title: Concomitant repeated intravesical injections of botulinum toxin-type A and laparoscopic antegrade continence enema; a new solution for an old problem.
abstract: OBJECTIVE
  To report our experience of treating bladder and bowel dysfunction in children with myelomeningocele, with simultaneous laparoscopic antegrade continence enema (LACE) and repeated intravesical injection of botulinum toxin-type A (BTX-A).
  
  
  METHODS
  Six girls and 14 boys (mean age, 8.7 years) with myelomeningocele were included in this study. All patients had received one or two intravesical injection(s) of BTX-A, but had persistent fecal incontinence or constipation despite improved urinary symptoms. We performed a two-port laparoscopic appendicostomy, immediately after repeated intravesical injection of BTX-A, through a V-shaped skin flap at McBurney's point. The stoma was finally covered by a quadrilateral skin flap, using the 'VQ' technique. The degree of urinary incontinence and bowel dysfunction were determined in each patient, and conventional urodynamic studies were performed 4 months after each injection.
  
  
  RESULTS
  All patients were followed-up for a mean (range) of 19.1 (14-33) months. Urinary continence improved significantly after the first injection, and remained constant after repeat injections. The maximum detrusor pressure, bladder compliance and capacity improved significantly (P < 0.001) compared with baseline. Interestingly, the simultaneous intravesical BTX-A injection/LACE procedure significantly improved all urodynamic variables compared with the values obtained after the last BTX-A injection alone. The laparoscopic procedure was well tolerated, and 19 (95%) children were nappy-free at the final follow-up. Only two patients had stoma stenosis, and one patient had minor stoma leakage.
  
  
  CONCLUSIONS
  Concomitant repeat intravesical injection of BTX-A and LACE can effectively manage bladder and bowel dysfunction in children with myelomeningocele. The procedure may further contribute to improve bladder urodynamic function, as effective evacuation of the bowel provides more room for bladder distension.
authors.affiliation: Paediatric Urology Research Center, Department of Urology, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: AbdolMohammad
authors.initials: A
authors.lastname: Kajbafzadeh
authors.forename: Amir Hassan
authors.initials: AH
authors.lastname: Mahboubi
authors.forename: Seyedmehdi
authors.initials: S
authors.lastname: Payabvash
mesh_terms: D000283:Administration, Intravesical; D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D004733:Enema / Q000379:methods*; D005242:Fecal Incontinence / Q000150:complications / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008591:Meningomyelocele / Q000150:complications / Q000628:therapy*; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000150:complications / Q000188:drug therapy*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A