MP47: Therapeutic effects of botulinum toxin a urethral sphincter injection on voiding dysfunction due to different bladder and urethral sphincter dysfunction
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膀胱及尿道括約肌功能障礙所引起之排尿障礙對於尿道括約肌肉毒桿菌注射的治療成效
王脩仁、李宇坤、郭漢崇
花蓮慈濟醫院 泌尿部
Therapeutic Effects of Botulinum Toxin A Urethral Sphincter Injection on Voiding Dysfunction due to Different Bladder and Urethral Sphincter Dysfunction
Hsiu-Jen Wang, Yu-Khun Lee, Hann-Chrong Kuo
Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan  
 
Purpose: To analyze treatment outcomes and identify predictive factors for urethral botulinum toxin A (BoNT-A) treatment of voiding dysfunction.
Materials and Methods: Patients with voiding dysfunction refractory to medical treatment were treated with injections totaling 100 U of BoNT-A into the urethral sphincter. Treatment outcomes were assessed at 1 month by Global Response Assessment and was analyzed by demographic and video-urodynamic study (VUDS).
Results: Eighty patients with non-neurogenic and 75 with neurogenic bladder dysfunction were included. Good outcomes were reported in 92 (59.4%) patients. Table 1 reveals treatment outcome was not related to gender, voiding dysfunction subtype, bladder function, or sphincter function. VUDS revealed baseline Qmax and an open bladder neck (BN) during voiding showed significant difference between groups (Table 2). An open BN was noted in 89 (96.7%) in 92 patients with successful outcome and tight BN in 54 (85.7%) who failed treatment (p<0.001). Patients with a successful outcome had significantly higher Qmax than those with failed outcome (p = 0.031). In patients with NNVD and non-DU, patients with successful outcomes had significantly higher Pdet than those with failed outcomes (p = 0.013). In patients without detrusor underactivity and non-neurogenic voiding dysfunction, those with good outcomes had significantly higher Pdet (p = 0.006). Significantly more patients with a successful outcome had an open BN during VUDS than those with a failed outcome. (Table 3)
Conclusions: BoNT-A urethral sphincter injection is effective in about 60% of patients with neurogenic or non-neurogenic voiding dysfunction.
 
 
Table 1. Treatment outcome according to patient characteristics at baseline
 
 
N
Good
outcome
Poor
outcome
P value
VD subtype
Idiopathic VD
Neurogenic VD
80
75
50 (62.5%)
42 (56%)
30 (37.5%)
33 (44%)
0.255
Gender
Male
Female
54
99
34 (59.3%)
60 (60.6%)
22 (40.7%)
39 (39.4%)
0.445
Bladder function
DO
DU
DHIC
HSB
57
59
25
14
36 (63.2%)
34 (57.6%)
15 (60%)
7 (50%)
21 (36.8%)
25 (42.4%)
10 (40%)
7 (50%)
0.819
Sphincter function
DV
DSD
Non-relaxing ES
115
23
7
70 (60.9%)
14 (60.9%)
8 (47.1%)
45 (39.1%)
9 (39.1%)
9 (52.9%)
0.550
VD, voiding dysfunction; DO, detrusor overactivity; DU, detrusor underactivity; DHIC, detrusor hyperreflexia and inadequate contractility; HSB, hypersensitive bladder; DV, dysfunctional voiding; DSD, detrusor sphincter dyssynergia; ES, external sphincter.
 
 
 
Table 2. The video-urodynamic characteristics between patients with good and poor treatment outcomes
 
Good outcome
Poor outcome
P value
 
(n=92)
(n=63)
 
Age (years)
62 ± 18.8
64.7 ± 20.3
0.692
First sensation of filling (mL)
140.1 ± 73.0
132 ± 74.6
0.792
Cystometric bladder capacity
338 ± 142
267 ± 135
0.153
Detrusor pressure (cmH2O)
25.2 ± 25.2
39.0 ± 40.7
0.344
Abdominal pressure (cmH2O)
36.7 ± 36.3
34.3 ± 38.1
0.860
Maximum flow rate (mL/s)
6.76 ± 5.19
2.89 ± 3.52
0.031
Post void residual volume (mL)
218 ± 5.19
202 ± 151
0.799
Open bladder neck
89 (90.8%)
9 (9.2%)
<0.001
Open BN      DU
          Non-DU
34 (94.4%)
55 (88.7%)
2 (5.6%)
7 (11.3%)
0.287
Tight BN       DU
          Non-DU
2 (7.7%)
1 (3.2%)
24 (24.6%)
30 (96.8%)
0.433
DO, detrusor overactivity; DU, detrusor underactivity; BN, bladder neck.
 
 
Table 3. Comparison of the baseline video-urodynamic parameters between patients with successful and failed treatment outcomes in different bladder and urethral sphincter dysfunctions
 
 
 
FSF/FS
(mL)
CBC
(mL)
Pdet
(cmH2O)
Pabd
(cmH2O)
Qmax
(mL/s)
PVR
(mL)
BN condition
Tight        Open
NVD-
non-DU
(n=42)       
S
F
p
111±52.3
157±80.7
0.050
262±129
381±149
0.010
32.1±26.7
26.0±22.2
0.456
18.9±18.8
26.0±26.1
0.316
7.22±6.03
3.60±3.94
0.044
162±124
285±174
0.011
1(8.3%)
11(91.7%)
26(86.7%)
4(13.3%)
0.000
NVD-DU  
(n=33)
S
F
p
182±104
230±91.6
0.174
384±150
431±124
0.336
6.06±8.65
2.53±4.03
0.139
71.3±47.0
68.2±35.9
0.837
4.50±4.26
3.76±3.62
0.596
253±143
329±161
0.164
0(0.0%)
16(100%)
16(94.1%)
1(5.9%)
0.000
NNVD- non-DU
(n=53)
S
F
p
132±52.8
141±57.0
0.576
350±140
343±109
0.836
39.6±28.9
23.2±17.5
0.013
29.4±32.6
39.1±29.7
0.272
8.00±4.08
6.23±4.57
0.144
176±137
228±129
0.168
1(5.3%)
18(94.7%)
30(88.2%)
4(11.8%)
0.000
NNVD-DU
(n=27)
S
F
p
161±72.4
180±79.0
0.563
373±115
360±171
0.815
7.85±8.20
7.86±7.56
0.998
40.0±27.3
34.3±40.7
0.679
4.90±5.57
3.57±3.87
0.567
275±171
274±182
0.993
3(33.3%)
6(66.7%)
17(94.4%)
1(5.6%)
0.002
NVD-DV  
(n=52)
S
F
p
145±66.4
215±96.7
0.013
323±151
450±149
0.008
19.9±25.3
9.89±14.9
0.139
38.5±35.4
49.4±37.5
0.329
6.04±6.33
3.50±3.43
0.129
202±130
328±177
0.016
1(5.9%)
16(94.1)
25(92.6%)
2(7.4%)
0.000
NVD-DSD  
(n=23)
S
F
p
113±102
168±83.8
0.152
261±134
344±102
0.099
29.7±24.8
21.8±25.6
0.435
31.4±42.5
44.6±43.9
0.450
7.33±3.74
3.91±4.39
0.042
157±124
289±148
0.021
0(0.0%)
8(100%)
15(83.3%)
3(16.7%)
0.000
NNVD-DV
(n=74)
S
F
p
144±63.4
149±66.0
0.735
361±132
349±127
0.709
28.1±28.0
20.9±17.0
0.175
31.4±29.1
40.6±32.7
0.218
6.92±4.96
5.77±4.48
0.327
213±160
237±135
0.514
4(14.8%)
23(85.2%)
45(93.8)
3(6.3%)
0.000
NNVD-NR
(n=6)
S
F
p
138±17.7
183±38.9
0.275
304±65.1
305±134
0.993
5.00±0.00
0.00±0.00
0.218
85.0±35.4
12.5±10.6
0.109
3.50±2.12
1.00±1.41
0.300
250±70.7
350±212
0.592
0(0.0%)
1(100%)
2(66.7%)
1(33.3%)
1.000
 
FSF: first sensation of filling, FS: full sensation, CBC: cystometric bladder capacity, Pdet: detrusor pressure, Pabd: abdominal pressure, Qmax: maximum, flow rate, PVR: postvoid residual, BN: bladder neck DO: detrusor overactivity, NVD: neurogenic voiding dysfunction, NNVD: non-neurogenic voiding dysfunction, DU: detrusor underactivity, DV, dysfunctional voiding; DSD, detrusor sphincter dyssynergia; NR: non-relaxing external sphincter, S: successful outcome, F: failed outcome
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