Outcome and cost analysis of sacral nerve modulation for treating urinary and/or fecal incontinence.

BACKGROUND: Sacral nerve modulation (SNM) is an established treatment for urinary and fecal incontinence in patients for whom conservative management has failed. OBJECTIVE: This study assessed the outcome and cost analysis of SNM compared to alternative medical and surgical treatments. METHODS: Clinical outcome and cost-effectiveness analyses were performed in parallel with a prospective, multicenter cohort study that included 369 consecutive patients with urge urinary and/or fecal incontinence. The duration of follow-up was 24 months, and costs were estimated from the national health perspective. Cost-effectiveness outcomes were expressed as incremental costs per 50% of improved severity scores (incremental cost-effectiveness ratio). RESULTS: The SNM significantly improved the continence status (P < 0.005) and quality of life (P < 0.05) of patients with urge urinary and/or fecal incontinence compared to alternative treatments. The average cost of SNM for urge urinary incontinence was ∈8525 (95% confidence interval, ∈6686-∈10,364; P = 0.001) more for the first 2 years compared to alternative treatments. The corresponding increase in cost for subjects with fecal incontinence was ∈6581 (95% confidence interval, ∈2077-∈11,084; P = 0.006). When an improvement of more than 50% in the continence severity score was used as the unit of effectiveness, the incremental cost-effectiveness ratio for SNM was ∈94,204 and ∈185,160 at 24 months of follow-up for urinary and fecal incontinence, respectively. CONCLUSIONS: The SNM is a cost-effective treatment for urge urinary and/or fecal incontinence.

Randomized, crossover study evaluating patient preference and the impact on quality of life of urisheaths vs absorbent products in incontinent men.

OBJECTIVE: • To evaluate the impact of urisheaths vs absorbent products (APs) on quality of life (QoL) in men with moderate to severe urinary incontinence (UI). PATIENTS AND METHODS: • A randomized, controlled, crossover trial in 61 outpatient adult men with stable, moderate to severe UI, with no concomitant faecal incontinence, was conducted from June 2007 to February 2009 in 14 urology centres. • Participants tested Conveen Optima urisheaths (Coloplast, Humlebaek, Denmark) with collecting bags and their usual AP in random order for 2 weeks each. • The impact of each on QoL was measured using the King's Health Questionnaire (KHQ) and the short form-12 acute questionnaire, and each patient's preference was recorded. • A 10-item patient questionnaire was also used to assess the product main advantages on an 11-point scale (0: worst; 10: best). A 72-h leakage diary was used to record the number and severity of leaks and daily product consumption. Safety was measured as the number of local adverse events. RESULTS: • All dimensions of the KHQ were scored lower with urisheaths, indicating an improvement in QoL. The greatest mean score reductions were in Limitations of Daily Activities (-10.24, P= 0.01) and Incontinence Impact (-7.05, P= 0.045). • The majority (69%) of patients preferred Conveen Optima urisheaths to their usual AP (P = 0.002). • Urisheaths scored significantly higher for all categories in the patient questionnaire (efficacy, self-image, odour management, discretion, skin integrity) except ease of use. • Safety was considered to be good. CONCLUSIONS: • Conveen Optima urisheaths showed a positive impact on QoL (according to the KHQ results) in moderate to severe incontinent men, who were long-term users of APs, and participants largely preferred urisheaths. • Conveen Optima urisheaths should be recommended to incontinent men in preference to APs.

Real-time heart rate variability and its correlation with plasma catecholamines during laparoscopic adrenal pheochromocytoma surgery.

BACKGROUND: We studied sympathovagal activity using real-time heart rate variability (HRV) and determined its relationship with plasma catecholamines to characterize short-term cardioregulatory mechanisms during laparoscopic adrenal pheochromocytoma surgery. METHODS: We recruited 20 patients with pheochromocytoma (Group P) and 20 with incidentaloma (Group I). HRV, systolic blood pressure and heart rate were continuously monitored. The low frequency and high frequency spectra denoted, respectively, sympathetic and parasympathetic activity. The low frequency/high frequency (LF/HF) ratio represented sympathovagal balance. Blood samples for epinephrine and norepinephrine assays were collected before, during, and after surgery. After log transformation of the repeated measures, a linear regression model was applied on their mean values. The correlation coefficients among variables were calculated using the Spearman rank test. RESULTS: No significant changes were observed in Group I. In Group P, epinephrine and norepinephrine increased in all patients during peritoneal insufflation and tumor resection. In 16 patients, systolic blood pressure, heart rate, low frequency, and LF/HF ratio increased concurrently. In four patients, low frequency and LF/HF ratio decreased. Three of these patients had normal systolic blood pressure and heart rate, and the fourth patient had hypotension and tachycardia. The high frequency component was enhanced in 15 patients and was stable in five. Low frequency was correlated with norepinephrine (r = 0.68, P < 0.001), systolic blood pressure (r = 0.66, P < 0.01), and heart rate (r = 0.62, P < 0.05). CONCLUSION: This study demonstrated a strong correlation between low frequency HRV, plasma norepinephrine, arterial blood pressure, and heart rate during pheochromocytoma surgery.

Subcutaneous pyelovesical bypass as replacement for standard percutaneous nephrostomy for palliative urinary diversion: prospective evaluation of patient's quality of life.

PURPOSE: To improve the quality of life of patients with palliative definitive percutaneous nephrostomy, we prospectively evaluated a subcutaneous ureteral bypass using a newly designed ureteral prosthesis. PATIENTS AND METHODS: A series of 19 patients receiving 27 subcutaneous tubes in replacement for percutaneous nephrostomy were evaluated. The ureteral prosthesis (Detour), a silicone tube glued inside a polyester tube, is inserted percutaneously into the renal pelvis to replace an established nephrostomy, tunneled subcutaneously, and introduced into the bladder through a small incision. All patients were followed every 3 months for 18 months or until death from tumor. Quality of life was assessed using the EORTC QLC-30 questionnaire; ultrasonography, intravenous urography, or both were used to assess the position and patency of the tubes. RESULTS: There was no failure of insertion and no operative or immediate complication. The mean follow-up was 7.8 months, 6.6 months for the 15 patients who died from their tumors and 1 year for the 4 patients still alive at the end of the study. Suprapubic parietal infection occurred in three patients with altered bladders (radiation cystitis or tumor progression). There was an improvement of the function scale as a result of the elimination of the external percutaneous tube and a parallel worsening of the symptom scale secondary to the progression of disease. Patient ratings of the global quality of life and satisfaction with the urinary diversion were improved because of the absence of the percutaneous tube. CONCLUSION: The subcutaneous pyelovesical bypass provides a better quality of life than a standard percutaneous nephrostomy tube in terminally ill patients by making them external-tube free.

[Recommendations for imaging in the investigation of non-neurological female urinary incontinence]. / Recommandations pour la pratique de l'imagerie dans l'évaluation d'une incontinence urinaire féminine non neurologique.

IMAGING: INDICATIONS FOR IMAGING: Apart from ultrasound assessment of post-voiding residual urine, radiological examinations are not recommended for the initial work-up of non-neurological female urinary incontinence. CYSTOGRAPHY: Cystography is not recommended as a first-line examination to evaluate uncomplicated stress, urge or mixed urinary incontinence. Cystography may be recommended in the case of complex, complicated or relapsing urinary incontinence, discordance between clinical findings and urodynamic assessment or in the presence of associated prolapse, in which case colpocystodefecography or even dynamic MRI should be preferred. URINARY TRACT ULTRASOUND: Ultrasound is not recommended for the initial work-up of pure stress urinary incontinence or genital prolapse Ultrasound without forced diuresis and after a spontaneous void, is recommended for the assessment of post-voiding residual urine and to assess complicated suburethral tape. Ultrasound is an optional examination in the case of complex or relapsing urinary incontinence, discordance between clinical findings and urodynamic assessment or in the presence of prolapse. PELVIC MRI: Dynamic MRI is not currently recommended for the initial work-up of urinary incontinence.

[Treatment of erectile dysfunction by phosphodiesterase-5 inhibitors and nonarteritic anterior ischemic optic neuropathy (NOIAN)]. / Traitement de la dysfonction erectile par les inhibiteurs de la phosphodiestérase-5 et troubles oculaires par neuropathie optique ischémique antérieure non artéritique (NOIAN).

INTRODUCTION: Following the notification of forty cases of varying degrees of vision loss in patients using phosphodiesterase-5 (PDE-5) inhibitors, the FDA (Food and Drug Administration) examined the possible link between these treatments of erectile dysfunction and NOIAN (nonarteritic anterior ischemic optic neuropathy). Following this investigation, the FDA requested modification of the summary of product characteristics (SPC) for this therapeutic category. The authors review this problem, especially in France. METHOD: The authors performed a search of the Pubmed database and the French Pharmacovigilance database. RESULTS: Since September 2006, 11 publications concerning 19 cases (14 with sildenafil and 2 with tadalafil) have been published. The mean age of these patients was 59.5 years (range: 42 to 69). Doses varied from 50 to 100 mg for sildenafil and 20 mg for tadalafil. Adverse effects (loss of visual acuity and decreased visual field) occurred between 30 min and 36 h after oral dosing. In 5 cases, treatment had been taken for more than one year. Ocular fundus examination showed papilloedema associated with several haemorrhages. Three patients presented a positive challenge. Several patients had a known risk factor for the development of NOIAN. One case was also reported to French Pharmacovigilance. DISCUSSION: The population with erectile dysfunction also often presents generalized endothelial disease, which also constitutes a risk factor for NOIAN. Although no cases of NOIAN were reported during the initial clinical trials, the rapid onset of NOIAN after the dose of PDE-5 inhibitor and several cases of positive challenge suggest a possible causal relationship with these drugs. The ocular action of PDE-5 inhibitors could be explained by a modification of retinal blood flow related to their pharmacological effects. CONCLUSION: The link between PDE-5 inhibitors and NOIAN has not been formally established. Before new studies are conducted to clarify this situation, practitioners must be aware of the potential ocular adverse effects related to the dose of PDE-5 inhibitors so that they can inform patients and notify any new cases. The SPCs of PDE-5 inhibitors were modified at the request of the FDA on 8 July 2005.

[Prospective study of the quality of life after palliative urinary diversion by subcutaneous pyelovesical bypass (Detour ureteric prosthesis)]. / Etude prospective de la qualité de vie après dérivation urinaire palliative par pontage réno-vésical sous cutané (prothèse urétérale Detour).

OBJECTIVE: To prospectively evaluate the quality of life of cancer patients at the palliative stage after implantation of an extra-anatomical ureteric prosthesis as an alternative to permanent percutaneous nephrostomy (PCN). MATERIAL AND METHODS: A series of 27 prostheses in 19 patients with PCN was prospectively evaluated. The ureteric prosthesis (Detour) consists of two concentric tubes glued to each other. The inner tube is made of silicone and the outer tube is made of polyester. This prosthesis is introduced percutaneously into the renal pelvis as an alternative to nephrostomy. It is tunnelled subcutaneously and is introduced into the bladder via a short incision. Patients were reviewed every three months for 18 months or until death. The EORTC QLQ-C30 self-administered questionnaire was used to evaluate the patients' quality of life. The functioning and position of the prostheses were verified by ultrasound and/or intravenous urography (IVU). RESULTS: There were no failures of prosthesis placement and no intraoperative or early postoperative complications. Injection of the suprapubic incision was observed in 3 cases, in patients with pre-existing bladder disease (radiation cystitis or bladder tumour). The mean follow-up was 7.8 months: 6.6 months for the group of patients who died (15) and 12 months for the 4 patients still alive at the end of the study. Functional scores improved due to elimination of the external nephrostomy tube. In parallel, physical score deteriorated due to disease progression. Overall quality of life and index of satisfaction were improved by elimination of the external diversion. CONCLUSION: Subcutaneous pyelovesical diversion ensures a better quality of life than classical percutaneous nephrostomy in cancer patients at the palliative stage.

[Development and validation of a model of training at home to the laparoscopy]. / Mise au point et validation d'un modèle d'entraînement à domicile à la laparoscopie.

INTRODUCTION AND OBJECTIVES: Practice on a Pelvitrainer training is an essential part of the training of surgeons in laparoscopy. Most university departments are equipped with this type of model, but this equipment is expensive, cumbersome and often poorly accessible. The authors propose a new laparoscopy home training model and compare its performances with those of the reference training model. MATERIAL AND METHOD: The laparoscopy home training model is composed of a laptop computer; a Web Cam and a translucent plastic box. Ten operators with various levels of training were timed during 4 simple exercises performed on the home training model and were then timed when performing 6 interrupted sutures with this model and with a Pelvitrainer RESULTS: All operators successfully performed the proposed exercises. The mean operating time was correlated with the level of training (35 minutes versus 15 minutes for the 3 most experienced operators). The suture time was comparable with the home trainer (14 minutes) and the Pelvitrainer (13 minutes). The home training model is less expensive (75 euros), more accessible and easier to install (3 minutes) than the Pelvitrainer and can be used outside of medicalized structures. CONCLUSION: Trainee operators can practice laparoscopy at home. The manufacture of a Home-trainer requires simple material. The training capacities of this model are similar to those of a Pelvitrainer, but it is less cumbersome, less expensive and more readily available. This type of model could be used by each operator at home to improve his/her performances and to accelerate training.

[Laparoscopy in the management of upper urinary tract stones based on a series of 18 cases]. / La laparoscopie dans la prise en charge des lithiases de la voie excrétrice supérieure. A propos de 18 cas.

OBJECTIVE: To evaluate the efficacy and morbidity of laparoscopic surgery in the management of upper urinary tract stones. MATERIAL AND METHOD: Between January 1998 and July 2004, 18 patients (14 males, 4 females) underwent laparoscopic extraction of an upper urinary tract stone. Stones were lumbar (n=13), ureteropelvic (n=2), iliac (n=1), inferior caliceal (n=1), and intradiverticular (n=1) with a mean diameter of 15 mm (range: 8-25 mm). Fifteen stones were obstructive. Laparoscopy was performed after failure of one or several previous treatments in 9 cases: ESWL (n=2), retrograde (n=1), anterograde ureteroscopy (n=6). A retroperitoneal approach (n=15) was used for caliceal and lumbar stones and a transperitoneal approach (n=3) was used for pyeloureteric and iliac stones. RESULTS: The mean operating time was 80 minutes (range: 40-150 min). The mean blood loss was 50 cc (range: 0-250 cc). The mean length of stay was 3.86 days (range: 2 to 7 days). Fifteen patients were drained by a double J stent for one month. The stone was removed by laparoscopy in every case. One patient developed a urinoma requiring surgical repair via a lumbar incision. CONCLUSION: Laparoscopy currently constitutes an attractive alternative for the treatment of upper urinary tract stones and, in this study, was indicated for first-line treatment of obstructive stones larger than 12 mm impacted in the ureter or after failure of previous treatments.

[Morbidity of unilateral and bilateral laparoscopic adrenalectomy according to the indication. Report of a series of 100 consecutive cases]. / Morbidité de la surrénalectomie laparoscopique uni et bilatérale selon l'indication: a propos de 100 cas consécutifs.

INTRODUCTION: Laparoscopic adrenalectomy is the reference technique for the treatment of adrenal tumours. This retrospective study reports the experience of 100 consecutive laparoscopic adrenalectomies, in order to assess its indications, the incision, the morbidity and to determine the limitations of this procedure. MATERIAL AND METHODS: Between April 1994 and June 2004, 100 laparoscopic adrenalectomies were performed in 92 patients via a transperitoneal (n = 93) or retroperitoneal (n = 7) approach, with 84 unilateral and 8 bilateral adrenalectomies. The mean age was 52 years. The operative and postoperative characteristics and the functional results were evaluated. RESULTS: The mean operating time was 112 min [70-175] via the retroperitoneal approach, 101 min [40-215] via the transperitoneal approach, and 135 min [120-270] for bilateral adrenalectomies. The mean tumour diameter was 44 mm [10-120 mm]. The mean blood loss was 215 ml [0-1210 ml]. Ten patients were transfused. The mean hospital stay was 3 days. Histology revealed 25 Conn adenomas, 20 cortisol-secreting adenomas and Cushing syndrome, 22 phaeochromocytomas, 20 metastases, 2 adrenal cortical adenomas, and 11 incidentalomas. Conversion to "open" surgery were necessary for technical difficulties in 6% of cases. There were 7 minor postoperative complications (7%) and 4 late complications (4%) (deep vein thrombosis, effusion, 2 local recurrences). Four patients in the group with secondary adrenal tumours were alive without recurrence 18, 20, 44 and 48 months after adrenalectomy. Antihypertensive treatment was stopped in 16 of the 25 patients operated for Conn adenoma. The mean follow-up was 31 months [5-98 months]. CONCLUSION: This technique has a low morbidity, requires minimal postoperative analgesia and a short hospitalisation. The retroperitoneal or transperitoneal approach must be chosen as a function of the patient's history and the surgeon's habits. Tumours larger than 8 cm can be resected, but with a higher morbidity. Laparoscopic adrenalectomy for malignant tumours is associated with higher morbidity.

[Treatment of benign prostatic hyperplasia (BPH) by transurethral needle ablation (TUNA) and 36-month follow-up of the retreatment rate]. / Traitement de l'hyperplasie bénigne de prostate (HBP) par thermocoagulation au moyen d'aiguilles par voie trans-urétrale (TUNA) et suivi a 36 mois du taux de retraitement.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is a disease affecting about 25% of men over the age of 40. One half of these men report symptoms that interfere with their daily activities. MATERIAL AND METHODS: In this multicentre study, 102 patients with BPH were treated by transurethral needle ablation (TUNA). The efficacy of treatment was evaluated for 12 months after the operation by means of Madsen and IPSS (International Prostate Symptom Score) scores. The course of uroflowmetry and quality of life (International Score) and sexual function were also assessed for one year. The safety of treatment was evaluated according to the type and frequency of complications. The results show an immediate and significant improvement of symptoms (p < 0.0001 for Madsen and IPSS scores and maximum flow rate between M0 and M12) demonstrating the efficacy of the TUNA system. A very positive impact of TUNA was demonstrated on quality of life. No negative impact was reported on sexual function and the operation had very few repercussions with a low adverse event rate. The retreatment rate (surgical and/or drug) was evaluated 36 months after the operation by means of an optional follow-up questionnaire subsequently completed by the investigators. RESULTS: After 3 years, based on the 80 questionnaires returned, 43 patients (53.8%) were stable and did not need any other medical or surgical treatment for BPH. Thirty-seven (37) patients (46.3%) required retreatment: 21 were treated with drugs (26%), 17 were treated surgically (21.25%) including 1 patient who was also retreated with drugs. This study demonstrates the significant and lasting improvement of BPH symptoms by TUNA, which constitutes an alternative attractive to surgery in young patients and/or patients worried about their sexuality.

[Severe hemorrhagic cystitis following allogenic bone marrow transplantation]. / Cystite hémorragique grave à distance d'une allogreffe de moelle.

The authors report the case of a 25-year-old woman with a history of acute lymphoblastic leukaemia in complete remission after being treated, three years previously, by chemotherapy, radiotherapy and allogeneic bone marrow transplantation, who was admitted to the urology department following an episode of haematuria with severe anaemia. This clinical case report illustrates the diagnostic and therapeutic approach adopted in relation to the severity of the haematuria, in which haemostatic surgery was only considered as a last resort.

[Urinary stones in subjects over the age of sixty]. / Lithiase urinaire chez le sujet âgé de plus de 60 ans.

OBJECTIVE: Urinary stones, affecting 10% of the French population, is a frequent disease. Data of the literature on this disease in subjects over the age of 60 years reveal age-related changes of risk factors, especially affecting urine composition, but very few data have been reported concerning the clinical characteristics of the disease. Due to the absence of recent data on urinary stones in subjects over the age of 60 in France, we decided to study the epidemiology and urological treatment of urinary stones in the elderly in France. MATERIAL AND METHOD: From November 2001 to August 2002, a survey concerning urinary stones in subjects over the age of 60 was performed by the Association Française d'Urologie Stone Committee among urologist members of the AFU. The parameters studied were epidemiological, clinical, metabolic and therapeutic. The results were analysed on the overall patient population and on the subgroup of patients over the age of 70. RESULTS: The study included 176 patients over the age of 60, 110 of whom were over the age of 70. These patients presented their first episode of urinary stones in 41% of cases. Renal colic was the most frequent presenting symptom. Signs of severity were frequently associated, with urinary tract infection in 24% of cases, associated with sepsis in 49% of cases after the age of 70 years. The incidence of uric acid stones was higher than in the general population. CONCLUSION: Urinary stones can often occur for the first time after the age of 60. This disease appears to be more serious than in the general population due to the high incidence of infectious complications. Uric stones also appear to be more frequent. A multidisciplinary study based on a larger population is necessary to confirm these results.

Targeted therapies in non-muscle-invasive bladder cancer according to the signaling pathways.

With 300,000 annually new cases worldwide, urothelial-cell carcinoma of the bladder (UCCB) is the second most common urologic neoplasm after prostate carcinoma. Non-muscle-invasive bladder cancer (NMIBC), which is not immediately life-threatening, represents 70% to 80% of these initial cases. Despite optimal treatment (transurethral resection with intravesical chemo- or immunotherapy), 70% of these NMIBC will recur, and 10% to 20% will progress, highlighting the need for a new therapeutic approach. Indeed, the identification of patients at high risk of disease recurrence and progression would be beneficial in predicting which patients with NMIBC would benefit from strict follow-up and which would benefit from a more aggressive therapy. To date, conventional treatment remains disappointing in terms of oncologic results and morbidity. The growing understanding in tumor biology has enabled the signaling pathways involved in bladder tumorigenesis and progression to be identified, but few molecular targets have been available until now. The encouraging results seen in various human carcinomas suggests that these new agents should become part of the arsenal of drugs available in the treatment of NMIBC, alone or in combination with already known agents. In this article, we have tried to highlight the main molecular signaling pathways involved in NMIBC tumorigenesis and progression, and the potential targets useful for improving the treatment of NMIBC.

The epithelial-mesenchymal transition-inducing factor TWIST is an attractive target in advanced and/or metastatic bladder and prostate cancers.

PURPOSE: Metastasis remains the main cause of death in both bladder (BCa) and prostate (PCa) cancers. The results of chemotherapy did not show any significant improvement of the survival the past years. Cancer research has led to the identification of signaling pathways involved and molecular targets that could change the natural history. The epithelial-mesenchymal transition (EMT), critical during embryonic development, becomes potentially destructive in many epithelial tumors progression where it is inappropriately activated. The cell-cell and cell-extracellular matrix interactions are altered to release cancer cells, which are able to migrate toward metastatic sites. Hallmarks of EMT include the down-regulation of E-cadherin expression, which is the main component of the adherens junctions. The protein TWIST is a transcriptional repressor of E-cadherin, tumor progression, and metastasis, and could be used as a molecular target to restore the chemosensitivity in BCa and PCa. MATERIALS AND METHODS: We selected the last 5-year basic research literature on EMT and TWIST but also clinical studies on BCa and PCa in which TWIST is overexpressed and could be considered as an efficient prognostic marker and molecular target. RESULTS: TWIST is considered as a potential oncogene promoting the proliferation and inhibiting the apoptosis. TWIST promotes the synthesis of the pro-angiogenic factor, vascular endothelial growth factor (VEGF) involved in tumor progression and metastasis. Apoptosis and angiogenesis are two essential cancer progression steps in many epithelial tumors, including BCa and PCa. CONCLUSIONS: With the targeted therapy, oncology has entered into a new era, which is going to be critical in cancer treatment in combination with traditional anticancer drugs.

Therapeutic management of de novo urological malignancy in renal transplant recipients: the experience of the French Department of Urology and Kidney Transplantation from Bordeaux.

OBJECTIVES: To determine and analyze the incidence, prognosis, and therapeutic strategy of de novo urological malignancies in a series of renal transplant recipients (RTRs). METHODS: A retrospective study of 1350 recipients between January 1998 and January 2008 was carried out; we reviewed the data of 42 de novo urological malignancies in 39 recipients. RESULTS: There were 21 cases of prostate cancer, 13 cases of renal cell carcinoma in 10 patients, 3 cases of renal graft tumors, and 5 cases of transitional cell carcinoma of the bladder. The overall incidence of urological neoplasms was 3.1%. The mean age of cancer diagnosis was 60 +/- 8.3 years. The mean duration of dialysis before cancer diagnosis was 35 +/- 37.5 months. About 92% of patients underwent hemodialysis (34/39) and the remaining underwent peritoneal dialysis (5/39). All the 39 recipients received cadaveric kidneys. The mean follow-up period for this study was 33 +/- 34.4 months (range 2-160 months). There appears to be a greater risk of urological neoplasm in RTRs. Prostate cancer and renal carcinoma can be treated in a similar manner than in general population with encouraging oncological results and low morbidity. However, the transitional cell carcinoma of the bladder remains particularly aggressive requiring optimal treatment despite the morbidity concerning the intravesical therapy. CONCLUSIONS: We can apply the standard medical and surgical treatment in RTRs, with encouraging oncological results if a strict screening program is established and followed by the patients.

Salvage radiotherapy after high-intensity focussed ultrasound for recurrent localised prostate cancer.

BACKGROUND: Radiotherapy is a treatment option in the case of local failure following treatment for localised prostate cancer with high-intensity focussed ultrasound (HIFU). OBJECTIVE: Our aim was to evaluate tolerance and oncologic control with salvage radiotherapy (SRT) after HIFU failure and to identify predictive factors of success. DESIGN, SETTING, AND PARTICIPANTS: From March 1995 to March 2008, all patients who presented with histologically proven persistent local disease following HIFU and were treated with curative intent SRT (with or without hormonal treatment) were included in this single-centre retrospective study. INTERVENTION: Patients underwent conformal radiotherapy. The median dose of conformal treatment was 72 Gy (65-78 Gy). MEASUREMENTS: The primary outcome measure was progression-free survival (PFS) defined as no biochemical relapse (three consecutive rises in prostate-specific antigen [PSA] with a velocity >0.4 ng/ml per year or PSA >1.5 ng/ml) and no additional treatment. Predictive factors of failure were examined in univariate and multivariate analyses. Adverse events in terms of urinary and digestive toxicity, urine incontinence, and erectile dysfunction (ED) were reported. RESULTS AND LIMITATIONS: The median (range) and mean (standard deviation) follow-up of the 100 patients analysed was 33 mo (5-164 mo) and 37.2 mo (23.6 mo), respectively. Eighty-three patients received SRT alone, and 17 received SRT and androgen-deprivation therapy. For the 83 patients treated with exclusive radiation therapy, PFS was 72.5% at 5 yr and 93%, 67%, and 55% for the low-, intermediate-, and high-risk groups, respectively. In the univariate analysis, PSA level prior to SRT, risk status, PSA nadir after SRT, PSA nadir after SRT >0.2 ng/ml, and time to achieve this nadir were all predictive of failure. In the multivariate analysis, PSA nadir post-SRT with a threshold at 0.2 ng/ml and time to achieve this nadir were the significant predictive factors of failure. Gastrointestinal toxicity was low; urinary toxicity grade < or =2 was 34.5%. Four were grade 3 (4.7%), one was grade 4 (1.2%), and one was grade 5 (1.2%). The incidence of severe ED (International Index of Erectile Dysfunction-5 score 5-10) was 14% pre-HIFU, and 51.9% and 82.3% pre- and post-SRT, respectively. Because our study was retrospective, results have to be interpreted cautiously. CONCLUSIONS: SRT provides satisfactory oncologic control after HIFU failure with little (or mild) additional toxicity. These results warrant further investigation.

Predictive risk factors for pain during extracorporeal shockwave lithotripsy.

PURPOSE: Extracorporeal shockwave lithotripsy (SWL) is a noninvasive but painful procedure. The aim of this study was to identify predictive risk factors for pain during SWL. PATIENTS AND METHODS: Two hundred twenty-two SWL treatments with the Lithostar lithotripter (Siemens) were included in a monocentric study. Patient and stone characteristics were prospectively collected in a database, and a standardized pain control protocol was administered 1 hour before treatment: paracetamol, nefopam, ketoprofen, and alprazolam. Subjective pain level was assessed with visual analog scale (VAS, 0-10). If VAS was >or=3, tramadol was added. If VAS was still >or=3, shockwave intensity was decreased or treatment was interrupted. The efficacy on stone fragmentation was evaluated 1 month after treatment. The need for adjuvant analgesia was compared with patient and stone characteristics to find out predictive risk factors for pain. RESULTS: The average subjective pain was 3.1. The need for supplementary analgesia was more frequent in women (p = 0.035), younger patients (p < 0.001), anxious and depressed patients (p = 0.018), in patients with previous SWL (p = 0.0185), in patients with a rib projected stone (p < 0.001), in patients with renal stones (p = 0.0535), and finally in patients with homogeneous stones (p = 0.02). Multivariate analysis revealed two independent risk factors for pain: young age (odds ratio = 5; p < 0.001) and rib projected stone (odds ratio = 5.23; p < 0.001). Stone fragmentation was worse in patients with an adjuvant analgesia requirement (p = 0.0311). CONCLUSION: Predictive risk factors for pain during SWL treatments were found: young age, rib projected stones, anxious and depressed patients, previous SWL treatment, and homogeneous stones. A higher analgesic requirement is necessary for these preselected patients to perform SWL and optimize its efficacy.