Cystoscopic injection of botulinum neurotoxin (BoNT) is typically performed under general anesthesia in pediatric patients with neurogenic bladder, accumulating anesthetic exposures and OR costs. As most of these patients already tolerate clean intermittent catheterization (CIC), it has become our practice to offer a trial of awake injection. We report our initial experience here. We hypothesized that higher sensory level, female sex, and absence of mental health issues or cognitive delay might predict successful first awake injection and decreased operative times.
Surgical records from two academic hospitals from 2018-2020 were reviewed. Generalized linear models were fit to determine predictors of success and procedural length.
Trial of awake injection was offered to 22 patients. 18 patients (8 female, 10 male, 4-20 years old) elected to proceed. All 18 patients were managed with CIC at baseline, 14 had anxiety or behavioral issues, 10 had cognitive delay, and 7 had sensory level below S2. Two patients (11%) required conversion to general anesthesia and one of these subsequently opted for a repeat awake injection trial. 15 patients (83%) had or planned subsequent injections awake. Of the remaining, one proceeded to bladder augment, one is considering ileovesicostomy, and one requested subsequent injections under anesthesia. No intraoperative complications occurred.
Awake BoNT injection is feasible in pediatric patients with neurogenic bladder managed with CIC, even in the setting of intact sensation, well-managed mental health issues, or cognitive delay, thereby increasing the viability of BoNT as an early tool in the management of neurogenic bladder.