Botox Injections Botulinum toxin A (BtxA), a neurotoxin produced by the anaerobic bacteria Clostridium botulinum, acts on peripheral cholinergic nerve endings to inhibit calcium-mediated release of acetylcholine vesicles at the presynaptic neuromuscular junctions. In a report from a multicenter study, a 73% continence rate occurred in 180 patients with neurogenic detrusor overactivity incontinence who underwent cystoscopic Botox injections (129). A recent prospective placebo-controlled trial in patients with refractory idiopathic urge incontinence demonstrated a 60% clinical response using the Patient Global Impression of Improvement score of 4 or greater with a median duration of response of 373 days. The Botox group did experience an increase in postvoid residual in 75% of the subjects (130). The off-label use of Botulinum A cystoscopic detrusor injections to treat refractory urge incontinence in women with and without neurologic impairment is gaining popularity. The procedure is done via cystoscopy and involves injecting 15 to 30 different detrusor muscle sites under direct visualization, sparing the bladder trigone and ureteral orifices.
Surgery to replace the function of a diseased bladder has been done for more than a century and over the past several decades has gained some popularity in treating people with intractable detrusor overactivity not responsive to any other form of management. These surgical options include (i) conduit diversion (creation of various intestinal conduits to the skin) or continent diversion (which includes a rectal reservoir or continent cutaneous diversion), (ii) bladder reconstruction, or (iii) replacement of the bladder with various intestinal segments. For a discussion of these techniques, both historical and current, the interested reader is referred to a review by Greenwell et al. (131). A Cochrane review found only two randomized trials that were of sufficient quality to include and concluded that there were no major differences in outcomes between the techniques and that higher quality research was needed (132). With the advent of sacral neuromodulation and cystoscopic injection with Botulinum A, these procedures are done much less often to treat women with detrusor overactivity.
Surgical Treatment of A wide variety of techniques are available for fistula repair (133,134). Traditionally, fistula repair
Fistulae was performed after a waiting period to allow the resolution of inﬂammation and formation of scar tissue. This is particularly important in the case of obstetric fistulas, in which the extent of the vascular injury to the soft tissues of the pelvis may not be apparent for many weeks. However, there is a recent trend toward early closure of small gynecologic fistulas (135). The keys to closure of a vesicovaginal fistula include wide mobilization of tissue planes so that the fistula edges can be approximated without any tension, close approximation of tissue edges, closure of the fistula in several layers, and meticulous attention to postoperative bladder drainage for 10 to 14 days. The closure of large fistulas will be enhanced by the use of tissue grafts (e.g., Martius labial fat-pad grafts, gracilis muscle ﬂaps) that provide an additional blood supply to nourish an area that has sustained vascular injury. The Latzko procedure used to close a vesicovaginal fistula is shown in Figure 26.14.