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EDITORIAL COMMENT

These authors highlight the experience at 1 institution withtreating a large group of children with neurogenic bladderdysfunction using intravesical electrotherapy. It is clear fromthe author long-term perspective that intravesical electrother-

apy improves bladder capacity by greater than 20% in 77% ofthe patients and it maintains acceptable detrusor pressure atcapacity along with minimal detrusor activity midway throughfilling in approximately 74% to 81%. In addition, the sensationof bladder fullness is attained and maintained in 62% of thechildren which, as the authors point out, helps the child knowwhen to catheterize and empty the bladder.

These observations are important for determining theefficacy of treatment in these children. However, the authorshave not addressed several other just as important issues.Based on pretreatment testing and the author extensiveexperience what children are not good candidates at all inwhom to even initiate this form of therapy? When do theauthors consider a patient refractory to stimulation sessionsand pursue an alternative course of treatment after 1 ormore therapy sessions? Conversely what response parame-ters encourage the authors to repeat the intravesical elec-trotherapy sessions after a period? How long are the effectsof therapy (detrusor muscle changes and sensory improve-ment) sustained and did each additional set of therapy ses-sions prolong or shorten these responses? After such anextensive analysis of their patient population are there anypatients whom the authors would not consider likely torespond to electrotherapy? Alternatively what patientswould they consider to be ideal candidates who would mostlikely benefit from this treatment program?

In trying to advocate intravesical electrotherapy as ameans of avoiding augmentation cystoplasty it is paramountthat these questions be answered.

Stuart B. BauerDepartment of Urology

Children’s Hospital BostonBoston, Massachusetts

REPLY BY AUTHORS

In our long-term experience with intravesical electrotherapywe have determined which patients may or may not respondto therapy. The myelomeningocele population responds thebest to therapy, especially those with small, poorly compli-ant bladders. Other therapies have often failed in this groupwho would otherwise require augmentation. Childrenyounger than 6 years typically have the most success withsensation. Patients who have a poor response to therapyand, therefore, are discouraged from this treatment modal-ity include those with a large hypotonic bladder, severedetrusor overactivity with frequent high pressure contrac-tions, unstable spinal lesions, complete cord transections,prior augmentations and no outlet resistance.

Responses are typically seen after 1 series of therapy. Ifno response is seen on cystometrogram when the patientsreturn for the second series, continuation of the program isdiscouraged. However, even a slight response is a predictorof success. Complete success may take up to 3 years aftertherapy has been finished.

Results are usually sustained for a lifetime. In patientswith close to 20 years of followup the improvements have notsubsided. These patients continue to have large capacitycompliant bladders with a degree of sensation. The excep-tion is those who have neurological setbacks, and thesepatients, if they responded previously, often improve withanother treatment series.

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