Augmentation enterocystoplasty is an effective and safe long term management option for patients with neurogenic bladder and diminished bladder compliance. It is a major reconstructive procedure and carries a significant risk of perioperative and post-operative complications. With the introduction and FDA approval of Onabotulinum Toxin A (BTX-A) for use in neurogenic bladder in 2011 many patients with impaired bladder compliance are able to try this therapy and delay the need for bladder augmentation. The aim of the study was to determine if there has been a change in the rates of bladder augmentation use for patients with neurogenic bladder over the last 11 years encompassing the FDA approval of BTX-A for neurogenic bladder indication. We hypothesize that BTX-A limits the need for bladder augmentation and thus there has been a decline in the rates of augmentation enterocystoplasty.

The electronic medical records and billing data was queried to extract the number of bladder augmentations and BTX-A injections done each year for the last 11 years at a single academic center. Study included patients greater then 18 years of age who had an office visit with a urology provider from 1/1/2007 to 1/1/2018 and had a diagnosis of neurogenic bladder. Bladder augmentation procedures were identified by CPT codes 51960, 51800 and BTX-A injection procedures were identified by CPT 52287, 53899.1, 52327, 52214 codes. Total number of patient visits per year with neurogenic bladder diagnoses seen by urology providers was used to adjust for the increasing volume of patients evaluated.

There were a total of 3303 adult patients with neurogenic bladder diagnoses evaluated at 9867 distinct encounters at a single center over 11 years. Ninety-two of those patients underwent a bladder augmentation based on CPT data. The procedures were reviewed to confirm that billing data was consistent with the actual procedure performed and 21 patients were excluded as they did not have augmentation enterocystoplasty. The final cohort was 54.5% (39/71) female and median age was 36 years (range 21- 66). The raw number of bladder augmentations for neurogenic bladder done at a single center fluctuated from 3 to 13 per year from 2007 to 2017 (Figure 1-a). When the total number of augmentations was adjusted for the number of visits with urology providers for neurogenic bladder the proportion of augments per year decreased from 1.40% (25/1791) in years 2007-2009 to 0.41% (15/3695) in 2015-2017 (OR 3.78, 95%CI 1.80 to 6.53, p < 0.001) (Figure 1-b). BTX-A billing data was available starting in 2012 and the number of BTX-A injections per year increased from 61 in 2012 to 341 in 2017 (Figure 1-a). The proportion of visits for BTX-A injections in neurogenic bladder cohort has steadily increased from 7.57% (61/806) in 2011 to 17.0%(341/2002) in 2017 (OR=0.44, 95%CI 0.33-0.59, p < 0.001) (Figure 1 - b).

The raw number of bladder augmentations per year has remained constant over the last 11 years but the rate of bladder augmentation per neurogenic bladder patient encounter has declined dramatically at a single institution. The number and rate of BTX-A use for patients with neurogenic bladder has increased since its approval in 2011 indicating a shift in management algorithm in patients with neurogenic bladder.

This study encompasses the era of the FDA approval of BTX-A use for neurogenic bladder and, while this is limited to billing data at a single institution, it confirms that rates of bladder augmentation are declining and rates of BTX-A use in neurogenic bladder are increasing dramatically. Further longitudinal and multi-institutional data is needed to determine if these trends hold true at the national level and to identify whether BTX-A offers a temporary delay to bladder augmentation or if it is a permanent long term solution for patients with neurogenic bladder and impaired compliance.