Letter to the Editor: “Early continence after ileal neobladder: objective data from inpatient rehabilitation”

Abstract

We read with interest the recent publication entitled “Early continence after ileal neobladder: objective data from inpatient rehabilitation” [1]. Authors retrospectively reviewed data from 283 male patients treated with a three-week inpatient rehabilitation after radical cystectomy (RC) and orthotopic neobladder (ONB) for bladder cancer, concluding that a dedicated rehabilitation program with a special multimodal continence therapy might improve early continence. We would like to thank Dr. Erdogan and coworkers for taking such an interest in the aforementioned issue and hope that others will take the time to understand its utility as much as they have. Indeed, their manuscript represents one of the few papers exploring modifications of urinary continence during the early recovery period after ONB and efficacy of a multimodal continence therapy. In this scenario, several baseline and postoperative features play a key role in determining functional outcomes and especially continence after RC. The creation of a lowpressure reservoir is a mainstay for the preservation of postoperative urinary continence. However, while the technique and the general shape of the neobladder might influence urodynamic results such as maximum capacity or compliance, unfortunately in this paper, no distinction was made according to the technique used for reconstruction. Similarly, we also found missing data about the surgical approach and we were not able to understand how many patients were treated either with an open or a robotic approach. Undeniably, robotic assistance might play a key role in early continence recovery: in fact, the robotic surgeon is able to perform an accurate apical dissection preserving a longer functional length of membranous urethra and carry out a more precise urethro-ileal anastomosis using a running suture, thus reducing the risk of anastomotic dehiscence and early incontinence, as compared to standard open approach [2, 3]. In addition, as correctly outlined by Authors, nerve sparing procedure was independently associated with lower urine loss at the end of inpatient rehabilitation. Once again, definition of surgical approach appears not less than paramount for a correct interpretation of data, since robotic platform might meaningfully assist the surgeon during neurovascular bundle preservation. Of course, optimizing nerve sparing procedure might be beneficial also for continence rates, since autonomic nerve fibers within neurovascular bundles innervate the striated urethral sphincter or pass through the sphincter to innervate the smooth muscle sphincter component of the membranous urethra [4]. As such, we wonder how results may have changed by adding surgical approach among covariates in the multivariable model. In summary, this report does serve as food for thought towards an in-depth knowledge of early functional outcomes after ONB, although some questions still remain unanswered. Undeniable merits must be recognized to Authors for their efforts and the relevance of the clinical message provided. However, we are still far from drawing definitive conclusions. In this regard, since we are aware many confounders may meaningfully impact on early continence after RC and ONB configuration, a proper stratification according to surgical approach and ONB technique might have contributed to provide more generalizable results in a hypothetical real-life scenario. This comment refers to the article available online at https ://doi. org/10.1007/s0034 5-020-03514 -3.