Effect of Botulinum Toxin A on Detrusor Overactivity and Renal Function in Chronic Spinal Cord Injured Patients

Study Overview
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Brief Summary
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To investigate the clinical effect of detrusor botulinum toxin A (BoNT-A) injection on neurogenic detrusor overactivity (NDO) and renal function and to compare the difference of expressions of sensory receptors and nerve growth factor (NGF) in the bladder wall of patients respond and not respond to BoNT-A injections in chronic spinal cord injured (SCI) patients.

Detailed Description
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Study Procedure A total of 30 patients with chronic suprasacral cord SCI will be enrolled in this study. All patients are more than 18 years old and have chronic suprasacral cord injury for more than 1 year. They have previously underwent an urodynamic study and have been proven having detrusor sphincter dyssynergia (DSD). The patients currently void by reflex, abdominal stimulation or clean intermittent catheterization (CIC), are free of indwelling catheter or cystostomy, and free of urinary tract infection (UTI) on their enrollment. During the screening period, a total glomerular filtration rate (GFR) should be less than 80 mL/min as measured by 99mTc-labelled diethylenetriamine pentaacetic acid (99mTc-DTPA) clearance renal scanning. Patients should also have adequate hand function or have a care-giver available for CIC. Other exclusion criteria include patients with detrusor underactivity and large bladder compliance, patients proven to have intrinsic sphincteric deficiency and patients who have hypersensitivity to botulinum toxin A (BTX-A) or constituent ingredients of BTX-A. BTX-A injection will be performed in the operation room under light intravenous general anesthesia to prevent autonomic dysreflexia and hyperreflexia during cystoscopy. A total of 300U BTX-A (BOTOX, 100 U/vial, Allergan Co., Irvine, USA) dissolved into 30 mL normal saline will be injected into 30 sites of the bladder including lateral, posterior wall and dome. The injection sites are widely distributed to cover the whole bladder wall. A 14 Fr Foley catheter will be routinely inserted after BTX-A injection and patients will be discharged the next morning and followed up at out-patient clinic. All patients will be instructed to keep on CIC or abdominal stimulation as they previously performed. BTX-A injections will be repeated 6 months after the first treatment, then follow up to 24 months. Before each BTX-A injection a videourodynamic study and GFR test will be performed. Patients were also requested to report the severity of urinary incontinence by the mean daily incontinence episodes within three days, Urogenital Distress Inventory (UDI-6 Short Form), Incontinence Impact Questionnaire (IIQ-7), self assessed QoL index and the global satisfaction rate (graded as 0 to 3, indicating none, mild, moderate and very satisfied) to this treatment. The adverse events such as urinary tract infection, hematuria, difficult urination are also recorded. This study should be approved by the Institutional Review Board and Ethics Committee of the hospital. Informed consent will be obtained before the screening and all patients are instructed about the possible complications related with BTX-A injection such as urinary retention, transient hematuria and subsequent urinary tract infection. Patients will be classified as responders and non-responders according to their clinical presentation and urodynamic study results. Responders are considered if they become dry or reduction of incontinence episodes by 50% and have a decrease of detrusor pressure reduction by 50% of the baseline value, otherwise, they are considered as non-responders. The end-point is set at 6 months after the BTX-A injection. There were two primary end-points: (1) the net change of the IIQ-7 and UDI-6 from baseline to 24 months, and (2) the net change of the GFR from baseline to 24 months. Secondary end-point efficacy measured the net change of the cystometric bladder capacity, bladder compliance, detrusor pressure during reflex voiding, end-filling pressure or detrusor leak-point pressure and postvoid residual volume from baseline to 24 months. Three bladder biopsies using a small cystoscopic biopsy forceps will be performed in all patients. The biopsy will be performed at baseline and each time-point just prior to intravesical BTX-A injection. The bladder biopsy specimens will be sent to pathological department for H-E staining to exclude the possibility of carcinoma in situ, and also will be embedded in O.C.T. medium and stored at -80℃ refrigerator or liquid nitrogen tank for investigations. The bladder biopsies will be prepared for measurement of NGF messenger RNA (mRNA) and immunohistochemistry investigation of the expression of Transient Receptor Potential Vanilloid 1 (TRPV-1), purinergic receptor P2X, ligand-gated ion channel, 3 (P2X3) receptors at baseline and 6 months after each BTX-A injection, and the difference of these sensory protein expressions between responders and .non-responders to BTX-A injection.

Official Title
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Effect of Botulinum Toxin A on Detrusor Overactivity and Renal Function in Chronic Spinal Cord Injured Patients - Clinical Effects and Investigating Mechanism of Action

Conditions
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Spinal Cord Injuries

Intervention / Treatment
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* Drug: Botulinum toxin A


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults with age of 19 years old or above Patients with chronic suprasacral cord SCI will be enrolled. Patients will be proven having NDO by videourodynamic study during the screening period. They also receive 99mTc-DTPA renal scanning for GFR at baseline. Patients with NDO induced urinary incontinence who have adequate hand function or have a care-giver available for CIC, and the baseline total GFR of less than 80 mL/min are main inclusion criteria Exclusion Criteria: Patients with detrusor underactivity and large bladder compliance, patients proven to have intrinsic sphincteric deficiency Patients who have hypersensitivity to BTX-A or constituent ingredients of BTX-A.

Ages Eligible for Study
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Minimum Age: 19 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Botulinum toxin A<br>BoNT-A (BOTOX 300U) | Drug: Botulinum toxin A<br>* BoNT-A (BOTOX 300U)<br>* Other names: BoNT-A (BOTOX 300U);|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Net Change of the Urinary Distress Inventory (UDI-6) | Efficacy: Net change of the UrinaryDdistress Inventory (UDI-6) from baseline and 12 months. The UDI-6 is a 6-item short forms on a 4-point scale ranging from 0 Not at all to 3 Greatly. The total UDI-6 score can therefore range from 0 to 18 (asymptomatic to very symptomatic). Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Incontinence Impact Questionnaire (IIQ-7) | Efficacy: Net change of the Incontinence Impact Questionnaire (IIQ-7) from baseline and 12 months. The IIQ-7 is a 7-item short forms on a 4-point scale ranging from 0 Not at all to 3 Greatly. Total IIQ-7 score ranges = 0 to 21 The total IIQ-7 score can therefore range from 0 to 21 (asymptomatic to very symptomatic). Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Quality of Life Index (QoL-I) | Efficacy: Net change of the quality of life index (QoL-I) from baseline and 12 months. The QoL-I on a 7-point scale ranging from 0 Delighted to 6 Terrible. The QoL-I ranges 0 to 6 Safety: Systemic adverse events | Baseline and 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Net Change of the Cystometric Bladder Capacity (CBC) | Efficacy: Net change of the cystometric bladder capacity (CBC) from baseline and 12 months Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Bladder Compliance | Bladder compliance is the result of a mathematical calculation of the volume required for a unit rise of pressure measured during a cystometric filling. Bladder compliance is calculated by dividing the volume change by the change in bladder pressure (mL/cmH2O). Efficacy: Net change of the bladder compliance from baseline and 12 months Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Maximum Flow Rate (Qmax) | Efficacy: Net change of the maximum flow rate (Qmax) from baseline and 12 months Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Void Volume | Efficacy: Net change of the void volume from baseline and 12 months Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Detrusor Pressure (Pdet) | Efficacy: Net change of the detrusor pressure (Pdet) from baseline and 12 months Safety: Systemic adverse events | Baseline and 12 months | 
| Net Change of the Postvoid Residual Volume (PVR) | Efficacy: Net change of the postvoid residual volume (PVR) from baseline and 12 months Results: Botulinum toxin A injection have increased postvoid residual urine volume in patients treated for bladder dysfunction. Treat only patients who are willing and able to initiate catheterization post-treatment, if required, for urinary retention. Safety: Systemic adverse events | Baseline and 12 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Nerve growth factor, P2X3 receptor, Transient Receptor Potential Vanilloid 1 (TRPV-1) receptor, Bladder function, Glomerular filtration rate, Detrusor overactivity, Spinal cord injury