Being a urologist trained to preserve bladder and renal function, I was amazed by the take-home message of the above-mentioned paper.1 By comparing transurethral and suprapubic catheters, stating that the risks of the two are even, the authors create the impression that using any of these options may be a good choice for the long-term treatment of patients with spinal cord injury. In my view, this statement has to be put into perspective.

In the introduction, the authors claim that indwelling catheters should be used only if they cannot be avoided. On the other hand, they state that from about 600 patient files available for review, 281 patients were equipped with an indwelling catheter. This seems to be an extremely high rate for a solution that should be used only if nothing else is feasible, especially as rather young patients (mean age about 30 years) were included. Furthermore, a substantial percentage of these patients were paraplegic, and may thus have been able to perform intermittent catheterization.

The authors state that the complication rates for urinary tract infection, stones and cancer were not significantly different between transurethral and suprapubic catheters. Still, the complication rates in both groups were rather high, with bladder stones in roughly 40% of the patients, urosepsis in more than 10% and gross hematuria in 20%. In all, 14.5% of the patients with indwelling catheters died from urosepsis—to me, this seems to be a rather high rate.

Furthermore, the evaluation of renal function was, at best, crude, as serum creatinine is known to be not a good marker for renal function in patients with spinal cord injury, and no renal imaging (ultrasound, radiologic studies) was described. Thus, renal function, one of the key markers for treatment of neurogenic bladder dysfunction, was not thoroughly assessed.

In summary, a comparison of the long-term consequences of indwelling catheters with those of intermittent catheterization may have augmented the scientific value of the manuscript. Doing so, it is evident that intermittent catheterization is superior to indwelling catheters of any kind.2, 3, 4 In this case, no misunderstanding about the status of indwelling catheters in the treatment of patients with neurogenic bladder dysfunction due to spinal cord injury would have been possible.