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Periureteral botulinum toxin type A injection in patients with ureteral stents decreases pain, narcotic use, study shows

Tuesday, February 09 2010 | Comments

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What's This? After ureteral stent placement, botulinum toxin type A injection significantly decreases postoperative pain and narcotic use, although it does not appear to have any effect on irritative stent symptoms, according to recently published results.

Despite the efficacy of ureteral stents to treat obstructed ureters, the stents are associated with significant morbidity, including pain, urinary urgency and frequency, dysuria, and hematuria, the authors explained. They theorized that many of these symptoms may be related to detrusor muscle spasms in and around the intramural ureter, so they sought to evaluate the effect of botulinum toxin type A injection in patients who were given indwelling stents after ureteroscopy.

The prospective single-blind study included 51 patients who were randomized to receive either botulinum toxin type A injection at a concentration of 10 U/mL to 3 locations around the ureteral orifice or no injection after unilateral ureteral stent insertion.

The Ureteral Stent Symptom Questionnaire (USSQ) was used to evaluate pain and urinary symptoms on postoperative day 7. The USSQ has domains including urinary symptoms, body pain, general health, work performance, sexual function, and any additional problems associated with stent placement. Patients were also asked to complete a log of narcotic use after stent placement until removal.

The USSQ was returned by 40 (78.4%) subjects and the narcotic log sheet by 35 (68.6%).

Postoperative pain was reported by a similar proportion of patients in both groups (76.2% of patients who received injections vs 75% of patients who did not receive injections). However, patients in the injection group reported an absolute pain score (range, 1-10) of 3.41 at postoperative day 7 as compared with a score of 6.00 reported by patients who did not receive injections, a difference that was statistically significant (P=.023).

Results from the narcotics log sheets showed that patients in the injection group used an average of 7.73 oxycodone/acetaminophen pills in an average of 2.71 days, while patients in the noninjection group used an average of 24.77 pills in an average of 7.00 days (P=.032).

Botulinum toxin type A injection did not have a significant impact of the rate of daytime frequency, nocturia, urgency, dysuria, and hematuria.

In the injection group, 92% of patients reported urinary frequency (voiding every 2 hours or sooner) versus 86.7% of patients in the control group who did so (P=.623). Nocturia rates were 68% in the injection group versus 60% in the control group (P=.736). There was also no significant difference between the treatment group and the control group in urinary frequency and painful urination (40% vs 46.7%; P=.749) or in the incidence of hematuria (60% vs 80%; P=.298).

Additionally, no significant difference was seen between the treatment group and control group with respect to individual USSQ quality-of-life domains (15.9 vs 19.1; P=.265).

There were no adverse events including urinary retention and allergic reactions reported by patients in the treatment group.

"[T]his study demonstrated a significant trend toward decreased pain and decreased narcotic use without a significant difference in postoperative morbidity from the medication or the injection process," the authors concluded. (Gupta M, et al. J Urol 2010:183:598-602.)

This information concerns a use that has not been approved by the Food and Drug Administration.

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