome

Scalene blocks are part of both the diagnostic and the treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, a paucity of data is available on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the therapeutic effects of botulinum toxin (Botox) scalene chemodenervation, with and without surgery, at a multidisciplinary referral center.

Botulinum toxin in the treatment of neuralgia and neuropathic pain

Introduction: Botulinum toxin is one of the most powerful neurotoxins currently known, with high affinity to the cholinergic synapse, which sufficiently inhibits the release of acetylcholine. Its use has proved to be effective in the treatment of many diseases of the musculoskeletal system. Although most of the therapeutic effects of botulinum toxin are due to the temporary relaxation of skeletal muscles (caused by inhibition of acetylcholine release), research is ongoing into its effects on the nervous system.&#x0D; Purpose of the work: The aim of the study is to analyze the effectiveness of botulinum toxin in the treatment of neuralgia and neuropathic pain.&#x0D; Method: The relevant samples were accessed by means of an electronic search in the PubMed database. The analysis used reviews and meta-analyzes posted on the platform over the last 10 years.&#x0D; Conclusions: Botulinum toxin has great potential in the treatment of pain. It is multitasking due to its favorable safety profile and long-lasting relief from a single injection compared to other pain medications. The side effects caused by it were assessed to be mild to moderate and included a local skin reaction (swelling), injection site pain, muscle weakness, flu symptoms, nausea and vomiting.&#x0D; Keywords: botulinum toxin; neuropathic pain; pain treatment; neuralgia; BoNT / A

An objective tool to measure the effect of botulinum toxin in blepharospasm and hemifacial spasm.

It is challenging to assess patients with blepharospasm (BSP) and hemifacial spasm (HFS) as these patients exhibit a wide range of amplitudes of eyelid movements. In order to quantify these movements, a mathematical algorithm, i.e. Fast Fourier Transform, can be employed to convert the signal from the time domain to the frequency domain. The result of this quantification represents the energy generated during the eyelid movements. In order to objectively assess the therapeutic effects of botulinum toxin (BoNT) in these patients, we evaluated the energy generated by the upper eyelid during spontaneous eyelid movements before and after treatment. A total of 39 patients with BSP and HFS were evaluated before and 30days after receiving onabotulinum toxin A injections. A high-speed camera and micro light-emitting diodes were used to register the spontaneous eyelid movements. The result of the quantification obtained using Fast Fourier Transform permitted assessment of the activity associated with the eyelid movements. We studied 78 eyelids. The total energy generated during spontaneous eyelid movements was significantly reduced after treatment in the patients with BSP (P=0.0018) and on the affected side in the patients with HFS (P=0.0058). The assessment of the energy generated by the upper eyelid during spontaneous eyelid movements enabled us to measure the therapeutic effects of BoNT in patients with these conditions. The use of this system could enable customized and fine adjustments to BoNT doses based on each patient's needs.

Therapeutic Effect of Botulinum Toxin A on Sensory Bladder Disorders-From Bench to Bedside.

Bladder oversensitivity arises from several different conditions involving the bladder, bladder outlet, systemic or central nervous system diseases. Increase of the bladder sensation results from activation of the sensory receptors in the urothelial cells or suburothelial tissues. Medical treatment targeting the overactive bladder (OAB) or interstitial cystitis (IC) might relieve oversensitive bladder symptoms (frequency, urgency and pain) in a portion of patients, but a certain percentage of patients still need active management. Botulinum toxin A (BoNT-A) has been demonstrated to have anti-inflammatory and antinociceptive effects in bladder sensory disorders and has been shown effective in the reduction of bladder oversensitivity and the increase of functional bladder capacity. For patients with OAB, urgency and urinary incontinence improved, while in patients with IC, bladder pain could be relieved in association with reduction of bladder oversensitivity after BoNT-A intravesical injection. Histological evidence has confirmed the therapeutic mechanism and clinical efficacy of intravesical BoNT-A injection on patients with OAB or IC. Bladder oversensitivity can also be relieved with the instillation of liposome encapsulated BoNT-A or low energy show waves (LESWs), which enable the BoNT-A molecule to penetrate into the urothelium and suburothelial space without affecting the detrusor contractility. Liposome encapsulated BoNT-A or combined LESWs and BoNT-A instillation might be future treatment alternatives for bladder oversensitivity in sensory bladder disorders.

Factors affecting the therapeutic effect of botulinum toxin A on trigeminal neuralgia: A follow-up retrospective study of 152 patients.

Botulinum toxin A (BTX-A) is a promising therapeutic modality against trigeminal neuralgia (TN) with certain controversies pertaining to its application. To provide further information on factors influencing the treatment outcomes of BTX-A, a retrospective study with 152 patients with TN treated with BTX-A was performed. The starting time and duration of the therapeutic effect, as well as side effects, of BTX-A in the treatment of TN were analyzed by sex, age, course of disease, number of branches and injected dose. A total of 136 patients exhibited symptom improvement within 2 weeks following BTX-A treatment as evaluated using a visual analog scale (VAS). The effect of BTX-A was sustained throughout the initial 6 months of the follow-up and was demonstrated to persist for as long as 28 months. Female sex, short disease course and high injection dose (>70 units) were associated with lower long-term VAS scores. Patients receiving short-term medium-(50–70 units) or high-dose injections were more likely to be completely cured. Patients with a median disease course (1–10 years) or multiple branches were more likely to exhibit facial asymmetry. Based on the stratified analysis, female patients with a median disease course (1–10 years) exhibited a higher incidence of side effects and male patients achieved better treatment outcomes with high BTX-A doses. BTX-A effectively alleviated patients with TN in both short or long term, although the treatment efficacy may depend on patient characteristics.

Epidermal Growth Factor (EGF) and Botulinum Toxin (BTX); Can Paralysis Be A Bless?

Botulinum toxin (BTX) commercially known as Botox is produced by Clostridium Botulinum, it has many different subtypes. It is a relatively safe agent with very few local and systemic adverse effects, and is currently used in a wide range of medical, dental and cosmetic procedures. BTX has the potential for an expanding range of applications in the future. In this article we review the mechanism of action, and all the well documented applications of BTX with a specific focus on its usage in the treatment of hyper-salivation and drooling. We propose a combination treatment for the above mentioned salivary gland conditions, which consists of BTX and Epidermal Growth Factor (EGF); a well-known potent polypeptide that promotes healing and repair. EGF is secreted though many bodily fluids including saliva. This combination treatment aims to prevent the atrophy of salivary glands that accompanies treatment with BTX. We aim to provide answers to the question whether BTX induced paralysis is a burden or bless? Our proposed combination treatment (BTX + EGF) will hopefully obtain the best of both worlds; the therapeutic effect of BTX and the healing potential of EGF. This will maintain the salivary glands‟ integrity and will allow for long term treatment with BTX with minimal side effects. Key words: Epidermal growth factor, Botulinum toxin, Clostridium, Salivary glands, Wound healing.

Therapeutic use of botulinum toxin in pain treatment

Botulinum toxin is one of the most potent molecule known to mankind. A neurotoxin, with high affinity for cholinergic synapse, is effectively capable of inhibiting the release of acetylcholine. On the other hand, botulinum toxin is therapeutically used for several musculoskeletal disorders. Although most of the therapeutic effect of botulinum toxin is due to temporary skeletal muscle relaxation (mainly due to inhibition of the acetylcholine release), other effects on the nervous system are also investigated. One of the therapeutically investigated areas of the botulinum neurotoxin (BoNT) is the treatment of pain. At present, it is used for several chronic pain diseases, such as myofascial syndrome, headaches, arthritis, and neuropathic pain. Although the effect of botulinum toxin in pain is mainly due to its effect on cholinergic transmission in the somatic and autonomic nervous systems, research suggests that botulinum toxin can also provide benefits related to effects on cholinergic control of cholinergic nociceptive and antinociceptive systems. Furthermore, evidence suggests that botulinum toxin can also affect central nervous system (CNS). In summary, botulinum toxin holds great potential for pain treatments. It may be also useful for the pain treatments where other methods are ineffective with no side effect(s). Further studies will establish the exact analgesic mechanisms, efficacy, and complication of botulinum toxin in chronic pain disorders, and to some extent acute pain disorders.

Changes in chemical coding of sympathetic chain ganglia (SChG) neurons supplying porcine urinary bladder after botulinum toxin (BTX) treatment.

Botulinum toxin (BTX) is a neurotoxin used in medicine as an effective drug in experimental therapy of neurogenic urinary bladder disorders. We have investigated the influence of BTX on the chemical coding of sympathetic chain ganglia (SChG) neurons supplying the porcine urinary bladder. The toxin was injected into the wall of the bladder. SChG neurons were visualized by a retrograde tracing method with fluorescent tracer fast blue (FB) and their chemical coding was investigated by double-labelling immunohistochemistry with antibodies against dopamine β-hydroxylase (DβH; a marker of noradrenergic neurons), neuropeptide Y (NPY), vasoactive intestinal polypeptide (VIP), somatostatin (SOM), galanin (GAL), Leu5-enkephalin (L-ENK) and neuronal nitric oxide synthase (nNOS). In both the control (n = 5) and BTX-treated pigs (n = 5), the vast majority (91 ± 2.3 % and 89.8 ± 2.5 %, respectively) of FB-positive (FB+) nerve cells were DβH+. BTX injections caused a decrease in the number of FB+/DβH+ neurons that were immunopositive to NPY (39.5 ± 4.5 % vs 74.5 ± 11.9 %), VIP (8.9 ± 5.3 % vs 22.3 ± 8.8 %), SOM (5.8 ± 2.3 % vs 17.4 ± 3.7 %) or GAL (0.9 ± 1.2 % vs 5.4 ± 4.4 %) and a distinct increase in the number of FB+/DβH+ neurons that were immunoreactive to L-ENK (3.7 ± 2.9 % vs 1.1 % ± 0.8 %) or nNOS (7.7 ± 3.5 % vs 0.8 ± 0.6 %). Our study provides novel evidence that the therapeutic effects of BTX on the mammalian urinary bladder are partly mediated by SChG neurons.

Short-term effect of botulinum toxin a injection on spastic equinovarus foot in cerebral palsy patients: a study using the foot pressure measurement system.

ObjectiveTo evaluate the therapeutic effect of botulinum toxin A (BTX-A) injection on spastic gastrocnemius (GCM) and tibialis posterior muscles (TPo) by using the foot pressure measurement system (FPMS).MethodsEighteen ambulatory CP patients were recruited in this study. BTX-A was injected into the GCM at a dose of 6-12 units/kg and TPo at a dose of 4-9 units/kg according to the severity of equinus and varus deformity. Foot contact pattern, pressure time integral (PTI), coronal index using the FPMS and Modified Ashworth Scale (MAS), and visual inspection of gait pattern were used for evaluation of the therapeutic effect of BTX-A injection. Clinical and FPMS data were statistically analyzed according to the muscle group.ResultsA significant decrease in the MAS score of the GCM and TPo was observed, and spastic equinovarus pattern during gait showed improvement after injection. The GCM+TPo injection group showed a significant decrease in forefoot, lateral forefoot pad, and lateral column PTI, and a significant increase in hindfoot PTI and coronal index. In the GCM only injection group, forefoot PTI and lateral column PTI were significantly decreased and hindfoot PTI was significantly increased. The TPo only injection group showed a significant decrease in lateral column PTI and a significant increase in the coronal index. Change in PTI in the hindfoot showed a significant correlation with the change in MAS score of the GCM. Change in PTI of the lateral column and coronal index showed a significant correlation with the change in MAS score of the TPo.ConclusionThe FPMS demonstrated the quantitative therapeutic effect of BTX-A on abnormal pressure distribution in equinovarus foot in detail. The FPMS can be a useful additional tool for evaluation of the effect of BTX-A injection.

Botulinum toxin therapy of cervical dystonia: duration of therapeutic effects.

We sought to explore the therapeutic effect of botulinum toxin (BT) therapy by analysing the time between the BT application and the onset of its decrease (treatment duration, TD), the inter-injection interval (II), and the excess time (ET, ET = II-TD). For this we studied 59 patients (37 females, 22 males, age 52.6 ± 10.9 years) with cervical dystonia (CD, Tsui score 9.0 ± 4.1) and BT therapy with Botox(®) and/or Xeomin(®) sequentially. Altogether 1,289 treatment cycles were evaluated. On average 21.8 ± 14.0 (4-66) treatment cycles were recorded for each patient. TD was 11.8 ± 2.7 weeks (7.8 ± 1.4 to 21.0 ± 3.9 weeks), II 15.4 ± 3.4 weeks (11.3 ± 1.3 to 27.8 ± 11.6 weeks) and ET 3.5 ± 2.4 weeks (23% of II). TD and II were stable throughout the treatment course. In 36% of the patients we found TD ≤10 weeks, in 83% TD ≤12 weeks. In 17% of the patients we saw treatment delays due to appointment difficulties, due to the patient's attempts to explore TD or his actual CD severity, from fear of adverse effects or due to psychiatric comorbidity. 19% of the patients showed prolonged treatment effects probably due to CD fluctuations. 0.38% of the injection series produced singular unexplained therapy failure (SUTF). Antibody-induced therapy failure did not occur. TD and II are stable on long-term monitoring. SUTF, treatment delays, and CD fluctuations can occur. 23% of the time patients are treated suboptimally. Our data suggest to reduce II. If II is to be reduced to ≤12 weeks, use of low antigenicity BT drugs might be useful.

A Pilot Study of Quantitative Measurements of Nasal Function in Rhinitis and the Therapeutic Effects of Botulinum Toxin

A Pilot Study of Quantitative Measurements of Nasal Function in Rhinitis and the Therapeutic Effects of Botulinum Toxin Objective: Symptoms of rhinitis can be attributed to the stimulation of cholinergic nerve endings, which leads to mucosal hypersecretion and an increase in nasal blood flow. As botulinum toxin is a powerful cholinergic blocker, the application of this toxin intranasally may help to decrease the symptom complex associated with rhinitis. A pilot study was designed to evaluate the use of hot wire airflow, measurement of stimulated secretions, and the effect of botulinum toxin on both. A quantitative assessment of this use in humans has never been performed. Study Design: Double-blind, placebo controlled randomized control trial. Methods: Botulinum toxin was injected into the inferior turbinates of 8 human subjects. Patients were their own controls, with each side randomized to receive onabotulinumtoxinA (BTX-A) (four 2.5 unit aliquots) or equivalent volume of normal saline.. Airflow was measured at baseline and each visit using hot-wire airflow device. Baseline and stimulated nasal secretions were collected on filter paper then weighed. The patients were followed monthly for a total of 4 months. Results: There was a statistically significantly greater airflow on the BTX-A treated sides compared with control sides at 4 months. There was also a statistically significant decrease in stimulated secretions at 3 months. There was a notable trend toward reduction of resting secretions and stimulated secretions in the BTX-A treated sides during the treatment period. There was also a trend toward greater airflow in the BTX-A treated sides during the treatment period.

Effects of botulinum toxin A on patient‐specific keloid fibroblasts in vitro

To test whether therapeutic effects of botulinum toxin A on patient- specific keloid tissue can be reproduced on the cellular level. Specifically, effects on cell proliferation and expression of growth factors and cytokines relevant for wound healing were to be tested. Experimental study including patient specific cell cultures of keloids. Patient-specific keloid tissue was tested in a cell culture model for effects of botulinum toxin incubation on cell proliferation and expression of the following cytokines and growth factors: IL-6 (interleukin-6), VEGF (vascular endothelial growth factor), TGF-β (transforming growth factor-β). None of the tested parameters of human keloid tissue were affected by botulinum toxin A incubation. The present study does not add evidence to suggest a significant therapeutic role of botulinum toxin injections for the treatment of keloids. N/A.

Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos

BACKGROUND: Hyperhidrosis is characterized by excessive sweating of the forehead, hands, feet, and armpits, either alone or in combination. It affects about 1% of the population. This study aimed to observe the effects of botulinum toxin in patients with hyperhidrosis and demonstrates the application technique of botulinum toxin, the areas of incidence of the disease, and the duration of the results. METHODS: A retrospective analysis of 39 patients with primary hyperhidrosis treated between July 2000 and July 2010 and followed up for 12 months was carried out. Of these patients, 36% were male and 64% were female. Patient ages ranged from 16 to 41 years. A total of 135 areas were treated. Treatment consisted of intradermal injections of botulinum toxin. The total dose applied ranged from 37.5 U to 150 U, with an average dose of 75 U for each treated area. RESULTS: The therapeutic effect of botulinum toxin was observed from the third day after treatment, with a 50% reduction in symptoms within the first week of treatment and up to 94% reduction in the number of hyperhidrosis events after the second week. The reduction of symptoms lasted, on average, for 7 months. No cases of compensatory hyperhidrosis or mortality were observed. CONCLUSIONS: The treatment of primary hyperhidrosis with type A botulinum toxin, although temporary, is an effective, safe, and minimally invasive treatment option. It has a high degree of satisfaction and allows patients to return to their professional activities on the same day. Side effects and complications are temporary, infrequent, and regress without sequelae.

Anterior and posterior sagittal shift in cervical dystonia: A clinical and electromyographic study, including a new EMG approach of the longus colli muscle

Anterior and posterior sagittal shift of the head are less common postures in cervical dystonia and, as such, have not been comprehensively studied. In this article, we have detailed both our clinical and electromyography (EMG) findings in 11 patients with prominent dystonic sagittal shift of the head. A new technique of injection of the longus colli, based on a laterocervical approach under EMG guidance, is described. We have detailed the clinical phenotypes of dystonic posterior sagittal shift or "double chin" posture (4 patients) and anterior sagittal shift or "goose neck" posture (7 patients) and proposed specific botulinum toxin (BoNT) treatment protocols for these postures. Seven patients with the goose-neck posture responded well (70%-90% benefit) to BoNT injections. Six patients responded to splenius capitii injections alone, and 1 patient needed, in addition, the injection into both sterno-cleido-mastoid muscles. Four patients with the double-chin posture responded well to BoNT injection (50%-80% benefit). Two patients responded to suprahyoid injection alone, and 2 patients needed, in addition, the injection into the sterno-cleido-mastoid and longus colli muscles. Dysphagia was avoided in all of the double-chin patient group by adjusting our injection technique into the suprahyoid and longus colli muscles. The individualised toxin BoNT protocols have resulted in an improved benefit. The new Longus colli injection technique has allowed for a therapeutic effect of botulinum toxin without causing dysphagia.

Editorial Comment on: Is Botulinum Neurotoxin Type A (BoNT-A) a Novel Therapy for Lower Urinary Tract Symptoms Due to Benign Prostatic Enlargement? A Review of the Literature

mechanism of botulinum toxin type A as a treatment modality of benign prostatic hyperplasia. Yons Med J 2006;47:706–14. [28] Larson TR, Scottsdalle AZ, Huidobro C, et al. Intraprostatic injection of botulinum toxin in the treatment of symptomatic LUTS, including sequential MRIs for accurate changes in size of the prostate. J Urol 2005;173(suppl):376. [29] Guercini F, Giannantoni A, Bard RL, et al. Intraprostatic botulin toxin injection in patients with severe benign prostatic hyperplasia: a multicenter feasibility study. J Urol 2005;173(suppl):376–7. [30] Silva J, Silva C, Saraiva L, et al. Intraprostatic botulinum toxin type A injection in patients unfit for surgery presenting with refractory urinary retention and benign prostatic enlargement. Effect on prostate volume and micturition resumption. Eur Urol 2008;53:153–9. [31] Maria G, Brisinda G, Civello IM, Bentivoglio AR, Sganga G, Albanese A. Relief by botulinum toxin of voiding dysfunction due to benign prostatic hyperplasia: Results of a randomized, placebo-controlled study. Urology 2003;62:259–64. [32] Kuo HC. Therapeutic effects of botulinum toxin A on large benign prostatic hyperplasia with persistent lower urinary tract symptoms and suboptimal treatment outcome of combination medical therapy—clinical and histological investigation of effects. J Urol 2007;177(suppl): 609–10. [33] Plante MK, Folsom JB, Zvara P. Prostatic tissue ablation by injection: a literature review. J Urol 2004;172:20–6.

Local injection of botulinum toxin A for palmar hyperhidrosis: Usefulness and efficacy in relation to severity

Botulinum toxin A is widely used in Europe and the USA for the treatment of localized hyperhidrosis, and its efficacy has been recognized. In this study, botulinum toxin A (Botox) was locally injected at 30 sites (2 U/injection) on the right palm in 27 patients with palmar hyperhidrosis (14 severe patients, 13 mild patients), and the results confirmed the efficacy of injection. The amount of sweat was then quantified for the left and right hands every month after local injection. The quantity of sweat on the treated hand was approximately one-fifth that on the untreated hand. In addition, the quantity of sweat on the untreated hand decreased slightly. Over time, the quantity of sweat on the treated hand increased slightly, but the quantity of sweat on the treated hand at 6 months after injection was less than half that before injection, and there were significant differences before and after injection. In the present study, severe sweating was defined as 1 mg/cm2/min or more and mild sweating as less than 1 mg/cm2/min, and the therapeutic effects of botulinum toxin A were analyzed in relation to severity. When compared to the mild cases, the quantity of sweat remained higher in the severe cases after botulinum toxin A therapy. Therefore, to achieve satisfactory effects in severe cases, it would be necessary to increase the number of injection sites, as well as injection dose.

Botulinum toxin A for the treatment of chronic anal fissure

Since its introduction for the treatment of strabismus, botulinum toxin (BoNT) has been increasingly used in the treatment of several disorders with excessive or inappropriate muscle contractions. The therapeutic effects of BoNT occur through the temporary chemodenervation caused by the injection into the local target muscle or skin. Modulation of muscle relaxation may be achieved by varying the dose of BoNT solution injected; most adverse effects are transient. Indeed, botulinum neurotoxin has been used to selectively weaken the internal anal sphincter as a treatment for chronic anal fissure in several randomized, controlled trials and open-label studies. The use of botulinum neurotoxin seems to be an effective and safe approach for the treatment of chronic anal fissure, particularly in patients at high risk for incontinence.

1836: Therapeutic Effect of Botulinum Toxin a on Large Benign Prostatic Hyperplasia with Persistent Lower Urinary Tract Symptoms and Suboptimal Treatment Outcome of Combination Medical Therapy-Clinical and Histological Investigation of Effects

1836: Therapeutic Effect of Botulinum Toxin a on Large Benign Prostatic Hyperplasia with Persistent Lower Urinary Tract Symptoms and Suboptimal Treatment Outcome of Combination Medical Therapy-Clinical and Histological Investigation of Effects