Albert Navarro-Luna

Clinical and cost effectiveness of sacral nerve stimulation for faecal incontinence.

Sacral nerve stimulation (SNS) has better results and safety than other surgical procedures for faecal incontinence. This prospective study assessed the clinical effectiveness and costs of SNS at a single centre.

Cost–effectiveness analysis of sacral neuromodulation (SNM) with Interstim for fecal incontinence patients in Spain

ABSTRACT Introduction: Fecal incontinence (FI) is a condition with a high impact on the psychological and social life of healthy people. Interstim, the sacral neuromodulation (SNM) therapy, has shown higher effectiveness and safety rates than surgical procedures like dynamic graciloplasty or artificial anal sphincter in patients with intact anal sphincter (IAS) and after sphincteroplasty in patients with structurally deficient anal sphincter (SDAS). Objective: To assess the cost-effectiveness of FI management in two scenarios – with and without SNM – and to estimate the potential budget impact of its progressive introduction in the Spanish setting. Methods: Two decision analytical models were developed (IAS and SDAS patients) representing the possible clinical paths for each of the scenarios (with and without SNM), as well as its clinical and economic consequences in the mid-to long term with a Markov model. Clinical and resource use data were retrieved from the literature and validated by a clinician expert panel. Effectiveness was measured with both QALYs and symptom-free years (SFY). A 3% discount rate was used for future costs and benefits (time horizon = 5 years). Prevalence figures were combined with Interstim sales forecasts to estimate the total number of patients to receive therapy over the next 5 years and the associated budget impact. Results: The introduction of Interstim in the therapeutic management of FI has an associated cost-effectiveness of €16 181 (IAS patients) and €22 195 (SDAS patients) per QALY gained. The progressive introduction of Interstim in 75 to 100 patients/year will have an estimated budget impact of 0.1% of incremental costs in patients with FI. Conclusions: Introducing Interstim in the management of FI in IAS and SDAS patients in the Spanish setting has shown to be an efficient measure with an incremental cost–effectiveness ratio below the accepted Spanish threshold (around €35 000/QALY), and with a relatively low additional cost for the Spanish NHS.

Sacral neuromodulation in a faecal incontinence patient with unknown sacral partial agenesis

We present a 21-year-old female patient with partial sacral agenesis and faecal incontinence (FI), treated with sacral neuromodulation (SNM). This patient has a polymalformative syndrome. When she was 15, she underwent radical surgery with anal reconstruction for her anterior ectopic anus. She had a St. Marks incontinence score of 15/24 when being assessed at our centre, with episodes of urge incontinence, soiling and an irregular depositional pattern with liquid stools. This article is protected by copyright. All rights reserved.

Propuesta de una nueva clasificación de consenso para la incontinencia fecal

Resumen Debido a la complejidad en los mecanismos involucrados en la continencia, existen multiples causas potenciales de este trastorno. Las causas de incontinencia y la agrupacion de los pacientes segun factores etiopatogenicos estan descritas en la literatura de forma muy variada, sin un consenso al respecto. Asi pues, el objetivo de esta revision es plantear a la comunidad cientifica una propuesta de nueva clasificacion de la incontinencia fecal que nos permita unificar criterios, que conlleven una mejora en el diagnostico y el tratamiento de los pacientes con incontinencia fecal. Se trata de una clasificacion etiopatogenica que se puede obtener con la historia clinica del paciente y una ecografia endoanal.

Gracilis Muscle Interposition for Rectourethral Fistula After Laparoscopic Prostatectomy: A Prospective Evaluation and Long-term Follow-up

BACKGROUND: Postoperative rectourethral fistula after radical prostatectomy is an infrequent but very serious problem. OBJECTIVE: We aimed to describe our experience with transperineal repair and unilateral gracilis muscle interposition in patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. DESIGN: This was a cohort study. SETTINGS: All of the procedures were performed at the same hospital by the same multidisciplinary team made up of a senior colorectal surgeon and a senior urologist. PATIENTS: Patients with postoperative rectourethral fistula after laparoscopic prostatectomy were included. INTERVENTION: Transperineal fistula repair and gracilis muscle interposition were included. MAIN OUTCOME MEASURES: Fistula healing rate was measured. RESULTS: Nine patients with postoperative rectourethral fistula were treated between November 2009 and February 2016. Four of them had received other previous treatments without success, and 5 had previously been treated with this technique. Seven patients had a fecal diverting stoma. After a median follow-up of 54 months (range, 2–72), all of the fistulas had successfully healed, and, to date, the patients remain asymptomatic without urinary diversion. Fecal diversion was closed in all but 1 patient. No intraoperative or infectious complications were detected. With the results of our series, we present specific technical details of our technique and hope to provide additional evidence of the low morbidity profile and excellent healing rate of this treatment. Moreover, we note that, although small, this series corresponds with a homogeneous group of patients with rectourethral fistula after radical prostatectomy in nonradiated prostate cancer. LIMITATIONS: This is a small but very homogeneous group of patients. CONCLUSIONS: Simple repair with perineal gracilis muscle interposition is a safe and effective technique for the treatment of postoperative rectourethral fistulas after nonradiated prostate cancer surgery.

Bilateral partial miotomy of the puborectalis for dyssynergic defecation: an unaffordable risk

Dear Editor: We read the article by Asciatore et al (Asciatore et al. Int J Colorectal Dis 2015:30;1729-1734) reporting on the bilateral division of the inner half of the puborectalis muscle (PRM) to treat dyssynergic defecation. The authors performed this technique on eight patients, and concluded that the procedure is feasible and minimally invasive with satisfactory clinical and functional results. There are, however, several issues that need to be considered. Although the authors performed a defecography, they do not provide any information on the results of the imaging studies, and the diagnosis of dyssynergic defecation seems to be based on certain measurements taken by anal/vaginal ultrasound. Impaired anal relaxation (or paradoxical contraction) may involve the PRM and/or the external anal sphincter, and it is not clear whether external anal sphincter relaxation was properly assessed. Therefore, in our opinion, anorectal physiology tests should be performed to assess the defecatory manoeuvre and to establish the diagnosis of dyssynergic defecation. Focussing on the outcomes, there is a discrepancy in the article as two patients reported to be Bunchanged^ according to the text, but only one according to the table. In any case, this improvement may be highly subjective and it is difficult to assess the real impact on patients’ quality of life. Moreover, six patients underwent an associated procedure (Block procedure) to treat a concomitant rectocele entrapping contrast on defecography. Therefore, whether the subjective improvement was attributable to one procedure or the other remains unknown. One patient that did not improve had undergone a previous STARR procedure, and it is rather unlikely that dyssynergic defecation was not present before the mentioned procedure. The authors state that another patient Bdespite being able to relax PRM on straining after surgery, still complained of troublesome OD^ and they point out that this fact shows Bthat other factors than PRM failed relaxation are involved^. We wonder whether the other factors they mentioned were considered before indicating the surgery. In addition, follow-up is too short to reach conclusions, as it was only 2 months in two cases and only exceeded 12 months in three patients. Moreover, only half of the patients were regularly visited, while the remaining four were only contacted by telephone. Nevertheless, the real purpose of this letter is to focus on the risk of faecal incontinence. As vaginal multiparous females were excluded, it should be assumed that female patients included had one child or were nulliparous. However, it should be noted that two of them were younger than 40 years old and two more were in their 40s, and potentially still able to have more pregnancies and were, therefore, at risk. However, childbirth is only one of the risk factors for faecal incontinence. As aetiology is commonly multifactorial, other factors may contribute to the impairment of continence along their lives. Taking this into account, procedures that may jeopardize continence should be discouraged. The authors do not provide any data on the scores on faecal incontinence before and after the procedure. They report a 52year-old woman who suffered an episode of incontinence of * Yolanda Ribas yribas@cst.cat

Pelvic organ prolapse - a tailored approach.

ies on rectal prolapse, but, to our knowledge, there are no studies comparing both approaches for other types of pelvic organ prolapse. Pelvic organ prolapses may present in an isolated manner or in a combined manner. although an isolated rectocele causing obstructive defecation could be repaired transvaginally, the abdominal approach would be preferable if an associated rectal intussusception or enterocele is responsible for further obstruction. therefore, it seems rather difficult to decide on 1 procedure of choice to treat pelvic organ prolapses in general, and, in our opinion, a tailored approach would be optimal. in the case of multiple structural abnormalities, ventral mesh rectopexy seems to have advantages over other procedures, but data on long-term morbidity and functional outcomes are yet to be known. We should keep in mind that the correlation between anatomic correction and functional outcome is frequently inconsistent.

The European Consensus Statement on sacral neuromodulation.

Dear Sir, We read with interest the article from Vettoretto et al. [1]. It is a well-structured analysis attempting to tease out the benefits of single incision laparoscopic appendicectomy (SILA). They conclude that SILA is an acceptable alternative to conventional laparoscopic appendicectomy and that better designed randomized controlled trials are necessary to evaluate the economic cost. In our experience the loss of triangulation in SILA does not justify the benefits from a reduced number of incisions, especially if a single 10 mm umbilical incision can be used for both laparoscopy and specimen extraction alongside two 5 mm (or 3 mm) ports for instrumentation. In our study of patients’ satisfaction with their scars at 4 years post laparoscopic cholecystectomy, using the validated Patient Scar Assessment Questionnaire [2], 90% of 195 patients rated the cosmetic outcome as either ‘excellent’ or ‘very good’ with the only dissatisfaction being expressed towards the umbilical incision [3]. The larger umbilical incision needed for SILA is therefore unlikely to result in increased patient satisfaction in the long term. The placement of peripheral ports allows a 5 mm or 3 mm laparoscope to be inserted at these sites for improved visualization during dissection of a retrocaecal or retroileal appendix. For these reasons we do not believe SILA is necessarily ‘the next step’ for laparoscopic appendicectomy.