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OBJECTIVE: The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). METHODS: All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. RESULTS/GUIDELINES: Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. CONCLUSION: Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.
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Hiperplasia Prostática/cirugía , Obstrucción Uretral/cirugía , Humanos , Masculino , Prostatectomía/métodos , Prostatectomía/normas , Hiperplasia Prostática/complicaciones , Obstrucción Uretral/etiologíaRESUMEN
INTRODUCTION: New surgical techniques for the treatment of benign prostatic obstruction (BPO) have emerged in recent years. We sought to give an overview on each of these technologies. MATERIAL: A comprehensive review of the literature between 2013 and 2020 was carried out by a panel of national experts already practicing these interventions. All the data were then discussed among all the co-authors in order to obtain a consensus with regard to the selected articles and their analysis. Finally, an inventory was drawn to provide an overview of these technological advances and their availability in France. RESULTS: The treatment benign prostatic obstruction has diversified greatly over the past 5 years. 5 new technologies have emerged, allowing today a transurethral non-ablative treatment (UROLIFT®, ITIND®), a transurethral ablative treatment (REZUM®), a transurethral ablative treatment with robotic assistance (AQUABEAM®) or an endovascular management by embolization of the prostatic arteries. Only UROLIFT® is considered an established technology in the latest EAU-Guidelines. The other four are under evaluation and recommendations have only been issued for two of them, AQUABEAM® and the embolization of the prostatic arteries. CONCLUSION: These new minimally invasive techniques aim to increase the therapeutic options for the management of BPO in order to offer a management more suited to the wishes of the patient. Some are positioned as an alternative to surgical or medical treatment, others between medical and surgical treatment. These technologies are not all at the same level of development, evaluation and level of proof, but have in common a limited distribution in France, in particular given their cost. Validated studies will allow them to position their subsequent use more precisely.
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Hiperplasia Prostática/cirugía , Obstrucción Uretral/cirugía , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Prostatectomía/métodos , Hiperplasia Prostática/complicaciones , Obstrucción Uretral/etiologíaRESUMEN
AIM: Management of urolithiasis has changed over the past decades. Outpatient surgery has become a major issue for healthcare systems. The aim of this study was to assess the feasibility of outpatient flexible ureteroscopy. METHODS: A single-center retrospective study has been conducted including all patients who underwent an outpatient flexible ureteroscopy between January 2012 and December 2013. Failure of outpatient management was defined as length of hospital stay>12 hours or readmission within 48 hours after discharge. Univariate analysis was performed to seek for predictors of failure of outpatient management. RESULTS: One hundred and fifty-seven patients who underwent a total of 174 procedures were included. They were mostly men (57.5 %), with a mean body mass index of 25.2kg/m2 (±4.3). The stones were mostly unique (64.3 %), with a mean size of 14.2mm (±11.2). Eighty patients had a double J stent preoperatively (46.5 %), and mean operative time was 64.2 minutes (±34.1). An ureteral access sheath was used in 39 procedures (22.4 %). A double J stent was left postoperatively in 103 patients (59.1 %). In total, 165 procedures (94.8 %) were performed successfully as outpatient surgery. On postoperative imaging, the stone-free rate was 69.5 %. Postoperative complications occurred in 3.4 % of cases and were mostly minor (i.e. Clavien 1-2; 83.3 %). Predictive factors of failed outpatient management were male gender (P=0.04), BMI (P=0.03), and anticoagulants intake (P=0.003). CONCLUSION: Outpatient flexible ureteroscopy for urinary stones is feasible and its low failure and complications rate may allow a wider spread of its use. LEVEL OF EVIDENCE: 4.
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Procedimientos Quirúrgicos Ambulatorios , Cálculos Renales/cirugía , Cálculos Ureterales/cirugía , Ureteroscopios , Ureteroscopía/instrumentación , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Ureteroscopios/efectos adversos , Ureteroscopía/efectos adversosRESUMEN
INTRODUCTION: The aim of this study was to report perioperative and oncological outcomes of robot-assisted radical cystectomy (RARC) in a single-center series and to evaluate the impact of the experience on perioperative outcomes. METHODS: Between March 2012 and January 2016, 41 patients underwent RARC associated with extended pelvic lymphadenectomy for muscle-invasive bladder cancer. All RARC included were performed by a single-surgeon in one center. Perioperative and oncological datas were collected prospectively. Recurrence-free (RFS), overall (OS) and cancer-specific survivals (CSS) were estimated using the Kaplan-Meier Method. The impact of the experience on perioperative data was estimated using Spearman's correlation test. RESULTS: Mean age was 67,7years (±10.6). Most patients underwent neoadjuvant chemotherapy (73.2%). Mean operative time and mean estimated blood loss were respectively 319.5minutes (±85.3) and 662.5mL (±360.9). Eight patients needed perioperative blood transfusion (19.5%). Conversion to open surgery was necessary in 3 cases (7.3%). Ileal neobladder was performed in 26.8% of the cases (54.5% being performed intracorporeal), and non-continent urinary diversion in 73.2%. Mean nodal yield was 17.7 (±9.3). Positive surgical margins were observed in 1 patient (2.3%). Mean length of stay was 13.2 days (±9.8). Postoperative complication rate was 46,3%. After a median follow-up of 16months, estimated 2 year-OS and CSS were respectively 62 and 76.1%. Estimated 2-year RFS was 67.6%. Perioperative outcomes improved with experience with a significant decrease in operative time (P=0.04) and a significant increase of nodal yield (P=0.05). CONCLUSION: In this single-center prospective study, satisfactory perioperative and oncological outcomes after RARC were observed despite the learning curve. Perioperative outcomes improved with surgeon's experience. Further studies are needed to confirm these findings. LEVEL OF EVIDENCE: 4.
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Cistectomía , Procedimientos Quirúrgicos Robotizados , Neoplasias de la Vejiga Urinaria/cirugía , Anciano , Quimioterapia Adyuvante , Femenino , Humanos , Masculino , Terapia Neoadyuvante , Tempo Operativo , Complicaciones Posoperatorias , Estudios Prospectivos , Neoplasias de la Vejiga Urinaria/tratamiento farmacológicoRESUMEN
PURPOSE: In case of pelvic lymph node and seminal vesicle dissection followed by prostate cancer intensity-modulated radiotherapy, the objective of the study was to evaluate the dosimetric benefit of reducing the target volume. PATIENTS AND METHODS: A total of 25 patients with high-risk prostate cancer had surgery first followed by intensity-modulated radiotherapy and androgen deprivation. Four treatment planning were simulated for each patient, based on two CT scans performed before and after surgery. The target volumes were: prostate-seminal vesicles-lymph nodes, prostate-lymph nodes, prostate-seminal vesicles and prostate only. The total dose was 46Gy in the seminal vesicles and lymph nodes, and 80Gy in the prostate. RESULTS: Compared to prostate target volume only, the addition of seminal vesicles and lymph nodes multiplied by a factor of 1.6 and 6.5 the target volume, respectively. Decreasing the target volume from prostate-seminal vesicles-lymph nodes to prostate-seminal vesicles, to prostate only decreased the rectal wall mean dose from 49Gy to 42Gy, to 36Gy, and the risk of late rectal bleeding from 4.4% to 3.2%, to 2.4% (P<0.05), respectively. The bladder wall mean dose decreased from 51Gy to 40Gy, to 35Gy (P<0,05), respectively. Not irradiating the lymph nodes decreased the absolute risk of diarrhea by 11%. CONCLUSION: Lymph node and seminal vesicle dissection before prostate cancer intensity-modulated radiotherapy allows decreasing moderately the risk of digestive toxicity.
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Escisión del Ganglio Linfático , Neoplasias de la Próstata/radioterapia , Radioterapia de Intensidad Modulada , Vesículas Seminales/cirugía , Adenocarcinoma/patología , Adenocarcinoma/radioterapia , Adenocarcinoma/cirugía , Relación Dosis-Respuesta en la Radiación , Hemorragia Gastrointestinal/etiología , Humanos , Masculino , Persona de Mediana Edad , Órganos en Riesgo , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , RectoRESUMEN
CONTEXT: Transrectal ultrasound guidance (TUG) during prostate endoscopic surgery can optimize the procedure by reducing the risk of capsular perforation and ascertain the treatment completeness. TUG is proposed during photoselective vaporisation of prostate (PVP). OBJECTIVE: To report four cases of rectal perforations during PVP with TUG and assess their occurrence. MATERIALS AND METHODS: This is a retrospective study including prostate endoscopic surgeries with TUG, performed in two centers between November 2011 and May 2013. Rectal perforations were identified. Surgical data, treatment modalities and postoperative outcomes of rectal perforations were analysed. RESULTS: Four rectal perforations were identified among 450 surgical procedures. Median age and prostate volume were 80 years old [62-91] and 40mL [13-150], respectively. Two perforations occurred during PVP with Greenlight(®) XPS 180W. Two perforations occurred during transurethral resection of prostate or cervicoprostatic incision. Patients were treated by systematic urinary drainage associated with colostomy or direct suture. Two patients died from this complication and two patients have satisfying functional outcomes at one year. CONCLUSION: TUG during prostate endoscopic surgery could lead to rectal perforation by protusion of the prostate and therefore should be used cautiously. LEVEL OF EVIDENCE: 5.
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Perforación Intestinal/etiología , Hiperplasia Prostática/cirugía , Recto/lesiones , Resección Transuretral de la Próstata/efectos adversos , Anciano , Anciano de 80 o más Años , Humanos , Análisis de Intención de Tratar , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de RiesgoRESUMEN
INTRODUCTION: Laparoscopy has become the gold-standard approach for excision of benign adrenal tumors but the question of its safety for malignant lesions is still controversial. Our aim was to evaluate the oncologic outcome of laparoscopic adrenalectomy for adrenal metastasis and to look for predictors of a negative surgical outcome. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent laparoscopic adrenalectomy for suspicion of adrenal metastasis between 2007 and 2013 at a single academic institution. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Univariate analysis was performed to determine risk factors of negative surgical outcome (positive surgical margins, complications, conversion, significant blood loss) and predictors of RFS and CSS. RESULTS: Thirteen patients underwent 14 laparoscopic adrenalectomies. All patients were operated by a single highly experienced surgeon. Complications occurred in 2 patients (15%): 2 blood transfusions (Clavien-score=2). There were 3 positive surgical margins (21%). Mean length of hospital stay was 4.3 days. Unadjusted RFS and CSS were respectively 48.4% and 83.3% at 1 year, 39.5% and 66.7% at 5 years. In univariate analysis, tumor size was the only risk factor of complication (P=.009) and conversion (P=0.009). Capsule invasion and tumor size were risk factors of positive surgical margins (P=0.01 and P<0.0001). One hundred percent of complications, conversion and positive surgical margins occurred in tumor>7.5 cm on preoperative CT-scan. No predictors of RFS and CSS was found in univariate analysis. CONCLUSION: Laparoscopic adrenalectomy for adrenal metastasis achieves good surgical and oncologic outcomes. When performed by highly experienced surgeon, complications and positive surgical margins occur only in tumors>7.5 cm. These patients may benefit from an open surgical approach.
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Neoplasias de las Glándulas Suprarrenales/secundario , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía/métodos , Laparoscopía/efectos adversos , Neoplasias de las Glándulas Suprarrenales/diagnóstico por imagen , Neoplasias de las Glándulas Suprarrenales/mortalidad , Adrenalectomía/efectos adversos , Anciano , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea/estadística & datos numéricos , Conversión a Cirugía Abierta , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Registros Médicos , Persona de Mediana Edad , Invasividad Neoplásica , Cintigrafía , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate the histological correlation between transuretral resection chips and biopsy cores within a population of patients who underwent resection of prostate (TURP) and prostate biopsies (BPx). PATIENTS AND METHODS: Clinical and tumoral data of 77 patients who had both procedures simultaneously or with a slight delay were collected. According to the presence of prostate cancer (Pca), 4 groups were defined: group 1 (TURP and BPx negative), group 2 (TURP positive, BPx negative), group 3 (TURP negative, BPx positive), group 4 (TURP and BPx positive). Means and proportions were compared using Anova and χ(2) test, respectively. RESULTS: The patients were older in groups 3 and 4 (79 and 76 respectively, P=0.65). The PSA was higher in the groups 3 and 4 (64 and 55 ng/mL) than the groups 1 and 2 (10.6 et 16 respectively, P=0.23). The number of positive biopsy was higher in the group 4 than the group 3 (5.6 vs. 4.6, P<0.0001), the chips were more invaded in the group 4 than the group 2 (41% vs. 11% P<0.0001), the Gleason score at TURP was higher in the group 4 than the group 2 (7.5 vs. 6.2 P<0.0001). CONCLUSION: Our study underlines that the Pca of transition and peripheral zones seems to have distinct characteristics. When chips of TURP and BPx were both invaded, it was due to an aggressive cancer. The decision to explore the peripheral zone in the case of positive TURP must take clinical context into consideration.
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Biomarcadores de Tumor/sangre , Biopsia con Aguja Gruesa , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/cirugía , Resección Transuretral de la Próstata , Anciano , Anciano de 80 o más Años , Biopsia con Aguja Gruesa/métodos , Humanos , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Pronóstico , Neoplasias de la Próstata/sangre , Estudios Retrospectivos , Resección Transuretral de la Próstata/métodosRESUMEN
PURPOSE: To report our first cases of robotic laparoendoscopic single-site (R-LESS) radical nephrectomy with the novel Da Vinci R-LESS platform (Intuitive Surgical, Sunnyvale, CA). METHODS: Six radical nephrectomies were performed with R-LESS Da Vinci single-site port and instruments. Data concerning patients characteristics, indication of surgery, operative and postoperative outcomes were collected. RESULTS: All procedures were completed successfully. Two patients required the placement of an additional port. Median operative, docking and console times were 179 min (range 120-318), 19 min (range 15-24) and 129 min (range 100-264), respectively. Median blood loss was 100 ml (range 50-800). No significant robotic-related problem was noticed during the procedures. There was no operative or major postoperative (Clavien >2) complication. Median length of hospital stay was 3 days. CONCLUSION: Our initial experience of R-LESS radical nephrectomies with the novel Da Vinci platform shows that the procedure is feasible. Indications, safety and place of the technique will be confirmed with growing experience.