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Concomitant repeated intravesical injections of botulinum toxin-type A and laparoscopic antegrade continence enema; a
AbdolMohammad Kajbafzadeh1, Amir Hassan Mahboubi, Seyedmehdi Payabvash
1Paediatric Urology Research Center, Department of Urology, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
Insights
This study shows that combining botulinum toxin-type A (BTX-A) injections with laparoscopic antegrade continence enema (LACE) effectively treats bladder and bowel dysfunction in children with myelomeningocele, leading to improved continence and urodynamic function.
Area of Science:
- Pediatric Urology
- Minimally Invasive Surgery
- Neurogenic Bladder and Bowel Dysfunction
Background:
- Children with myelomeningocele often experience complex bladder and bowel dysfunction.
- Previous treatments like botulinum toxin-type A (BTX-A) injections may not fully resolve fecal incontinence or constipation.
- Laparoscopic antegrade continence enema (LACE) offers a surgical approach for bowel management.
Purpose of the Study:
- To evaluate the efficacy of simultaneous laparoscopic antegrade continence enema (LACE) and repeated intravesical botulinum toxin-type A (BTX-A) injections.
- To assess the combined impact on bladder and bowel dysfunction in pediatric myelomeningocele patients.
- To report surgical outcomes and patient continence status.
Main Methods:
- A cohort of 20 children (mean age 8.7 years) with myelomeningocele and persistent fecal incontinence/constipation underwent the combined procedure.
- Laparoscopic appendicostomy (LACE) was performed following repeated intravesical BTX-A injections.
- Urodynamic studies and assessment of urinary/bowel continence were conducted post-procedure.
Main Results:
- Significant improvement in urinary continence was observed, with 95% of children becoming nappy-free.
- Urodynamic parameters including maximum detrusor pressure, bladder compliance, and capacity showed significant improvement (P < 0.001).
- The combined BTX-A and LACE procedure demonstrated superior urodynamic outcomes compared to BTX-A alone, with good tolerability and minimal complications.
Conclusions:
- Simultaneous repeat intravesical BTX-A injections and LACE provide an effective management strategy for bladder and bowel dysfunction in children with myelomeningocele.
- This combined approach can enhance bladder urodynamic function by facilitating effective bowel evacuation.
- The procedure offers a promising solution for improving quality of life in this patient population.
Objective:
To report our experience of treating bladder and bowel dysfunction in children with myelomeningocele, with simultaneous laparoscopic antegrade continence enema (LACE) and repeated intravesical injection of botulinum toxin-type A (BTX-A).
Patients And Methods:
Six girls and 14 boys (mean age, 8.7 years) with myelomeningocele were included in this study. All patients had received one or two intravesical injection(s) of BTX-A, but had persistent fecal incontinence or constipation despite improved urinary symptoms. We performed a two-port laparoscopic appendicostomy, immediately after repeated intravesical injection of BTX-A, through a V-shaped skin flap at McBurney's point. The stoma was finally covered by a quadrilateral skin flap, using the 'VQ' technique. The degree of urinary incontinence and bowel dysfunction were determined in each patient, and conventional urodynamic studies were performed 4 months after each injection.
Results:
All patients were followed-up for a mean (range) of 19.1 (14-33) months. Urinary continence improved significantly after the first injection, and remained constant after repeat injections. The maximum detrusor pressure, bladder compliance and capacity improved significantly (P < 0.001) compared with baseline. Interestingly, the simultaneous intravesical BTX-A injection/LACE procedure significantly improved all urodynamic variables compared with the values obtained after the last BTX-A injection alone. The laparoscopic procedure was well tolerated, and 19 (95%) children were nappy-free at the final follow-up. Only two patients had stoma stenosis, and one patient had minor stoma leakage.
Conclusion:
Concomitant repeat intravesical injection of BTX-A and LACE can effectively manage bladder and bowel dysfunction in children with myelomeningocele. The procedure may further contribute to improve bladder urodynamic function, as effective evacuation of the bowel provides more room for bladder distension.
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