How to define failure of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity.

INTRODUCTION: Neurogenic detrusor overactivity (NDO) has a major impact on patients' quality of life and can lead to upper urinary tract complications. Intradetrusor botulinum toxin type A injections are administered as second-line treatment to these patients following the failure of anticholinergic agents. The aim of the DETOX 2 study is to propose a consensus definition of the failure of intradetrusor botulinum toxin injections for NDO in patients presenting spinal cord injury, spina bifida, or multiple sclerosis (MS) with self-catheterization. METHOD: This study followed the method adopted by the French National Authority for Health for recommendations by consensus. Based on a review of the literature and a preliminary survey, a steering committee compiled a questionnaire and selected a rating group comprising 16 experts from the Neuro-Urology Committee of the French Urology Association (cnuAFU) and Genulf. The experts were asked to complete the online questionnaire. At the end of the first round, all participants came together to discuss any disagreements and a second-round online questionnaire was completed to reach a consensus. RESULTS: Thirteen of the 16 experts approached completed both rounds of questionnaires. A strong consensus was reached for two proposals (median score = 9/10) which were therefore included in the definition from the first round: at least one repeat injection of the same botulinum toxin at the same dose must be given to rule out failure on technical grounds and a duration of efficacy <3 months must be considered a failure. At the end of round 2, a relative consensus was reached regarding the clinical criterion defining failure (median score = 7/10) and the urodynamic criterion of failure (median score = 8/10). An additional proposal was selected during this second round on the need for a voiding diary (median score = 8/10). CONCLUSION: The first consensus definition of failure of an intradetrusor injection of TB-A for NDO has been achieved with this study: persistence of detrusor overactivity with maximum detrusor pressures >40 cm H2O and/or a compliance issue and/or persistence of urinary incontinence and/or urgency and/or a number of daily self-catheterizations >8/day and/or efficacy <3 months. This study will help to standardize research on the failure of the intradetrusor botulinum toxin for NDO in clinical practice and clinical research.

Botulinum Toxin Type A Injection After Failure of Augmentation Enterocystoplasty Performed for Neurogenic Detrusor Overactivity: Preliminary Results of a Salvage Strategy. The ENTEROTOX Study.

OBJECTIVE: To evaluate the clinical efficacy, urodynamic effect and safety of Botulinum Toxin A (BTXA) injections after failure of augmentation enterocystoplasty (AE) performed for neurogenic detrusor overactivity. PATIENTS AND METHODS: We performed a multicenter retrospective study that included patients who had AE and at least one injection of BTXA after AE in 15 GENULF (French Speaking Neuro-Urology Study Group) centers. Clinical and urodynamic data were collected from medical files according to a standardized questionnaire and colligated in an anonymous database. RESULTS: Thirty-three patients with an injection of BTXA after AC in 9 out of 15 centers were included. Mean age at the time of AE was 24 ± 15 years. Overall efficacy (defined by clinical efficacy associated with a request by the patient for reinjection) was observed in 58% of the patients. Mean maximum cystomanometric capacity increased by 28% (333 ± 145 vs 426 ± 131 mL; P = .007) and maximum detrusor pressure (Pdet max) decreased by 43% (44 ± 37 vs 25 ± 18 cm H2O; P = .02) after BTXA. Only one side effect was recorded out of the 152 procedures (transient generalized muscle weakness without respiratory distress). CONCLUSION: In patients with failure after AE performed for neurogenic detrusor overactivity, injection of BTXA in the enlarged bladder was effective in over half of the cases with low morbidity. If this therapeutic approach were confirmed, it could be proposed as an alternative to AE surgical revision.

Management of febrile urinary tract infection among spinal cord injured patients.

BACKGROUND: Urinary tract infection (UTI) among patients with neurogenic bladder is a major problem but its management is not well known. We studied the relationship between antibiotic regimen use and the cure rate of those infections among 112 patients with neurogenic bladder. METHODS: We studied a retrospective cohort of febrile UTI among patients with neurogenic bladder. Drug selection was left to the discretion of the treating physicians, in accordance with current guidelines. Patients were divided into 3 groups according to antibiotic treatment duration (<10 days, between 10 and 15 days, and >15 days). We analysed clinical and microbiogical cure rate one month after the end of antibiotic treatment. RESULTS: The three groups of patients were similar, especially in terms of drug treatment (equal distribution). The cure rates were not significantly different (71.4 %, 54.2 %, and 57.1 %, respectively; p = 0.34). Moreover, there was no difference in cure rate between mono and dual therapy (44 % for monotherapy vs. 40 % for dual therapy; p = 0.71). CONCLUSION: This descriptive study supports the efficacy of antimicrobial treatment duration of less than 10 days and the use of monotherapy to treat febrile UTI among patients with neurogenic bladder. A randomized control trial is required to confirm these data.

Successful pregnancies and healthy live births using frozen-thawed sperm retrieved by a new modified Hotchkiss procedure in males with retrograde ejaculation: first case series.

BACKGROUND: In couples presenting with retrograde ejaculation refractory to medical treatment, the first choice of fertility treatment should be Assisted Reproductive Techniques using rapidly purified spermatozoa retrieved from post-ejaculatory urine. The Hotchkiss technique and modified variants are simple and efficient for retrieving sperm from the bladder. We developed a new protocol, including a novel modified Hotchkiss technique involving sperm cryopreservation. The aim was to study the pregnancy rate and birth rate achieved by intra cytoplasmic sperm injection (ICSI) using frozen-thawed sperm retrieved from the bladder with this novel modified Hotchkiss technique in patients with refractory retrograde ejaculation. RESULTS: In this descriptive retrospective, single-center study, we analyzed the local database of all patients who banked sperm at the CECOS Laboratory Biology of Reproduction of La Conception University Hospital, Marseille, France, between 2004 and 2014. A total of 2171 patients banked sperm during this time, including 63 patients with retrograde ejaculation, of whom ten patients banked sperm that had been retrieved by the modified Hotchkiss technique. These ten couples underwent 26 ICSI cycles: nine clinical pregnancies were achieved in six couples, including eight after fresh embryo transfer and one after thawed embryo transfer, resulting in seven live births. The average live birth rate per transfer was 28 %. CONCLUSIONS: We report the largest series of births using frozen-thawed spermatozoa retrieved from post-ejaculatory urine by a modified Hotchkiss technique. This series of births demonstrates that this new modified Hotchkiss technique allows for successful association with sperm cryopreservation, leading to an efficient and easy management of couples with refractory retrograde ejaculation.

CONTEXTE: Chez les couples dont l'homme présente une éjaculation rétrograde réfractaire au traitement médical, la première ligne de traitement de l'infertilité est le recours à l'aide médicale à la procréation (AMP) utilisant des spermatozoïdes purifiés des urines après éjaculation. La technique de Hotchkiss et les techniques de Hotchkiss modifiées sont simples et efficaces pour récupérer les spermatozoïdes de la vessie. Nous avons développé un nouveau protocole avec une nouvelle technique de Hotchkiss modifiée impliquant une cryoconservation des spermatozoïdes obtenus. L'objectif de cette étude était d'étudier les taux de grossesses et de naissances obtenues après injection intra cytoplasmique de spermatozoïdes (ICSI) provenant de paillettes congelées à partir des spermatozoïdes purifiés des urines avec la nouvelles méthode de Hotchkiss modifiée, chez les patients atteints d'éjaculation rétrograde réfractaire. RÉSULTATS: Dans cette étude descriptive monocentrique rétrospective, nous avons analysé la base de données locale de tous les patients ayant conservé du sperme au CECOS du laboratoire de biologie de la reproduction de l'hôpital universitaire de la Conception à Marseille, France, entre 2004 et 2014. Un total de 2171 patients a conservé du sperme pendant cette période. Soixante trois présentaient une éjaculation rétrograde, parmi lesquels 10 ont conservé du sperme qui avait été purifié des urines selon la méthode de Hotchkiss modifiée. Ces 10 couples ont réalisé 26 tentatives d'ICSI. 9 grossesses cliniques ont été obtenues chez 6 couples; 8 après transfert d'embryon frais, et une après transfert d'embryon congelé, ayant conduit à 7 naissances. Le taux moyen de naissance par transfert était de 28 %. CONCLUSIONS: Nous rapportons ici la plus large série de naissances utilisant des paillettes de spermatozoïdes purifiés des urines après éjaculation rétrograde selon une méthode de Hotchkiss modifiée. Cette série de naissances démontre que cette nouvelle technique de Hotchkiss permet une association réussie avec la cryoconservation du sperme, permettant une prise en charge facile et efficace des couples avec éjaculation rétrograde réfractaire.

Motor branch of extensor carpi radialis longus: anatomic localization.

OBJECTIVE: To identify extensor carpi radialis longus (ECRL) motor nerve coordinates in relation to anatomic surface landmarks. DESIGN: Descriptive study. SETTING: Anatomy institute of a school of medicine in Paris, France. CADAVERS: Fresh adult cadaver upper limbs (N=20). INTERVENTION: Anatomic dissection of upper limbs. MAIN OUTCOME MEASURES: Three measurements (mm) were taken of the position of the ECRL motor branch: the distance between the lateral epicondyle and the emergence of the ECRL branch along the forearm axis, the branch depth, and the ratio between the distance corresponding to the nerve depth and the intercondylar distance. RESULTS: The radial nerves of 4 men and 6 women (age range 59-80 y) were identified between the brachioradialis and the ECRL and traced proximally to the lateral epicondyle. The injection point was between the lateral epicondyle posteriorly and the wrist extensor group anteriorly. Direction was perpendicular to the axis of the forearm. Mean depth was 35.6 mm (minimal value: 24.0; maximal value: 58.0; SD=9 mm). Ratio between nerve depth and intercondylar distance was .46 (.37; .53±.05). CONCLUSIONS: The ECRL motor nerve branch is easy to reach using specified landmarks. Selective motor nerve block of the ECRL branch should be considered in the clinical assessment to test the capacity of the extensor carpi radialis brevis to extend the wrist alone and to assess the command and overactivity of antagonists before surgery.

Intrathecal baclofen pump: a foreign-body reaction case report and its solution.

CASE REPORT: A 43-year-old woman with cerebral palsy and disabling spasticity underwent a series of 4 implantations of intrathecal baclofen pumps, performed by two teams. A history of 3 aseptic local skin reactions over the site of insertion started 4 months after the first insertion, once with partial pump exposure. There were no clinical or biological signs of infection. Skin patch tests were negative. Relocation of the system was followed by a relapse, while removal of the pump was followed each time by complete resolution of the symptoms. Histological findings showed slight mononuclear dermal infiltration without epidermal lesions, which excluded contact dermatitis. Pump intolerance with a foreign-body reaction was diagnosed. A pump wrapped with polyethylene terephthalate was reimplanted. No recurrence of symptoms occurred after a 3-year follow-up period, with improvement in impairment, activity and satisfaction due to intrathecal baclofen therapy. CONCLUSION: A foreign-body reaction after intrathecal baclofen pump implantation is a rare complication, which has not been reported previously, and which is associated with negative skin patch tests. In cases with no signs of infection, skin intolerance must be suspected and dermatological assessments should be carried out. Replacement with a pump wrapped in an inert coating is an effective and available solution.

Botulinum toxin effect on voluntary and stretch reflex-related torque produced by the quadriceps: an isokinetic pilot study.

BACKGROUND: An understanding of the mechanical effects of botulinum toxin type A (BoNT A) on spastic and voluntary muscle contraction may help predict functional responders. OBJECTIVE: To compare the effect of BoNT A on the voluntary and stretch reflex-related torques produced by activation of the rectus femoris (RF). METHODS: This was a prospective open study where 15 incomplete spinal cord injury patients, impaired by a stiff-knee gait, with RF hyperactivity in mid-swing quantified by formal gait analysis (GA), were assessed before and after RF BoNT A injection (Botox, 200 UI). MAIN OUTCOME MEASURES: Included isokinetic peak torque (and angle at peak torque) at 0° (supine) and 90° (seated) during passive stretch (10 deg/s, 90 deg/s, and 150 deg/s), and voluntary contraction (60 deg/s) of the quadriceps. Secondary measures included impairment by Modified Tardieu Scale (MTS), peak knee flexion and spatial-temporal data by GA, activity (6-minute walking test, timed stair climbing), and discomfort (Verbal Rating Scale). RESULTS: Voluntary torque decreased (-16%; P = .0004) but with only a trend toward a decrease in stretch reflex-related torque. The angle at spastic torque increased at 90 deg/s (+5°; P = .03), whereas MTS, peak knee flexion (+4°; P = .01), spatial-temporal data, timed stair climbing test (25%; P = .02), and discomfort were significantly improved. CONCLUSION: BoNT A appeared to delay the stretch-reflex angle at peak torque, whereas the voluntary torque decreased. After strict patient selection, BoNT A injection into the RF muscle led to improvements in impairment, activity, and discomfort.

[Neurogenic bladder]. / Problèmes vésico-sphinctériens de la personne handicapée.

Urinary symptoms are frequent in case of neurologic diseases, symptoms depends on the pathology as well as the extend and the location of the disease. Initial evaluation includes clinical, biological, urodynamic and radiologic assessment in order to precise symptoms quality of life and risk factors of medical complications. Treatment efficacy, adaptation to incapacities, evolution of the disease and complications require close follow up specially in the spinal cord injury and myelomeningocele population. Multidisciplinary approach is often required to optimise treatment strategy.