Tow Adela M, Toh Khai-Lee, Chan Siew-Pang, Consigliere David
Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore.
Ann Acad Med Singap. 2007 Jan;36(1):11-7.
Managing neurogenic detrusor overactivity (NDO) successfully in spinal cord-injured patients is a challenge. The aims of preserving kidney function by achieving safe bladder pressures with anticholinergic medication often leave a significant proportion of patients with side effects. Botulinum toxin type A has been shown to be a promising alternative.
Spinal cord injury patients who had NDO, on clean intermittent self-catheterisation, and were refractory to oral medications, were recruited. Three hundred units of botulinum toxin type A (Botox) in 30 mL NaCl solution were injected under cystoscopic guidance into the bladder.
Fifteen patients were recruited of whom 9 were tetraplegic and 6 were paraplegic. Eleven (73.3%) had complete injuries. There was a significant reduction in the mean number of leakages from 3.75 +/- 1.79 pre-injection to 0.67 +/- 1.31 and 1.5 +/- 1.5 at 6 and 26 weeks postinjection, respectively (P <0.05). Seventy-five per cent, 37.5% and 50% were completely dry at 6, 26 and 39 weeks post-injection, respectively. The mean maximal catheterisable volume increased from 312.3 +/- 145.6 mL pre-injection to 484.6 +/- 190 mL, 422.3 +/- 157.3 mL and 490.0 +/- 230.4 mL at 6, 26 and 39 weeks post-injection, respectively (P <0.005). Maximum detrusor pressure decreased significantly from 66.3 +/- 22.6 cmH2O to 21.2 +/- 23.1 cmH2O and 33.6 +/- 30.2 cmH2O at 6 and 26 weeks post-injection, respectively (P <0.05). The volume at which reflex detrusor contractions first occurred increased from 127.8 +/- 57.5 mL pre-injury to 305.7 +/- 130.8 mL at 6 weeks and 288.3 +/- 13.0 mL at 26 weeks post-injection (P <0.05). Mean cysometric bladder capacity increased from 187.8 +/- 69.2 mL to 305 +/- 136.4 mL and 288.3 +/- 13.0 mL at 6 and 26 weeks post-injury, respectively (P <0.05). Sixty per cent of patients were completely off medications at 6 and 26 weeks post-injection. One patient had urinary tract infection and 1 experienced autonomic dysreflexia during cystoscopy. Satisfaction levels increased from 4.3 +/- 2.3 pre-injury to 7.2 +/- 1.9 and 7.3 +/- 2.3 at 6 weeks and 26 weeks, respectively. This also correlated with fewer leakages.
Botulinum toxin type A injected into the detrusor is safe and efficacious for spinal cord injured patients with refractory detrusor overactivity. This effect is maintained at 26 weeks post-injection.
成功管理脊髓损伤患者的神经源性逼尿肌过度活动（NDO）是一项挑战。使用抗胆碱能药物实现安全的膀胱压力以保护肾功能的目标，往往会使很大一部分患者出现副作用。A型肉毒杆菌毒素已被证明是一种有前景的替代方法。
招募患有NDO、进行清洁间歇性自我导尿且对口服药物难治的脊髓损伤患者。在膀胱镜引导下，将300单位A型肉毒杆菌毒素（保妥适）溶于30 mL氯化钠溶液中注入膀胱。
共招募了15名患者，其中9名是四肢瘫痪患者，6名是截瘫患者。11名（73.3%）患者为完全性损伤。平均漏尿次数从注射前的3.75±1.79次显著减少至注射后6周时的0.67±1.31次和26周时的1.5±1.5次（P<0.05）。分别有75%、37.5%和50%的患者在注射后6周、26周和39周时完全无漏尿。平均最大可导尿量从注射前的312.3±145.6 mL分别增加至注射后6周时的484.6±190 mL、26周时的422.3±157.3 mL和39周时的490.0±230.4 mL（P<0.005）。最大逼尿肌压力在注射后6周时从66.3±22.6 cmH₂O显著降至21.2±23.1 cmH₂O，在26周时降至33.6±30.2 cmH₂O（P<0.0）。反射性逼尿肌收缩首次出现时的尿量从损伤前的127.8±57.5 mL增加至注射后6周时的305.7±130.8 mL和26周时的288.3±13.0 mL（P<0.05）。平均膀胱测压容量从损伤前的187.8±69.2 mL分别增加至注射后6周时的305±136.4 mL和26周时的288.3±13.0 mL（P<0.05）。60%的患者在注射后6周和26周时完全停用药物。1名患者发生尿路感染且1名患者在膀胱镜检查期间出现自主神经反射异常。满意度从损伤前的4.3±2.3分别提高至注射后6周时的7.2±1.9和26周时的7.3±2.3。这也与漏尿减少相关。
向逼尿肌注射A型肉毒杆菌毒素对难治性逼尿肌过度活动的脊髓损伤患者安全有效。这种效果在注射后26周时仍能维持。
