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S22-12
(P)
ENDOSCOPIC BOTULINUM TOXIN INJECTION FOR NEUROPATHIC BLADDER
DYSFUNCTION: IS INTRA-DETRUSOR DELIVERY TRULY HAPPENING?
Fahad ALYAMI, Paul R. BOWLIN, Darius BAGLI, Martin A. KOYLE and Armando J. LORENZO
THE HOSPITAL FOR SICK CHILDREN, UNIVERSITY OF TORONTO, UROLOGY, Toronto, CANADA
PURPOSE
Botulinum neurotoxin A (BoNT/A) treatment has become a viable option for patients with neuropathic bladder
dysfunction (NPBD) who fail medical management. Bladder BoNT/A injection mechanism of action is thought to be
mediated by chemodenervation of the bladder muscle. Intra-detrusor (ID) and submucosal (SM) injections techniques
has been described. By creating a SM bleb, visual confirmation of insertion depth provides assurance, in contrast to the
ID delivery, which relies solely on estimated depth of injection. In the present study we describe concurrent ultrasound
(US) assessment at the time of BoNT/A bladder injection and correlate sonographic with endoscopic findings.
MATERIAL AND METHODS
Between January and May 2014 we performed cystoscopy and BoNT/A injection with US surveillance in a total of 8
patients with NPBD who were on maintenance BoNT/A program. All procedures were done under general anesthesia, by
one surgeon, and trans-abdominal US was performed. When feasible, we employed the US images to determine depth
and position of the injection, segregated based on the surgeon's impression of a SM and the ID delivery by endoscopy
(blinded to findings on US). We only included data for injection sites with visualization on both modalities.
RESULTS
We included 8 patients with an age range of 5-12 years. There were no reported complications and all patients reported
stable response on follow-up. We confirmed the injections site accurately with US in 39/40 (97%) and 5/23 (22%) in
the SM and ID space respectively. No cases of intra-peritoneal delivery were encountered.
CONCLUSIONS
This study demonstrates that trans-abdominal US-guided bladder BoNT/A injection may provide additional information
regarding depth. By US evaluation, it appears that SM delivery is reliable based on visual cues, whilst ID attempts often
result in delivery outside of the detrusor muscle. If accurate ID delivery is preferred, intra-operative US provides a
novel, non-invasive way of obtaining real-time feedback.