A Single-institution Series of Botulinum Toxin Injection for Refractory Neurogenic Bladder in Children
Didi Theva, MD1; Archana Rajender, MD1; Bartley Cilento, MD2; Stuart Bauer, MD2
1Boston Medical Center, Boston, MA; 2Boston Children's Hospital, Boston, MA
BACKGROUND: When neurogenic bladder (NGB) dysfunction is refractory to antimuscarinic medication, botulinum toxin (Botox) injections may be a reasonable alternative to improving bladder function. We aimed to describe our institution′s experience using Botox in children with NGB, including changes in urodynamic (UDS) parameters and success rates.
METHODS: Children receiving Botox for refractory NGB, between 2008-2015, were identified from surgical records. Patient characteristics and UDS parameters (capacity, detrusor overactivity [DO], and maximum detrusor pressure [Pdet]) were collected via retrospective chart review. Botox success was defined as improvement of incontinence, DO, capacity or maximum Pdet at capacity. Among those who improved, the number of additional injections and the duration between each was collected.
RESULTS: Of the 27 patients who received Botox, a majority was female (59%), with a median age of 16 (IQR 10, 19) at first injection. Spinal dysraphism was the most common etiology (81%) compared to transverse myelitis (7%), dysfunctional voiding (7%) and spinal cord injury (4%). Eight (30%) had a successful response from Botox. There was no significant difference in age or sex for successful response to Botox. There was improvement in capacity by a median of 24% compared to group without success from Botox (median 20% increase) After the first injection, there was a mean improvement in Pdet by 1.9% for all patients. The 8 who experienced success had a mean improvement in Pdet by 30% compared to the failure group; the latter 19 patients had an increase in Pdet of 6.9% after first injection. Prior to Botox therapy, 13 patients (48.1%) had DO (5 in success group and 8 in failure group) and 22 (81.5%), experienced incontinence (5 in success group, 17 in failure group). Of the patients who experienced success with Botox, all had resolution of DO and 80% had improvement of incontinence. Of those who failed Botox, only 50% had resolution of DO and none had improvement in incontinence. Those with success received a median of 4 (range 2-5) additional injections over a 3.9-year median follow up. The duration of effect extended with each Botox administration with a median incremental increase of two months per injection (range 0-5.5). Of the 19 where Botox was unsuccessful, 11 were further maintained on CIC and anticholinergic therapy while 8 underwent (or are scheduled for) bladder augmentation.
CONCLUSIONS: Botox was successful in 30% of children with refractory NGB. When successful, there was improvement in compliance, DO and incontinence, as well as a modest incremental increase in effect duration. Botox is a less invasive surgery for a subset of children with NGB than other management options and should be considered before undertaking more involved procedures.
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