Summary and Case
Summary
Background: A 49-year old man initially underwent clam ileocystoplasty 14 years ago. A revision of this original procedure was required 11 years ago for intractable detrusor overactivity secondary to transverse myelitis; he experienced only temporary symptomatic improvement that lasted 6 months after each procedure. Despite the use of oral anticholinergic drugs, the patient subsequently needed to perform clean intermittent self-catheterization approximately 10 times every 24 h, and when he presented to our department, he still suffered from occasional episodes of urgency incontinence that required the regular use of a penile sheath.
Investigations: Symptom severity was assessed using a 4-day bladder diary.
Diagnosis: Cystometry confirmed the presence of terminal detrusor overactivity.
Management: After the patient provided his informed consent, he was treated as an outpatient with intradetrusor injections of botulinum toxin A, delivered under local anesthesia by a minimally invasive technique that used a flexible cystoscope. A significant improvement was noted in the patient's lower urinary tract symptoms, urodynamic parameters and quality of life, measured at 4 and 16 weeks after treatment. The patient was completely dry at both follow-up visits and was able to discontinue the use of anticholinergic drugs and the penile sheath for a total of 11 months.
The Case
A 49-year old man presented with a 17-year history of detrusor overactivity secondary to transverse myelitis, for which he underwent clam ileocystoplasty 14 years ago. He then needed a revision of the original procedure 3 years later. Both procedures provided symptomatic relief that lasted only 6 months. The patient continued to experience significant lower urinary tract symptoms (LUTS) and, when referred to our department, usually had to wear a penile sheath despite his use of clean intermittent self-catheterization (CISC) and oral anticholinergic agents.
His initial evaluation on presentation to our department included a 4-day bladder diary that assessed voiding frequency (mean number of CISCs in 24 h), urgency (mean number of CISCs associated with urgency in 24 h), and incontinence (mean number of urge incontinence episodes in 24 h). Standard subtraction cystometry was also performed after discontinuation of anticholinergic drugs for 10 days, to look for evidence of detrusor overactivity and determine the maximum cystometric capacity (MCC) and maximum detrusor pressure during bladder filling (Pdetmax). The effect of the patient's condition on his quality of life (QOL) was measured using the short forms of the Urogenital Distress Inventory and Incontinence Impact Questionnaire.
The bladder diary confirmed the presence of significant LUTS ( Table 1 ), which were attributed to terminal detrusor overactivity as demonstrated by the patient's cystometry findings (Figure 1A). Cystometry also showed a decrease in MCC and an increase in Pdetmax ( Table 1 ). The patient was distressed by his frequency and urge incontinence (as shown by a maximum score in Urogenital Distress Inventory questions 1 and 2), which had had a large effect on his physical and social activities (as shown by maximum scores in Incontinence Impact Questionnaire questions 2-5).[1]
Figure 1.
Changes in subtraction cystometry after treatment with BTX-A injections. (A) Terminal detrusor overactivity at reduced cystometric capacity was present before BTX-A treatment. (B) Restoration of maximum cystometric capacity to normal levels, and an improvement in filling detrusor pressure trace had occurred by 4 weeks post-treatment. (C) A further improvement, with almost complete abolition of detrusor overactivity, was noted at 16 weeks post-treatment. Note that the detrusor pressure values recorded here correspond to the end filling pressures, not to the maximum detrusor pressure. Abbreviations: Pabd (red), intra-abdominal pressure (cmH2O); Pdet (purple), detrusor pressure (cmH2O); Pves (light blue), intravesical pressure (cmH2O); Qura (yellow), flow rate of voiding; Vinfus (green), infused volume; Vura (dark blue), volume of voided urine.
After consultation and discussion about the possible major complications such as generalized muscle weakness, paralysis and the probable need for intensive care unit admission, the patient consented to treatment with intradetrusor injections of botulinum toxin A (BTX-A). After oral antibiotic prophylaxis (ciprofloxacin 500 mg, started immediately), 20 ml of 2% lignocaine gel was instilled into the patient's urethra. The bladder was accessed using a flexible cystoscope (CYF-4, Olympus Keymed, Milton Keynes, UK) that accommodates a flexible injection needle with a working length of 1,050 mm and a needle length of 4 mm (MAJ-656, Olympus Keymed). A total of 200 U of BTX-A (BOTOX® Allergan Ltd, UK) diluted in 20 ml of normal saline was injected via the cystoscope under local anesthesia, at 20 different sites into the bladder wall (sparing the trigone) as previously described,[2] and at least 1 cm away from the bowel-bladder anastomosis. The procedure was completed in 30 min. The patient graded his discomfort from these injections at 3 on the verbal 11-point Box Scale.[3]
The patient was discharged fit and well after a 24 h observation period, and given a 5-day course of prophylactic antibiotics (ciprofloxacin 500 mg twice daily). He was assessed 4 and 16 weeks after the procedure, with cystometry, a bladder diary, QOL questionnaires and cystoscopy, as at baseline. At 4 weeks, improvements were noted in all LUTS and in the QOL scores, which had improved further at 16 weeks ( Table 1 ). The patient was completely dry on CISC only at both follow-up visits, and did not require anticholinergic drugs or the use of a penile sheath. Urodynamic parameters showed progressive amelioration, with normalization of both MCC and Pdetmax at 16 weeks ( Table 1 and Figure 1A-1C), with an almost complete abolition of evidence of detrusor overactivity (Figure 1C). Both follow-up cystoscopies were unremarkable. There were no side effects of BTX-A treatment.
The patient reported a partial return of his LUTS 11 months after BTX-A treatment, which to date (currently 2 years after BTX-A treatment) have been successfully controlled with the addition of oral anticholinergic drugs. His neurological condition remains unchanged since pre-BTX-A screening.
Nat Clin Pract Urol. 2007;4(5):280-284. © 2007
Nature Publishing Group
Cite this: Successful Treatment with Botulinum Toxin A After Failed Augmentation Ileocystoplasty - Medscape - May 01, 2007.
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