[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]. / Antibioprophylaxie et bilan urodynamique : recommandations de bonne pratique par consensus formalisé.

OBJECTIVE: The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS). MATERIALS AND METHODS: Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group). RESULTS: Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH2O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement). CONCLUSION: These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics. LEVEL OF EVIDENCE: 4.

[Post-traumatic syringomyelia: What should know the urologist?]. / Syringomyélie post-traumatique : ce que doit savoir l'urologue ?

The incidence of post-traumatic syringomyelia (PTS) is estimated according to recent studies at 25 to 30% of patients with traumatic spinal cord injuries in magnetic resonance imaging (MRI), which remains the gold standard exam for syringomyelia diagnosis and monitoring. Syringomyelia is translated by an increased cord signal (similar to CSF) with low-density T1-weighted image and high-density T2-weighted image, which extends beyond site of initial lesion at least to two vertebral segments. Two conditions are required for development of PTS: traumatic spinal cord injury and blocked the flow of CSF epidural. The mean interval from spinal cord injury to diagnosis SPT was 2.8years (range, 3months to 34years). The commonest symptoms are pain and sensory loss. PTS should be suspected if the patient has new neurological symptoms above level of injury, such as dissociated sensory injuries, reflexes abolition, and motor deficit, after the neural function becomes stable for certain time. In urologic practice, new neurological symptoms could be bladder and/or erectile dysfunction. The medical management based on prevention efforts with closed-glottis pushing, which could aggravate the syrinx cavity. In urology, extracorporeal shockwave lithotripsy, and laparoscopic or robotic surgery could extend the syrinx cavity for the same reason (increase abdominal pressure). The indications for surgical intervention and optimal surgical treatment technique for patients with PTS are not consensual. The literature demonstrated that surgery PTS is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.

[Laparoscopic sacrocolpopexy results contingent on mesh position]. / Résultats anatomiques et fonctionnels des promontofixations par cœlioscopie en fonction de la position des prothèses.

OBJECTIVES: Do the number and the position of meshes in laparoscopic sacrocolpopexy influence anatomical or functional postoperative results in genital prolapse treatment? PATIENTS AND METHODS: Ninety patients were treated for genital prolapse by laparoscopic sacrocolpopexy between January 1998 and 2007. Eleven had an anterior single mesh, 36 a single posterior mesh and 43 a double mesh. RESULTS: Four patients with late postoperative complications needed a new surgical procedure. Three of them had a double mesh. Thirteen anatomical recurrences (14 %) were found. Eleven recurrences had a single posterior mesh and eight needed a new surgical procedure. Two other recurrences had a double mesh. Only one needed a new surgical procedure. No recurrence was noticed in the anterior single mesh group. The observed pelvic floor dysfunction rates were respectively for the single anterior mesh group, posterior single mesh group and double mesh group: constipation 20 % 64 % 35 %, anal incontinence 0 % 14 %/2 %, urgency 0 %/8 %/12 %, stress urinary incontinence 27 % 14 %/31 %. CONCLUSION: Double mesh reduced anatomical recurrence, but increased surgical complications and postoperative dysfunctions.

[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.

[Urodynamic investigations in children]. / Place des investigations urodynamiques chez l'enfant.

Performing urodynamic investigations in children presents some difficulty due to the lack of any normogram, and due to the results that vary with age. Such investigation is therefore carried out only when clinical examination and radiological assessment fail to explain a voiding dysfunction. The procedure should be performed in a urodynamic unit that has paediatric expertise. A specific paediatric procedure is to be respected when performing uroflowmetry and cystometry in children. Assessing the urethral pressure profile is very difficult since moving a catheter along the urethra causes a reflex activity of the pelvic floor muscles. Main indications are: neuropathic bladders, voiding dysfunctions, urinary infections, anorectal malformations and pelvic tumours. As in adults, urodynamic investigations are useful when selecting a therapeutic strategy.

[Post-traumatic stenosis of the membranous urethra]. / Sténoses post-traumatiques de l'urètre membraneux.

Secondary urethral stricture is the most serious complication of traumatic rupture of the membranous urethra, directly related to the treatment of the rupture. In a series of 45 patients treated for urethral rupture with a minimal follow-up of 5 years, 30 developed stricture (66%). An urethral guide, inserted in 31 cases, was responsible for the stricture in 26 of these cases (84%). This stricture developed rapidly (average of 7.4 months), whether the initial rupture was complete or incomplete and was longer (average of 35 mm) in the case of complete rupture. End-to-end urethrorraphy performed between the 15th and 35th day in 14 patients was complicated by 4 secondary strictures (28%). The treatment of the stricture depended on the initial treatment of the rupture and the radiological length of the stricture. In the case of stricture secondary to an urethral guide, end-to-end urethrorraphy for a stricture less than or equal to 40 mm (12 cases) and 2 stage urethroplasty for a stricture greater than 40 mm (4 cases) achieved a good result in 68.8% of cases. The strictures secondary to end-to-end urethrorraphy (4 cases) were treated by direct vision urethrotomy (3 cases) with 100% of immediate good results and by urethral telescoping (1 case) complicated stress urinary incontinence.

[Multifactorial urodynamic study of 115 patients with dysuria and benign prostatic hypertrophy]. / Etude multifactorielle des équilibres urodynamiques chez 115 patients dysuriques porteurs d'une hypertrophie bénigne de prostate.

Discriminant analyses based on preoperative urodynamic parameters have proved inaccurate in predicting functional results after prostatectomy. To investigate the cause of this failure, we studied a group of 115 patients consecutively referred for prostatism and selected for prostatic surgery only on clinical criteria and flow rate. A preoperative urodynamic work-up was performed, including cystometry and urethrometry. The patients were reexamined 2 months postoperatively and underwent control uroflowmetry. All preoperative urodynamic data were computed simultaneously using principal component analysis and canonical discriminant analysis. The significance of the diagrams obtained with these multifactorial analyses was more closely examined than in previous studies. The results of classification by the discriminant function demonstrating the best combination of preoperative urodynamic variables resulted in 44% of patients being correctly rated. Examination of the diagrams showed that the major cause of failure in previous studies was the great variety of urodynamic conditions in men with prostatism, which indicates a need for multifactorial interpretation of the results of urodynamic explorations.

Intermittent androgen suppression in the treatment of metastatic prostate cancer.

BACKGROUND: To assess the feasibility of intermittent androgen suppression in patients with metastatic prostate cancer and to quantify the improvement in the quality of life. METHODS: Forty-three patients with M1 b prostate cancer were treated by intermittent hormonal deprivation using luteinizing hormone-releasing hormone (LHRH) analogue alone (n = 11), or associated with an antiandrogen (n = 32). The prospective nonrandomized study required an initial therapy period of 12 months with a stable biological response during 6 months (PSA, testosterone). Treatment was resumed when the serum PSA value recovered to 20 ng/ml, or when local failure or new bone metastasis occurred. The assessment of quality of life was carried out using the EORTC QLQ-C30. RESULTS: The mean follow-up time was 43.7 months. After the initial 12 months of androgen suppression, one patient with a minimal disease was off-therapy with a follow-up of 18 months. For the 42 other patients, the mean off-therapy period was 6.7 months. In the second therapy period (9-12 months), 7 patients were hormono-independent and died with a mean survival time of 27 months; 35 patients were responders. The mean off-therapy length in the second cycle was short (3.8 months). After this time, androgen suppression therapy was reintroduced permanently, but 10 patients were hormono-independent. No difference was observed in the EORTC QLQ-C30 between therapy and off-therapy periods, only a rapid decrease in adverse events due to the hormonal deprivation was reported in all cases during the off-therapy period. CONCLUSIONS: Intermittent androgen suppression in patients with M1 b prostate cancer could be associated with a significant period off-therapy in the first cycle (55.8%), and with a chance of second hormone response. But in the second cycle, the off-therapy period length was short and required a careful follow-up.