High dose botox injection for treatment of high grade vesicoureteral reflux in a complicated pediatric case: A case report

Abstract

Vesicoureteral reflux (VUR) is a medical condition affecting the bladder and kidneys. Management depends on bladder capacity and compliance. This study found that high-dose BoNT-A is effective in managing high-grade VUR in pediatric patients. In our case, a 3-year-old male with sacral agenesis and neurogenic bladder, experienced a decrease in creatinine levels and improved vesicoureteral reflux after 20 units/kg of BoNT-A were injected into the detrusor and about 100 units were injected into the external sphincter at 3, 9, and 6 o’clock positions.

1 Introduction

Vesicoureteral reflux (VUR) is a medical condition characterized by the retrograde flow of urine from the bladder into the ureters and kidneys and can be classified as either primary or secondary , generally exhibit a malfunctioning lower urinary tract, potentially resulting from obstruction or neuropathology. Secondary VUR occurs as a result of dysfunction within the urinary system, in contrast to the primary type.

In neurogenic bladder patients, secondary VUR is less prone to spontaneous resolution and is less likely to be remedied with antireflux surgery, regardless of the technique or surgical method employed. The prevalent factor that probably distinguishes this patient population from attaining the success rates of the core VUR population is inadequate bladder dynamics. The management of reflux in neurogenic bladder, whether through CIC/anticholinergics, selective and nonselective alpha blockers, ureteral reimplantation, endoscopic surgery, or bladder augmentation, hinges on the optimization or preservation of sufficient bladder capacity and compliance for enhanced outcomes. The risks and advantages of management alternatives must be evaluated with regard to each specific circumstance.

Botulinum Toxin A (BoNT-A) serves as a safe and effective second-line treatment for children with neurogenic bladder who do not respond to standard conservative therapies. Botulinum toxin type A injections have demonstrated efficacy in enhancing continence, augmenting bladder capacity, and decreasing bladder pressure. Botulinum toxin type A injections may be effective in treating vesicoureteral reflux.

Here, we report a case investigating the efficacy and safety of high-dose BoNT-A injections (20 unit/kg) for treating high-grade VUR in a complicated pediatric case.

2 Case presentation

Our case was a three-year-old male with a history of incomplete sacral agenesis and neurogenic bladder who presented with complaints of daytime and nocturnal incontinence, frequent urinary tract infections, and a high serum creatinine level (2.5 mg/dL). In this patient, the left kidney was nonfunctional, and the right kidney had high-grade vesicoureteral reflux ( Fig. 1 ). This patient was refractory to treatment with anticholinergicsm, alpha-blockers and clean intermittent catheterization.

A renal scan with Tc-99m-DPTA showed negligible function of the left kidney, normal perfusion, and function of the right kidney. Differential renal function (DRF) was 96.4 % and 3.6 % for the right and left kidneys, respectively. Several high-amplitude phasic detrusor overactivities, high-pressure low-flow patterns of voiding, and a high post-void residual volume were observed in the urodynamic study.

Finally, 20 units/kg of BoNT-A (MASPORT®500, Masoon Darou, Alborz, Iran) were injected into the detrusor and about 100 units were injected into the external sphincter at 3, 9, and 6 o’clock positions. After injection, the patient’s serum creatinine level dropped to 0.8 mg/dl, and he maintained good urinary control. In control VCUG after 6 weeks, significant improvement was seen in the shape of the bladder, and the right vesicoureteral reflux was completely eliminated ( Figs. 1 and 2 ).