Department of Urology, University of California San Francisco, San Francisco, California.
J Urol. 2022 Sep;208(3):702-710. doi: 10.1097/JU.0000000000002709. Epub 2022 Apr 21.
Cystoscopic injection of botulinum neurotoxin (BoNT) is typically performed under general anesthesia in pediatric patients with neurogenic bladder, accumulating anesthetic exposures and operating room costs. As most of these patients already tolerate clean intermittent catheterization (CIC), it has become our practice to offer a trial of awake injection. We report our initial experience here. We hypothesized that higher sensory level, female sex and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times.
Surgical records from 2 academic hospitals from 2018-2020 were reviewed. Generalized linear models were fit to determine predictors of success and procedural length.
Trial of awake injection was offered to 22 patients. Eighteen patients (8 female, 10 male, 4-20 years old) elected to proceed. All 18 patients were managed with CIC at baseline, 14 had anxiety or behavioral issues, 10 had cognitive delay and 7 had sensory level below S2. Two patients (11%) required conversion to general anesthesia and one of these subsequently opted for a repeat awake injection trial. Fifteen of the 18 patients (83%) had or planned subsequent injections awake. Of the remaining, 1 proceeded to bladder augment, 1 is considering ileovesicostomy and 1 requested subsequent injections under anesthesia. No intraoperative complications occurred.
Awake BoNT injection is feasible in pediatric patients with neurogenic bladder managed with CIC, even in the setting of intact sensation, well-managed mental health issues or cognitive delay, thereby increasing the viability of BoNT as an early tool in the management of neurogenic bladder.
在患有神经源性膀胱的儿科患者中，膀胱镜下注射肉毒杆菌神经毒素（BoNT）通常在全身麻醉下进行，这会增加麻醉暴露和手术室成本。由于这些患者大多数已经能够耐受清洁间歇性导尿（CIC），因此我们开始尝试在清醒状态下进行注射。我们在此报告我们的初步经验。我们假设较高的感觉水平、女性性别以及没有心理健康问题或认知障碍可能预测首次清醒注射的成功和手术时间的缩短。
回顾了 2018 年至 2020 年 2 所学术医院的手术记录。使用广义线性模型确定成功和手术时间的预测因素。
共 22 例患者尝试清醒注射。18 例患者（8 例女性，10 例男性，4-20 岁）选择继续进行。所有 18 例患者在基线时均接受 CIC 治疗，14 例患者存在焦虑或行为问题，10 例患者存在认知障碍，7 例患者的感觉水平低于 S2。2 例患者（11%）需要转为全身麻醉，其中 1 例随后选择再次进行清醒注射试验。18 例患者中的 15 例（83%）有或计划随后进行清醒 BoNT 注射。其余患者中，1 例进行了膀胱扩大术，1 例考虑行回肠膀胱术，1 例要求在全身麻醉下进行后续注射。术中无并发症发生。
在接受 CIC 治疗的神经源性膀胱的儿科患者中，清醒状态下注射 BoNT 是可行的，即使在感觉完整、心理健康问题或认知障碍得到良好管理的情况下，也可以增加 BoNT 作为神经源性膀胱管理早期工具的可行性。
