非脊髓神經源性排尿功能障礙女性患者接受尿道括約肌A型肉毒桿菌毒素注射治療後的臨床療效及尿動力學預測因子

張天霖、郭漢崇

佛教慈濟醫療財團法人花蓮慈濟醫院 泌尿部

Clinical Efficacy and Urodynamic Predictors of Successful Treatment Outcomes Following Urethral Sphincter Botulinum Toxin A Injection in Women with Non-Spinal Cord Neurogenic Voiding Dysfunction

Tien-Lin Chang, Hann-Chorng Kuo

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

Purpose: Neurogenic voiding dysfunction caused by neurological diseases is frequently encountered in clinical practice. This study aimed to evaluate the clinical efficacy and identify urodynamic predictors of a successful outcome following urethral sphincter botulinum toxin A (BoNT-A) injection in women with this condition.

Materials and Methods: This is a retrospective cohort study. Women diagnosed with non-spinal cord neurogenic voiding dysfunction who presented with difficulty voiding and significant post-void residual (PVR) urine volume received 100 units of BoNT-A via urethral sphincter injection. The primary outcome was assessed 3 months posttreatment. Treatment success was defined as improved voiding function with voiding efficiency (VE) >67% and elimination of catheterization. Patients not meeting these criteria were classified as treatment failures. Baseline videourodynamic parameters were analyzed to identify differences between successful and unsuccessful treatment groups. Multivariate logistic regression was employed to determine independent predictors of treatment success.

Results: A total of 158 women were enrolled, including 35 with cerebrovascular disease, 22 with Parkinson’s disease, 10 with dementia, and 91 with peripheral nervous system disorders.Only 28.5% achieved a successful outcome, while 40.5% showed partial improvement but continued to experience high PVR and required catheterization. Women in the success group exhibited significantly higher baseline voiding pressures (Pdet), maximum flow rates (Qmax), and VE, along with lower PVR volumes, compared with those in the failure group. Urethral sphincter discoordination was associated with higher success rates, whereas detrusor underactivity, tight bladder neck, and poor external sphincter relaxation were linked to poorer outcomes. At 3 months following urethral BoNT-A injection, 45 patients (28.5%) showed a successful response, defined as Grade 2 (n = 40, 25.3%) or Grade 3 (n = 5, 3.2%) improvement in voiding difficulty. An additional 64 patients (40.5%) experienced reduced voiding difficulty, although many continued to have high PVR volumes and required CIC. The remaining 49 patients (31.0%) showed no improvement in symptoms. Regarding treatment outcomes by baseline VUDS diagnosis, success rates (Grade 2 or 3 improvement) were observed in 5.6% (4/71) of patients with DU or DA, 49.4% (38/77) of those with DO, none with BND, 62.5% (35/56) with urethral sphincter discoordination, and 11.0% (10/91) with PRES (Table 1). The adverse events after urethral BoNT-A injection were minimal, among the 158 patients, only 3 had mild bleeding at the injection sites, which were resolved spontaneously. No patients developed urinary tract infection or other complications related with this minor procedure. Logistic regression analysis identified higher baseline P_det and Q_max as independent predictors of successful treatment (Table 2).

Conclusions: This study offers important guidance for clinicians in selecting suitable candidates with neurogenic voiding dysfunction for urethral BoNT-A injection. Patients exhibiting DU or DA, BND or PRES as well as low baseline values of detrusor pressure (P_det), maximum flow rate (Q_max), VE, BOOI, BCI, and large CBC and PVR are less likely to benefit from this treatment. Conversely, a higher baseline voiding P_det and smaller PVR are predictive of a successful outcome following urethral BoNT-A injection in women with neurogenic voiding dysfunction.

Table 1. Treatment outcomes following urethral botulinum toxin A injection in women with neurogenic voiding dysfunction

CVA: cerebrovascular accident, PD: Parkinson’s disease, DU: detrusor underactivity, DA: detrusor acontractile, DO: detrusor overactivity, BND: bladder neck dysfunction, USD: urethral sphincter discoordination, PRES: poor external sphincter relaxation, Pdet: detrusor pressure, Qmax: maximum flow rate, PVR: post-void residual, CBC: cystometric bladder capacity, VE: voiding efficiency, BOOI: bladder outlet obstruction index, BCI: bladder contractility index

Table 2. Logistic regression analysis of predictive factors for treatment response to urethral botulinum toxin A injection in women with neurogenic voiding dysfunction

BCI: bladder contractility index, BOOI: bladder outlet obstruction index, CBC: cystometric bladder capacity, Pdet: detrusor pressure, PVR: post-void residual, Qmax: maximum flow rate, VE: voiding efficiency, VUDS: videourodynamic study