O2210: Optimizing Postoperative Pain Management in Bladder Exstrophy: The Role of OnabotulinumtoxinA

Background: We sought to evaluate the postoperative benefits of OnabotulinumtoxinA (Botox) injections in patients with classic bladder exstrophy (CBE) and cloacal exstrophy (CE) undergoing bladder reconstruction or exstrophy closure.

Methods: CBE and CE patients who underwent bladder reconstruction or exstrophy closure between 2018-2024 were retrospectively identified from an institutional database. Bladder reconstruction was defined as any combination of the following procedures - bladder neck reconstruction, bladder neck transection, Mitrofanoff or Monti catheterizable channel creation, and bladder augmentation. Patients undergoing bladder reconstruction were stratified by concurrent ureteral reimplantation necessitating ureteral stent placement. Data on postoperative course, medications, and complications were collected.

Results: Among the 49 patients undergoing bladder reconstruction, 15 received Botox and 34 did not. Of the 34 exstrophy closures, 12 received Botox and 22 did not. In patients undergoing bladder reconstruction without ureteral reimplantation necessitating ureteral stents, Botox significantly reduced anticholinergic use (0.11 mg/kg/day, IQR 0.00-0.12 vs. 0.15 mg/kg/day, IQR 0.11-0.20, p=0.02) and oxycodone use (0.00 mg/kg/day, IQR 0.00-0.12 vs. 0.24, IQR 0.13-0.52 mg/kg/day, p=0.03). These patients also experienced fewer days with pain scores above 0 (4.00, IQR 2.00-8.00 vs. 10.00, IQR 6.00-12.00, p=0.03) and above 4 (1.00, IQR 0.00-4.00 vs. 6.00, IQR 2.50-8.50, p=0.02). In contrast, patients undergoing bladder reconstruction with ureteral reimplantation necessitating ureteral stents showed no significant differences in medication use or pain scores (all p>0.05). Complication rates were comparable across groups (all p>0.05). Botox did not significantly impact postoperative course, medication requirements, or complication rates in exstrophy closures (all p>0.05).

Conclusion: Intraoperative Botox reduced opioid and anticholinergic use, as well as postoperative pain, among exstrophy patients undergoing bladder reconstruction without ureteral reimplantation requiring ureteral stents. This demonstrates its potential as an effective adjunct for postoperative pain in exstrophy patients undergoing select reconstruction.