Department of Urology, Craigavon Area Hospital, Portadown, UK.
Department of Urology, Austin Health, Melbourne, Australia.
World J Urol. 2019 May;37(5):891-898. doi: 10.1007/s00345-018-2456-7. Epub 2018 Aug 23.
One quarter of patients will not respond to initial intra-detrusor Botulinum toxin A (BTX) injections for detrusor overactivity. Alternative treatment options include long-term catheterization, sacral neuromodulation, urinary diversion or bladder augmentation. Some of these procedures are invasive. This review explores modifications to BTX delivery that can improve outcome.
A search of Medline, Embase and Cochrane Library to December 2017 was performed according to Preferred Reporting Items for Systematic Review and Metaanalysis (PRISMA) guidelines. Search criteria included, dose escalation, increasing injection site number, trigone injection, switching preparation and alternative methods of BTX delivery.
Several modifications to BTX delivery may improve response. There is moderate evidence that increasing the dose from 100 U to 200 U results in statistically better symptom control. Trigone-including injections were associated with significantly improved patient-reported symptom scores, as well as superior results in urodynamic outcomes without risking urinary retention and vesico-ureteric reflux. Switching from onabotulinum (OTA) or abobotulinum (ATA) or vice versa may also improve response in over 50% of patients as shown in limited studies. Increasing the number of injection sites is not beneficial. Indeed, decreasing the number of injections to as low as three sites does not result in decreased clinical outcomes. Injection-free delivery is associated with lower efficacy compared to conventional intradetrusor injections.
Before contemplating alternative treatments, practitioners can try to improve on BTX delivery. Firstly, the dose can be increased to 200 U; the trigone included in the injection sites and switching brands may also be helpful.
四分之一的患者对初始膀胱内肉毒杆菌毒素 A（BTX）注射治疗逼尿肌过度活动症不会产生反应。替代治疗方案包括长期导管插入、骶神经调节、尿流改道或膀胱扩大术。其中一些手术具有侵入性。本综述探讨了可以改善结果的 BTX 输送方式的改进。
根据系统评价和荟萃分析的首选报告项目（PRISMA）指南，对 Medline、Embase 和 Cochrane Library 进行了截至 2017 年 12 月的检索。搜索标准包括剂量递增、增加注射部位数量、三角区注射、转换制剂和 BTX 输送的替代方法。
BTX 输送方式的几种改进可能会改善反应。有中等质量的证据表明，将剂量从 100U 增加到 200U 可使症状控制在统计学上更有效。三角区包括注射与患者报告的症状评分显著改善相关，以及在不增加尿潴留和膀胱输尿管反流风险的情况下在尿动力学结果方面具有更好的效果。在有限的研究中，从注射用肉毒毒素 A（OTA）或注射用阿替毒素（ATA）切换或反之亦然，也可能使超过 50%的患者的反应得到改善。增加注射部位的数量没有好处。事实上，将注射次数减少到低至三个部位并不会导致临床结果下降。无注射给药与传统膀胱内注射相比，疗效较低。
在考虑替代治疗方法之前，医生可以尝试改进 BTX 输送方式。首先，可以增加剂量至 200U；将三角区包括在注射部位内，并且更换品牌可能也会有所帮助。
