從錄影尿路動力學尋找肉毒桿菌素在治療尿道擴約肌張力過強成功與否預測因子
陳聖復1、江元宏1、張嘉峰1、李振霖1郭漢崇1
1佛教花蓮慈濟綜合醫院泌尿部
Video-urodynamic predictive factors of successful urethral onabotulinumtoxinA treatment of neurogenic or non-neurogenic urethral sphincter hyperactivity
Sheng-Fu Chen1, Yuan-Hong Jiang1, Jia-Fong Jhang 1, Cheng-Ling Lee1, Hann-Chorng Kuo1
Department of Urology, Buddhist Tzu Chi General Hospital and Tzu Chi University1
Purpose: Urethral sphincter dysfunction may be neurogenic or non-neurogenic in origin, is a treatment challenge for urologists. In recent decades, urologists have used onabotulinumtoxinA injection into the urethral sphincter to treat such voiding dysfunction. However, urethral sphincter onabotulinumtoxinA injection for voiding dysfunction remains an off-label treatment, and not all patients have successful treatment results. In this study, we retrospectively analyzed recently treated patients to identify the video-urodynamic predictive factors for the success of onabotulinumtoxinA treatment in patients with voiding dysfunction due to urethral sphincter hyperactivity
Materials and Methods: This retrospective study enrolled patients from 2011 to 2016 who were examined for consecutive patients with voiding dysfunction due to urethral sphincter hyperactivity proved by video-urodynamic study refractory to medical treatment who were treated with 100 U of onabotulinumtoxinA (Allergan, Irvine, CA, USA) injected into the urethral sphincter. Any urinary tract infection was well controlled before treatment. Each 100-U vial of onabotulinumtoxinA was reconstituted to 4 mL with normal saline, making the concentration equivalent to 25 U/mL. The onabotulinumtoxinA was injected into the urethral sphincter at the 3, 6, 9, and 12-o’clock positions in approximately equal aliquots.
Treatment outcomes were assessed 1 month after urethral onabotulinumtoxinA injection. Patients were requested to report their global response assessment (GRA). Adverse events after onabotulinumtoxinA injections were also recorded and appropriate treatments were given if needed. The assessment parameters including International Prostate Symptom Score (IPSS), Qmax, voided volume and post void residual (PVR) were measured at baseline and 1 to 3 months after onabotulinumtoxinA treatment. The video-urodynamic variables were compared between patients with good and poor treatment outcomes. The changes of assessment parameters from baseline to post-treatment were also compared between patients with neurogenic and non-neurogenic urethral sphincter hyperactivity.
Results: Of the 95 patients of urethral sphincter hyperactivity, 53 had non-neurogenic (22 men and 31 women, aged 66.6 ± 16.9 years) and 42 had neurogenic etiologies (17 men and 25 women, aged 55.5 ± 19.7 years). After onabotulinumtoxinA injection, good outcomes were reported in 58 (61.1%) patients and poor outcomes, in 37 (38.9%). Table 1 lists the patient demographics, and Table 2 shows the baseline video-urodynamic characteristics. Treatment outcomes were not related to age, gender, or voiding dysfunction subtype
Patients with good outcomes had a significantly smaller volume at first sensation of filling (p=0.046), greater Pdet (p=0.027), higher Qmax (p=0.017) and smaller PVR (p=0.006). An open bladder neck during voiding was the only predictor of successful therapeutic outcome (88% good outcomes, 12% poor outcomes, p<0.001). Table 3 showed non-neurogenic voiding dysfunction had a significantly longer therapeutic duration than those with neurogenic voiding dysfunction (9.55±4.18 vs 7.44±2.91 months, p=0.033). In adverse effects, 18 patients reported increasing incontinence, including 6 with stress urinary incontinence and 12 with urgency urinary incontinence. Patients with neurogenic voiding dysfunction had significantly higher rates of developing de novo urinary incontinence (14 vs 4). De novo urinary tract infection was also observed in 12 (22.2%) patients overall.
Conclusions: OnabotulinumtoxinA urethral sphincter injection is effective in 61.1% of patients with voiding dysfunction due to neurogenic or non-neurogenic voiding dysfunction refractory to conventional medical treatment. Careful evaluation of the bladder neck opening at baseline provides predictive value for a successful treatment outcome. However, urinary incontinence might be a de novo adverse event after the urethral sphincter onabotulinumtoxinA injections.