Botulinum toxins. Although several botulinum toxin compounds are in clinical use, the doses among them are not interchangeable:
• OnabotulinumtoxinA (OnaBoNTA) – Botox • AbobotulinumtoxinA (AboBoNTA) – Dysport • IncobotulinumtoxinA (IncoBoNTA) – Xeomin • RimabotulinumtoxinB (RimaBoNTB) – Myobloc/NeuroBloc
OnaBoNTA is the only botulinum toxin approved to treat OAB in the US (approved after the initial AUA/SUFU guideline was published, now in the revised Guideline), and is the main botulinum toxin with any published clinical data in OAB.
At 12 weeks, onaBoNTA significantly reduced UUI vs. placebo (60.8% vs. 29.2%23; 62.8% vs. 26.8%24), with mean percent change from baseline favoring onaBoNTA in daily episodes of incontinence (-47.9 vs. -12.523; -53.1 vs. -16.824), urgency (-31.6 vs. -10.023; -41.1 vs. -8.424), micturitions (-16.9 vs. 4.123; -19.7 vs. -6.024), and nocturia (-20.2 vs. 0.223; -25.1 vs -8.824). All patients studied were refractory to prior therapy with antimuscarinics. Patients also reported greater improvement in the QoL measures. A higher percentage of patients on the onaBoNTA arm, compared with placebo, initiated clean intermittent catheterization (6.1% vs. 023; 6.9% vs. 0.7%24) and tested positive for a urinary tract infection (UTI) (24.5% vs. 9.2%23; 24.1% vs. 9.6%24).
The duration of effect of onaBoNTA was defined by patient request for retreatments; they were eligible for retreatment if they requested it, had a minimum of 12 weeks from the previous treatment, had at least 2 UUI episodes on a 3-day diary, and had a postvoid residual (PVR) of <100 mL.23,24 Median time to retreatment request was 166 days (~24 weeks). Efficacy was sustained for up to 5 treatments,25 and maintained efficacy with repeat injection has been observed in the literature for both OAB and NDO.26,27
Augmentation cystoplasty. Reserved for patients refractory to conservative management and other therapies,4 this surgery carries a significant risk profile, including bladder stones, mucus, small-bowel obstruction, surgical complications, and perforation.28