We read with great interest the prospective cohort study on urodynamic assessment of detrusor function in the acute phase of traumatic spinal cord injury (SCI) by Vasudeva et al.[1] in the recent issue of the journal. We noticed certain discrepancies in the article which require clarification. In the methodology, it is mentioned that - "In patients who developed autonomic dysreflexia, the urodynamic study (UDS) was aborted and the bladder was emptied," this is in contrast with the results section which states - "no patient developed autonomic dysreflexia." Furthermore, UDS parameters which are relevant, i.e., Pdet@Qmax, maximum cystometric capacity, and high input impedance more significant than 100 MOhms on electromyography (suggestive of detrusor sphincter dyssynergia (DESD)), are not mentioned in the results section. Also, a similar study has already been carried out by Watanabe et al.,[2] where they documented the urodynamic findings in the acute phase of SCI in 161 patients within 2 weeks of the injury and showed that neurogenic lower urinary tract dysfunction is present in 41% of the patients with mildest forms of incomplete SCI (AIS E). Finally, the study protocol does not mention the Institutional Ethics Committee's approval number. We would also like to highlight a few points to add further value to the study. The study will be more impactful if a subgroup analysis is performed, as the clinical profiles of suprasacral and infrasacral SCI are different. Also, correlating the findings of focal neurological examination with the UDS findings will add more value to the study. This is because of the anatomical proximity of the somatic and the autonomic nervous systems in the spinal cord, resulting in a strong association between the motor and the urological impairment in patients with SCI, as reported by Pavese et al.,[3] who found that lower extremity motor score, assessed within the first 40 days after the SCI, can reliably predict the urinary continence and complete bladder emptying 1 year after the injury. Furthermore, the recovery of the detrusor reflex is slower as compared to the bulbocavernosus reflex or the deep tendon reflex, so a clinical examination is a must, as the recovery of the bulbocavernosus reflex or the deep tendon reflex suggests the termination of the phase of spinal shock.[4] The study would have provided more robust evidence if, in patients with unfavorable urodynamic parameters, a follow-up UDS was considered at 1 to 3 months after the initiation of the treatment (e.g., antimuscarinics, neuromodulation, intradetrusor onabotulinumtoxinA injections, etc.) to assess the therapeutic effects and to fine-tune the treatment, if required. Also, performing a subgroup analyses, to investigate the risk factors for unfavorable urodynamic parameters, would have added more value to the study. In the future, if a randomized study is planned, to compare early versus late (or no) urodynamic investigation, it will add to the available evidence. In the Indian scenario, the patients with SCI are usually managed with an indwelling per urethral catheter (PUC) at least for a period of 1 to 3 months after the injury. Hence, in these patients, the risk to the upper tracts is mitigated by the indwelling PUC and therefore, the purpose of the study is moot for these patients. However, this needs to be assessed in a randomized controlled trial setting. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
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