title: Single-center experience with botulinum toxin endoscopic detrusor injection for the treatment of congenital neuropathic bladder in children: effect of dose adjustment, multiple injections, and avoidance of reconstructive procedures.
abstract: OBJECTIVE
  Since 2007, intra-detrusor OnabotulinumtoxinA (OnabotA) injections have been selectively offered at our institution for cases in which maximal anticholinergic therapy failed or was not tolerated. Herein we present our experience with this approach.
  
  
  METHODS
  We prospectively obtained data on 17 patients who underwent OnabotA injections over a 4-year period. Demographic information, number of injections, and dose delivered were captured. Children were monitored with baseline and post-injection renal ultrasound, urodynamics, and assessed for side effects, satisfaction, and symptom improvement.
  
  
  RESULTS
  Forty-three sessions were performed with injections given every ∼ 6 months. Mean patient age was 10.7 years (range, 3-17). Compared with baseline, after the first injection, mean bladder capacity adjusted for age and compliance improved by 27% (p = 0.039) and 45.2% (p = 0.041), respectively. After subsequent injections, these values increased to 35.7% (p = 0.043) and 55.1% (p = 0.091), respectively. Out of 13 symptomatic patients, ≥ 50% improvement was reported in ten (76.9%) and complete resolution in seven (53.8%). However, all three patients in whom the maximum dose of OnabotA was reduced from 300 to 200 units complained of recurrent symptoms. Fourteen children avoided surgical reconstruction as a second line of treatment. Overall patient/parental reported satisfaction rate was 70.6% (12/17).
  
  
  CONCLUSIONS
  Intra-detrusor OnabotA injection is a promising intervention for management of neuropathic bladder in selected patients. Our data demonstrate improvement in symptoms and urodynamic parameters. Although an optimal dose has not been determined for children, we found optimal response with a maximum administration of OnabotA up to 300 units.
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
authors.forename: V
authors.initials: V
authors.lastname: Figueroa
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Romao
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
authors.forename: J L
authors.initials: JL
authors.lastname: Pippi Salle
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
authors.forename: M A
authors.initials: MA
authors.lastname: Koyle
authors.affiliation: Division of Urology, McMaster Children's Hospital and McMaster University, Hamilton, ON, Canada.
authors.forename: L H P
authors.initials: LH
authors.lastname: Braga
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
authors.forename: D J
authors.initials: DJ
authors.lastname: Bägli
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada. Electronic address: armando.lorenzo@sickkids.ca.
authors.forename: A J
authors.initials: AJ
authors.lastname: Lorenzo
mesh_terms: D000283:Administration, Intravesical; D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D002170:Canada; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003558:Cystoscopy / Q000379:methods; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006776:Hospitals, Pediatric; D006801:Humans; D008297:Male; D020714:Maximum Tolerated Dose; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D061214:Patient Safety; D011446:Prospective Studies; D019651:Plastic Surgery Procedures; D018570:Risk Assessment; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D001750:Urinary Bladder, Neurogenic / Q000151:congenital* / Q000188:drug therapy* / Q000503:physiopathology; D014563:Urodynamics
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A
keywords: Children; Incontinence; Intravesical drug administration; Neuropathic bladder; OnabotulinumtoxinA