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Can We Minimize The Need For Augmentation Cystoplasty Using Bladder Botulinum Toxin Injection In Combination With Oral Medications? A Large Single Center Experience Of A Pediatric Bladder Dysfunction Program
Kay Rivera, MD1, Mandy Rickard, NP
1, Ihtisham Ahmad, BSc
2, Zwetlana Rajesh, BSc
2, Max Freeman, BSc
2, Jin Kyu Kim, MD
2, Michael Chua, MD
1, Armando Lorenzo, MD
1, Joana Dos Santos, MD
1.
1The Hospital for Sick Children, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada.
BACKGROUND: Pediatric patients with neurogenic and non neurogenic voiding dysfunction, particularly patients with refractory urinary incontinence, bladder overactivity, small bladder capacity, and/or poor compliance, have traditionally been managed with augmentation cystoplasty. We describe our experience with our intradetrusor botulinum toxin injection program (IBTIP) to improve continence rates and video-urodynamics (VUDS) parameters in this population, with or without concomitant oral medication.
METHODS: We retrospectively reviewed our IBTIP pediatric and adolescent patients who underwent injections between 2011 and 2024. Outcomes included continence rates, medication utilization, and VUDS parameters before and after botulinum toxin treatments, as well as progression to bladder augmentation or other continence surgery.
RESULTS: We identified 144 patients (69 females), of which 139 (96.5%) underwent the procedure due to urinary incontinence; three (2.1%) had small contracted bladders, and two (1.4%) had refractory pelvic pain. The most common etiology was neurogenic bladder (NGB, n=120; 83%), followed by posterior urethral valves (n=10; 7%) and non-neurogenic overactive bladder (n=5; 4%); 134 patients (93.1%) were on intermittent catheterization. The median age at first Botulinum toxin injection was 9.5 years (IQR 8), with a median number of injections 3 (IQR 5), and a median follow up of 14 years (IQR 7). Complications were minimal (15 [10%] having UTIs, 2 [1%] reporting worsening constipation, and 4 [3%] reporting hematuria).
One hundred fifteen (80%) patients had improved continence, of which 45 (31%) were dry on botulinum toxin alone, and 86 (60%) were dry with the addition of oral medications. Of those without improvement with botulinum toxin, 8 (6%) were eventually dry with escalation in oral medications, and 9 (8%) required further surgery. Only 5 (3%) received an augmentation cystoplasty (Table 1).
There was no significant difference in rates of dryness between NGB versus non NGB patients (8 [33%] vs. 37 [31%], p=0.807). Patients were significantly more likely to be completely dry with more Botulinum toxin injections (5±3.5 vs 3.7 ±3.7, p=0.04). Significantly fewer patients were on any medication after botulinum toxin (p <0.01); moreover, there was a significant reduction in the use of oxybutynin (p<0.01), and increasing reliance on mirabegron (p<0.01) (Table 2). Bladder capacity had a median increase of 27% (IQR 18%) after botulinum toxin injection. There was a significant decrease in rates of small cystometric capacity (70 vs. 28; p <0.01) and overactivity (46 vs. 16; p<0.01) on post-botulinum toxin injection VUDS.
CONCLUSIONS:
Our long-term experience with the IBTIP program highlights its effectiveness in the treatment of recalcitrant neurogenic and nonneurogenic pediatric voiding dysfunction. Alone or in combination with oral medications, botulinum toxin yields significant, sustainable improvements in continence and urodynamics parameters, allowing the majority of patients to avoid an augmentation cystoplasty.
Table 1. Response to bladder botulinum toxin with or without medications | N=144 (%) |
| Improved continence: | 115 (80) |
| Dry with botulinum toxin alone | 45 (31) |
| Dry with botulinum toxin and medication | 86 (60) |
| No improvement with botulinum toxin: | |
| Dry with medication alone | 8 (6) |
| Proceeded to other surgery | 9 (8) |
| Bladder augmentation | 5 (3) |
| Sacral neuromodulation | 2 (1) |
| Urethral sling, bladder neck reconstruction | 2 (1) |
Table 2. Medication use before and after botulinum toxin | Before botulinum toxinN=144 | After botulinum toxinN=144 | p value |
| No medication | 17 (12) | 58 (40) | <0.01 |
| Oxybutynin | 92 (63) | 22 (15) | <0.01 |
| Solifenacin | 12 (8) | 21 (15) | 0.09 |
| Mirabegron | 11 (7) | 26 (18) | <0.01 |
| Solifenacin + mirabegron | 8 (5) | 14 (10) | ns |
| Oxybutynin + solifenacin | 0 (0) | 1 (0.5) | ns |
| Tolterodine | 3 (2) | 2 (1) | ns |
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