Efficacy of toxin-A Botulinum for treating intractable bladder hyperactivity in children affected by neuropathic bladder secondary to myelomeningocele: an alternative to enterocystoplasty]

AIM: To verify the efficacy of botulinus toxin A (TB-A) in treating children with neuropathic bladder secondary to myelomeningocele (MMC) with detrusor hyperactivity/low compliance, resistance to pharmacological therapy, and candidates for enterocystoplasty. METHODS: From January 2002 to June 2003, a group of 7 patients was selected (4 females, 3 males, mean age, 9.8 years, age range, 5-17 years) with detrusor hyperactivity, clean intermittent catheterization and resistance to pharmacological therapy. Two patients presented with grade 2-3 monolateral vesicoureteral reflux (VUR). All patients were incontinent despite catheterization. Botulinus toxin A was administered under general or local anesthesia by the injection of 200 IU of toxin diluted in 10 cc of physiologic solution with a metal or a flexible needle (3.7 F/21 GA). The needle was fully inserted into the detrusor muscle in about 20 sites, and 0.5 cc of solution were injected in each site, except the trigonum vesicae. Follow-up included ultrasound examination of the urinary tract and urodynamic studies performed at 6, 12 and 24 weeks and biannually thereafter. Micturition cystography was performed 3 months after the intervention. Urodynamic parameters were leak point pressure (LPP), leak point volume (LPV) and specific volume at 20 cm H2O pressure. The results were analyzed using the Wilcoxon test. RESULTS: A significant increase in LPV (range, 30-108%, mean, 77.6%) and in specific volume at 20 cm H2O pressure (CS 20) was observed in all patients. No significant change in LPP was found. One patient previously treated with the Cohen reimplantation technique experienced transient VUR which resolved spontaneously within 1 month. No major side effects from the injection of TB-A occurred. All patients were hospitalized for 24 hours with catheterization. CONCLUSIONS: The preliminary results in this small sample of patients suggest that the use of TB-A is efficacious in significantly improving urodynamic parameters and urine storage volume at low pressures in patients with neuropathic bladder resistant to pharmacological therapy.