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許兆畬 利用肉毒桿菌毒素注射膀胱逼尿肌治療頑固性神經性逼尿肌過動----單一機構超過十五年的經驗 2016/12/30 下午 05:07:55 0
原 文 題  目 More Than 15 Years of Experience with Intradetrusor OnabotulinumtoxinA Injections for Treating Refractory Neurogenic Detrusor Overactivity: Lessons to Be Learned
作  者 Lorenz Leitner, Sharmistha Guggenbuhl-Roy, Stephanie C. Knupfer
出  處 European Urology
出版日期 September 2016
評 論 自2000年以來,利用肉毒桿菌毒素注射膀胱逼尿肌來治療神經性逼尿肌過動,已經在臨床獲致不錯的效果。但是長期有系統地追蹤臨床效果,及患者是否能因為有效而長期規則注射的比率仍然不詳。本文先說明橋腦上相關的腦部病變會影響下泌尿道的神經控制,干擾到膀胱儲尿期造成膀胱容量降低同時產生神經性逼尿肌過動的現象,因此可合併或不合併尿失禁。再往下面的脊椎病變更會造成排尿障礙,典型的就是逼尿肌及尿道括約肌的共濟失調。作者利用200至300單位的肉毒桿菌毒素注射在52個上述案例(脊椎損傷、脊柱裂、多發性硬化症及其他神經病變)的膀胱逼尿肌,追蹤十年以上,再來看病人下泌尿道症狀進步情形(每天尿次數、尿失禁減少次數)及尿動力(儲尿期最高膀胱壓、膀胱順應性)的臨床效果,還有長期規則注射的情況。
平均追蹤12±2年,60%(32/52)是脊椎損傷,15%(8/52)是脊柱裂,14%(7/52)是多發性硬化症及10%(5/52)其他神經病變病患。結果有60%(31/52)一直維持規則注射,40%(21/52)雖經多次注射最終還是放棄改用抗膽鹼藥物或神經調控治療:但是探討起來有效而選擇放棄的有將近一半的19% (10/52),真正沒效而放棄的是另一半的21% (11/52),所以我們可以說80%是有效的(每天尿次數少於八次、尿失禁次數減少75%以上、儲尿期最高膀胱壓小於40 cmH2O、膀胱順應性大於或等於20 ml/cmH2O)。值得注意還有兩點,第一是有六個原本能自己解尿的病患有四位(67%)因注射後導致排尿障礙要重新改回自我清潔導尿,最終放棄注射改成神經調控治療。第二是多發性硬化症治療效果差,只有14%(1/7)有效。
這篇文章告訴我們長時間的追蹤下,神經性逼尿肌過動應用肉毒桿菌毒素注射在膀胱逼尿肌上,80%效果是不錯的。但是臨床上的好處及壞處以及可能衍生的問題,必須在開始治療前,先提供給病患,以讓病患決定是否使用該項治療的依據。然而如果以後有長時間有系統的回顧及整合分析文章,勢必證據力能更強,更能提供我們更正確的治療依據。
abstract Background:Intradetrusor onabotulinumtoxinA (BoNT-ONA) injections have become a well-established therapy for refractory neurogenic detrusor overactivity (NDO). However, little is known about long-term outcome and patients’ adherence to this treatment.
Objective:To assess long-term outcomes of intradetrusor BoNT-ONA injections and
patients’ adherence to treatment.

Design, setting, and participants:A consecutive series of 52 patients who underwent first intradetrusor BoNT-ONA injections for refractory NDO >10 yr ago were evaluated retrospectively and prospectively at a single university spinal cord injury (SCI) centre.
Outcome measurements and statistical analysis: Primary outcome was current neurourologic treatment. Secondary outcomes were urodynamic parameters. For data comparison, the paired/unpaired t test, chi-square test, and McNemar test were used.

Results and limitations:Mean duration since first intradetrusor BoNT-ONA injections was 12 ±2 yr. Most patients (61% [32 of 52]) suffered from SCI, 15% (8 of 52) from spina bifida, 14% (7 of 52) from multiple sclerosis (MS), and the remaining (10% [5 of 52]) from other neurologic disorders. Almost 60% (31 of 52) of all patients are continuing with intradetrusor BoNT-ONA injections but only 14% (1 of 7) of the patients with MS. Lack of clinical and/or urodynamic response (21% [11 of 52]) and switching to another treatment (antimuscarinics and/or neuromodulation) despite appropriate BoNT-ONA efficacy (19% [10 of 52]) were the reasons for discontinuation. In patients continuing BoNT-ONA treatment, the positive effect was sustained after repeat injections (p < 0.05).

Conclusions:Although intradetrusor BoNT-ONA injections are a highly effective therapy for refractory NDO, approximately 40% of the patients discontinue treatment over time. All prospective neurologic patients should be given this information, and it needs to be considered in the treatment decision-making process.

Patient summary:Approximately 60% of the patients treated with intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity continue this therapy long term with good therapeutic effects.
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