[Impact of neoadjuvant chemotherapy on the peri-operative morbidity of radical cystectomy for muscle invasive bladder cancer]. / Impact de la chimiothérapie néoadjuvante sur la morbidité péri-opératoire de la cystectomie pour tumeur de vessie infiltrant le muscle.

INTRODUCTION: Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone. METHODS: Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications. RESULTS: We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001). CONCLUSION: NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.

[Clinical practice guidelines: Synthesis of the guidelines for the surgical treatment of primary pelvic organ prolapse in women by the AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l'AFU, le CNGOF, la SIFUD-PP, la SNFCP, et la SCGP.

OBJECTIVE: Develop guidelines for surgery for primary pelvic organ prolapse (POP). METHODS: Literature review, establishment of levels of evidence, external review, and grading of recommendations by 5 French academic societies: Association Française d'Urologie, Collège National des Gynécologues et Obstétriciens Français, Société Interdisciplinaire d'Urodynamique et de Pelvi-Périnéologie, Société Nationale Française de Colo-proctologie, and Société de Chirurgie Gynécologique et Pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B). A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C).

[Clinical practice guidelines: Summary of recommendations for first surgical treatment of female pelvic organ prolapse by 5 French academic societies: AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : Synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l´AFU, le CNGOF, la SIFUD-PP, la SNFCP et la SCGP.

OBJECTIVE: Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse. METHODS: Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.

[Assessment before surgical treatment for pelvic organ prolapse: Clinical practice guidelines]. / Bilan avant le traitement chirurgical d'un prolapsus génital : Recommandations pour la pratique clinique.

INTRODUCTION: The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique? MATERIAL AND METHODS: This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]). RESULTS: It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology. CONCLUSION: Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. © 2016 Published by Elsevier Masson SAS.

[Treatment of Urinary incontinence associated with genital prolapse: Clinical practrice guidelines]. / Traitement de l'incontinence urinaire associée au prolapsus génital : Recommandations pour la pratique clinique.

INTRODUCTION: Prolapse and urinary incontinence are frequently associated. Patente (or proven) stress urinary incontinence (SUI) is defined by a leakage of urine that occurs with coughing or Valsalva, in the absence of any prolapse reduction manipulation. Masked urinary incontinence results in leakage of urine occurring during reduction of prolapse during the clinical examination in a patient who does not describe incontinence symptoms at baseline. The purpose of this chapter is to consider on the issue of systematic support or not of urinary incontinence, patent or hidden, during the cure of pelvic organs prolapse by abdominal or vaginal approach. MATERIAL AND METHODS: This work is based on an systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systematic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement). RESULTS: In case of patent IUE, concomitant treatment of prolapse and SUI reduces the risk of postoperative SUI. However, the isolated treatment of prolapse can treat up to 30% of preoperative SUI. Concomitant treatment of SUI exposed to a specific overactive bladder and dysuria morbidity. The presence of a hidden IUE represents a risk of postoperative SUI, but there is no clinical or urodynamic test to predict individually the risk of postoperative SUI. Moreover, the isolated treatment of prolapse can treat up to 60% of the masked SUI. Concomitant treatment of the hidden IUE therefore exposes again to overtreatment and a specific overactive bladder and dysuria morbidity. CONCLUSION: In case of overt or hidden urinary incontinence, concomitant treatment of SUI and prolapse reduces the risk of postoperative SUI but exposes to a specific overactive bladder and dysuria morbidity (NP3). The isolated treatment of prolapse often allows itself to treat preoperative SUI. We can suggest not to treat SUI (whether patent or hidden) at the same time, providing that women are informed of the possibility of 2 stages surgery (Grade C). © 2016 Published by Elsevier Masson SAS.

[Can the urine dipstick be used in the diagnosis of urinary bacterial colonizations in a preoperative urological assessment?]. / La bandelette urinaire peut-elle être utilisée pour le diagnostic des colonisations bactériennes urinaires dans le bilan préopératoire urologique?

PURPOSE: The use of the dipstick urinalysis has been validated for the diagnosis of symptomatic urinary infections, cystitis and pyelonephritis thanks to an excellent negative predictive value. For prostatitis, it is rather its positive predictive value that is interesting. The aim of this study is to validate its use in the screening of urinary colonizations in the preoperative assessment in urology. METHODS: A monocentric prospective study was carried out for one year in 2011 comparing the data from the urine dipstick test with a fresh-voided midstream urinary examination and culture performed on the day of admission with the same urine sample in 598 asymptomatic patients programmed for a urological procedure. The gold standard to diagnose a microbiological-confirmed urinary tract infection or colonization was uropathogen growth of ≥10(3) colony-forming units per ml (cfu/mL) with or without leucocyturia. RESULTS: The study disclosed 5% of colonized patients. The urine dipstick test had a 65% sensitivity and a 97% negative predictive value. However, the low sensitivity of the urine dipstick test entailed 34% of false negatives. CONCLUSION: In spite of a good negative predictive value linked to a low prevalence of colonized patients (5%), the low sensitivity of the urine dipstick test entails a non-negligible number of false negatives. Its use as a single test of preoperative screening would expose colonized patients to the prospect of an operation, which seems to be unacceptable for some of them, notably endoscopic ones. LEVEL OF EVIDENCE: 4.

[Guidelines for treatment of non-neurological urinary incontinence in women using periurethral injections]. / Recommandations pour le traitement de l'incontinence urinaire féminine non neurologique par injections péri-urétrales.

Currently there are no data reported in the literature supporting the recommendation for peri-urethral injections in first-line treatment. However, some authors emphasize that periurethral injection techniques can be used because of their good risk/benefit ratio in patients who are fragile, those who have already undergone surgery, and those who do not wish to have surgery. This option should be chosen based on efficacy, safety, and the patient's wishes. The product used should remain based on safety, ease of use, price, and the urologist's preferences. In all cases, efficacy decreases with time and repeated injections are often necessary to maintain a satisfactory result. The injectables are a possible first-line choice in very elderly patients and in those who do not wish to undergo surgery. After failure of surgical treatment and/or if there is sphincter deficiency, peri-urethral injections can be an alternative to a new surgery, but one must be aware that the results are clearly inferior to balloons or the sphincter. In cases where the urethra is attached due to previous interventions, peri-urethral injection is not indicated.

[Synthesis of the guidelines for the treatment of non-neurological urinary incontinence in women]. / Synthèse des recommandations pour le traitement de l'incontinence urinaire féminine non neurologique.

The last two decades have brought about new medical and surgical treatments revolutionizing care for non-neurological urinary incontinence in women. Many studies, often randomized prospective studies with sufficient follow-up, have validated the therapeutic choices and shown them not to be part of a fad or marketing pressures. The French Association of Urology (L'Association Française d'Urologie), through its Committee on Women's Urology and Pelviperineology (Comité d'Urologie et de Pelvipérinéologie de la Femme), proposes its recommendations. These were established by an expert group of specialists (urologists, gynecologists, and physical therapists), based on a review of the literature but taking into account the daily practices in academic and private practice settings. Between evidence-based medicine and reality in the field, these recommendations attempt to propose realistic and applicable strategies.

[Cure of rectocele by vaginal way]. / Traitement des rectocèles par voie basse.

Rectocele is a rectal hernia through the posterior vaginal wall. There is three levels of rectocele. High rectocele is caused by the uterosacral and cardinal ligaments stretching; it needs prerecti fascia placation with a sacrofixation of an associated prolapsus of uterus or vaginal vault. The middle rectocele is linked with a rectovaginal fascia defect; the preferential choice for middle rectocele is midline fascial plication; superior myoraphy gives dyspareunia. The inferior rectocele results of a destruction of the perineal body; the treatment is a myoraphy with vulvoraphy. Complete rectocele would be an indication for a posterior mesh.

[Endoscopic removal of renal stones through laparoscopic access of the ureter and the pelvis]. / Urétérorénoscopie perlaparoscopie dans le traitement des calculs du rein.

PURPOSE: We studied the efficiency and the morbidity of endoscopic removal of kidney stones during laparoscopic removal of ureteral stone. MATERIAL AND METHODS: Six patients presenting with an ureteral stone resisting to ESWL and four patients presenting with an UPJ obstruction were studied. Every patient had one to five associated kidney stones. The patients were operated with transperitoneal laparoscopic ureterolithotomy or pyeloplasty. An endoscopy of the upper urinary tract was realized during the same operating time through laparoscopic access. A flexible ureteroscope (five cases) or semi-flexible ureteroscope (one case) were used after ureterolithotomy. A fibroscope (four cases) was used before pyeloplasty. The endoscope was introduced through the port of the iliac fossa and the stones were extracted with a basket grasper. The patients were followed by abdominal plain film 12 weeks after surgery, by IPV six weeks after surgery and then annually with abdominal plain film and ultrasound. RESULTS: No operative complication arose. Nine of 10 patients had a complete extraction of the kidney stones (one patient had an extraction only of four out of five kidney stones). No damage of any endoscope was observed. At a minimum follow-up of 18 months, no fistula nor stenosis of the ureter was diagnosed. CONCLUSION: Endoscopic removal of kidney stones through laparoscopic access of the upper urinary tract is effective, sure and reproducible. Such procedure requires experience in laparoscopy and endoscopy of the upper urinary tract. The evaluation of this procedure must be pursued.

[Replacement enterocystoplasty in man (except Hautmann): principles and technical considerations]. / Entérocystoplastie de substitution chez l'homme (Hautmann exclu): principes et applications techniques.

Orthotopic urinary reservoir using a bowel segment has become the most favoured form of diversion after radical cystectomy. Ideal neobladder has to (i) store the urine with a low pressure bladder substitute, (ii) protect the upper urinary tract and (iii) provide a better quality of life enabling volitional voiding. A lot of techniques have bee described to construct a reservoir, however, all of them are based on the principle of intestinal loop detubulation. Many intestinal segments have been used, but ileum seems to be preferred in Europe. The upper urinary tract is mainly protected by a low neobladder pressure, rather than an additional antireflux flap-valve-type implantation technique which may increase the risk of uretero-enteric stricture. No significant difference in functional outcome can be observed among the several techniques. In selected cases, orthotopic bladder replacement is well tolerated and feasible and appears to be the gold standard after cystectomy.

[Transurethral injections under local anaesthesia for ambulatory treatment of stress urinary incontinence in women: indications, feasibility and results]. / Injections trans-urétrales sous anesthésie locale en ambulatoire dans l'incontinence urinaire d'effort féminine: indications, faisabilité et résultats.

OBJECTIVE: The aim of the study was to evaluate feasibility and results of ambulatory transurethral injections of Macroplastique using the system MIS under local anaesthesia, for treatment of female stress urinary incontinence. MATERIAL AND METHODS: We have performed a prospective multicentre study which has enrolled 20 patients between January 2003 and May 2004. Mean age was 72.8 ans (range 40 to 91). Preoperative inclusion criterias were positive stress test, 24 hours PAD test more than 10 g and post-void residual less than 100 ml. Urethral hypermobility was present in 8 patients (42.1%), and 3 patients was diagnosed as intrinsic sphincter deficiency (16.7%) on urodynamics examination. Pre and post-operative evaluation of urinary symptoms and quality of life were performed with the MHU score (Mesure du Handicap Urinaire), the Ditrovie score and the Contilife scale. The Macroplastique implant (Uroplasty) contains silicone and a bioabsorbable gel. Injections were perfomed under the mid-urethral mucosa (2.5 ml at 6 hours and 1.25 ml at 2 and 10 hours) using the system MIS (Uroplasty). No cystoscopy was required and the mean operative time was 15 minutes. RESULTS: The procedure was feasible under pure local anaesthesia in all cases. No intra-operative complications occurred. Postoperative complications had included 2/19 local pain (10.5%), 3/19 minimal urethrorrhagia (15.8%) and 6/19 urinary retentions (31.6%), which were treated by heterologous intermittent catheterization during 3 to 20 days. Eight patients returned home the same day (42.1%). The mean hospital stay was 2.3 days. Mean postoperative follow-up was 8.3 months (range 2.7 to 19.1). No patient required a second injection. Results had shown a 36.9% success rate (7/19), 52.6% improvement (10/19) and 10.5% failure (2/19). At follow-up, stress test was negative in 66.7% of patients (12/18) and PAD test was<10 g in 66.7% (10/15). Modifications on maximal flow rate were non significant after injections. Postoperatively, all urinary symptoms were improved except nocturia and voiding difficulties. Quality of life was improved on all parameters. CONCLUSION: The surgical treatment of female stress urinary incontinence by transurethral injections of Macroplastique using the system MIS under local anaesthesia was feasible in all cases with a success or improvement rate of 89.5% at a mean follow-up of 8.3 months. Ambulatory treatment was compromised by the high rate of postoperative urinary retention (31.6%).

[Vesicovaginal fistula]. / Fistules vésicovaginales.

Urinary fistula to the vagina has been described since the beginning of the written record. In developed nations, these fistulas are usually unfortunate complications of gynecologic or other pelvic surgery and radiotherapy. Historically, birth trauma accounted for most vesicovaginal fistulas, and it remains the major cause of urinary fistulas in many underdeveloped nations. Once a vesicovaginal fistula is suspected, a thorough vaginal examination should be performed to identify its size and location, especially in relation to the trigone and eliminate a ureterovaginal fistula which can be associated in up to 10% of cases. Numerous methods for the treatment of vesicovaginal fistulae have been described. Abdominal, and vaginal approaches are used for the repair of vesicovaginal fistulae. The approach selected is dependent on many factors, but is probably best determined by the experience and training of the surgeon. The techniques of the vaginal approach involve tension-free closure of the fistula with or without excision of the tract, creation of an anterior vaginal wall flap and appropriate use of vascularized interposition grafts. The abdominal approach may be used to treat all types of vesicovaginal fistulae and is the preferred approach when concomittant ureteral reimplantation is required. Postoperative care is similar for both vaginal and abdominal vesicovaginal fistula repair. Adequate uninterrupted bladder drainage is the most critical aspect of postoperative management. A voiding cystourethrogram is performed at 10 postoperative days to confirm closure of the fistula.

[Treatment of stress urinary incontinence with percutaneous colposuspension: unsatisfactory technique]. / Traitement de l'incontinence urinaire d'effort par colposuspension percutanée: une technique non satisfaisante.

OBJECTIVE: The objective of this study was to evaluate the results of a percutaneous needle colposuspension technique with bone fixation (Vesica system) in the treatment of female urinary stress incontinence (USI) of the woman, with a minimum follow-up of one-year. MATERIAL AND METHODS: 34 women aged 35 to 86 years (mean: 62 years) were treated for USI due to bladder neck hypermobility according to the Vesica technique. All patients had a positive preoperative Bonney manoeuvre without sphincter incompetence on urethral pressure profile. RESULTS: Overall, 1 year postoperatively, 9 patients (26%) were completely dry and did not wear any protection, 19 (56%) were improved, but still presented occasional leaks and 6 (17%) were considered to be failures. Physical examination revealed postoperative leaks in 24 patients with recurrence of hypermobility and positive Bonney manoeuvre in every case. There was one subcutaneous abscess and 2 cases of persistent pain at the bone implant site. No cases of bone infection or screw explantation were observed. No cases of retention beyond the 3rd postoperative day were observed. CONCLUSION: The percutaneous colposuspension technique gives disappointing results at one year due to recurrence of urethral hypermobility in every case.

[Esthetic and functional results of the transperitoneal laparoscopic approach in nephrectomy]. / Conséquences esthétiques et fonctionnelles de l'abord laparoscopique transpéritonéal pour la néphrectomie.

OBJECTIVE: To evaluate the aesthetic and functional sequelae of laparoscopic transperitoneal nephrectomy. MATERIAL AND METHODS: Twenty-one laparoscopic transperitoneal nephrectomies were performed between 1996 and 1999. Four trocars were used in 9 patients and 3 trocars were used in 12 patients. In all patients of the series, nephrectomy was performed without manual assistance and the kidney was extracted from the iliac fossa after enlarging a trocar orifice. A questionnaire evaluating the aesthetic sequelae of the operation, resumption of everyday activities and the patient's general satisfaction was sent to each patient by mail. RESULTS: 17 patients completed the questionnaire after a mean follow-up of 12.2 months (range: 2 to 33 months). Scars were cosmetically satisfactory in 100% of cases, painless in 100% of cases and were considered to be invisible in 58.8% of cases. All patients were satisfied with the operation, but only 70.6% would have recommended this procedure to a friend or relative. 57.1% of the patients hospitalised for less than 5 days considered the hospital stay to be too brief and 42.9% considered it to be barely sufficient. Time to resumption of everyday activity varied considerably (7 to 70 days) with a mean of 32 days and was not correlated with operative complications. CONCLUSION: Laparoscopic transperitoneal nephrectomy achieves good aesthetic and functional results, but patients are not satisfied with the short hospital stay. Resumption of everyday activity does not appear to depend on the postoperative course.

A new prostatic stent for the treatment of benign prostatic hyperplasia in high-risk patients.

OBJECTIVES: The objective of this study was to evaluate the efficacy and safety of a new prostatic stent (Trestle((R)), Boston Scientific Microvasive) for the treatment of BPH in patients with complete urinary retention and considered to be inoperable. METHODS: The efficacy of the stent was evaluated in terms of return of micturition, level of patient satisfaction, uroflowmetry and residual urine. Any stents removed were examined by infrared spectrophotometry for the presence of crystalline encrustations. RESULTS: From December 1997 to April 1999, 20 stents were inserted under local anaesthesia in 17 patients aged 54-90 years. Stents remained in place for an average of 3.5 months. Two migrations were reported. The mean maximum flow rate was 13.7 ml/s and the mean residual urine was 110 ml. The infrared spectrophotometry study revealed a glycoprotein film on stents in place for 1-6 months, accompanied by uric acid crystals on stents in place for 9 months. CONCLUSION: The Trestle prostatic stent is effective and constitutes a good alternative to surgical treatment in patients with a high operative risk.