Early findings on OnabotulinumtoxinA for postoperative pain control in bladder exstrophy

Postoperative pain management in bladder reconstruction and exstrophy closure is challenging due to unique physiological differences in exstrophy patients, surgical complexity, and heightened risk of painful bladder spasms. While opioids and anticholinergics are used for pain relief, their prolonged use is associated with complications.

We sought to evaluate postoperative benefits of OnabotulinumtoxinA (Botox) injections in patients with classic bladder exstrophy (CBE) and cloacal exstrophy (CE) undergoing bladder reconstruction or exstrophy closure.

CBE and CE patients who underwent bladder reconstruction or exstrophy closure between 2018 and 2024 were identified from an institutional database. Bladder reconstruction was defined as any combination of the following procedures - bladder neck reconstruction, bladder neck transection, Mitrofanoff or Monti catheterizable channel creation, and bladder augmentation. Reconstructive patients were stratified by concurrent ureteral reimplants necessitating ureteral stent placement. Data on postoperative course, medications, and complications were collected.

Among 48 patients undergoing bladder reconstruction, 14 received Botox and 34 did not. Of the 34 exstrophy closures, 12 received Botox and 22 did not. In patients undergoing bladder reconstruction without ureteral reimplants necessitating ureteral stents, Botox significantly reduced oxybutynin use (0.09 mg/kg/day vs. 0.15 mg/kg/day, p = 0.02) and oxycodone use (0.00 mg/kg/day vs. 0.11 mg/kg/day, p = 0.03). These patients also experienced fewer days with pain scores above 0 (4.00 days vs. 10.00 days, p = 0.04) and above 4 (2.00 days vs. 6.00 days, p = 0.04). In contrast, bladder reconstruction patients with ureteral reimplantation necessitating ureteral stents showed no significant differences in medication use or pain scores (all p > 0.05). Botox did not significantly impact postoperative course, medication requirements, in exstrophy closures (all p > 0.05).

Botox injections significantly improved postoperative outcomes and reduced medication use in exstrophy patients undergoing bladder reconstruction without ureteral reimplantation that necessitate ureteral stent placement. However, there was no statistical significance noted in the intervention group compared to controls in cases involving ureteral reimplantation with stent placement. Furthermore, Botox showed no postoperative advantages in exstrophy closure, where surgical complexity may limit its therapeutic efficacy. Limitations include the retrospective design and small sample size.

Intraoperative Botox reduced opioid and anticholinergic use, as well as postoperative pain, among exstrophy patients undergoing bladder reconstruction without ureteral reimplants requiring ureteral stents. This demonstrates its potential as an effective adjunct for postoperative pain in exstrophy patients undergoing select reconstruction.