Letter 2: Surgical treatment of oesophageal perforation (Br J Surg 2008; 95: 805–806)

Sir We read with great interest the most recent article by the investigators of the Dutch TME trial. The introduction and first part of the discussion amount to an excellent synopsis of the pathophysiology of urinary dysfunction (UD) associated with rectal dissection and should be essential reading for all colorectal trainees. The expert design and large cohort of patients in the Dutch TME trial has allowed this excellent and detailed report on the prevalence and incidence of UD after rectal cancer surgery. It is clear that a number of patients develop de novo (or surgically-induced) UD after TME, most notably in terms of bladder emptying. Initial emphasis in the paper is on pelvic autonomic nerve damage during dissection; however the authors acknowledge that the increasing age of the cohort over the study period, female gender with postmenopausal loss of oestrogen and other unavoidable surgical factors such as disruption of the levator plate mechanism, may also contribute to the findings. The simplified grouping of data for the multivariate analysis into patients with or without UD after TME has perhaps smothered the contribution of radiotherapy to the worsening of pre-existing or de novo UD over time. To conclude that surgery is the main factor that contributes to UD states the obvious. We believe that the authors cannot conclude that radiotherapy does not cause UD since there was no randomization to radiotherapy alone. They perhaps should conclude that the addition of radiotherapy to TME surgery confers no additional disadvantage. K. Boyle Department of Colorectal Surgery, Leicester Royal Infirmary, Leicester, LE1 5WW, UK DOI: 10.1002/bjs.6401