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Long-Term Continence Rates And Video-Urodynamics Parameters Before And After Intra-Detrusor Botulinum Toxin Injection In A Large Cohort Of Pediatric And Adolescent Neurogenic Bladder Patients
Kay Rivera, MD1, Mandy Rickard, NP
1, Ihtisham Ahmad, BSc
2, Zwetlana Rajesh, BSc
2, Abby Varghese, NP
1, 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: Intra-detrusor injections of botulinum toxin A for treatment of neurogenic bladder conditions, including detrusor overactivity, urinary incontinence, or overactive bladder, is well described in adults, while available data for pediatric patients is limited. Herein, we offer long-term data on the effect of bladder botulinum toxin injections in pediatric neurogenic bladder dysfunction, focusing on continence rates and video-urodynamic (VUDS) parameters.
METHODS: We performed a retrospective chart review of neurogenic bladder patients who were seen at our institution between 2011 and 2024. We captured demographic variables as well as improvement in continence, defined as ≥ 50% improvement in incontinence episodes, and VUDS parameters before and after intra-detrusor botulinum toxin injections, including cystometric capacity, bladder compliance, and presence of detrusor overactivity.
RESULTS: We identified 120 neurogenic bladder patients (63 male). The most common underlying etiology was myelomeningococele (88 patients ; 73.3%), followed by caudal regression (5%) and post-surgical neuropathic damage (4.2%). The median age at initial referral was 359.5 days, and median age at first botulinum toxin injection was 10 years old (IQR 8.6). The median number of injections was 3 (IQR 5) with a median follow-up of 15 years (IQR 6.8).
Ninety-six (80.0%) reported improved continence following injections. Of these, 37 (30.8%) reported complete resolution of incontinence without the need for adjuvant oral medications. Five (4.2%) patients reported no improvement and 6 (5%) reported an initial positive effect on incontinence, but decreasing efficacy with succeeding injections. The most common range of interval between injections was 3-6 months. Four months (5%) and six months (5%) were the most commonly identified time periods for worsening or recurrence of symptoms by patient report. With regard to complications, 13 (10.8%) patients had UTIs, 2(1.7%) described worsened constipation and 3 (2.5%) had bothersome hematuria.
There was a significant reduction in the number of patients with reduced bladder capacity before and after injection (59 [57%] vs. 24 [31%]; p < 0.01) (Table 1), with a increase in bladder capacity of 27% (IQR 15%). We also noted significant decreases in rates of reduced bladder compliance (p 0.04) and detrusor overactivity (0.01). There were no significant changes in appearance of bladder contour (p 0.08) or trabeculations (p 0.87) on voiding cystourethrogram, nor on rates of high-grade reflux before and after botulinum toxin injection (p 0.73)
CONCLUSIONS:Our data demonstrates that intra-detrusor botulinum toxin injections are a safe and effective intervention to improve continence rates, bladder capacity, compliance, and detrusor overactivity in pediatric patients with neurogenic bladder. These long-term data support the value of botulinum toxin injections in children, which should be considered as part of the options for standard of care.
Table 1. Urodynamics parameters | | Preop VUDS n= 104 (%) | Postop VUDSn= 77 | p |
| Bladder capacity | Normal bladder capacity | 40 (38) | 49 (64) | <0.01 |
| Bladder capacity low for age 59 (57) | 59 (57) | 24 (31) | <0.01 |
| Bladder compliance | Normal | 35 (34) | 47 (61) | <0.01 |
| Reduced | 44 (42) | 21 (31) | 0.04 |
| Detrusor activity on filling | Normal | 44 (42) | 58 (75) | <0.01 |
| Overactive | 39 (38) | 14 (18) | 0.01 |
Table 2. Voiding cystourethrogram parameters and imaging characteristics | | Preop VCUGn= 104 (%) | Postop VCUGn= 77 (%) | p |
| Bladder wall contour | Smooth | 25 (24) | 28 (36) | 0.08 |
| Trabeculated | 46 (44) | 35 (45) | 0.87 |
| Diverticulae | Yes | 10 (10) | 9 (12) | 0.65 |
| No | 61 (59) | 54 (70) | 0.11 |
| High grade VUR (>/=3) | | 21 (20) | 14 (18) | 0.73 |
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