Repeated botulinum-A toxin injections in the treatment of myelodysplastic children and patients with spinal cord injuries with neurogenic bladder dysfunction.
OBJECTIVE
To examine the effects of repeated detrusor injections of botulinum-A toxin (BTX) for possible changes in bladder function, muscular structure of the detrusor, increase in BTX tolerance (tachyphylaxis) and side-effects, as BTX is a new treatment alternative for patients with a neurogenic bladder condition that is difficult to treat and refractory to anticholinergic medication.


METHODS
Between 2000 and 2005, 19 patients with myelodysplasia (MDP) and 25 spinal cord-injured (SCI) patients were treated with repeated suburothelial BTX injections (Dysport, Ipsen-Pharma, Ettlingen, Germany) or injections into the intramural detrusor. The follow-up was > or = 3 years (range 3-5, median 4.5).


RESULTS
Detrusor compliance, bladder capacity, and detrusor pressure at maximum filling improved significantly (P < 0.001) compared to baseline after each BTX injection. There was prolonged efficacy of each BTX administration and all repeated injections in the paediatric and adult patients with neurogenic bladder dysfunction over a median follow-up of 4.5 years. There was no evidence for drug tolerance or changes in the morphological appearance of the bladder. Safety was good: no complications were associated with the injection procedure itself. Early in the treatment programme, three patients who received a dose of 1000 units Dysport showed systemic side-effects and generalized muscle weakness. These resolved without intervention and did not recur after reducing the adult dose to 750 units (paediatric dose 20 units/kg, not >400 units), which seems to be the optimum for good efficacy with an adequate safety margin.


CONCLUSIONS
BTX injection is a safe and effective treatment for neurogenic detrusor hyperreflexia. Repeat treatments are as effective as the first: there was no indication of a lack of efficacy due to tachyphylaxis, antibody formation, or fibrosis of the detrusor muscle in this sample.
Akbar
Michael
M
Department of Orthopaedic Surgery, University of Heidelberg, Heidelberg, Germany. Michael.Akbar@ok.uni-heidelberg.de
Abel
Rainer
R
Seyler
Thorsten M
TM
Bedke
Jens
J
Haferkamp
Axel
A
Gerner
Hans J
HJ
Möhring
Klaus
K
D000328:Adult; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage* / Q000009:adverse effects; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007267:Injections; D008297:Male; D009436:Neural Tube Defects / Q000150:complications* / Q000503:physiopathology; D009465:Neuromuscular Agents / Q000008:administration & dosage* / Q000009:adverse effects; D012189:Retrospective Studies; D013119:Spinal Cord Injuries / Q000150:complications* / Q000503:physiopathology; D016896:Treatment Outcome; D001750:Urinary Bladder, Neurogenic / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D014563:Urodynamics / Q000502:physiology
D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A