ZiMM: A deep learning model for long term and blurry relapses with non-clinical claims data.

This paper considers the problems of modeling and predicting a long-term and "blurry" relapse that occurs after a medical act, such as a surgery. We do not consider a short-term complication related to the act itself, but a long-term relapse that clinicians cannot explain easily, since it depends on unknown sets or sequences of past events that occurred before the act. The relapse is observed only indirectly, in a "blurry" fashion, through longitudinal prescriptions of drugs over a long period of time after the medical act. We introduce a new model, called ZiMM (Zero-inflated Mixture of Multinomial distributions) in order to capture long-term and blurry relapses. On top of it, we build an end-to-end deep-learning architecture called ZiMM Encoder-Decoder (ZiMM ED) that can learn from the complex, irregular, highly heterogeneous and sparse patterns of health events that are observed through a claims-only database. ZiMM ED is applied on a "non-clinical" claims database, that contains only timestamped reimbursement codes for drug purchases, medical procedures and hospital diagnoses, the only available clinical feature being the age of the patient. This setting is more challenging than a setting where bedside clinical signals are available. Our motivation for using such a non-clinical claims database is its exhaustivity population-wise, compared to clinical electronic health records coming from a single or a small set of hospitals. Indeed, we consider a dataset containing the claims of almost all French citizens who had surgery for prostatic problems, with a history between 1.5 and 5 years. We consider a long-term (18 months) relapse (urination problems still occur despite surgery), which is blurry since it is observed only through the reimbursement of a specific set of drugs for urination problems. Our experiments show that ZiMM ED improves several baselines, including non-deep learning and deep-learning approaches, and that it allows working on such a dataset with minimal preprocessing work.

Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP).

OBJECTIVES: To describe the step-by-step learning curve of the holmium laser enucleation of the prostate (HoLEP) surgical technique. SUBJECTS/PATIENTS AND METHODS: A prospective, multicentre observational study was conducted, involving surgeons experienced in transurethral resection of the prostate and open prostatectomy but never having performed HoLEP. The main judgment criterion was the ability of the surgeon to perform four consecutive successful procedures, defined by the following: complete enucleation and morcellation within <90 min, without any conversion to standard transurethral resection of the prostate (TURP), with acceptable stress, and with acceptable difficulty (evaluated by Likert scales). Each surgeon included 20 consecutive cases. RESULTS: Of nine centres, three abandoned HoLEP before the end of the study due to complications, and one was excluded for treating patients off protocol. Only one centre achieved the main judgment criterion of four consecutive successful HoLEP procedures. Overall, the procedures were successfully performed in 43.6% of cases. Reasons for unsuccessful procedures were mainly operative time >90 min (n = 51), followed by conversion to TURP (n = 14), incomplete morcellation (n = 8), significant stress (n = 9), or difficulty (n = 14) during HoLEP. Ignoring operating time, 64% of procedures were successful and four out of five centres did four consecutive successful cases. Of the five centres that completed the study, four chose to continue HoLEP. CONCLUSION: Even in a prospective training structure, HoLEP has a steep learning curve exceeding 20 cases, with almost half of our centres choosing to abandon or not to continue with the technique. Operating time and difficulty of the enucleation seem the most important problems for a beginner. A more intensely mentored and structured mentorship programme might allow safer adoption of the procedure.

[Impact on professional practices of a care protocol implemented between usual hospital care and hospital at home]. / Impacts sur les pratiques professionnelles d’un protocole de soins mis en place entre l’hospitalisation avec hébergement et l’hospitalisation à domicile.

BACKGROUND: Implementation of a care protocol between usual hospital care and hospital at home (HAH) could improve the quality of care and decrease fragmentations of the French healthcare system. This study evaluated the impact on professional practices of a care protocol implemented between a surgery unit and hospital at home. METHODS: Twenty healthcare professionals (nurses, head nurses, physicians) from HAH and a Paris public hospital urology unit were interviewed by a public heath physician. Semistructured interviews were analyzed using the grounded theory. RESULTS: Professional practices were modified with better traceability of care, greater safety for professionals and for patients, standardization of practices and improved continuity of interventions between hospital and hospital at home. However, these changes in practices appeared to be limited to the protocol itself and indicated potential enhancement of technical aspects to the detriment of human contact. CONCLUSION: This care protocol has an encouraging impact on the quality of care. These results demonstrate the value of extending this approach to other wards to improve continuity of care between usual hospital care and hospital at home.

Prostate cancer outcomes in France: treatments, adverse effects and two-year mortality.

BACKGROUND: This very large population-based study investigated outcomes after a diagnosis of prostate cancer (PCa) in terms of mortality rates, treatments and adverse effects. METHODS: Among the 11 million men aged 40 years and over covered by the general national health insurance scheme, those with newly managed PCa in 2009 were followed for two years based on data from the national health insurance information system (SNIIRAM). Patients were identified using hospitalisation diagnoses and specific refunds related to PCa and PCa treatments. Adverse effects of PCa treatments were identified by using hospital diagnoses, specific procedures and drug refunds. RESULTS: The age-standardised two-year all-cause mortality rate among the 43,460 men included in the study was 8.4%, twice that of all men aged 40 years and over. Among the 36,734 two-year survivors, 38% had undergone prostatectomy, 36% had been treated by hormone therapy, 29% by radiotherapy, 3% by brachytherapy and 20% were not treated. The frequency of treatment-related adverse effects varied according to age and type of treatment. Among men between 50 and 69 years of age treated by prostatectomy alone, 61% were treated for erectile dysfunction and 24% were treated for urinary disorders. The frequency of treatment for these disorders decreased during the second year compared to the first year (erectile dysfunction: 41% vs 53%, urinary disorders: 9% vs 20%). The frequencies of these treatments among men treated by external beam radiotherapy alone were 7% and 14%, respectively. Among men between 50 and 69 years with treated PCa, 46% received treatments for erectile dysfunction and 22% for urinary disorders. For controls without PCa but treated surgically for benign prostatic hyperplasia, these frequencies were 1.5% and 6.0%, respectively. CONCLUSIONS: We report high survival rates two years after a diagnosis of PCa, but a high frequency of PCa treatment-related adverse effects. These frequencies remain underestimated, as they are based on treatments for erectile dysfunction and urinary disorders and do not reflect all functional outcomes. These results should help urologists and general practitioners to inform their patients about outcomes at the time of screening and diagnosis, and especially about potential treatment-related adverse effects.

Prospective, multidimensional evaluation of sexual disorders in men after laser photovaporization of the prostate.

INTRODUCTION: A few studies have investigated the impact of photovaporization of the prostate (PVP) on sexual function and were mainly focused on erectile function. AIMS: To comprehensively evaluate the impact of PVP on sexual function. METHODS: A prospective evaluation involved sexually active patients needing surgical relief of bladder outlet obstruction due to benign prostatic enlargement in a single center between August 2007 and November 2011. All patients underwent PVP using the GreenLight HPS™ 120W system (AmericanMedicalSystems, Minnetonka, MN, USA). MAIN OUTCOME MEASURES: Patients were evaluated preoperatively and postoperatively by International Prostate Symptom Score (I-PSS), I-PSS question 8, uroflowmetry parameters (maximum urinary flow rate [Qmax ] and postvoid residual [PVR] volume), Danish Prostate Symptom Score Sexual items (DAN-PSSsex), and overall sexual satisfaction using a seven-grade Likert scale. Operative parameters and postoperative complications were also assessed. Preoperative and postoperative values were compared using the Pearson chi-square test and the Wilcoxon paired test. A multivariable model was used to investigate the determinants of variation of global sexual satisfaction. RESULTS: One hundred and two consecutive patients with 12-month follow-up data were included in the analysis. Urinary parameters (I-PSS, Qmax , and PVR) were significantly improved compared with preoperative values. Compared with baseline, postoperative erection symptom score was not significantly different, whereas ejaculation symptom score was significantly worse. Global DAN-PSSsex score was unchanged, but DAN-PSSsex symptom score was worse (P = 0.04) and DAN-PSSsex bother score was significantly improved (P < 0.0001). Global sexual satisfaction was significantly improved compared with baseline (P = 0.02) and was significantly associated with I-PSS but not with erection and ejaculation score in a multivariable model. CONCLUSION: Ejaculation is the main sexual function impacted by PVP. Despite this, sexual satisfaction and bother due to sexual symptoms were significantly improved, probably due to the positive impact of urinary symptom relief.

Transurethral plasma vaporization of the prostate: 3-month functional outcome and complications.

UNLABELLED: Study Type - Therapy (multi-centre cohort). Level of Evidence 2b. OBJECTIVE: To evaluate the early functional outcomes of transurethral plasma vaporization of the prostate (TUVis) in a multicentre study. PATIENTS AND METHODS: A prospective multicentre observational study was conducted in eight urology departments. The inclusion criterion was benign prostatic hyperplasia (BPH) requiring surgical treatment. Patients on anti-coagulant therapy were not excluded. The TUVis procedure was performed according to a classic transurethral resection of the prostate (TURP) scheme following the manufacturer's recommendations. We evaluated subjective functional outcome using self-questionnaires (International Prostate Symptom Score [IPSS] and five-item International Index of Erectile Function [IIEF-5]) and objective criteria (prostate volume, prostate-specific antigen [PSA], uroflowmetry, post residual volume) at baseline and at 1- and 3-month follow-ups. All types of complications were systematically recorded. RESULTS: Despite 52% of patients receiving anticoagulant therapy before surgery, we reported only 3% with haemorrhagic complications, no blood transfusion, a mean catheterization time of 44 h and a mean postoperative stay of 2.9 nights. No significant change in irrigation time, catheter time or hospital stay was observed in patients with or without anticoagulant therapy. The IPSS and bother scores significantly decreased after the 3-month follow-up (57% and 59%, respectively), but the average remaining prostate volume was 29 cc and the tissue ablation rate was only 0.5 cc/min. Three major complications occurred, consisting of two urinary fistulas and one partial bladder coagulation. CONCLUSIONS: The TUVis procedure has a proven fast postoperative recovery time, good short-term functional outcome and good haemostatic efficiency. However, the tissue ablation rate was lower than expected and we encountered three major complications, the mechanisms of which remain unclear. Considering the high energy level required to create the plasma effect, the generator, cable and resectoscope must be carefully checked before each procedure.

Prospective short-term evaluation of transurethral needle ablation procedure in an ambulatory setting.

OBJECTIVE: To assess the results of transurethral needle ablation (TUNA) (Prostiva®, Medtronic, France) performed in an ambulatory setting in men with lower urinary tract symptoms (LUTS)/benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A multicenter open-label study was conducted. Short-term success was defined by ability to leave the hospital on the evening of the intervention, and absence of rehospitalization due to complications during the first postoperative month. Sexual and urinary functions were evaluated by validated questionnaires. RESULTS: The procedure was successful in 44/49 patients. Sexual and ejaculatory function was not affected or slightly improved in the majority of patients. Urinary parameters improved with a 32% decrease in the International Prostate Symptom Score. At 1 month postoperation, more than 80% of patients were satisfied, and 36/41 patients were prepared to undergo the procedure again if needed. Our study was limited by the short follow-up duration. CONCLUSIONS: TUNA can be successfully performed in an ambulatory setting under local and/or general anesthesia with a high level of patient satisfaction and a low short-term morbidity, especially on sexual function. Thus, the procedure is a suitable mini-invasive option for patients who cannot/do not want to take medical therapy or undergo invasive surgical procedures, or want to preserve their sexual function.

Surgical management of BPH in patients on oral anticoagulation: transurethral bipolar plasma vaporization in saline versus transurethral monopolar resection of the prostate.

INTRODUCTION: To compare postoperative outcomes of patients on oral anticoagulation (OA) treated with transurethral plasma vaporization of the prostate in saline water (TUVis) and transurethral resection of the prostate (TURP). MATERIALS AND METHODS: Between January and December 2009, 111 patients on OA therapy were treated with either TURP or TUVis in eight centers. Types of OA and perioperative management were collected. Postoperative outcomes were statistically compared between the two groups. RESULTS: A total of 57 (51%) and 54 (49%) patients were treated with TURP and TUVis, respectively. Types of OA were not significantly different between the two groups, but bladder catheterization prior to surgery was more frequently observed in the TUVis group. Before surgery, 28 patients were treated with warfarin alone, 74 with a platelet aggregation inhibitor (PAI) alone, and 9 with a combination of both. PAI was withdrawn preoperatively in 50 patients. All treatments with warfarin were switched for heparin. Comparison of the two groups showed significantly less hemorrhagic complications after TUVis. Patients treated with TUVis experienced less bladder washouts (2% versus 18%, p = 0.008), less late hematuria (4% versus 19%, p = 0.02), and lower decrease of serum hemoglobin (mean decrease of 0.66 versus 1.47 g/dL, p = 0.02). Postoperative bladder catheterization and hospital stay were significantly shorter, whereas the rate of urinary retention was significantly higher. Three months after surgery, functional results were not significantly different between the two groups. CONCLUSIONS: In patients on OA, TUVis led to significantly less bleeding, as well as shorter bladder catheterization and hospital stay than TURP.

Impact of lower urinary tract symptoms on discomfort in men aged between 50 and 80 years.

BACKGROUND/AIMS: There are only a few surveys on the prevalence of lower urinary tract symptoms (LUTS) among the general population. The aim of this survey was to assess the prevalence of LUTS and their impact on discomfort in men. METHODS: A questionnaire was mailed to 3,877 men aged 50-80 years, which included questions on their medical history, demographic and sociological status, and also the International Prostate Symptom Score (IPSS) with additional questions on discomfort related to urinary symptoms. RESULTS: The response rate was 81.5%. Prevalence of mild and severe IPSS was 89.2%. Specific bother for each urinary symptom depended on symptom frequency: urgency, frequency, weak stream, nocturia, incomplete emptying, intermittency and straining 1 time out of 5 were responsible for discomfort in respectively 4.9, 6.1, 7.1, 7.5, 8.7 and 9.9%; the same symptoms more than half of the time were responsible for discomfort in respectively 32.8, 38, 45.3, 45.6, 53.2 and 58.7%. Urgency was much more deeply implicated in discomfort than frequency of nocturia. CONCLUSIONS: Urinary symptoms in men are very common. Nocturia is the most frequent but has a low impact on discomfort. Urgency has a higher impact on discomfort and should therefore be considered in treatment decision-making.

Laser treatment of benign prostatic hyperplasia in patients on oral anticoagulant therapy: a review.

We assessed the therapeutic efficacy and safety of laser prostatectomy (LP) for treating benign prostatic hyperplasia (BPH) in patients on oral anticoagulation. We systematically reviewed previous reports, using the Pubmed database and bibliographies of retrieved articles and reviews. The oral anticoagulation included coumarin derivatives and platelet-aggregation inhibitors (PAI). Previous studies do not allow the establishment of definitive conclusions for managing patients on oral anticoagulation and who require BPH surgery. No randomized studies are available. Nevertheless, compared to transurethral resection of the prostate (TURP), LP seems to decrease the risk of haemorrhage in patients taking PAI or coumarin derivatives. Therefore, LP is a useful alternative to TURP for managing patients on oral anticoagulation, and could be proposed as the first intention for those patients. Continuing PAI during the procedure is feasible. A replacement of coumarin derivatives by low molecular weight heparin is preferable. No conclusion can be reached on the preferred type of laser technique to treat these patients, but data on laser enucleation is much less abundant and conclusive than that on laser vaporization.

[Medical management of uncomplicated benign prostatic hyperplasia: a new decision algorithm]. / Prise en charge médicale de l'hypertrophie bénigne de la prostatenoncompliquée: proposition d'un nouvel algorithme décisionnel.

Management of benign prostatic hyperplasia (BPH) is currently undergoing profound changes. Medical treatment is not only symptomatic, but may also seek to modify the natural history of the disease, especially by reducing the risk of acute urinary retention. Medical treatment is no longer limited to a single drug: the combination of 2 different drugs from different treatment categories appears superior to single-drug treatment in some patients. Two instrumental techniques - microwave or radiofrequency thermotherapy, previously proposed as alternatives to surgery - are more appropriate as alternatives to medical treatment. These various items make it possible to construct a decision algorithm that is based at each stage on a decision shared with the patient. This algorithm to provide decision aid in management of uncomplicated symptomatic HBP takes initial disease indicators and other patient indicators into account together with its course under treatment, which has not previously been considered by international guidelines.

[Value of antidiuretic, anticholinergic, and anti-inflammatory drugs and botulinum toxin for the treatment of voiding disorders related to BPH (CTMH-AFU forum 2005)]. / Intérêts des antidiurétiques, des anticholinergiques, des anti-inflammatoires et de la toxine botulinique pour le traitement des troubles mictionnels liés à l'HBP (forum CTMH-AFU 2005).

New therapeutic approaches have recently been investigated in order to improve the voiding disorders of patient with lower urinary tract symptoms related to benign prostatic hyperplasia. The purpose of this article is to provide a review of these treatments: anti-inflammatory, antidiuretic, anticholinergic and botulinum toxin. Anticholinergic drugs associated with a risk of urinary retention, appear to be effective for irritative disorders in combination with an alpha-blocker. Antidiuretics can be proposed in patients younger than 65 with disabling polyuria confirmed by a voiding diary, related to BPH and refractory to conventional treatment of BPH. The interaction between inflammation and BPH has not yet been clarified, but anti-inflammatory drugs appear to improve symptoms and may have a place in short-term treatment of BPH, as their long-term use is not recommended and COX-2 inhibitors have been withdrawn from the market. Finally, botulinum toxin could have a place in the treatment of disorders related to BPH if clinical studies confirm the recently published promising results. These new approaches will probably be integrated into guidelines and flow-charts for the treatment of voiding disorders related to BPH.

[The role of the IPSS (International Prostate Symptoms Score) to evaluate the frequency of disability induced by each of the 7 symptoms. (CTMH-AFU study)]. / Comment pondérer directement l'IPSS par la fréquence de la gêne induite par chacun des 7 symptômes ? (etude du CTMH-aFU).

INTRODUCTION: Evaluation of a patient with voiding disorders related to benign prostatic hyperplasia is theoretically performed by means of the IPSS score, which comprises only one global quality of life question. This study used a questionnaire to evaluate the frequency of disability induced by each of the symptoms of the IPSS in a representative sample of the French population and then proposed a weighting of the IPSS score by the statistical weight of disability of each symptom without having to increase the number of questions. METHODS: A survey on the voiding behaviour of French men was performed by TNS Sofres Healthcare by questionnaire between 18/4/03 and 27/5/03 in a panel of 3877 men aged 50 to 80 years representative of the French population. This survey comprised demographic and sociological questions as well as the IPSS score. A specific question concerning the disability induced by each of the 7 symptoms ("Does it bother you enormously, a lot, slightly, not at all? ") was added. RESULTS: Each symptom induced a different type of disability: the most marked disability was induced by urgent micturition and uri nary frequency, while interrupted stream only had a minor impact. Statistical modelling was performed to obtain a coefficient for each level of frequency of the symptom, directly integrating the theoretical statistical weight of the specific disability. With this statistical method, the frequency of each of the 7 symptoms was weighted by a coefficient from 0.00 to 1.54 according to the disorder and its frequency. A total of 35 coefficients were necessary to construct the score as a function of the frequencies of disability of the 7 symptoms. This method was used to classify disorders according to the degree of disability that they induced, the most disabling being urgency (from 0 to 1.54), followed by straining to urinate (0 to 1.17), and then each of the other 5 symptoms. CONCLUSION: The original feature of this new score is that it directly integrates the frequency and theoretical specific disability of each of the 7 symptoms of the IPSS score. However, it needs to be validated by a prospective clinical trial.

[Role of prostatic stents and transurethral microwave thermotherapy in the treatment of voiding disorders related to benign prostatic hyperplasia (CTMH-AFU forum 2005)]. / Place des endoprothèses prostatiques et de la thermothérapie micro-ondes transuréthrales dans le traitement des troubles mictionnels liés à l'HBP? (Forum CTMH-aFU 2005).

Prostatic stents and microwave thermotherapy are minimally invasive techniques for the treatment of voiding disorders related to benign prostatic hyperplasia. A review of the literature evaluates the place of these treatments in 2006. Permanent prostatic stenting is rarely used, but remains a treatment option for patients with obstructive disorders and a formal anaesthetic contraindication. Temporary stenting can be used to predict the effect of resection in selected patients. Finally, microwave thermotherapy, not widely used in France, has a promising clinical efficacy and occupies a place between medical treatment and surgery.

[Do urologists apply benign prostatic hyperplasia clinical practice guidelines? Survey on the complementary investigation request modalities in France]. / Les urologues appliquent-ils les recommandations sur la prise en charge de l'hyperplasie bénigne de la prostate? Enquête sur les modalités de prescription des examens complémentaires en France.

INTRODUCTION: In an attempt to standardize clinical practice, a number of authorities (American, European, international) have published guidelines for the assessment and treatment of men with lower urinary tract symptoms (LUTS) related to BPH. In order to determine the impact of these guidelines on daily practice, we conducted a survey of the initial management of BPH by French Urologists. METHODS: A clear and simple clinical situation was defined and sent to the 796 urologists members of the Association Française d'Urologie: a 65-year-old man presenting with moderate and bothersome lower urinary tract symptoms (LUTS) suggestive of BPH. Various items concerning the choice of complementary investigations were proposed. The last question evaluated the first-line drug prescription. The replies were then analysed as a function of the type of practice and the urologist's age. RESULTS: 184 urologists answered the questionnaire. The mean age of the responding urologists was 47.5 years. 31.6% of responses were derived from hospital urologists, 52.2% from private urologists and 16.2% from urologists with a mixed practice, which corresponds to the distribution of urology practices in France. Assessment of BPH comprised clinical interview and digital rectal examination for all urologists, IPSS score for 23.3%, serum creatinine for 44.7%, dipstick urinalysis and/or urine culture for 72.7%, PSA assay for 98%, uroflowmetry for 65%, renal ultrasound for 80.8%, bladder ultrasound for 84.5%, suprapubic prostatic ultrasound for 61.8%, transrectal ultrasound for 54.2%, post-voiding residue for 89.9%, fibroscopy for 4.7% and 59.6% of urologists would have instituted medical treatment by this first visit. The initial assessment was similar regardless of the type of practice or the urologist's age (greater than or less than 45 years). Hospital urologists and urologists in mixed practice performed statistically more IPSS scores, uroflowmetry or fibroscopy and fewer bladder or renal ultrasound examinations. CONCLUSION: The management of BPH in France is globally similar among urologists regardless of their age or type of practice and does not correspond to current international and national guidelines. These guidelines, designed to limit the number of examinations in countries with ageing populations who are particularly affected by lower urinary tract symptoms, must be more widely diffused. However, this diffusion is not sufficient to ensure acceptance and application of these guidelines. It is therefore essential to conduct real practice surveys among practitioners to evaluate these guidelines, demonstrate differences and try to understand these differences.

[Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging.male (MSAM-7)]. / Troubles urinaires du bas appareil et dysfonction sexuelle masculine: l'enquête MSAM-7 ou enquête multinationale de l'homme agé.

OBJECTIVES: Lower urinary tract symptoms (LUTS), which are often caused by benign prostatic hypertrophy (BPH), and sexual dysfunction are common in older men, with an overall prevalence of > 50% in men aged > 50 years. Men with LUTS have been reported to experience sexual dysfunction, including ejaculatory loss, painful ejaculation, and erectile dysfunction. This study was conducted to investigate the relationship between LUTS and sexual problems in aging men. METHODS: A large-scale, multinational survey was conducted in the US and six European countries to systematically investigate the relationship between LUTS and sexual dysfunction in older men. Detailed questionnaires were mailed to a national representative sample of men aged 50 to 80 years in each country. Selection was made on the basis of age, occupation, geographie region, and population density. LUTS and sexual function were assessed by validated symptom scales, including the International Prostate Symptom Score, the Danish Prostatic Symptom Score, and the International Index of Erectile Function. Subjects also completed a health and demographics questionnaire. RESULTS: A total of 34,800 surveys were mailed out, 14,254 were completed and returned, and 12,815 were deemed evaluable and included in the analysis. Results were consistent from one country to another. Although 90% of the men had LUTS, only 19% had sought medical help for urinary problems and only 11% were medically treated. Sexual activity was reported by 83% of the sample, with 71% reporting at least one episode of sexual activity during the previous 4 weeks. Sexual disorders and their bothersomeness were strongly related to both age and severity of LUTS. The relationship between sexual problems and LUTS is independent of comorbidities such as diabetes, hypertension, cardiac disease, and hypercholesterolemeia. CONCLUSIONS: Sexual activity is common in a majority of men over age 50 and is an important component of overall quality of life. The presence and severity of LUTS are independent risk factors for sexual dysfunction in older men. These results highlight the clinical importance of evaluating LUTS in patients with sexual dysfunction, and the need to consider sexual issues in the management of patients with benign prostatic hypertrophy.

Ex vivo comparison of available morcellation devices during holmium laser enucleation of the prostate through objective parameters.

UNLABELLED: BACKGROUND and Purpose: Holmium laser enucleation of the prostate (HoLEP) is a recognized option for surgical management of benign prostatic hyperplasia (BPH). While laser parameters and enucleation techniques have been widely investigated, morcellation techniques remain poorly evaluated in the literature. Our goal was to objectively evaluate the available devices used for morcellation during HoLEP. MATERIAL AND METHODS: An in vitro evaluation of two morcellators (Lumenis and Wolf) and two nephroscopes (Wolf and Storz) was conducted. For morcellators, the following parameters were assessed: Aspiration power (time to aspirate 1 L of water), morcellation power (g of baked chicken meat morcellated in 2 minutes), and visual control of the cutting part of the device (visible or not visible). For nephroscopes, data collected were: Field of vision (measured on a 4 cm distant sight) and irrigation flow (time needed to drain a 3-liter bag of water suspended at 1 m of height). RESULTS: For the Wolf and Lumenis morcellators, aspiration power parameters were 20.4 mL/s and 22.2 mL/s, and morcellating power parameters were 2.5 g and 6 g of tissue per minute, respectively. The cutting part of the Wolf morcellator was permanently under control during the procedure, whereas the distal part of the cutting device was out of vision control with the Lumenis. Evaluation of Storz and Wolf nephroscopes showed that field of vision was larger with the Storz, and irrigation flow was 0.35 and 0.52 L/min, respectively. CONCLUSIONS: The Storz nephroscope has a greater field of vision but less important blood flows. The Lumenis morcellator is faster than the Wolf morcellator. These objective data could set up the basis for a prospective trial comparing the two devices.

Management of lower urinary tract symptoms related to benign prostatic hyperplasia in real-life practice in france: a comprehensive population study.

BACKGROUND: Male lower urinary tract symptoms (LUTS) are one of the most treated diseases, but little is known about patient trajectories in current clinical practice. OBJECTIVE: To describe the dynamic treatment patterns of LUTS presumably due to benign prostatic obstruction (BPO). DESIGN, SETTINGS, AND PARTICIPANTS: All prescriptions of α1-adrenergic receptor blocking agents (α1-blockers), 5α-reductase inhibitors (5-ARIs), and phytotherapy, and all surgeries related to BPO performed in France from 2004 to 2008 were identified using two distinct administrative claim databases maintained by the National Health Insurance system that covers the entire population. After linking the two data sets, all consecutive treatment events were analyzed for each patient. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Drug prescription details were assessed for each year, region, and prescriber qualification. Medical treatment initiation, interruption, evolution, and events after surgical management (hospital stay, reoperation, complication rates, and subsequent medical prescriptions) were also investigated. RESULTS AND LIMITATIONS: Overall, 2 620 269 patients were treated within 5 yr, with important geographic variations. Medical treatment was interrupted for approximately 16% of patients. The α1-blockers were prescribed most frequently, but phytotherapy surprisingly accounted for 27% of all monotherapies and 54% of all combination therapies. General practitioners and urologists (92% and 3.7% of overall prescribers, respectively) exhibited a similar prescription profile. Treatment initiation was medical in 95.4% of cases, consisting primarily of monotherapy using α1-blockers (60.3%), phytotherapy (31.8%), or 5-ARIs (7.9%). Treatment was modified at extremely high rates within 12 mo of initiation (8.7%, 14.6%, and 12.9%, respectively). The median hospital stay for surgical management was far higher than in clinical trials. Long-term surgical complications and reoperation rates favored open prostatectomy. Incidence of pharmacologic treatment after surgery was as high as 13.8% at 12 mo. CONCLUSIONS: This unique dynamic evaluation of clinical practice revealed unexpected results that contrast with previously published evidence from clinical trials. This approach may merit monitored and targeted measures to improve the level of care in the field.

Photoselective vaporization of the prostate with GreenLight 120-W laser compared with monopolar transurethral resection of the prostate: a multicenter randomized controlled trial.

BACKGROUND: Evidence supporting the widespread use of GreenLight High Performance System (HPS) 120-W photoselective vaporization of the prostate (PVP) is lacking. OBJECTIVE: To assess the noninferiority of PVP compared with transurethral resection of the prostate (TURP) on urinary symptoms and the superiority of PVP over TURP on length of hospital stay. DESIGN, SETTING, AND PARTICIPANTS: A multicenter randomized controlled trial was conducted. INTERVENTION: Patients underwent monopolar TURP or PVP with the GreenLight HPS 120-W laser. MEASUREMENTS: International Prostate Symptom Score (IPSS), Euro-QOL questionnaire, uroflowmetry, Danish Prostate Symptom Score Sexual Function Questionnaire, sexual satisfaction, and adverse events were collected at 1, 3, 6, and 12 mo. The two groups were compared using the 95% confidence interval (CI) of median difference for testing noninferiority of the IPSS at 12 mo and the student t test for testing the difference in length of hospital stay. RESULTS AND LIMITATIONS: A total of 139 patients (70 vs 69 men in each group) were randomized. Median IPSS scores at 12-mo follow-up were 5 (interquartile range [IQR]: 3-8) for TURP versus 6 (IQR: 3-9) for PVP, and the 95% CI of the difference of the median was equal to -2 to 3. Because the upper limit of the 95% CI was >2 (the noninferiority margin), the hypothesis of noninferiority could not be considered demonstrated. Median length of stay was significantly shorter in the PVP group than in the TURP group, with a median of 1 (IQR: 1-2) versus 2.5 (IQR: 2-3.5), respectively (p<0.0001). Uroflowmetry parameters and complications were comparable in both groups. Sexual outcomes were slightly better in the PVP group without reaching statistical significance. CONCLUSIONS: The present study failed to demonstrate the noninferiority of 120-W GreenLight PVP versus TURP on prostate symptoms at 1 yr but showed that PVP was associated with a shorter length of stay in the hospital. TRIAL REGISTRATION: NCT01043588.

Clinical and economic impact of malnutrition per se on the postoperative course of colorectal cancer patients.

BACKGROUND & AIMS: To assess the medico-economic impact of malnutrition in patients who underwent surgery for colorectal cancer. METHODS: We performed post-hoc analyses of data from the Alves et al. prospective study. Using standard criteria of malnutrition, 2 groups were created a posteriori: Well-nourished (WN) and Mal-nourished (MN) patients. The 2 groups were statistically adjusted for age, cancer status, and scheduled surgery. Individual costs were valued using the French National Cost Study. Postoperative morbidity, mortality, hospital length-of-stay (LOS), and discharge setting were compared. We defined 3 scenarios, the most accurate estimate and its upper and lower limits, to assess the economic impact of malnutrition. RESULTS: 453 patients were included in the analyses. Complication and mortality rates were not significantly different between the 2 groups. MN patients had a mean LOS 3.41 days significantly longer than WN patients (p = 0.017). In MN patients, the cost of hospital stay was increased by around 3360 €, creating an annual impact of 10,159,436 € for French non-profit hospitals. CONCLUSIONS: Malnutrition in colorectal cancer surgical patients is associated with an increased LOS resulting in significant budget impact. Further studies are needed to investigate this impact and the related cost-benefit of perioperative specialized nutritional support and implementation of the ERAS protocol in this homogeneous category of patients.