Year : 2011 | Volume
: 27 | Issue : 2 | Page : 296--297
Intravesical electromotive botulinum toxin-A administration: Will it be the standard treatment for refractory neurogenic detrusor overactivity?
Neeraj Kumar Goyal, Rahul Yadav, Apul Goel
Department of Urology, CSM Medical University (Upgraded king George's Medical College), Lucknow, Uttar Pradesh, India
Department of Urology, CSM Medical University (Upgraded king George«SQ»s Medical College), Lucknow, Uttar Pradesh
|How to cite this article:|
Goyal NK, Yadav R, Goel A. Intravesical electromotive botulinum toxin-A administration: Will it be the standard treatment for refractory neurogenic detrusor overactivity?.Indian J Urol 2011;27:296-297
|How to cite this URL:|
Goyal NK, Yadav R, Goel A. Intravesical electromotive botulinum toxin-A administration: Will it be the standard treatment for refractory neurogenic detrusor overactivity?. Indian J Urol [serial online] 2011 [cited 2020 Jan 19 ];27:296-297
Available from: http://www.indianjurol.com/text.asp?2011/27/2/296/82865
Electromotive drug administration (EMDA) is based on the electrokinetic phenomenon of iontophoresis. This is an active method of transmitting charged drugs through the tissues, using a repulsive electrical current. The present study is the first report of intravesical electromotive botulinum toxin-A administration (BoNTA/EMDA) in children with myelomeningocele (MMC) having neurogenic detrusor overactivity (NDO).  This study was a prospective evaluation of 15 children with refractory NDO, who did not respond to conventional therapy. The study evaluated the effect ofBoNTA/EMDA on urinary and fecal incontinence, vesicoureteral reflux (VUR) status, and various urodynamic parameters in patients with MMC. The urodynamic parameters of interest included the reflex volume (the volume at which the first uninhibited detrusor contraction occurred), end-fill pressure, maximal detrusor pressure, and maximal bladder capacity (MBC). This procedure was performed under local anesthesia using 2% lignocaine jelly. A 10F indwelling catheter containing a silver spiral electrode was put and bladder was filled with sterile water. BoNTA at a dose of 10 IU/kg was added to the intravesical solution. Two dispersive electrode pads were applied at the level of the umbilicus. The catheter and electrode pads were attached to a pulsed current generator to deliver a maximal current of 10 mA for 15 min. No additional therapy was given after this procedure. 
Monthly follow-up was done to see for possible side effects of BoNTA including any muscle weakness, diplopia, dysphagia, blurred vision, or hematuria. The study parameters were re-evaluated at 1, 4, and 9 months after the procedure. On follow-up, the mean reflex volume and MBC increased significantly and the mean maximal detrusor pressure and end-fill pressure decreased significantly at 1 month. This improvement in the urodynamic parameters was consistent at 9 months of follow-up. Daytime incontinence had improved significantly, 1 month after treatment (2.25 ± 0.7 versus 0.62 ± 0.7 episodes; P = .01), and this effect was persistent in the remaining 8 months of the study. Twelve children (80%) had documented VUR of different grades on initial evaluation. At the final follow-up, VUR had completely resolved in 4 patients, 7 experienced grade reductions, and no patient had VUR of grade ≥ 3. Twelve children had neuropathic bowel dysfunction before the procedure. At the final follow-up, six had complete alleviation and four reported moderate improvement. Procedure-related side effects consisted of transient skin erythema at the site of electrodes in four children and a burning sensation at the urethral meatus in two children. No systemic or focal muscle weakness was reported.
The standard treatment used for NDO in children with MMC is oral anticholinergics combined with clean intermittent catheterization. However 10-15% of patients do not respond or get serious side effects.  Therapeutic modalities described for these non-responding bladders include intravesical oxybutynin, intravesical injections of BoNTA, and augmentation cystoplasty. Intravesical BoNTA injections have shown good response in the treatment of NDO, through transitory detrusor smooth muscle paralysis.  But frequent injections are required to maintain the therapeutic effect, which needs to be performed under general anesthesia using rigid cystoscope. Therefore, the modality though effective is associated with repeated hospitalizations, local complications, and increased therapeutic costs. Apart from this, different injection sites might result in inconsistent outcomes and an unpredictable duration of effect.
Electromotive BoNTA delivery (BoNTA/EMDA) was first used successfully for the treatment of palmar hyperhidrosis.  In urology, the electromotive administration of various drugs is reported for local anesthesia, superficial bladder cancer, and recurrent non-infectious cystitis. 
The present study is the first report of intravesical electromotive drug administration of BoNTA in children with MMC having refractory NDO. It has shown excellent short-term results. Significant improvements seen in all the urodynamic parameters have persisted for 9 months, as compared to the short lasting and inconsistent effects noted with intravesical injections. There is homogeneous distribution of BoNTA using electromotive administration which overcomes the problem of inconsistent drug delivery. Due to this homogeneous delivery, the trigone is probably also paralyzed. Contrary to the previous belief of inducing VUR by paralysis of trigone, substantial improvement in VUR status is noted in the present study. Considerable improvement in fecal incontinence is also noted using BoNTA/EMDA. This improvement is probably because of the dependence of urination and defecationon common neural pathways from spinal segments S2-S4. So, this relatively non-invasive technique showed wonderful and longer lasting effects compared to previous mode of drug delivery. However, randomized controlled trials are required before committing it as the technique of choice, to treat this difficult group of children.
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