The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up



Hamid et al.[1] describe the use of the mesh wallstent in detrusor-external sphincter dyssynergia (DESD) in a well-written but small study. However, we are unclear about some of the conclusions derived from the study. The authors state that there was no significant change in the erectile function of these patients; we were unable to find any evidence for this statement in the methods or the results. Were any scales of erectile dysfunction used, e.g. the International Index of Erectile Function [2] or the Brief Sexual Function Inventory? Similarly, bladder neck incision was stated to impair fertility in these patients, with no reference to published reports. Importantly, the fertility status of the patients should have been examined, as stents can easily obstruct the ejaculatory ducts, either by migration to cover the verumontanum or by fibrosis or epithelialization.

The authors also state that electrocautery sphincterotomy is complicated by erectile dysfunction in 2.8–64% of men. This is understood to be a consequence of thermal injury to the cavernosal nerve and consequently its incidence can be minimised by using a ‘cold’ knife, applying it at the 12 o'clock position (and not laterally), or by using modifications of the technique suggested by Barton et al.[3]. In addition, Schneider et al.[4] found this complication in only one patient of 18 468 after urethrotomy.

Our other concerns with this technique are the loss of easy accessibility to the bladder when required, such as for urinary retention (especially if the patient presents acutely at a general centre) or cystoscopy for bladder surveillance or to treat bladder stones. Furthermore, surely the stainless-steel stent would in the long term predispose the bladder to squamous metaplasia and squamous cell carcinoma of the bladder, as much as a long-term catheter (which is well known) and therefore warrant cystoscopic follow-up? [5]. It is of concern therefore that this subgroup of patients who receive wallstents do not receive the cystoscopic follow-up recommended for similar patients with long-term catheters.