Injeção de toxina botulínica intradetrusora no tratamento de bexiga neurogênica refratária a anticolinérgicos: influência da urodinâmica e morfologia vesical

Abstract

OBJECTIVES: To assess whether cystography and urodynamics may help predict which patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergics respond better to treatment with injection of botulinum toxin A (BTX-A) and the effectiveness and quality of life in relation to treatment. METHODS: Thirty-four patients with spinal cord injury were evaluated prospectively. All emptied the bladder by clean intermittent catheterization, had incontinence and detrusor overactivity despite the use of 40 mg or more of oxybutynin and underwent to bladder injection of BTX-A (300UI). Pretreatment evaluation included urodynamics, ultrasound, cystography and quality of life questionnaire (ICIQ - SF). Follow-up consisted of urodynamics and office visit four months after treatment. Cystography was evaluated by bladder shape, capacity and presence of diverticula. Urodynamic parameters used for assessment were maximum cystometric capacity, maximum detrusor pressure, compliance and reflex volume. RESULTS: After injection of BTX-A, 70 % of patients had good results, staying 4 months or more continents. There were significant differences in most urodynamic parameters before the procedure, in the group with good response compared to those with unsatisfactory response. Patients who showed best response were those with greater maximum cystometric capacity (p = 0.019), higher reflex volume (p = 0.041), greater compliance (p=0.043). There was no statistical difference from the maximum detrusor pressure (p=0.691). The maximum cystometric capacity (p<0.001) and the reflex volume (p<0.001) increased while the maximum detrusor pressure decreased (p<0.001), the effect on compliance was not statistically significant (p = 0.366). There was no statistic difference on parameters of cystography between the groups in relation to shape (p=0.271), capacity (p>0.720) and presence of diverticula (p>0.999). There was significant improvement in quality of life scores with the median reduction from 18 to five (p<0.001), indicating satisfaction with the outcome. CONCLUSIONS: The parameters evaluated at cystography were not able to help predict the response to injection of BTX-A in the treatment of refractory NDO. It was noted in this study that the most parameters of urodynamic were better in patients that responded to the treatment, except the maximum detrusor pressure. There was also improvement in most urodynamic parameters, except compliance, as well as important patient satisfaction with the results, according to the questionnaire of quality of life.