Influence du score de Gleason des marges chirurgicales de prostatectomie totale sur la récidive biologique.

OBJECTIVES: The aim of this study was to assess the impact of the aggressiveness of cancer cells at the level of positive surgical margins (PSM) on the biochemical recurrence rate (BRR) by studying the Gleason score (GS) at this level. METHODS: We included all radical prostatectomy (RP) procedures performed from January 2007 to November 2011. All of the RP specimens with PSM were reviewed to determine the GS at the level of PSM. We compared the GS at PSM with BRR. RESULTS: A total of 658 RP were analysed, among which 16% had PSM. From the 101 patients with PSM included, 32% had biochemical recurrence (BR) with a median follow-up of 38 months. GS at PSM was significantly associated with earlier BR (P=0.008). Univariate analysis showed that GS at PSM (P=0.013), initial PSA (P<0.0001), pathologic GS (P<0.001), length of PSM (P=0.013), and seminal vesicle invasion (P<0.0001) were predictors of BR. Multivariate analysis confirmed that PSA greater than 10ng/mL and length of PSM greater than 3mm were independent prognostic factors for BR, but GS at the level of PSM was not. CONCLUSION: GS at PSM was not confirmed as an independent risk factor for BR. Initial PSA greater than 10ng/mL and length of PSM greater than 3mm were the sole independent predictors for BR. LEVEL OF PROOF: 4.

[Eight years of experience with HIFU for prostate cancer: Oncological and functional results]. / Huit ans d'expérience dans le traitement du cancer de prostate par HIFU, résultats oncologiques et fonctionnels.

OBJECTIVE: To study the oncologic and functional results of HIFU as a first-line treatment for localized prostate cancer. MATERIAL AND METHOD: Enrolment of patients between 2006 and 2011 for the first treatment against localized prostate cancer with HIFU (Integrated Imaging(®), EDAP-TMS, Vaulx-en-Velin, France). The biochemical recurrence-free survival was calculated by using the Phoenix criterion (PSA>nadir+2 ng/mL). The functional complications were assessed clinically and through standardised questionnaires. RESULTS: The condition of 191 patients was assessed at a mean follow-up of 55.5 ± 22.7 months. In 10,1% of the treatments, an incident during the medical procedure was observed with the volume of the prostate (P=0.026) as risk factor. The overall survival, the survival and the metastatic free survival rate were respectively 89.5%, 98.4% and 97.4%. The biochemical free survival rate for 5 years was 87.5%, 69% and 39% respectively for the low, medium and high-risk groups of d'Amico classification. Eighty-six percent of the patients with a PSA nadir ≤ 0.3 ng/mL were relapse free at 5 years. Whereas only 48% of the patients with a nadir>0.3 ng/mL did not. Only 17.8% of the patients had a rescue treatment with an average delay of 31.1 months. The urinary and sexual impairment was significant but 78.1% of the patients were dry at the end of the study. The most common complication found in 18.3% of the patients was the prostatic obstruction. CONCLUSION: The oncologic and functional results of the HIFU seem similar to the other first-line treatments results and reveal that the HIFU is a therapeutic option for the treatment of prostate cancer in men over 70 years. LEVEL OF EVIDENCE: 5.

[Partial nephrectomy on solitary kidney: Renal function outcome and predictive factors of impairment]. / Néphrectomie partielle pour cancer sur rein unique : évolution de la fonction rénale et facteurs prédictifs de son altération.

OBJECTIVES: To assess the postoperative functional outcome of PN in solitary kidney and define some predictive factors of renal change. MATERIAL AND METHODS: A monocentric series of 45 partial nephrectomies on solitary kidneys, performed between 1988 and 2014, was retrospectively analyzed. Pre-, per- and postoperative clinicopathological data were collected in the UroCCR database. The evolution of early, medium and long-term postoperative Glomerular Filtration Rate (GFR) was evaluated. Predictive factors of GFR decline and hemodialysis were assessed in multivariate analysis. RESULTS: Mean age was 61 years old (±10.8). Mean preoperative GFR and tumor size were respectively 59.6 mL/min (±18.7) and 3.9 cm (±2.6). Vascular clamping was performed in 41 cases (91%). Median time of warm ischemia was 20 minutes (2-60). Mean follow-up was 66 months (±47). Mean GFR at day 5, 1 month and last follow-up were respectively 46.4 mL/min, 50.3 mL/min and 53.1 mL/min. At day 5 and at last follow-up, a GFR decrease ≥ 20% was found in 20 patients (44.4%) and in 16 patients (35.5%), respectively. Five patients (11%) required definitive hemodialysis (HD) at last follow-up. At day 5, tumor size>4 cm (0.006) and operative time (P=0.003) were independent predictive factors of GFR decline. At 1 year, RENAL ns ≥ 10 was the only independent predictive factor of GFR alteration (P=0.0007). Preoperative GFR was significantly associated with final hemodialysis (P=0.023). CONCLUSION: Partial nephrectomy allows most of the patients presenting with renal cell carcinoma on solitary kidney to be free of hemodialysis. Tumor complexity, tumor size and preoperative GFR seems to play a determinant role on postoperative functional outcome. These non-modifiable predictive factors should be recognized and taken into account to better select patients with high risk of postoperative renal failure. LEVEL OF EVIDENCE: 5.

[Vaginal mesh exposure after prolapse surgery. A descriptive study of 43 cases: Epidemiology and therapeutic management]. / Expositions prothétiques vaginales après chirurgie du prolapsus. Étude descriptive sur 43 cas: épidémiologie et prise en charge thérapeutique.

OBJECTIVE: To describe the prevalence and time of occurrence of vaginal mesh exposure based on the initial surgical approach of prolaps. To describe their therapeutic management. MATERIAL: Descriptive retrospective study of 43 women followed for vaginal mesh exposure diagnosed during a follow-up visit or motivated by symptoms. The initial surgery was performed abdominally (promontofixation) or vaginally. The therapeutic management was carried out by medical and/or surgical (prosthetic resection partial or complete). RESULTS: The prevalence of vaginal exposure was 7.3% in case of vaginal initial surgery and 2.8% in case of promontofixation initial (P=0.02). Mesh exposure have appeared earlier in case of vaginal initial surgery compared to promontofixation (14.9 months vs. 45.2 months). After vaginal initial surgery, vaginal mesh exposure appeared to third within 6 months postoperatively (9/29). The success rate of medical treatment was 21.4%. In total, 31% of women initially made vaginally and 64.9% of women initially made abdominally required at least two surgeries to get a cure. CONCLUSION: Vaginal mesh exposure may be away from the initial surgery, especially when the first initial surgery was abdominal. The medical treatment of vaginal mesh exposure led to poor results. The overall rate of healing in our experience was good but at the cost of considerable morbidity as a significant proportion of patients required two or more surgical interventions.

[Multicenter study of Advance ® suburethral sling for treatment of postoperative urinary incontinence of male]. / Évaluation multicentrique de la bandelette sous-urétrale Advance ® dans le traitement de l'incontinence urinaire masculine postopératoire.

OBJECTIVES: To estimate in the medium term, the efficiency and morbidity of Advance(®) for the treatment of postoperative urinary incontinence for male, and determine predictive preoperative factors of success or failure. MATERIAL AND METHODS: Retrospective multicentric clinical study of patients presenting a postoperative urinary incontinence and treated by Advance(®) suburethral sling. The importance of the preoperative incontinence was classified in three groups: light (pad-test<50 g/day or 1 pad/day), moderated (pad-test between 50 and 100 g/day or 2 or 3 pads/day), severe (pad-test>100 g/day or >3 pads/day). The functional results were classified in 4 categories: continence and improvement, defining the criterion of success and unchanged situation and deteriorated situation defining the criterion of failure. RESULTS: Sixty-six patients were included from 2008 till 2013. The radical prostatectomy was responsible in 85.5% of the cases. The incontinence was light, moderated and severe for respectively 43.4%, 35.6% and 21% of the patients. After treatment, 39.4% of the patients were continent and 78.9% in situation of success. The rate of success decreased with the severity of the incontinence (respectively 94%, 74% and 56%). For 9 patients, implantation of artificial urinary sphincter was performed without operative difficulties. Complications were urine retention (n=4), hematoma (n=3) and scrotal pains persistent more than one postoperative month (n=11). CONCLUSION: Advance(®) suburethral sling is a technique in which the efficiency decreases with the severity of the incontinence, but which does not seem to prevent from implanting artificial urinary sphincter. Its main problem is the apparition of scrotal pain.

[Idiopathic overactive bladder and BOTOX(®): Literature review]. / Hyperactivité vésicale idiopathique et BOTOX(®): revue de la littérature.

AIM: Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence. RESULTS: Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL. CONCLUSION: Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB.

[Holmium laser enucleation of the prostate as a day case surgery: prospective evaluation of the first 30 patients]. / Énucléation de la prostate au laser Holmium en chirurgie ambulatoire : évaluation prospective des 30 premiers patients.

OBJECTIVES: To evaluate the feasibility of holmium laser enucleation of the prostate (HoLEP) as a day case surgery. MATERIAL AND METHODS: Observational prospective study including 30 consecutive patients after exclusion of unstable diseases and anticoagulant therapy. Patients were discharged before 8PM and the urinary catheter was removed at home the next morning. The monitoring included a phone call after 24hours and clinical evaluations after 1 and 3month follow-up. Clinical data were prospectively collected and complications were classified according to the Clavien-Dindo classification. RESULTS: The mean age of the study population was 63.8, prostate volume was 75.3cc, maximum urinary flow rate was 9.5mL/s, and IPSS was 22.9. The conversion rate to conventional hospitalization was 3.3%. After 3months follow-up, readmission and reoperation rates were respectively 16.6% and 3.3%. The overall complication rate was 66% (Clavien I=57.7%, II=38.5%, III=3.8%). The satisfaction rate was 100% (score=9.2/10). The mean prostate volume at 3months follow-up was 23.3cc, maximum urinary flow was 25.6mL/s, and IPSS was 4.7. CONCLUSION: This study confirmed the feasibility of HoLEP as a day case surgery for selected patients. Conversion rate to conventional hospitalization and complications of grade >2 were less than 5% while the satisfaction rate was high. LEVEL OF EVIDENCE: 3.

[Sacral neuromodulation: results of a monocentric study of 93 patients]. / Neuromodulation sacrée : résultats d'une série monocentrique de 93 cas.

INTRODUCTION: Sacral nerve stimulation (NMS) is a therapeutic alternative for the treatment of urinary functional disorders as diverse as overactive bladder (OAB), urinary retention or pelvic pain syndromes. With the increasing use of NMS, we must deal with the postoperative management of this therapy. OBJECTIVE: We report the results, postoperative adverse events and their management in our center. PATIENTS: This is a retrospective single-center single-operator study of 93 patients who were tested for NMS between January 2005 and December 2013. RESULTS: Of the 93 patients, 78 had a definitive implantation of the device for OAB (n=44), urinary retention (n=11), pain, interstitial cystitis (n=12), bladder hyperactivity and pain (n=8) or dysuria (n=3). The average follow-up was 38.86 months (2.06 to 88.3±28.9). Among patients with OAB, 75% had a clinical improvement greater than or equal to 50%, 11.3% were considered as cured. Among patients with urinary retention, 63.5% were improved. Painful patients were improved for 58.3% of them, 2 were considered as cured. We reported 3 early postoperative complications (2 local infections, 1 hematoma), and adverse events in 49 patients (multiple visits for parameter settings, revision of the device [n=38], explantation [n=14]). CONCLUSION: Our results confirm the long-term effectiveness of NMS for the treatment of refractory overactive bladder, urinary retention, chronic pelvic pain, vesico-uretral dyssynergies. Studies are still needed to improve the selection of ideal candidates, identify prognostic factors and reduce the rate of complications and revisions. LEVEL OF EVIDENCE: 4.

Guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management: Translation of French recommendations.

OBJECTIVE: Provide guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 13 experts quoting proposals, subsequently reviewed by an independent group of experts. RESULTS: In the case of patients with urinary tract infection, it must be treated and injection postponed. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by patient. The injection can be performed after local anesthesia of the bladder and urethra (lidocaine), supplemented where necessary by nitrous oxide inhalation and sometimes under general anesthesia. Injection is performed in the operating room or endoscopy suite. The bladder should not be too filled (increased risk of perforation). Treatment should be applied in 10 to 20 injections of 0.5 to 1 mL homogeneously distributed in the bladder at a distance from the urethral orifices. It is not recommended to leave a urinary catheter in place except in cases of severe hematuria. The patient should be monitored until resumption of micturition. After the first injection, an appointment must be scheduled within 3 months (micturition diary, uroflowmetry, measurement of residual urine and urine culture). Performance of self-catheterisation should be questioned in the case of a symptomatic post-void residual and/or a residue>200 mL. A new injection may be considered when the clinical benefit of the previous injection diminishes (between 6 and 9 months). A period of three months must elapse between each injection. CONCLUSIONS: Implementation of these guidelines may promote best practice usage of BoNTA with optimal risk/benefit ratio.

[Intra-detrusor injection of botulinum toxin for female refractory idiopathic overactive bladder syndrome]. / Injections intra-détrusoriennes de toxine botulinique pour l'hyperactivité vésicale idiopathique réfractaire de la femme.

INTRODUCTION: Botulinum toxin-A detrusor injections are now approved for use (extension of marketing authorization) in the management of refractory idiopathic overactive bladder. The goal of the current study was to study the value and efficacy of this therapy. PATIENTS AND METHODS: A literature review was performed on Medline, Embase and Cochrane databases, using the following keywords: botulinum toxin; overactive bladder syndrome; urinary incontinence; detrusor injection. RESULTS: The recommended first step dose is 50 units of BOTOX(©) (dose selected for tolerance assessment). However, the cure rates for urge incontinence are greater with 100 units. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by the patient, because of the risk of urinary retention (6%). The administration of BOTOX(©) comprises an intra-detrusor injection using a cystoscope, performed under local anesthesia. Clinical improvement is generally observed in the first two weeks after the injection. Patients should be considered for reinjection when the clinical effect of the previous injection has diminished, approximately 6-9 months after the first injection. An injection of 100 units may be considered when the clinical benefit of the 50-unit injection is not satisfactory concerning incontinence symptoms. CONCLUSION: Botulinum toxin detrusor injections may be offered to women who develop refractory OAB.