Differential impact of COVID-19 on urological surgeries in public and private institutions between 2019 and 2021 in France.

INTRODUCTION: The COVID-19 pandemic disrupted all routine health care services in 2020. To date, data regarding adjustment and coverage of surgical backlog in the post-COVID era actually remains scarce. The aim of this study was to compare the number of urological procedures coded between 2019 and 2021 in public and private institutions to (i) quantify the variation in surgical activity linked to the shutdown in 2020 and (ii) study the adjustment of procedures over the year 2021. MATERIALS AND METHODS: This is a comprehensive retrospective analysis of all urological surgeries coded between January 1, 2019 and December 31, 2021 in France. Data were extracted from the open access dataset of the national Technical Agency for Information on Hospital Care (ATIH) website. In total, 453 urological procedures were retained and allocated in 8 categories. Primary outcome was the impact of COVID-19 analyzed by the 2020/2019 variation. The secondary outcome was the post-COVID catch-up analyzed by the 2021/2019 variation. RESULTS: Surgical activity in public hospitals dropped by 13.2% in 2020 compared to 7.6% in the private sector. The most impacted areas were functional urology, stones and BPH. Incontinence surgery did not recover at all in 2021. BPH and stone surgeries were far less impacted in the private sector, with even explosive activity in 2021, post-COVID period. Onco-urology procedures were roughly maintained with a compensation in 2021 in both sectors. CONCLUSION: The recovery of surgical backlog was much more efficient in the private sector in 2021. The pressure on the health system associated to the multiple COVID-19 waves may generate a gap between public and private surgical activity in the future.

Preoperative risk factors for complications after flexible and rigid ureteroscopy for stone disease: A French multicentric study.

BACKGROUND: With an increasing prevalence in industrialized countries, lithiasis represents a public health problem with significant economic cost. Ureteroscopy is nowadays the main treatment for kidney and ureteral stones with increasingly broad indications. While this treatment is relatively safe and effective, the complications can be severe. AIM: The aim of this study was to investigate the preoperative risk factors of complication in the 30 days following a rigid or flexible ureteroscopy in a large cohort of patients. METHODS: A retrospective multicenter study was conducted in 5 French centers between January 1st 2017 and 31st December 2018. All flexible and rigid ureteroscopies performed were included. All preoperative and per operative data were collected in an electronic database. Outcomes and complications within 30 days of the procedure were also collected. Univariate and multivariable analyses evaluated for potential predictors of postoperative complications. RESULTS: 1124 procedures were included. According to the occurrence of a postoperative complication, patients were divided into two groups, 109 in the group with complications. The majority of complications were minor, with only 13.7% classified as Clavien 3-4. In univariate analysis, ASA score>2 (odd ratio, OR=1.68, P=0.04), WHO performance status≥1 (OR=1.50, P=0.04) and neurologic disease (OR=2.78, P=0.005) were predictors of postoperative complications. In multivariable analysis, Charlson's score (OR=0.79, P=0.01) and ASA score>2 (OR=1.48, P=0.03) were independents risk factors of postoperative complication. Concerning major complications, in univariate analysis, cardiovascular disease (OR=3.71, P=0.032) and BMI (OR=0.87, P=0.02) were the only predictors of major complications after ureteroscopy. Only BMI was found In multivariable analysis (OR=0.86, P=0.01) CONCLUSION: Baseline characteristics and comorbidities of the patients, especially neurological diseases, were the main risk factors for short-term complications after ureteroscopy. Ureteroscopy remains a relatively safe and effective procedure. However, we advise surgeons to take precautions with fragile patients with multiple comorbidities or neurological disease.

Perioperative infectious risk in urology: Management of preoperative polymicrobial urine culture. A systematic review. By the infectious disease Committee of the French Association of urology.

INTRODUCTION: The aim was to assess the risk of postoperative infections in patients with preoperative polymicrobial urine culture and to provide the urologist with practices to minimise the risk of infection in these clinical situations. METHODS: A systematic literature review was carried. All national and international recommendations have been reviewed. Data collection has been performed from the Cochrane, LILACS and the Medline database. 31 publications were selected for inclusion. RESULTS: Risk of infection in patients without ureteral stents or urinary catheters with previous polymicrobial urine culture is low. In the absence of leukocyturia, the urine sample can be considered as sterile. With ureteral stents or urinary catheters, the colonisation by biofilm ranges from 4 to 100% depending on the duration and ureteral stents or urinary catheters type. Urine culture is positive 24 to 45% of the time when ureteral stents or urinary catheters are known to be colonised. The post-operative risk of infection in endo-urological surgery in a patient with ureteral stents or urinary catheters is estimated around 8 to 11% depending on the type of surgery. A retrospective study reports a postoperative infections rate of 18.5% in photo selective vaporization of the prostate with preoperative polymicrobial urine culture. CONCLUSIONS: Scientific data are limited but for patients without ureteral stents or urinary catheters, in the absence of leukocyturia, the polymicrobial urine culture can be considered as negative. Considering a preoperative polymicrobial urine culture as sterile in patients with colonised ureteral stents or urinary catheters is at risk of neglecting a high risk of postoperative infections or sepsis even in case of perioperative antibiotic prophylaxis. It should not always be considered sterile and therefore, a perioperative antibiotic therapy could be an acceptable option.

[Guidelines from the Infectious Disease Committee of the French Association of Urology and The Neuro-Urology Committee of the AFU: antibiotic prophylaxis for sacral neuromodulation]. / Recommandations de bonnes pratiques cliniques : antibioprophylaxie et neuromodulation des racines sacrées par le Comité d'infectiologie de l'Association française d'urologie (CIAFU) et le Comité de neuro-urologie de l'AFU.

INTRODUCTION: In urology, antibiotic prophylaxis is advised by the French Association of anesthesiology (SFAR) and the Infectious Disease Committee of the French Association of urology guidelines published in 2010. No guideline exists concerning the implantation of neuromodulation implants. MATERIAL AND METHOD: A literature analysis was performed on sacral modulation and antibiotic prophylaxis. Then guidelines were discussed by reviewers. Items that showed no consensus were then discussed again to arrive at recommendations. RESULTS: Antibiotic prophylaxis is recommended during the test phase as well as in the case of installation of sacral neuromodulation (Grade C). Antibiotic recommended (Grade B) are: cefotetan or cefoxitin, 2g dose by slow intravenous injection or amoxicillin-clavulanic acid at a dose of 2 g, intravenously or, in the case of allergy vancomycin at a dose of 15 mg/kg or the clindamycin has 600 mg intravenously. CONCLUSIONS: Despite the lack of high level of evidence, antibiotic prophylaxis seems necessary when setting up of electrode case of sacral neuromodulation.

[Flexible cystoscopes: disinfection and microbiological surveillance practices among French urologists]. / Cystoscopes souples : pratiques de désinfection et de surveillance microbiologique parmi les urologues français. Une enquête du comité d'infectiologie de l'AFU.

INTRODUCTION: According to the French regulatory authorities, the highest level of disinfection must be achieved for flexible cystoscopes, as they enter a sterile cavity, the current method being peracetic acid disinfection and sterile water terminal rinsing. MATERIAL AND METHODS: The concordance between regulations and the routine was researched using a self-administered questionnaire sent to all French urologists. RESULTS: Responses from 78 urology units, totalling 317 urologists (26% response rate) were analysed. As a whole, 51.2% of centers followed all recommendations on disinfection. There was no microbiological surveillance in 16.6% of centers, although microbiological tests were performed in two out of three centers before using a new endoscope or when returning from maintenance. CONCLUSION: Improvements are needed, both in the disinfection process and the microbiological surveillance. Low temperature sterilization and the use of sterile disposable sheaths may represent an alternative.

[Diagnosis and treatment of acute uncomplicated urethritis of men: guidelines from the French committee of infectious disease of the French association of urology (CIAFU)]. / Recommandations de bonnes pratiques cliniques : diagnostic et traitement des uréthrites aiguës non compliquées de l'homme, par le comité d'infectiologie de l'Association française d'urologie (CIAFU).

Resistance progression of the Neisseria gonorrhoeae to quinolones and the decreasing sensitivity to cephalosporin implicate to actualise the guidelines for managing urethritis. We present the guidelines from the committee of infectious diseases of the French Association of Urology to manage acute urethritis.

[Recommendations of the Infectious Disease Committee of the French Association of Urology (AFU): antibiotic prophylaxis for urological procedures]. / Recommandations de bonnes pratiques cliniques: l'antibioprophylaxie en chirurgie urologique, par le Comité d'infectiologie de l'association française d'urologie (CIAFU).

The French Association of anesthesiology (SFAR) has published in 1999 the Antibiotic prophylaxis guidelines. Antibiotic resistance has increased and new procedures appeared so new recommendations were needed. We present the antibiotic prophylaxis guidelines from the committee of infectious diseases of the French Association of Urology.

[Treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff]. / Traitement de l'incontinence urinaire masculine par sphincter urinaire artificiel avec manchette intracaverneuse.

OBJECTIVE: The aims of this study are to describe the implantation technique of an artificial urinary sphincter (AUS) with intracavernous cuff, define the indications and report the preliminary results of this technique. MATERIAL AND METHOD: A single-centre retrospective study was carried out in 10 patients with a median age of 66 years. The aetiology of urinary incontinence was radical prostatectomy alone in four cases, combined with radiotherapy in four cases and transurethral resection of the prostate in two cases. The initial treatment consisted of AUS in seven cases and suburethral tape in two cases and the last patient had not been previously treated. Failure of AUS was due to atrophy in three cases and urethral erosion in four cases. Six patients needed to use more than three pads per day. Erections were absent in all patients. All patients were treated by insertion of an intracavernous cuff according to the same technique: perineoscrotal incision on the median raphe, dissection of the bulbar urethra and inferior aspect of the corpora cavernosa, vertical incision of the tunica albuginea on either side of the urethra, passage of the cuff from one incision to the other behind the tunica albuginea and leaving the tunica albuginea against the urethra, and closure of the tunica albuginea by interrupted sutures leaving a passage for the cuff. The median follow-up was 15.5 months. RESULTS: The median operating time was 90 min. No intraoperative complication was observed. Two patients had to be explanted because of infection of the material. Seven of the remaining eight patients were satisfied and six of them needed less than one pad per day. A history pelvic irradiation did not appear to have any impact on the results. CONCLUSION: The treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff is a simple technique that improves the trophicity and calibre of the urethra underneath the cuff. This technique achieved good results in patients with a history of pelvic irradiation.

[Role of helical tomodensitometry in the early diagnosis of renal infarction]. / Intérêt de la tomodensitométrie hélicoïdale dans le diagnostic précoce de l'infarctus rénal.

INTRODUCTION: Renal infarction is a rare and often difficult diagnosis. The objective of this study was to demonstrate that contrast-enhanced spiral CT in patients presenting features of renal colic, can establish the diagnosis by confirming the presence of infarction of the renal parenchyma. MATERIAL AND METHODS: Over a 10-month period, the authors proposed the following decision flow-chart for all patients admitted with clinical features of renal colic: plain abdominal x-ray and first-line renal ultrasound, which, in the absence of a diagnosis (stones or dilatation of cavities), were completed by unenhanced spiral CT scan. When these examinations were normal, contrast-enhanced spiral CT scan was then performed. RESULTS: 300 patients were included in this study, and CT was performed in 40 cases. This management allowed the diagnosis of infarction of the renal parenchyma in three patients, who are described here. When unenhanced CT sections do not reveal any abnormality, contrast-enhanced sections are essential to visualize the infarcted zone, seen as a triangular low density lesion with clearly defined margins and a vascular topography. CONCLUSION: Contrast-enhanced spiral CT should now be considered to be the reference examination for the assessment of non-documented renal colic. This recent imaging modality should allow the diagnosis of a greater number of infarctions of the renal parenchyma, which formerly remained undiagnosed.

[Treatment of idiopathic retroperitoneal fibrosis]. / Le traitement de la fibrose rétropéritonéale idiopathique.

Idiopathic retroperitoneal fibrosis is a rare disease and a delay in diagnosis may cause renal failure. Medical treatment i.e. corticotherapy or more recently, tamoxifene has been used successfully. This approach is recommended in patients either with moderate obstruction of the upper urinary, risk of major surgery or in cases of recurrence after surgical treatment. Ureterolysis using conventional surgery or laparoscopy remains the treatment of choice. This procedure should be considered in patients with neoplasic fibrosis, corticoresistant fibrosis or in cases of peri-aneurysm fibrosis.

[Consultation skills in urology: a model for teaching and evaluation]. / Les compétences de consultant en urologie: une modélisation pour l'enseignement et l'évaluation.

OBJECTIVE: Consultation activity is an important aspect of urological practice, but the specific teaching of this activity is underdeveloped. The objective of this study was to establish a list of consultancy skills as a basis for a planned and structured approach to teaching and evaluation of consultancy skills in urology. MATERIAL AND METHOD: Two-step qualitative protocol: 1) Establishment of an initial list of skills based on data of the literature; 2) Submission of this list to a series of "focus groups" (urologists, interns, referring physicians) in order to validate and progressively refine the model. RESULTS: The items identified were classified into 3 distinct lists: 1) theoretical knowledge; 2) technical skills specific to urology, predominantly performed in the consulting setting, 3) interpersonal skills exclusively concerning the consultant-referring physician relationship. CONCLUSIONS: The consensual specification of these skills can be used to objectively define teaching and evaluation strategies for urology consultancy skills.

[Contribution of lumboscopy in the treatment of pyeloureteral junction syndromes. Report of 25 cases]. / Apport de la lomboscopie dans le traitement des syndromes de la jonction pyélourétérale. A propos de 25 cas.

OBJECTIVE: Evaluation of the results of lumboscopic repair of ureteropelvic junction syndromes. MATERIAL AND METHOD: Retrospective study of 25 consecutive lumboscopic retroperitoneal pyeloplasties performed over 3 years in 14 women and 11 men with symptomatic ureteropelvic junction syndrome. RESULTS: The mean operating time was 200 minutes (range: 120-360 minutes) and mean blood loss was 60 ml. Surgical conversion was necessary in three cases due to the difficulty of dissection and in one case because of rupture of the ureter. Analgesic prescription was generally only necessary for the first 2 postoperative days. The mean hospital stay was six days (range: 2-16 days). Patients were able to return to work an average of 10 days after the operation. With a mean follow-up of 9 months (range: 6 to 18 months), all patients were asymptomatic except for one patient who reported pain at a trocar site. Follow-up urography at 3 months showed marked improvement in 18 patients (85.7%), moderate pyelocaliceal dilatation in 2 cases and one failure. CONCLUSION: Lumboscopic pyeloplasty is an alternative to endopyelotomy. It provides a comparable success rate to that of conventional surgery, while reducing the morbidity, length of hospital stay and convalescence. However, it requires mastery of intracorporeal suture techniques.

[Unusual tumor: liposarcoma of the spermatic cord]. / Une tumeur rare: le liposarcome du cordon spermatique.

Spermatic cord liposarcoma is a rare tumour, as only 60 cases have been reported in the literature. They represent 7% of all malignant spermatic cord tumours. The authors report a new case of spermatic cord liposarcoma unusual by its inflammatory and fibrotic features, occurring in an 83-year-old man in poor general health. Treatment consists of surgical resection as widely as possible. Adjuvant radiotherapy is sometimes effective on local recurrences. Despite the slow rate of progression of this tumour, prolonged surveillance is required due to the high risk of late recurrence.

[Intraurethral Macroplastic injections in the treatment of urinary incontinence after prostatic surgery]. / Les injections intra-urétrales de Macroplastique dans le traitement de l'incontinence urinaire après chirurgie prostatique.

OBJECTIVES: To evaluate the results and the place of a minimally invasive intraurethral injection technique designed to improve the efficacy of the urethral sphincter in urinary incontinence after prostatic surgery. MATERIALS AND METHODS: A prospective study of 26 Macroplastique injections performed in 15 patients with a mean age of 66.4 years (range: 54 to 78 years) was conducted over an 18-month period. Eleven patients received 2 injections. Prostatic surgery consisted of retropubic radical prostatectomy (9 cases), transurethral resection (4 cases) or open prostatectomy (2 cases). Three patients received pelvic irradiation. Evaluation at 1, 3 and 12 months consisted of clinical questionnaire and urodynamic assessment. RESULTS: Rapid deterioration of the initial improvement was observed (40% success at 1 month; 71% at 3 months; 33% at 6 months; 26% at 12 months). No significant influence was demonstrated for post-prostatectomy radiotherapy, the patient's age, more proximal bladder dysfunction, severity of incontinence or preoperative status. However, better results were observed when the resting urethral closure pressure remained higher than 30 cm H2O. CONCLUSION: We believe that intraurethral injections still have a place in the therapeutic armamentarium for incontinence after prostatic surgery with satisfactory initial results, which unfortunately deteriorate after 3 months. Our study confirms the value of Macroplastique compared to other substances. It is difficult to define the predictive factors of failure, but a closure pressure greater than 30 cm H2O remains essential. Finally, an interval of at least 3 months should be observed before repeating this procedure in the case of an insufficient result.

[The value of examination and treatment using laparoscopy in non-palpable testes: apropos of a series of 48 cases]. / Intérêt de l'exploration et du traitement par coelioscopie des testicules impalpables: à propos d'une série de 48 cas.

OBJECTIVES: Laparoscopy now constitutes the reference technique for the diagnosis and treatment of cryptorchid testes. We report our experience over the last three years (1993-1996). MATERIAL AND METHODS: 48 strictly impalable testes were investigated in 46 boys between the ages of 11 months and 14.5 years (mean age: 40 months). The intraperitoneal investigation assessed both deep inguinal regions looking for gonads, vas deferens and pedicles. Intra-abdominal gonads were ligated and their pedicle was sectioned laparoscopically allowing transinguinal descent 6 months later according to the Fowler-Stephens technique. RESULTS: We found 21 cases of typical antenatal torsion, including one bilateral case (pedicle and vas deferens present, but gonad absent), one case of total unilateral agenesis and 3 cases of incomplete agenesis (only the vas deferens was detected) and performed three resections of the gonadal rest for histological examination. The first-stage of cryptorchid testis descent was performed in 20 cases, by laparoscopy in 19 cases (1 failure of insufflation). Definitive descent was possible in 13 cases, with early onset of atrophy in only one case. CONCLUSION: Laparoscopy is therefore a simple technique, allowing a definitive diagnosis and two-stage descent without increasing the risk of testicular atrophy.