Technical aspects of botulinum toxin type A injection in the bladder to treat urinary incontinence: reviewing the procedure.
OBJECTIVE
Standardise the injection technique with botulinum toxin type A (BoNT A) in the bladder of patients with overactive bladder (OAB) [idiopathic overactive bladder (iOAB) or neurogenic overactive bladder (nOAB) with urinary incontinence], using a literature review and a survey of an International expert panel.


METHODS
PubMed literature searches of BoNT A in adults with iOAB/nOAB together with a survey of 13 experts from 10 countries.


RESULTS
Data from 21 articles and completed questionnaires were collated. The procedure can be carried out in an out-/inpatient setting. Dose used in clinical studies vs. clinical practice was 300 and 200 U for nOAB and 200 and 100 U for iOAB. Recent studies have also demonstrated that there are no clinically relevant benefits between 100 and 150 U in iOAB or between 300 and 200 U in nOAB, though adverse effects are increased with higher doses. Usually, 30 sites for nOAB (range: 6.7-10 U/ml) and 20-30 sites for iOAB (range: 5-10 U/ml) are injected in clinical studies vs. 20-30 sites of 1 ml/injection for 200 U in nOAB and 10-20 sites of 0.5-1 ml/injection for 100 U in iOAB in clinical practice. BoNT A is usually injected directly into the detrusor, sparing the trigone. Flexible or rigid cystoscopes are used. The needle should be typically 22-27 gauge and 4 mm in length and should have a stopper to avoid any leakage or perforation of the bladder wall while ensuring a targeted injection.


CONCLUSIONS
Based on the literature and survey analysis, recommendations are proposed for the standardisation of the injection procedure.
Urology and Kidney Transplantation, Aix Marseille University, Marseille, France.
G
G
Karsenty
R
R
Baverstock
K
K
Carlson
D C
DC
Diaz
F
F
Cruz
R
R
Dmochowski
S
S
Fulford
A
A
Giannantoni
J
J
Heesakkers
A
A
Kaufmann
L
L
Peyrat
J
J
Thavaseelan
P
P
Dasgupta
D000283:Administration, Intravesical; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D009465:Neuromuscular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D011795:Surveys and Questionnaires; D001743:Urinary Bladder; D001750:Urinary Bladder, Neurogenic / Q000188:drug therapy*; D053201:Urinary Bladder, Overactive / Q000188:drug therapy*; D014549:Urinary Incontinence / Q000188:drug therapy*
D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A