Transcript Document

The efficacy of injection
of Botulinum Toxin A into
the bladder wall for the
treatment of detrusor
overactivity
 Soma Lahiri
 Glyn Constantine
 Good Hope Hospital, Sutton Coldfield,
UK
Overactive bladder
 ‘Urgency with or without urge incontinence usually
with frequency and nocturia’ (ICS)
 DO: Urodynamic diagnosis
Treatment
 Medical
Anticholinergics
Physiotherapy & bladder training
(physiotherapists and incontinence advisors)
 Surgical Management
Botulinum Toxin A
Sacral nerve root stimulation : 60 %
Augmentation cystoplasty and urinary
diversion
NICE Oct 2006
Botulinum Toxin A
 Isolated in 1897 by Van Ermengem
 First used in 1980: Strabismus
 Schurch et al 2000: Neurogenic
DO in pateints with spinal cord
injury.
 Rapp et al: Idiopathic overactive
bladder
Mechanism of action
 Inhibits release of Acetylcholine
 Reduced release of glutamate
and substance P
Duration of action
 Onset of action :
 Duration of action:
 Chemodenervation:
1- 3 weeks
9 -12 months
3- 6 months
Sahai et al 2005
Complications
 Influenza-like syndrome
 Increased electrophysiological jitter or pareses in
some distant muscles (transient)
 Rarely, hypersensitivity reactions
Contraindications
 generalised disorders of muscle activity, e.g.
myasthenia gravis
 blood clotting disorders
 pregnancy& breastfeeding
Safety in urology
 Unlicensed
 Randomised trials
Michael et al 2009
Brubaker et al 2008
Our protocol
 Patient Selection:
2 or more anticholinergics
Refractory to treatment
Can’t tolerate the side effects
Urodynamics showing DO
Bladder retraining (Outpatients)
 Excluded if voiding problems and Current UTI
 Counseling:
Unlicensed
May need long term self-catheterisation
Our protocol
 Daycase under GA
 Prophylactic antibiotics for 3 days
 Follow up 4 weeks & 6 months
(patient led thereafter)
Dosage and sites
 200u Botox (Botulinum Toxin A)
 Diluent: 16 mls Normal Saline
 32 sites (0.5 mls/ site = 6.25u of Botox )
 Avoiding the trigone and the ureteric openings
Instruments
 Rigid Cystoscope (12°)
 Bard Transurethral Injection system
Injection needle: 1.3cm length, 23 gauge
 Olympus system:
Injection needle: 4mm length, 27 gauge
Cost
 Day case procedure
 Botox 200 units
 Needle
=
=
£284
£41.57
_______
£325.57
Aim
 To look at
Improvement in symptoms
Duration of symptom relief
Success of repeat injections
Complications
Methodology
 Retrospective study
 Case note and electronic data review
 2 hospital sites
Good Hope Hospital, Sutton Coldfield
Sir Robert Peel Hospital, Tamworth
Results
 n= 51
 Average age: 55.4y
(Range 31 yrs to 77 yrs)
 Average parity: 2
Results:
st
1
injection
 Overall improvement:
91 %
 Daytime incontinence:
80 %
 Frequency and urgency:
75 %
 Nocturia:
55 %
(Quality of life)
Results:
nd
2
injection
 65% of those who had 1st injection had 2nd injection
 Average interval between first and second
treatments: 15.7 months
 Success rate: 93 %
 28 % said ‘not as good as the first’
 6 % said no improvement
Results:Treatment 3
 64 % of those who had 2 injections had 3rd
injection
 Average interval between the 2nd & 3rd treatment
10 months
 Success rate: 75%
Complication
Urinary tract infection:
12 %
Retention/ Self catheterisation:
3%
Pain:
2%
Lack of sensation:
1%
Summary
 Improvement
Treatment 1: 91%
Treatment 2: 93%
Treatment 3: 75%
 Complication:
UTI
Interval 15 mths.
Interval 10 mths.
Conclusions
 Very useful alternative
 Our regime improved symptoms without causing
retention
 As efficacy reduces with number of injections,
? increase the dose in repeat injections
Acknowledgements:
Records Department
BICOG
Thank you.
Doseage Regimens described
 200 20 sites: brubaker et al 2008
 200 – 300 u 40 sites schurch et al 2006
 100 u 30 sites 26 werner et al 2006
 300 u30 sites 10 women hajebrahimi et al