[Urology]. / Urologie.

Over this last year, urology has progressed both in oncology and reconstructive surgery. Genomic tests have been since quite a few years foreseen as very promising prognostic factors of prostate cancer, however remaining not clearly convincing. At last, the present data available seem to favour their contribution to improve selecting patients for active surveillance. For the same cancer, but at a metastatic stage resistant to androgenic deprivation, therano stics is providing an elegant targeting of disseminated tumor cells using a PSMA radio-active ligand fatal for the latter. Finally, penile urethral strictures appear to convincingly benefit on a long-term basis from a new method to place the substitution tissue which will restore urethral caliber.

C'est entre l'oncologie et la chirurgie reconstructive que l'urologie a poursuivi, en 2021, sa quête de progrès et de mises au point. Voilà plusieurs années que la génomique est attendue comme pourvoyeuse de capacités pronostiques dépassant les facteurs classiques. Plus lentement qu'attendu, la surveillance active du cancer de la prostate apparaît en être la bénéficiaire principale. Ce même cancer, mais au stade métastatique résistant à la déprivation androgénique, profite de la théranostique, qui cible le récepteur du Prostate-Specific Membrane Antigen de la cellule tumorale, avec un ligand radioactif fatal pour cette dernière. Enfin, la chirurgie des sténoses urétrales péniennes se voit enrichie d'une nouvelle manière de placer le tissu de substitution qui agrandira le calibre urétral, conférant à ce type de reconstruction une durabilité et une esthétique probantes.

Blood-Based Multi-Cancer Detection Using a Novel Variant Calling Assay (DEEPGENTM): Early Clinical Results.

This is an early clinical analysis of the DEEPGENTM platform for cancer detection. Newly diagnosed cancer patients and individuals with no known malignancy were included in a prospective open-label case-controlled study (NCT03517332). Plasma cfDNA that was extracted from peripheral blood was sequenced and data were processed using machine-learning algorithms to derive cancer prediction scores. A total of 260 cancer patients and 415 controls were included in the study. Overall, sensitivity for all cancers was 57% (95% CI: 52, 64) at 95% specificity, and 43% (95% CI: 37, 49) at 99% specificity. With 51% sensitivity and 95% specificity for all stage 1 cancers, the stage-specific sensitivities trended to improve with higher stages. Early results from this preliminary clinical, prospective evaluation of the DEEPGENTM liquid biopsy platform suggests the platform offers a clinically relevant ability to differentiate individuals with and without known cancer, even at early stages of cancer.

[Novelties in Urology 2019]. / Urologie.

At the turn of the second decade of the 21st century, advances in urology are driven by technobiologic progress and the strive for minimally invasiveness. Prostate disease benefits above all, with significant improvement in benign prostatic hyperplasia mini-invasive surgery and metastatic prostate cancer imaging. Chronic micturition syndromes also benefit from this trend, so as robotic surgery, whose latest promising innovation, the single port model, will have to find its place and confirm its non-inferiority as compared with the current latest multi-arm da Vinci robot.

À la fin de la deuxième décennie du 21e siècle, le progrès en urologie est conditionné par les avancées techno-biologiques et l'intention chirurgicale de diminuer l'invasivité des interventions. Les maladies prostatiques sont les principales bénéficiaires de cette évolution. Ainsi, les améliorations sont significatives dans la chirurgie de l'hyperplasie bénigne de la prostate ainsi que pour l'imagerie du cancer métastatique. Les syndromes de dysfonction mictionnelle chronique et la chirurgie robotique se positionnent également dans cette perspective, cette dernière notamment avec une nouvelle plateforme da Vinci à trocart unique, qui n'est actuellement pas encore disponible en Europe. La chirurgie robotique à trocart unique devra par ailleurs encore démontrer sa non-infériorité par rapport à la dernière version multi-bras en service du robot da Vinci.

[Augmented reality in urology : present and future]. / Réalité augmentée en urologie : actualité et avenir.

Minimally invasive surgery has recently gained popularity. This paradigm shift involves a series of potential difficulties from the surgeon's perspective. With recent developments these obstacles are gradually being overcomed. Recent navigation systems offer major improvements in the way information is acquired, displayed, and integrated into the surgical workflow through augmented reality. Finally, the progress of robotics has helped to improve the minimally invasive dexterity and competence of the surgeon. This article sumarizes the main and most recent developments in the areas mentionned above, analyzes the current limits that still need to be addressed, and suggests possible future directions.

La réalité augmentée en urologie a gagné en popularité ces dernières années. Des systèmes de navigation récents offrent des améliorations majeures en termes d'information acquise, qui est affichée et intégrée dans le flux de travail chirurgical, grâce à la réalité augmentée. De même, le progrès de la robotique a contribué à améliorer la dextérité et la compétence mini-invasives du chirurgien. Cet article résume les principaux et les plus récents développements dans les domaines susmentionnés, analyse les limites actuelles qui doivent encore être abordées et suggère des orientations futures possibles.

[Diagnosis and management of small solid renal masses]. / Diagnostic et prise en charge des lésions tissulaires rénales de petite taille.

Discovery of small solid renal masses via echography, CT-scan or MRI is common in current medical practice, with more than 70 % found incidentally. Although they include benign lesions, most are renal cell carcinomas. A radiological assessment, associated if necessary with a percutaneous renal biopsy, leads to their diagnosis in the vast majority of cases. Minimally invasive partial nephrectomy has become the standard surgical technique in specialized centers. Ablative therapies (radiofrequency and cryotherapy) and active surveillance are other possible therapeutic approaches. A benefit-risk assessment of these treatments considering patient age, kidney function and comorbidities, is key in the management of these small solid renal masses.

La mise en évidence de petites lésions tissulaires rénales par échographie, scanner ou IRM, est fréquente dans la pratique médicale actuelle, avec plus de 70 % de découvertes fortuites. Bien qu'elles comprennent des lésions bénignes, la plupart sont des carcinomes à cellules rénales. Un bilan radiologique, associé si nécessaire à une biopsie rénale percutanée, permet de déterminer leur diagnostic dans la majorité des cas. La néphrectomie partielle mini-invasive est devenue la technique chirurgicale de référence dans les centres spécialisés. Les traitements ablatifs (radiofréquence et cryothérapie) et la surveillance active sont d'autres approches thérapeutiques envisageables. Une balance des risques et bénéfices de ces traitements, pondérée avec l'âge, la fonction rénale et les comorbidités du patient, est essentielle dans la prise en charge de ces lésions rénales.

[Erectile dysfunction, an urologic and multidisciplinary approach]. / Dysfonction érectile, une prise en charge urologique et multidisciplinaire.

Erectile dysfunction (ED) is a common complaint, both in the general medicine and the urology out-patient clinic. The quite recent availability of effective treatments has profoundly changed the perception of sexual health in society, which has become more demanding. We should see erectile or sexual function as a health marker. Its causes are often diverse but we can classify them as somatic (vascular, neurological, endocrine, tissue-related, iatrogenic) or psychogenic. Management should be etiological if possible. It often goes first by reducing cardiovascular risk factors and then by prescribing a vasodilating agent functioning through the inhibition of phosphodiesterase 5. When modifiable cardiovascular risk factors are identified, we refer the patient to a specialized consultation. ED is to be seen as a warning sign of a preventable disease or cardiovascular event.

La dysfonction érectile (DE) est une plainte fréquente en consultation de médecine générale ou d'urologie. L'arrivée de traitements efficaces a modifié profondément la perception de la santé sexuelle dans la société, qui est devenue plus exigeante. Ainsi, la fonction érectile et sexuelle a désormais émergé comme un marqueur de santé globale. Les causes de la DE sont souvent mixtes : elles peuvent être somatiques (vasculaire, neurologique, endocrine, tissulaire, iatrogène) ou psychogènes. La prise en charge doit être étiologique si possible. Elle passe souvent d'abord par la réduction des facteurs de risque cardiovasculaire (FRCV) puis par un soutien médicamenteux vasodilatateur par inhibition de la phosphodiesérase 5. Lorsqu'on identifie des FRCV modifiables, nous adressons le patient en consultation spécialisée de prévention cardiovasculaire. La DE doit être vue comme un signe d'alerte prédictif de maladie ou d'événement cardiovasculaire évitable.

80-W GreenLight Laser Vaporization Versus Transurethral Resection of the Prostate for Treatment of Benign Prostatic Obstruction: 5-Year Outcomes of a Single-center Prospective Randomized Trial.

OBJECTIVE: To assess long term functional and safety follow-up data after 80-W GreenLight photoselective vaporization (GL PV) of the prostate and transurethral resection of the prostate (TURP). MATERIALS AND METHODS: Prospective randomized trial at a single tertiary referral center (Geneva, Switzerland). Patients were recruited in the outpatient clinic if they met the criteria for surgical treatment of benign prostatic obstruction. At baseline, 238 patients were treated either with the 80-W GL PV or monopolar TURP. After 5 years, data were available from 105 patients: 44 GL PV patients and 61 TURP patients. The primary outcome measure was the International Prostate Symptom Score (IPSS). Secondary outcome measures included maximum urinary flow rate (Qmax), postvoidal residual (PVR) and reoperation rate. Statistical analyses were performed using Stata 14 (StataCorp). RESULTS: After 5 years of follow-up, mean improvements in International Prostate Symptom Score, postvoidal residual and maximum urinary flow rate were similar in both groups. The re-treatment rate was 14.3% in the GL PV group vs 11.9% in the TURP group (P = .9). CONCLUSION: Noninferiority of the GL PV to TURP was confirmed in all functional and safety outcomes at 5-year follow-up. GL-PV could be a safe surgical alternative for patients suffering from benign prostatic obstruction.

[Medical treatment of micturition problems in men : what the general practitioner needs to know]. / Traitement médicamenteux des troubles mictionnels de l'homme : l'essentiel pour le médecin généraliste.

Considering the high prevalence of lower urinary tract symptoms in men, and owing to the development of a better focused pharmacotherapy, general practitioners (GPs) have been already for a decade first in line to prescribe an initial medication. With the intent to improve this shared care, we give an overview of the two main syndromes, obstructive and irritative, and their medication, in order to reinforce knowledge transfer and optimize coordination between GPs and urologists.

En raison de l'importante prévalence des troubles mictionnels masculins et du développement d'une pharmacothérapie de mieux en mieux ciblée, le praticien interniste-généraliste se trouve depuis plus d'une décennie en première ligne pour leur prise en charge médicamenteuse. Dans la perspective d'améliorer cette gestion partagée, nous présentons les deux principaux syndromes obstructif et irritatif, ainsi que leur traitement pharmacologique, afin de pérenniser le transfert de connaissances et la coordination entre le praticien-généraliste et l'urologue.

[Intravesical microwave thermo-chemotherapy for the treatment of non-invasive bladder cancer]. / Thermo-chimiothérapie intravésicale par radiofréquence pour le traitement du cancer non invasif de la vessie.

Non-invasive urothelial carcinoma of the bladder is known for its significant rate of recurrence after transurethral resection (TURB) even after adjuvant intravesical chemotherapy or immunoprophylaxis. Therefore, new and more effective approaches for the management of non-invasive bladder tumors have been developed and are progressively introduced in clinical practice. Recently, the endovesical administration of a combined regimen using a cytostatic agent and microwave-induced hyperthermia appears to be highly efficient and possibly superior to intravesical chemotherapy alone for none invasive bladder cancer.

Le carcinome urothélial non invasif de la vessie (n'envahissant pas le détrusor) est grevé d'un risque de récidive significatif malgré les instillations endovésicales adjuvantes avec des agents chimio- ou immunothérapeutiques suite à la résection endoscopique de la tumeur vésicale. Dans ce contexte, de nouvelles approches thérapeutiques potentiellement plus efficaces ont été récemment développées et sont progressivement introduites dans la pratique clinique courante. L'une de ces dernières est la combinaison d'une hyperthermie endovésicale à l'instillation intravésicale d'agents chimiothérapeutiques classiquement administrés lors de la prise en charge des cancers non invasifs. Ce nouveau traitement apparaît être d'une efficacité supérieure à celle de l'instillation simple d'agents chimiothérapeutiques endovésicaux.

[Laparoscopic cystectomy-urinary diversion with robotic assistance : which future ?] / Cystectomie-dérivation par laparoscopie robot-assistée : quel avenir ?

Known for its significant morbidity, radical cystectomy must improve minimally invasively. Rapidly but sporadically initiated at the beginning of the robotic era 15 years ago, laparoscopic cystectomy-urinary diversion has slowly progressed technically. It is actually optimally standardized to be entirely performed intra-corporealy. Its technical difficulty remaining high, robotic cystectomy should remain in expert hands with a significant recruitement to remain performant.

Connue pour sa morbidité significative, la cystectomie radicale se doit d'évoluer vers des techniques mini-invasives. Rapidement initiée sporadiquement, au début de l'ère robotique il y a 15 ans, la cystectomie-dérivation par laparoscopie sous assistance robotisée a lentement progressé dans sa mise au point technique, actuellement standardisée de manière optimale pour être réalisée intégralement intracorporellement. Sa difficulté technique restant élevée, la cystectomie robotisée doit donc rester en mains expertes disposant d'un recrutement suffisant pour demeurer performantes.

Post-kidney Transplant Robot-assisted Laparoscopic Ureteral (Donor-receiver) Anastomosis for Kidney Graft Reflux or Stricture Disease.

OBJECTIVE: To report our experience with robot-assisted ureteral anastomosis for kidney graft. Kidney graft complex ureteral strictures or symptomatic vesicoureteral reflux may require complex reconstruction. This is classically done through an open surgical access, which adds to the morbidity of kidney transplantation. The da Vinci robot enables performance of complex laparoscopic procedures and may hence be used for such reconstructions. PATIENTS AND METHODS: We retrospectively reviewed all patients undergoing robotic surgical revision for stricture or reflux disease over a 3-year period. Contemporary patients who underwent open surgery were used as a control group. RESULTS: Ten patients underwent a robotic attempt, of whom 4 needed conversion to open surgery. Seven patients underwent an open surgery. Preoperative demographics were similar in both groups. The median operative time was 293 minutes, with a shorter operative time in the open group. The group of patients who could be completed robotically had a significantly lower postoperative length of stay (5 vs 9 days), quicker return to normal food intake (postoperative day 1 vs 3), and quicker control of pain without opiates (postoperative day 1 vs 4) than the converted or open group. Morbidity was comparable with 1 late Clavien IIIb complication in each subgroup (open, converted, and robotic group). After a median follow-up of 43 months, renal function was stable and there were no recurrent graft infections. CONCLUSION: Robotic ureteral reconstruction for kidney graft patients is feasible and efficient, and offers the classical advantages of minimally invasive surgery with outcomes comparable with open series.

Transrectal Ultrasound-Guided Prostate Biopsy for Cancer Detection: Performance of 2D-, 3D- and 3D-MRI Fusion Targeted Techniques.

INTRODUCTION: The study aimed to evaluate 3 different modalities of transrectal ultrasound (TRUS)-guided prostate biopsies (PBs; 2D-, 3D- and targeted 3D-TRUS with fusion to MRI - T3D). Primary end point was the detection rate of prostate cancer (PC). Secondary end point was the detection rate of insignificant PC according to the Epstein criteria. PATIENTS AND METHODS: Inclusion of 284 subsequent patients who underwent 2D-, 3D- or T3D PB from 2011 to 2015. All patients having PB for initial PC detection with a serum prostate-specific antigen value ≤20 ng/ml were included. Patients with T4 and/or clinical and/or radiological metastatic disease, so as these under active surveillance were excluded. RESULTS: Patients with T3D PB had a significantly higher detection rate of PC (58 vs. 19% for 2D and 38% for 3D biopsies; p = 0.001), with no difference in Gleason score distribution (p = 0.644), as well as detection rate of low-risk cancers (p = 0.914). Main predictive factor for positive biopsies was the technique used, with respectively a 3- and 8-fold higher detection rate in the 3D- and T3D group. For T3D-PB, there was a significant correlation between radiological cancer suspicion (Prostate Imaging Reporting and Data System Score) and cancer detection rate (p = 0.02). CONCLUSIONS: T3D PB should be preferred over 2D PB and 3D PB in patients with suspected PC as it improves the cancer detection rate.

Outcome of patients with nonmetastatic muscle-invasive bladder cancer not undergoing cystectomy after treatment with noncisplatin-based chemotherapy and/or radiotherapy: a retrospective analysis.

Transurethral resection of bladder tumor (TURBT), radiotherapy, chemotherapy, or combinations can be used in patients with muscle-invasive bladder cancer (MIBC) not undergoing cystectomy. Nevertheless, unfitness for cystectomy is frequently associated with unfitness for other therapeutic modalities. We report the outcome of patients with MIBC who did not undergo cystectomy and did not receive cisplatin-based chemotherapy. Selection criteria for the study were nonmetastatic MIBC, no cystectomy, no cisplatin-based chemotherapy. Chemotherapy and/or radiotherapy should have been used aside from TURBT. Forty-nine patients (median age 79), managed between April 2001 and January 2012, were included in this analysis. Median Charlson Comorbidity Index was 5, while 76% were unfit for cisplatin. Treatment included radiotherapy (n = 7), carboplatin-based chemotherapy (n = 25), carboplatin-based chemotherapy followed by radiotherapy (n = 10), and radiochemotherapy (n = 7). Five-year event-free rate was 26% (standard error [SE] = 7) for overall survival, 23% (SE = 7) for progression-free survival, and 30 (SE = 8) for cancer-specific survival (CSS). Patients who were treated with combination of radiotherapy and chemotherapy had significantly longer CSS compared to those treated with radiotherapy or chemotherapy only (5-year CSS rate: 16% [SE 8] vs. 63% [SE 15], P = 0.053). Unfit-for-cystectomy patients frequently receive suboptimal nonsurgical treatment. Their outcome was poor. Combining chemotherapy with radiotherapy produced better outcomes and should be prospectively evaluated.

[Acute urinary retention: a mechanical or functional emergency]. / Rétention urinaire aiguë: une urgence d'origine mécanique ou fonctionnelle.

Acute urinary retention is one of the most frequent urologic emergencies. It occurs mostly in elderly males that suffer from prostate enlargement. Very rare in women, it is essentially caused by vaginal prolapse and neurologic disease. Patients with acute urinary retention suffer from lower abdominal pain and cannot void. Medical history is the cornerstone of diagnosis. Rarely palpable on abdominal examination, an overfilled bladder may be revealed by dullness on supra-pubic percussion. Acute urinary retention may lead to a decrease in kidney function, and on the long term to detrusor hypocontractility. The initial management is bladder drainage by urethral or suprapubic catheterization. Post obstructive diuresis and hematuria are possible complications. Subsequent evaluation is performed by the urologist on an ambulatory basis.

La rétention urinaire aiguë (RUA) est une des urgences urologiques les plus fréquentes. Il s'agit d'un problème essentiellement masculin, souvent dans un contexte d'hypertrophie prostatique. Elle est très rare chez la femme, le plus souvent en raison d'un prolapsus vaginal ou d'une maladie neurologique. En cas de RUA, une forte douleur pelvienne est associée à l'impossibilité d'uriner. Le diagnostic est basé sur l'anamnèse. Cliniquement, la région sus-pubienne est tendue et douloureuse, la vessie est rarement palpable mais une matité sus-pubienne est détectable. La RUA peut se compliquer d'une insuffisance rénale aiguë, ou à plus long terme, d'une hypocontractilité détrusorienne. La prise en charge repose sur le drainage vésical. Les possibles complications sont le syndrome de levée d'obstacle ou l'hématurie. Le bilan étiologique est réalisé à distance en consultation urologique ambulatoire.

[Non infectious pollakiura of women : diagnosis and treatment]. / Pollakiurie non infectieuse de la femme : bilan et traitement.

Overactive bladder is a frequent condition, often underdiagnosed, which affects deeply the quality of life of patients. The main burden linked to this syndrome is the limitation of every day life activities and the emotional impact which can even lead to depression.This impact on quality of life makes it a public health problem due to the high costs which stem from its management. In this context, a prompt and correct diagnosis, excluding all differential diagnosis, is essential before considering treatment options.

L'hyperactivité vésicale est un trouble fréquent, souvent sousdiagnostiqué, affectant la qualité de vie des patients atteints : limitation des activités quotidiennes, impact émotionnel profond, voire dépression. Les conséquences sur la qualité de vie en font un problème de santé publique aux coûts élevés pour le patient et la société. Dans ce contexte, le diagnostic doit être rapide et efficace. Les diagnostics différentiels doivent être soigneusement exclus avant d'envisager tout traitement.