脊髓損傷合併神經性逼尿肌過動症患者接受逼尿肌肉毒桿菌毒素A注射之治療療效與預測因子

郭漢崇¹、黃子修¹、江元宏¹、張嘉峰¹、林琮翊¹、李雨霜¹、楊家誠¹、劉民慶¹、游婉茹²、張天霖¹

佛教慈濟醫療財團法人花蓮慈濟醫院 泌尿部, 護理部

 Therapeutic Efficacy and Predictive Factors of Detrusor Botulinum Toxin A in Patients with Spinal Cord Injury and Neurogenic Detrusor Overactivity

 Hann-Chorng Kuo¹, Tsu-Hsiu Huang¹, Yuan-Hong Jiang¹, Jia-Fong Jhang¹, Tsung-Yi Lin¹, Yu-Shuang Lee¹, Chia-Cheng Yang¹, Ming-Ching Liu¹, Wan-Ru Yu², Tien-Lin Chang¹

 ¹ Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan;

² Department of Nursing, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan

Purpose:  Neurological diseases and spinal injuries frequently impair lower urinary tract function and lead to neurogenic bladder. Spinal cord lesions (SCL) interrupt the neural pathways that coordinate bladder filling and emptying, resulting in neurogenic detrusor overactivity (NDO) with or without detrusor sphincter dyssynergia (DSD). To date, no study has specifically examined predictors of treatment success for intradetrusor Botox in SCL-related NDO. This study aimed to evaluate the therapeutic effects of intradetrusor Botox injections and to identify predictors of response in this population.

Materials and Methods: We retrospectively reviewed 167 patients with NDO underwent detrusor BoNT-A injection at our institution in recent 22 years. Therapeutic efficacy was evaluated by subjective satisfaction (global response assessment, GRA ≥ 2) in urgency, incontinence symptoms, or autonomic dysreflexia symptoms). The success rate was compared among patients with different SCI levels and lower urinary tract dysfunction. Multivariate logistic regression was performed to find out predictive factors for a successful outcome (GRA= 2 or 3).

Results: The mean age of the cohort was 40.9 ± 14 years, with a predominance of male patients (65.3%). Patients were categorized by neurological level into cervical and thoracic <T6 (n = 70), thoracic ≥T6 (n = 87), and lumbosacral (L + S, n = 10) subgroups. Terminal DO was detected in 92.8% of all patients, while DU, BND, and low bladder compliance were observed in 21.6%, 12.6%, and 5.4%, respectively. The distribution of DSD subtypes was as follows: type I (28.1%), type II (37.7%), and type III (32.9%). Treatment outcomes by GRA category did not differ significantly across lesion levels (GRA = 3 in 54.3% vs 50.6% vs 30.0%, P = 0.665). Age was the only variable that differed across lesion levels, with significantly older patients in the C and <T6 subgroup (P = 0.001). Sex distribution and the prevalence of DO, DU, BND, low compliance, and DSD subtypes were similar across lesion levels. Urodynamic parameters also showed no significant differences among lesion levels, except for a borderline lower BCI in the L + S subgroup (P = 0.050). Table 1 shows the baseline characteristics and videourodynamic parameters in patients with different GRA. Regarding preoperative urodynamic parameters, patients in the successful group exhibited a higher detrusor pressure (41.9±20.3 cmH₂O vs. 22.9±13.4 cmH₂O, p <0.001), lower voiding efficiency (0.28±0.31 vs. 0.40±0.35, p =0.045), higher bladder outlet obstruction index (33.2±21.9 vs. 12.7±15.2, p <0.001), and higher bladder contractility index (63.6±33.0 vs. 48.4±27.9, p =0.010) compared with the unsuccessful group (Table 2).

Conclusion: Detrusor BoNT-A injection provided effective symptom control in SCI patients with NDO, with a 76.6% success rate after the first treatment. Female sex, higher detrusor pressure, higher BOOI and BCI, lower VE are associated with better therapeutic response.