- Email: [email protected]
Re: Opposing Views
400
LETTERS TO THE EDITOR/ERRATA
Reply by Authors: Many authors have investigated the predictive factors for urinary incontinence after radical prostatectomy. However, due to space limitations regarding number of references, we were unable to include all articles. We confirm that the study by Saito et al described the different predictive factors concerning post-radical urinary incontinence.1 The study also measured urine loss the first day after catheter withdrawal with the 24-hour pad test, which often is not investigated. Nevertheless, we could not find additive information for patients regarding duration of urinary incontinence. The main aim of our study was to predict accurately the duration of incontinence based on the different significant predictive factors. As mentioned in our article, only Twiss3 and Ates4 et al reported on the prediction of duration of urinary incontinence after radical prostatectomy by giving a continence index or a prediction equation. However, we agree that reference to the article by Saito et al is relevant because it also mentions urine loss on day 1 after catheter removal.1 1. Saito S, Namiki S, Numahata K et al: Relevance of postcatheter removal incontinence to postoperative urinary function after radical prostatectomy. Int J Urol 2006; 13: 1191.
3. Twiss C, Martin S, Shore R et al: A continence index predicts the early return of urinary continence after radical retropubic prostatectomy. J Urol 2000; 164: 1241.
2. Namiki S, Kwan L, Kagawa-Singer M et al: Urinary quality of life after prostatectomy or radiation for localized prostate cancer: a prospective longitudinal cross-cultural study between Japanese and U.S. men. Urology 2008; 71: 1103.
4. Ates M, Teber D, Gozen AS et al: A new postoperative predictor of time to urinary continence after laparoscopic radical prostatectomy: the urine loss ratio. Eur Urol 2007; 52: 178.
Re: Opposing Views T. B. Boone and I. Perkash J Urol 2009; 181: 1538 –1540.
To the Editor: Today detrusor relaxation combined with intermittent catheterization is regarded as standard treatment in patients with neurogenic detrusor overactivity due to spinal cord injury (SCI).1 However, in a substantial percentage of patients intermittent catheterization cannot be established. Therefore, decreasing the detrusor leak point pressure still is a viable treatment option, especially in quadriplegic men.2 These 2 editorials, which offer opposing views, present 2 methods for achieving this goal— external sphincterotomy and external urethral stenting. External sphincterotomy is currently regarded as the gold standard. Long-term followup has demonstrated satisfying results in the majority of patients.2 External urethral stents provide a potentially reversible option for treatment of detrusor external sphincter dyssynergia (DESD) with success rates comparable to sphincterotomy. Boone, a supporter of urethral stents, states that only a randomized prospective trial comparing laser sphincterotomy and UroLume® stent placement will answer the debate. However, treatment of DESD in patients with SCI is not as simple as that. First, there are other treatment options that were not mentioned in this debate. Botulinum toxin A (BTX-A) injections in the external sphincter offer another therapeutic option in this cohort of patients.3 Although the effect is often less pronounced than with sphincterotomy, it offers a reversible treatment option without insertion of a foreign body. Furthermore, there exist thermosensitive stents that can easily be removed without surgical intervention. Results of temporary treatments with these stents are favorable.4 Additionally randomization of patients with SCI and DESD to either stenting or sphincterotomy is difficult, since several factors must be considered. Young patients may insist on reversible treatment strategies. Whereas sphincterotomy reduces outlet resistance by incision, a stent is a foreign body that stays in the region of the external sphincter. Especially in patients with autonomic dysreflexia we frequently observe a temporary or even permanent increase in autonomic dysreflexia triggered by the stent. In patients with chronic urinary tract infections BTX-A might be preferable, as chronic bacteriuria may promote incrustation of the stents.
LETTERS TO THE EDITOR/ERRATA
401
The decision to apply one of these treatments (sphincterotomy, BTX-A, temporary or permanent urethral stent) cannot be solved by a randomized prospective study, but care must be taken to find the best possible solution for each individual. These treatments are not simply either/or options. A possible algorithm for treatment of DESD in the presence of spinal cord injury may involve 1) BTX-A or temporary stents in patients who desire a reversible treatment or first want to know if they can accept permanently wearing a condom catheter (if severe autonomic dysreflexia is present, BTX-A should be preferred in these patients, and if patients are satisfied with BTX-A, the urologist can continue that treatment or proceed to permanent urethral stent or sphincterotomy), 2) external sphincterotomy in men who opt for a permanent solution and 3) placement of a permanent urethral stent in the event of sphincterotomy failure. Respectfully, Juergen Pannek Department of Neuro-Urology Swiss Paraplegic Center Nottwil, Switzerland 1. Nosseir M, Hinkel A and Pannek J: Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury. Neurourol Urodyn 2007; 26: 228.
3. Chen SL, Bih LI, Huang YH et al: Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury. J Rehabil Med 2008; 40: 744.
2. Perkash I: Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: long-term followup results. J Urol 2007; 177: 1026.
4. Hamid R, Arya M, Wood S et al: The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience. Eur Urol 2003; 43: 539.
Reply by Boone: While I appreciate the comments regarding use of an external urethral stent for managing dyssynergia, they miss 2 important points. The first point concerns the nature of the academic exercise. I was asked to take the side of using urethral stents vs external sphincterotomy to manage dyssynergia. I urged caution and judicious use of urethral stents in the setting of dyssynergia. I was not asked to provide other potential therapies or to describe my own decision algorithm for managing these cases. Certainly I am aware of the use of BTX-A for treating dyssynergia and the role it may have as such. However, it is not approved for use in the lower urinary tract by the Food and Drug Administration. Along with deviating from my charge to discuss stents in a limited fashion, I chose not to endorse BTX-A outside of Food and Drug Administration approval or an approved and valid clinical trial. Reply by Perkash: As indicated, the role of transurethral sphincterotomy (TURS) in patients with quadriplegia has been fairly well accepted. Use of urethral stents as an alternative mode of treatment to improve bladder drainage seems reasonable in patients who are not mentally prepared for permanent incontinence. However, there are certain problems, as indicated in the editorial by Boone. Stents are difficult to remove once they have been indwelling for a couple of years. They can also aggravate autonomic dysreflexia (AD) by local irritation.1 Finally they can extrude into the bladder when placed close to the bladder neck. Therefore, it is not a choice procedure in patients with AD. Another problem not appreciated is a constant leakage of urine following placement of a stent that leaves the urethra open all the time, as opposed to incision for TURS, which would open on triggered or attempted voiding. A constantly leaking urethra interferes with sexual activity and also leads to a small contracted bladder. Therefore, I agree that it would be worthwhile to do a controlled study against TURS, as recommended by Boone. Heat sensitive stents, which can easily be removed, and injections of BTX-A in the urethral external sphincter could be other trial options until a patient is ready for TURS. Following TURS patients have to wear external condom drainage. Thus, it is important to see if they can hold an external condom following TURS. A semirigid implant may be needed.2 The algorithm mentioned by Pannek seems appropriate. However, I am unsure whether a simple injection of BTX-A in the sphincter will significantly reduce AD, since perineal injections do not adequately relax the bladder neck unless it is injected through the cystoscope. Long-term (5 to 27
402
LETTERS TO THE EDITOR/ERRATA
years) successful results of TURS have been reported in 77% of patients with SCI.3 The majority of failures are due to inadequate surgical relief, a strictured noncompliant urethra following electrocautery incision or poor detrusor contractility. Laser TURS seems to be a better choice for a successful outcome in most patients and particularly following failed TURS. 1. Perkash I and Wolfe V: Detrusor hyperreflexia and its relationship to posterior bladder neck sensor mechanism in spinal injured patients. Neurourol Urodyn 1991; 10: 125.
3. Takahashi R and Kimoto Y: Long-term follow up of sphincterotomy in spinal cord injured men. Nippon Hinyokika Gakkai Zasshi 2008; 99: 7.
2. Perkash I, Kabalin JN, Lennon S et al: Use of penile prostheses to maintain external condom catheter drainage in spinal cord injury patients. Paraplegia 1992; 30: 327.
ERRATUM BLADDER AFFERENT ACTIVITY WITH AND WITHOUT SPINAL CORD TRANSECTION Volume 182, Number 5, page 2504: Stefan De Wachter is an author of this article.
LETTERS TO THE EDITOR/ERRATA
Reply by Authors: Many authors have investigated the predictive factors for urinary incontinence after radical prostatectomy. However, due to space limitations regarding number of references, we were unable to include all articles. We confirm that the study by Saito et al described the different predictive factors concerning post-radical urinary incontinence.1 The study also measured urine loss the first day after catheter withdrawal with the 24-hour pad test, which often is not investigated. Nevertheless, we could not find additive information for patients regarding duration of urinary incontinence. The main aim of our study was to predict accurately the duration of incontinence based on the different significant predictive factors. As mentioned in our article, only Twiss3 and Ates4 et al reported on the prediction of duration of urinary incontinence after radical prostatectomy by giving a continence index or a prediction equation. However, we agree that reference to the article by Saito et al is relevant because it also mentions urine loss on day 1 after catheter removal.1 1. Saito S, Namiki S, Numahata K et al: Relevance of postcatheter removal incontinence to postoperative urinary function after radical prostatectomy. Int J Urol 2006; 13: 1191.
3. Twiss C, Martin S, Shore R et al: A continence index predicts the early return of urinary continence after radical retropubic prostatectomy. J Urol 2000; 164: 1241.
2. Namiki S, Kwan L, Kagawa-Singer M et al: Urinary quality of life after prostatectomy or radiation for localized prostate cancer: a prospective longitudinal cross-cultural study between Japanese and U.S. men. Urology 2008; 71: 1103.
4. Ates M, Teber D, Gozen AS et al: A new postoperative predictor of time to urinary continence after laparoscopic radical prostatectomy: the urine loss ratio. Eur Urol 2007; 52: 178.
Re: Opposing Views T. B. Boone and I. Perkash J Urol 2009; 181: 1538 –1540.
To the Editor: Today detrusor relaxation combined with intermittent catheterization is regarded as standard treatment in patients with neurogenic detrusor overactivity due to spinal cord injury (SCI).1 However, in a substantial percentage of patients intermittent catheterization cannot be established. Therefore, decreasing the detrusor leak point pressure still is a viable treatment option, especially in quadriplegic men.2 These 2 editorials, which offer opposing views, present 2 methods for achieving this goal— external sphincterotomy and external urethral stenting. External sphincterotomy is currently regarded as the gold standard. Long-term followup has demonstrated satisfying results in the majority of patients.2 External urethral stents provide a potentially reversible option for treatment of detrusor external sphincter dyssynergia (DESD) with success rates comparable to sphincterotomy. Boone, a supporter of urethral stents, states that only a randomized prospective trial comparing laser sphincterotomy and UroLume® stent placement will answer the debate. However, treatment of DESD in patients with SCI is not as simple as that. First, there are other treatment options that were not mentioned in this debate. Botulinum toxin A (BTX-A) injections in the external sphincter offer another therapeutic option in this cohort of patients.3 Although the effect is often less pronounced than with sphincterotomy, it offers a reversible treatment option without insertion of a foreign body. Furthermore, there exist thermosensitive stents that can easily be removed without surgical intervention. Results of temporary treatments with these stents are favorable.4 Additionally randomization of patients with SCI and DESD to either stenting or sphincterotomy is difficult, since several factors must be considered. Young patients may insist on reversible treatment strategies. Whereas sphincterotomy reduces outlet resistance by incision, a stent is a foreign body that stays in the region of the external sphincter. Especially in patients with autonomic dysreflexia we frequently observe a temporary or even permanent increase in autonomic dysreflexia triggered by the stent. In patients with chronic urinary tract infections BTX-A might be preferable, as chronic bacteriuria may promote incrustation of the stents.
LETTERS TO THE EDITOR/ERRATA
401
The decision to apply one of these treatments (sphincterotomy, BTX-A, temporary or permanent urethral stent) cannot be solved by a randomized prospective study, but care must be taken to find the best possible solution for each individual. These treatments are not simply either/or options. A possible algorithm for treatment of DESD in the presence of spinal cord injury may involve 1) BTX-A or temporary stents in patients who desire a reversible treatment or first want to know if they can accept permanently wearing a condom catheter (if severe autonomic dysreflexia is present, BTX-A should be preferred in these patients, and if patients are satisfied with BTX-A, the urologist can continue that treatment or proceed to permanent urethral stent or sphincterotomy), 2) external sphincterotomy in men who opt for a permanent solution and 3) placement of a permanent urethral stent in the event of sphincterotomy failure. Respectfully, Juergen Pannek Department of Neuro-Urology Swiss Paraplegic Center Nottwil, Switzerland 1. Nosseir M, Hinkel A and Pannek J: Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury. Neurourol Urodyn 2007; 26: 228.
3. Chen SL, Bih LI, Huang YH et al: Effect of single botulinum toxin A injection to the external urethral sphincter for treating detrusor external sphincter dyssynergia in spinal cord injury. J Rehabil Med 2008; 40: 744.
2. Perkash I: Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: long-term followup results. J Urol 2007; 177: 1026.
4. Hamid R, Arya M, Wood S et al: The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience. Eur Urol 2003; 43: 539.
Reply by Boone: While I appreciate the comments regarding use of an external urethral stent for managing dyssynergia, they miss 2 important points. The first point concerns the nature of the academic exercise. I was asked to take the side of using urethral stents vs external sphincterotomy to manage dyssynergia. I urged caution and judicious use of urethral stents in the setting of dyssynergia. I was not asked to provide other potential therapies or to describe my own decision algorithm for managing these cases. Certainly I am aware of the use of BTX-A for treating dyssynergia and the role it may have as such. However, it is not approved for use in the lower urinary tract by the Food and Drug Administration. Along with deviating from my charge to discuss stents in a limited fashion, I chose not to endorse BTX-A outside of Food and Drug Administration approval or an approved and valid clinical trial. Reply by Perkash: As indicated, the role of transurethral sphincterotomy (TURS) in patients with quadriplegia has been fairly well accepted. Use of urethral stents as an alternative mode of treatment to improve bladder drainage seems reasonable in patients who are not mentally prepared for permanent incontinence. However, there are certain problems, as indicated in the editorial by Boone. Stents are difficult to remove once they have been indwelling for a couple of years. They can also aggravate autonomic dysreflexia (AD) by local irritation.1 Finally they can extrude into the bladder when placed close to the bladder neck. Therefore, it is not a choice procedure in patients with AD. Another problem not appreciated is a constant leakage of urine following placement of a stent that leaves the urethra open all the time, as opposed to incision for TURS, which would open on triggered or attempted voiding. A constantly leaking urethra interferes with sexual activity and also leads to a small contracted bladder. Therefore, I agree that it would be worthwhile to do a controlled study against TURS, as recommended by Boone. Heat sensitive stents, which can easily be removed, and injections of BTX-A in the urethral external sphincter could be other trial options until a patient is ready for TURS. Following TURS patients have to wear external condom drainage. Thus, it is important to see if they can hold an external condom following TURS. A semirigid implant may be needed.2 The algorithm mentioned by Pannek seems appropriate. However, I am unsure whether a simple injection of BTX-A in the sphincter will significantly reduce AD, since perineal injections do not adequately relax the bladder neck unless it is injected through the cystoscope. Long-term (5 to 27
402
LETTERS TO THE EDITOR/ERRATA
years) successful results of TURS have been reported in 77% of patients with SCI.3 The majority of failures are due to inadequate surgical relief, a strictured noncompliant urethra following electrocautery incision or poor detrusor contractility. Laser TURS seems to be a better choice for a successful outcome in most patients and particularly following failed TURS. 1. Perkash I and Wolfe V: Detrusor hyperreflexia and its relationship to posterior bladder neck sensor mechanism in spinal injured patients. Neurourol Urodyn 1991; 10: 125.
3. Takahashi R and Kimoto Y: Long-term follow up of sphincterotomy in spinal cord injured men. Nippon Hinyokika Gakkai Zasshi 2008; 99: 7.
2. Perkash I, Kabalin JN, Lennon S et al: Use of penile prostheses to maintain external condom catheter drainage in spinal cord injury patients. Paraplegia 1992; 30: 327.
ERRATUM BLADDER AFFERENT ACTIVITY WITH AND WITHOUT SPINAL CORD TRANSECTION Volume 182, Number 5, page 2504: Stefan De Wachter is an author of this article.