Juliette Hascoet

Outcomes of intra-detrusor injections of botulinum toxin in patients with spina bifida: A systematic review

Bladder management in spina bifida patients relies on clean intermittent catheterization and oral antimuscarinics with a significant failure rate. The efficacy of intradetrusor injections of botulinum toxin has been confirmed in patients with spinal cord injury or multiple sclerosis but not in patients with myelomeningocele.

Intradetrusor Injections of Botulinum Toxin A in Adults with Spinal Dysraphism

Purpose: The aim of the current study was to determine the outcomes of botulinum toxin A intradetrusor injections in adult patients with spina bifida. Materials and methods: All patients with spinal dysraphism who underwent intradetrusor injections of botulinum toxin A from 2002 to 2016 at a total of 14 centers were retrospectively included in analysis. The primary end point was the global success of injections, defined subjectively as the combination of urgency, urinary incontinence and detrusor overactivity/low bladder compliance resolution. Univariate and multivariate analysis was performed to seek predictors of global success. Results: A total of 125 patients were included in study. The global success rate of the first injection was 62.3% with resolution of urinary incontinence in 73.5% of patients. All urodynamic parameters had improved significantly by 6 to 8 weeks compared to baseline, including maximum detrusor pressure (–12 cm H2O, p <0.001), maximum cystometric capacity (86.6 ml, p <0.001) and compliance (8.9 ml/cm H2O, p = 0.002). A total of 20 complications (3.6%) were recorded for the 561 intradetrusor botulinum toxin A injections, including 3 muscular weakness complications. The global success rate of the first injection was significantly lower in patients with poor compliance (34.4% vs 86.9%, OR 0.08, p <0.001). On multivariate analysis poor compliance was associated with a lower global success rate (OR 0.13, p <0.001). Female gender (OR 3.53, p = 0.01) and patient age (OR 39.9, p <0.001) were predictors of global success. Conclusions: Intradetrusor botulinum toxin A injections were effective in adult patients with spina bifida who had detrusor overactivity. In contrast, effectiveness was much lower in adult patients with spina bifida who had poor bladder compliance. The other predictors of global success were female gender and older age.

Artificial Urinary Sphincter in Male Patients with Spina Bifida: Comparison of Perioperative and Functional Outcomes between Bulbar Urethra and Bladder Neck Cuff Placement

Purpose We evaluated the perioperative and long‐term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism. Materials and Methods We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation‐free and revision‐free device survival was estimated by the Kaplan‐Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure. Results A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision‐free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation‐free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75). Conclusions In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

Intradetrusor Injections of Botulinum Toxin Type A in Children With Spina Bifida: A Multicenter Study

OBJECTIVE To assess the effectiveness of intradetrusor injections of botulinum toxin type A (IDBTX-A) in children with spina bifida. METHODS All patients aged less than 16 years old who underwent IDBTX-A between 2002 and 2016 at 6 institutions were included in a retrospective study. Our primary endpoint was the success rate of IDBTX-A defined as both clinical improvement (no incontinence episodes between clean intermittent catheterizations [CICs], absence of urgency, and less than 8 CICs per day) and urodynamic improvement (resolution of detrusor overactivity and normal bladder compliance for age) lasting ≥12 weeks. Predictive factors of success were assessed through univariate analysis. RESULTS Fifty-three patients with a mean age of 8.5 years were included. All patients were under CIC and 88.7% had received anticholinergics with either poor efficacy or bothersome adverse events. The global success rate of the first injection (clinical and urodynamic) was 30%. Patients with closed spinal dysraphism had a significantly better success rate than patients with myelomeningocele (P = .002). The clinical success rate was 66% and was significantly associated with maximum urethral closure pressure (34 cm H2O vs 54.4 cm H2O, P = .02). The urodynamic success rate was 34%. Maximum cystometric capacity (P <.0001) and compliance (P = .01) significantly improved after the first IDBTX-A and maximum detrusor pressure tended to decrease (P = .09) except in the subgroup of patients with poor compliance. After a mean follow-up of 3.7 years, 23 patients (43.4%) required augmentation cystoplasty. Excluding 6 patients who were lost to follow-up, 38.3% of patients were still undergoing botulinum toxin injections at last follow-up. CONCLUSION In this series, despite the fact that IDBTX-A enabled clinical improvement in 66% patients, urodynamic outcomes were poor resulting in a low global success rate (30%).

Long-term discontinuations of botulinum toxin A intradetrusor injections for neurogenic detrusor overactivity: a multicenter study

Purpose: Data are lacking on long-term outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity. The aim of this study was to assess the outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity after more than 10 years of followup. Materials and Methods: We retrospectively reviewed the charts of all consecutive neurological patients who had received onabotulinumtoxin A or abobotulinumtoxin A intradetrusor injections for neurogenic detrusor overactivity between January 2002 and November 2007 at a total of 3 academic centers. The primary outcome measure was the 10-year discontinuation rate. Other outcomes of interest were failure, reasons for discontinuation and subsequent treatments of neurogenic detrusor overactivity. Discontinuation-free and failure-free survival was estimated by Kaplan-Meier analyses. Results: A total of 140 patients were included in study. The 10-year discontinuation-free and failure-free survival rates were 49.1% and 73%, respectively. The most common reason for discontinuation was failure in 43.7% of cases, which was primary and secondary in 17.2% and 26.5%, respectively. Secondary failure occurred after a median of 8 injections and a median of 80.1 months from the first injection. Other reasons for discontinuation were patient decision in 28.1% of patients, nonbotulinum toxin A related improvement of urinary incontinence in 14.1%, neurological condition progression in 12.5% and an adverse event in 1.6%. Discontinuation-free survival was significantly poorer in patients with spina bifida than in patients with multiple sclerosis or spinal cord injury (p = 0.02). Conclusions: More than half of the patients with neurogenic detrusor overactivity discontinued intradetrusor botulinum toxin A within the first 10 years after the initial injection. Patients with spina bifida are at high risk for discontinuation.

AMS-800 Artificial urinary sphincter in female patients with stress urinary incontinence: A systematic review

To perform a systematic review of studies reporting the outcomes of AMS‐800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD).

Reliability of urinary cytology and cystoscopy for the screening and diagnosis of bladder cancer in patients with neurogenic bladder: A systematic review

To assess the reliability of urinary cytology and cystoscopy to screen and diagnose bladder cancer in patients with NB.

Robot-assisted AMS-800 Artificial Urinary Sphincter Bladder Neck Implantation in Female Patients with Stress Urinary Incontinence

BACKGROUND Widespread adoption of the AMS-800 artificial urinary sphincter (AUS) in female patients has been hampered by the surgical morbidity of its implantation through an open approach. OBJECTIVE To describe a standardized technique of robotic bladder neck AUS implantation in female patients, and to report the perioperative and functional outcomes obtained by multiple surgeons with this technique. DESIGN, SETTINGS, AND PARTICIPANTS We retrospectively reviewed the charts of all female patients who underwent robotic AUS implantation for urinary incontinence due to intrinsic sphincter deficiency between March 2012 and March 2017 in five institutions. Most of the 10 surgeons involved were not highly experienced in female AUS implantation and/or in robotic surgery. SURGICAL PROCEDURE The AUS is implanted at the bladder neck through a transperitoneal robotic approach. The finger placed by the assistant surgeon in the vagina is paramount to expose the vesicovaginal space and guide the robotic surgeon throughout the bladder neck dissection. MEASUREMENTS The primary endpoint was the incontinence categorized as complete continence(ie, no pads used), improved incontinence, or unchanged incontinence. RESULTS AND LIMITATIONS Forty-nine female patients underwent a robotic AUS implantation. There were eight intraoperative complications (16.3%): five bladder neck injuries and three vaginal injuries. Nine patients experienced postoperative complications (18.3%), but only two were Clavien ≥3 (4.1%). After a median follow-up of 18.5 mo, one explantation (vaginal erosion, 2.1%) and three revisions (one mechanical and two nonmechanical failure, 6.1%) were needed. At last follow-up, 40 patients were fully continent (81.6%), six had improved incontinence (12.2%), and three had unchanged incontinence (6.1%). CONCLUSIONS In this first multicenter series of robot-assisted AUS implantation, our technique appeared feasible, safe, and reproducible with perioperative and functional outcomes in the early learning curve not inferior to those reported in large series of open AUS implantation from tertiary referral centers. PATIENT SUMMARY Robot-assisted bladder neck AMS-800 artificial urinary sphincter implantation in female patients with stress urinary incontinence resulting from intrinsic sphincter deficiency is feasible, safe, and reproducible with promising outcomes.

PD64-08 CAN WE AVOID BLADDER AUGMENTATION IN CASE OF FAILURE OF A FIRST INTRADETRUSOR BOTULINUM TOXIN INJECTIONS IN PATIENTS WITH SPINAL DYSRAPHISM?

courses per patient). The urodynamic patterns were detrusor overactivity in 48.6% of patients, isolated poor compliance in 33.6% of patients and combination of poor compliance and detrusor overactivity in 17.8%. The toxin used was in the vast majority onabotulinum toxin A at a dosage of 200 U in 43 patients (34.7%) and 300 U in 62 patients (49.2%). Twenty patients (16.1%) received initially abobotulinum toxin A 750 injections. Global success rate of the first injection was 68.8% with resolution of urinary incontinence in 73.5% of patients. Ninety-six patients (76.8%) underwent a second injection and the mean interval between the first and second injections was 7.5 months. Success rate was significantly lower in case of poor compliance (49% vs. 87%; p<0.0001). In contrast, success rates did not differ significantly between open and closed spinal dysraphism (66.7% vs. 72.3%; p1⁄40.51). The two other predictors of success were female vs. male gender (83.3% vs. 51.7%; p1⁄40.0002) and age (OR1⁄40.1; p1⁄40.005). Out of 561 injections, 20 adverse events were noted (3.6%) including three fatigue/muscular weakness. CONCLUSIONS: IDBTI seems effective in spina bifida patients showing detrusor overactivity regardless of the type of spinal dysraphism (open or closed). In contrast, the effectiveness is much lower in spina bifida patients with poor compliance bladder. The safety of IDBTI in patients with spinal dysraphism is statisfactory

PD64-07 INTRADETRUSOR INJECTIONS OF BOTULINUM TOXIN A IN ADULT PATIENTS WITH SPINAL DYSRAPHISM: RESULTS OF A MULTICENTER STUDY

METHODS: The charts of all patients who underwent a switch to IDI of ATA after failure of an IDI of OTA at six departments of neurourology were retrospectively reviewed. The main outcomes of interest were the bladder diary data and four urodynamic parameters: maximum cystometric capacity (MCC), maximum detrusor pressure (PDET max) and volume at first uninhibited detrusor contraction (UDC). Data were compared before and after treatment with OTA and ATA, using Stuart, Wilcoxon and paired-t tests for paired samples and univariate logistic regression was performed to seek for predictors of switch success. RESULTS: Out of 57 patients included, 38.6% were primary non-responders to Botox, and in secondary non-responder a median number of 5 OTA IDI were performed before failure (range 1-17). Persistent urinary incontinence was observed in 84.2% patients, and 75.4% had persistent detrusor overactivity. Six weeks after the first injection of Dysport, no adverse events were reported. A significant decrease in number of urinary incontinence episodes per day was observed in 52.63% of patients (p <0.001) and all patients experienced a reduction in PDET Max (-8.1 cmH20 on average; p1⁄40.003). MCC significantly increased by a mean of 41.2 ml (p1⁄40.02). The proportion of patients with no UDC increased significantly at after ATA injections (from 15.79% to 43.9%; p1⁄40.0002). Hence, 32 patients draw clinical and/or urodynamic benefits from the botulinum toxin switch from OTA to ATA (56.14%). After a median follow up of 21 months, 87% of responders to BTA switch were still treated successfully with BTA. In univariate analysis, three variables were associated with BTA switch success: low MCC before first ATA IDI (OR1⁄420.4;p1⁄40.01) and dose of ATA (OR1⁄4 10.9; p1⁄40.048) were predictive of increased success rates; poor compliance was predictive of lower success rate (OR1⁄40.2; p1⁄40.04). CONCLUSIONS: Most patients refractory to OTA (Botox) (56.14%) draw benefits from the switch to ATA (Dysport). Low MCC and dose of ATA were predictive of success of BTA switch while poor compliance was predictive of failure.