Marianne de Sèze

Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: Results of a multicenter prospective study†‡§

Electrostimulation is an established therapeutic option for neurogenic urinary disorders. The aim of this study was to investigate the efficacy of the noninvasive technique of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with multiple sclerosis (MS) and troublesome symptoms of an overactive bladder (OAB).

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

First-line urological evaluation in multiple sclerosis: validation of a specific decision-making algorithm

Background: Urinary disorders that lead to urological complications are frequent in multiple sclerosis, resulting in diminished quality of life. Urinary management guidelines are scarce and targeted to neuro-urology specialists. Objective: This study aimed to construct and validate an algorithm dedicated to neurologists and general practitioners to facilitate first-line evaluation and treatment of urinary disorders associated with multiple sclerosis. Methods: 49 items concerning urological symptom evaluation and therapeutic strategies were derived from literature analysis and evaluated by an expert panel. The Delphi method established consensus between the experts and allowed development of the First-Line Urological Evaluation in Multiple Sclerosis (FLUE-MS) algorithm. Two questions from the Urinary Bothersome Questionnaire in Multiple Sclerosis were included and their validation to verify comprehensiveness and acceptability was also conducted. Results: Three rounds of expert review obtained consensus of all 49 items and allowed finalisation of the algorithm. Comprehension and acceptability of two Urinary Bothersome Questionnaire in Multiple Sclerosis questions were verified (mean comprehensiveness score: 1.99/2 [99.7% total comprehensiveness], mean acceptability score: 1.99/2 [99.1% complete acceptability]). Conclusion: The FLUE-MS algorithm was designed for neurologists and general practitioners, enabling identification of ‘red flags’, timely patient referral to specialist neuro-urology units, and appropriate first-line therapy.

Cranberry versus placebo in the prevention of urinary infections in multiple sclerosis: a multicenter, randomized, placebo-controlled, double-blind trial

Objective: Our aim was to assess the usefulness of cranberry extract in multiple sclerosis (MS) patients suffering from urinary disorders. Methods: In total, 171 adult MS outpatients with urinary disorders presenting at eight centers were randomized (stratification according to center and use of clean intermittent self-catheterization) to cranberry versus placebo in a 1-year, prospective, double-blind study that was analyzed using a sequential method on an intent-to-treat basis. An independent monitoring board analyzed the results of the analyses each time 40 patients were assessed on the main endpoint. Cranberry extract (36 mg proanthocyanidins per day) or a matching placebo was taken by participants twice daily for 1 year. The primary endpoint was the time to first symptomatic urinary tract infection (UTI), subject to validation by a validation committee. Results: The second sequential analyses allowed us to accept the null hypothesis (no difference between cranberry and placebo). There was no difference in time to first symptomatic UTI distribution across 1 year, with an estimated hazard ratio of 0.99, 95% CI [0.61, 1.60] (p = 0.97). Secondary endpoints and tolerance did not differ between groups. Conclusion: Taking cranberry extract versus placebo twice a day did not prevent UTI occurrence in MS patients with urinary disorders. Trial Registration NCT00280592.

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.

Sacral neuromodulation and pregnancy: Results of a national survey carried out for the neuro-urology committee of the French Association of Urology (AFU)

To assess the impact of sacral neuromodulation (SNM) on pregnancy and vice‐versa, by identifying women who had received SNM for lower‐urinary tract symptoms (LUTS) and had become pregnant.

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.