[MRI of the axial skeleton for evaluation of prostate cancer extent in french Guyana]. / IRM du squelette axial pour le bilan du cancer de prostate en Guyane française.

INTRODUCTION: Spread evaluation of Prostate Cancer (PC) in French Guyana is bothered by the lack of bone scintigraphy. The availability of 4 MRI allows to develop alternatives using Axial Skeleton MRI (AS MRI). We report the related results. MATERIAL: AS MRI was done in patients with diagnosis of high risk PC: PSA>=10ng/ml and/or Gleason Score>=7 (predominant Gleason grade 4) and/or clinical T2b and/or T2b/T3 MRI and/or >50% positive biopsies. AS MRI was including spine, pelvis and skull assessement.The results were systematically compared to the clinical, biological and biopsy features. RESULTS: Amongst 163 AS MRI performed, 30 were positive and 133 negative. Of these 133 patients, 60 were submited to radical prostatectomy with or without lymphadenectomy. In these 133 patients with negative AS MRI, median PSA was 11ng/ml (1-51) and 27 (20,3%) had PSA>20ng/ml. In patients with positive AS MRI, only 1 had PSA<20ng/ml and predominant Gleason grade 3. CONCLUSION: Our study shows that AS MRI assessement is especially usefull in patients who are most likely to have bone metastasis that is to say those with PSA>20ng/ml and/or predominant Gleason grade 4. LEVEL OF EVIDENCE: 3.

[A long distance between home and hospital does not bother ambulatory surgery for ureteroscopy in French Guyana]. / Une grande distance entre le domicile et l'hôpital ne contre-indique pas l'ambulatoire pour urétéroscopie en Guyane française.

INTRODUCTION: French Guyana is 83,500 km2 wide (equivalent to 1/6 of France). Communes are distant. Public urology is set in Kourou only. These particularities led to develop ambulatory urological surgery including for patients living far away from the reference centre. We report our experience with patient ureteroscopy (URS). MATERIAL: The study is retrospective (2018-2019), and includes 125 patients. Among these patients, 19.2% live in Kourou, 71.1% live 40 to 100km from the hospital and 9.7% beyond 100km. Every patient had an outpatient procedure for rigid and/or flexible URS to treat stone disease, including in lower calyx [LC] (38.4%). Ambulatory surgery was also proposed to the patients living away with the usual restrictions. Complications, results and switch to conventional hospitalisation (CH) were studied. RESULTS: Mean stone size was 10,5mm (4-30), stone density was 1030 UH (470-1700). The postoperative complication rate was 4%. There were 90.4% 'stone free' patients (85.4% for LC). One patient was rehospitalised within 48hours for acute flank pain and 9 patients had a switch of ambulatory to CH: 6 for discharge too late and 3 for complication (fever and/or pain). Distance between home and hospital was linked neither to complication rate, nor to switch to CH. CONCLUSION: Ambulatory URS is possible without further complications in selected patients living beyond 100km from the hospital, because of a specific organisation and an appropriate training of the caregivers involved in postoperative patient care. LEVEL OF PROOF: 3.

[Epidemiology of prostate cancer (PCa) in French Guyana (FG) - Preliminary results]. / Épidémiologie du cancer de la prostate en Guyane française ­ Données préliminaires.

INTRODUCTION: Epidemiology of prostate cancer (PCa) in French Guyana (FG) is not well documented yet. It differs from the reported one in French West Indies due to a younger population, less exposed to agricultural pesticides with also much lower level of medical information and care. MATERIAL: The incidence and mortality rates available in the regional register of cancers are reported for the period 2010-2014. The characteristics of 242 consecutive prostate biopsy series performed between 2017 January and 2019 October for abnormal digital rectal examination (DRE) and/or PSA>4ng/mL are also described. RESULTS: PCa incidence in FG is 94.4°/°°°° and specific mortality 16.9°/°°°°. Among the biopsies, 77.7% (188/242) are positive with a mean PSA of 72.6ng/mL (1-4000) at a mean age of 66years (50-89), 34% (64/188) with an abnormal DRE, 12.3% (23/188) with a PSA>50ng/mL and 28.2% (53/188) with a Gleason score≥8. CONCLUSION: In spite of young population, less exposure to environmental risk factors and high rate of racial mixing, the early PCa diagnosis is still a challenge in FG. The observed incidence and mortality rates suggest underestimation of PCa cases and too late specific care what is also suggested by adverse pathological and biological characteristics of the tumors at the time of diagnosis. LEVEL OF EVIDENCE: 3.

[Urethral strictures treated with excision and primary anastomosis: Impact of etiology on care pathways and management]. / L'urétroplastie par résection­anastomose en un temps : impact du mécanisme lésionnel sur la prise en charge et les résultats.

BACKGROUND AND OBJECTIVES: Excision and primary anastomosis is a common treatment of the short urethral posterior strictures. Strictures can be associated to pelvic bone fractures, endourological procedure (iatrogenic) or idiopathic. Whether outcomes are different with respect to etiology is still under reported. Herein, we aimed to explore the impact of etiology on care pathway and management of patients treated with excision and primary anastomosis for urethral strictures. PATIENTS AND METHODS: Between January 2004 and December 2015, 97 patients were referred and treated with excision and primary anastomosis for a short urethral stricture. Data were extracted from a single institutional registry and retrospectively analyzed. Patients were sorted into 3 groups with respect to the etiology: pelvic bone fracture (n=23), iatrogenic (n=24) and idiopathic (n=50). Preoperative patient's and stricture characteristics as well as postoperative outcomes of the three groups were compared using Student or Chi2 tests as appropriate. Specifically, recurrence rate and time to first recurrence was analyzed according to a Cox proportional hazard model. RESULTS: Patients with strictures caused by pelvic bone fracture were younger (P<0.001), more likely to have a suprapubic catheter (P=0.007), and no attempted procedures before the referral (P<0.001). Strictures length and maximum flowmetry were similar in all groups. Postoperatively, 90-d complications and flowmetry were similar in both groups. After a mean follow-up of 25±24 (range: 1-102) months, 27 (27.8 %) patients recurred. According to our model, etiology did not seem to impact overall recurrence rate. However, when the subgroup of patients with recurrence were analyzed, strictures associated with pelvic bone seemed to recur faster than the 2 remaining groups. CONCLUSION: With some limitations of due to the population size and the retrospective design of the analysis, etiology impacted care pathway in terms of referral and initial management of patients treated with excision and primary anastomosis for a short urethral posterior stricture. However, recurrence rate and mid-term outcomes seem less impacted. LEVEL OF EVIDENCE: 4.

[Evaluation of the operating results and costs associated with the implementation of a flexible ureteroscopy activity within a university hospital center]. / Évaluation des résultats opératoires et des coûts liés à la mise en place d'une activité d'urétéroscopie souple au sein d'un centre hospitalo-universitaire.

INTRODUCTION: The increasing use of flexible ureteroscopy (USSR) sets the cost problems inevitably associated with the fragility of these endoscopes. The aim of this work is to clear from a recent example (universitary hospital) results, costs during the implementation of this technique. MATERIAL AND METHODS: This is a retrospective study conducted from December 2012 (date of introduction of the activity) in March 2015 concerning the USSR made in a French universitary hospital for stone disease. In this analysis, the cost of consumables was not evaluated, nor the costs of the operating theater or hospitalization. RESULTS: One hundred forty-one hundred and thirteen patients USSR were conducted by seven surgeons. Seventeen breakages and failures have been identified and have led to the sending of the endoscope for repair. Breakage rate and failure was 12%. All failures were treated with a standard exchange of the device (including 4 standard exchanges made under warranty). The estimated average cost of outages was 3600 euros. This represents an average cost per procedure of about 625 euros (acquisition plus cost of failures) without counting the costs of sterilization or high-level disinfection. The impossibility of relocating the lower calyx stones is associated with an excess risk of breakage (odd ratio: 2.92 CI95: [1.02; 8.37]). CONCLUSION: This study is novel because it focuses on the cost of implementing a technique in a French university hospital. The use of flexible ureteroscope to unique uses might be an interesting source of savings in the implementation of this technique. This remains to be evaluated. LEVEL OF EVIDENCE: 5.

[Introduction of the photoselective vaporization of the prostate in an outpatient setting: Outcomes after the first 100 cases]. / Introduction de la photovaporisation de prostate en ambulatoire : résultats sur les 100 premiers patients.

BACKGROUND AND OBJECTIVES: Our objective was to describe the progressive introduction of photoselective vaporization of the prostate (PVP) in an academic department of urology in an outpatient care setting and report our outcomes after the first 100 cases. PATIENTS AND METHODS: Since May 2014, XPS GreenLight™ (Boston Scientific-AMS, USA) PVP in the treatment of benign prostatic hyperplasia was introduced in our department. A prospective local registry was opened to collect patients' demographics, preoperative characteristics and surgical outcomes including operative time, length of stay, catheterization time, and postoperative complications as well as functional outcomes. We also assessed limitations to the outpatient care setting. RESULTS: Conversion to TURP was reported in 6 % for uncontrolled bleeding. Overall, 21 % patients needed more than 1-day catheterization. After 6 months of follow-up, 3 patients (prostate volume 50, 117, and 178mL) had reintervention (second PVP). Ninety days' complications were reported to be up to 6 % (3 urinary obstructions, 1 prostatitis, 1 transfusion and a severe sepsis). After 8 months, an 80 % plateau of outpatient care setting was achieved. Anesthesiologists counter-indicated outpatient care in 59 % of the cases. CONCLUSIONS: A progressive introduction of the PVP in an outpatient care setting is associated with a low complication rate. A plateau was achieved in less than 100 procedures. The major limitation of the outpatient care setting was patients' competitive comorbidities and not disease characteristics. LEVEL OF EVIDENCE: 4.

[Castration modalities in prostate cancer: Are they all equal?]. / Modalités de castration dans la prise en charge du cancer de la prostate: sont-elles toutes équivalentes ?

AIM: The aim of this literature review was to focus on the new highlights regarding oncologic and safety outcomes depending on the type of castration used. MATERIAL: Literature search using various algorithms "prostate cancer", "castration", "agonist", "antagonist", "orchiectomy", "GnRH", "FSH", "androgen deprivation therapy" has been performed in April 2015, through the PubMed and Embase databases. RESULTS: GnRH agonists and antagonists are both currently used in clinical practice. Nevertheless, differences regarding their pharmacologic properties have been highlighted in recent studies, specifically regarding the rapidity, sustainability and depth of the castration, but also the decrease in FSH level. Such differences may have oncological impact on the patient, regarding the disease biological control and the time to progression, and a tolerability impact, especially on the cardiovascular risks. The role of the depth and the sustainability of the castration in one hand, the FSH impact in the other hand, as well as a direct inhibition on extra-pituitary GnRH receptors by antagonist might explain these differences. CONCLUSIONS: Recent studies suggest differences between GnRH agonists and antagonist that could impact the patient clinical outcomes. However, further high level of evidence comparative studies remains warranted.

[Neoadjuvant chemotherapy in muscular invasive bladder cancer: Complications and consequences with cystectomy]. / Chimiothérapie néoadjuvante dans le cancer de vessie infiltrant le muscle : complications et conséquences sur la réalisation de la cystectomie.

INTRODUCTION: The fear of the deterioration of the patient's condition related to the toxicity of neoadjuvant chemotherapy is a barrier to its development. This multicenter retrospective study aims to present the secondary effects of neoadjuvant chemotherapy and its impact on the achievement of cystectomy. MATERIALS AND METHODS: Patients with urothelial carcinoma classified cT2 to cT4a N0M0 were included. Chemotherapy with 6 cycles of MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) followed by a cysto-prostatectomy or anterior pelvectomy was scheduled. RESULTS: A total 32 patients were included. Six cycles of neoadjuvant chemotherapy were performed in all 11 patients. Shutdown causes were toxicity in 85% of cases. Cystectomy was performed in 86.6% of patients. Surgery was not performed in 6 patients. The reasons were the alteration of the general condition in 2 cases, 2 patients had advanced cancers diagnosed intraoperatively, and 2 refused surgery. Complications of grades 3 and 4 according to the classification of Clavien and Dindo had occurred respectively in 15.3% and 11.5%. DISCUSSION: This study reports results close to what is found in the literature on the effects of neoadjuvant chemotherapy on achieving cystectomy, but it has some limitations: the retrospective analysis of data on surgery and the lack of control group. In addition, the short follow-up does not yet allow to know the long-term oncological results. CONCLUSION: This study supports the fact that the toxicity of neoadjuvant chemotherapy does not seem to cause a significant risk of non-completion of cystectomy. LEVEL OF EVIDENCE: 4.

[Practice uptake in France before and after the 2010 French guidelines on kidney cancer]. / Évolution des pratiques de la chirurgie rénale avant et après les recommandations de l'AFU de 2010.

INTRODUCTION AND OBJECTIVE: Compared to the 2007 edition, the 2010 French urological association onco-urology guidelines boarded the indications of partial nephrectomy (PN) as long as the procedure is technically feasible. The aim of this study was to assess national practice with respect to kidney surgery in the 2 years before and after current guidelines. MATERIALS AND METHODS: The national database of the Agence Technique de l'Information sur l'Hospitalisation (ATIH) was queried for procedures performed between 2009 and 2010 (era 1) and between 2011 and 2012 (era 2). The coding system of the Classification Commune des Actes Médicaux (CCAM) was used to extract kidney related procedures. For each era, procedures were sorted into partial versus radical nephrectomy (RN), laparoscopic/robotic versus open approach, and private versus public hospital. The two eras were then compared. RESULTS: Overall, 28,000 and 28,907 procedures were reported in era 1 and 2 with mean 14,000 and 14,450 procedures per year respectively. PN increased from 30% to 35% (P<0.0001) between the two eras. This uptake was similar in public and private hospitals. Accordingly, laparoscopic/robotic approach has significantly increased between the two eras (35% versus 39%, P<0.0001) and even more importantly in public hospitals (P=0.0017). There was a significant increase in laparoscopic/robotic PN as well as a decrease in open RN over the years of the study period. CONCLUSION: This study showed the development of PN and the minimally invasive approach. Over the study period, minimally invasive procedure uptake was higher in public hospitals.

Repeat mid-urethral sling for recurrent female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence. METHODS: A total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed. RESULTS: All patients had urethral hypermobility and 12.9 % had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP) ≤ 20 cmH2O]. Median MUCP was 41 cmH20. Overactive bladder was found in 5.7 % of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49 %), transobturator tape (48 %), or mini-sling (3 %). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7 %) patients were subjectively cured and 18 (16.1 %) improved (76.8 % success overall) with a mean follow-up of 21 months. Success rates were 72.2 and 81.8 % for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success. CONCLUSIONS: Repeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77 % successful in a group of patients with persistent urethral hypermobility. A retropubic approach might be preferred for patients with low urethral closure pressures.

[Novel agents for the therapy of castration-resistant prostate cancer: overview of pivotal studies and new strategies to come]. / Nouvelles thérapeutiques dans le cancer de la prostate résistant à la castration : panorama des études pivotales et nouveaux schémas thérapeutiques à venir.

OBJECTIVE: Recently, new agents have been developed in the treatment of prostate cancer. Our aim was to review phase III studies that involved novel agents in the treatment of castration resistant prostate cancer. METHODS: PubMed databases were searched for original articles published with the search terms: prostate cancer, castration resistant, metastatic, targeted therapy, biologic agents, immunotherapy and clinical trials. Proceedings from 2008 of conferences of the American Society of Clinical Oncology, American Urological Association, and the European Association of Urology were also searched. We included phase III studies that involved: abiraterone, MDV 3100, cabazitaxel, sipuleucel-T, radium-223, and denosumab. RESULTS: Abiraterone and MDV 3100 are two new hormotherapies that showed an increased overall survival of 15 and 18 months respectively before after docetaxel based chemotherapy in randomized trials. Cabazitaxel became the standard second line chemotherapy after docetaxel. Sipuleucel-T has emerged as the first approved vaccine in prostate cancer. It showed a 22 % reduction of mortality and a prolonged survival time of 4.1 months compared to placebo. A radium-223 based metabolic radiotherapy has showed a better overall survival, delayed and reduced skeletal-related events in placebo controlled randomized trials. Denosumab also delayed the first skeletal-related event in a zoledronic acid controlled trial (20.7 versus 17.1 months, P=0.0002). Moreover, Denosumab delays bone metastases by 4.1 months compared to placebo. CONCLUSION: The novel agents that emerged in the treatment of prostate cancer showed an efficacy in placebo controlled trials. They added new tools in the armamentarium of therapies of castration resistant prostate cancer.

[CCAFU Recommendations 2013: Prostate cancer]. / Recommandations en onco-urologie 2013 du CCAFU : Cancer de la prostate.

INTRODUCTION: The sub Comittee prostate of the CCAFU established guidelines for diagnostic, treatment, evaluation and standart of care of prostate cancer. METHODS: Guidelines 2010 were updated based on systematic literature search performed by the sub-Comittee in Medline and PubMed databases to evaluate references, levels of evidence and grade of recommandation. RESULTS: Pathological examination of the tissue specimens was defined specifically for Gleason score according to ISP 2005 recommandations. Prostate and pelvis RMN became the reference in terms of radiological exam. Individual and early diagnosis of prostate cancer was defined and role of PSA was precised. Active surveillance became one of the standart of care of low-risk tumors, radical prostatectomy remained one of the options for all risk group tumors, length of hormonotherapy in association with radiotherapy was precised according to the risk group. Side effects of hormonotherapy treament needed specific supervision ; hormonotherapy had no indication in case of non metastatic tumors and intermittent hormonotherapy in metastatic tumors. New hormonal drugs in pre and post chemotherapy and bone target drugs opened new therapeutics pathways. CONCLUSION: From 2010 to 2013, standarts of care of prostate cancer were modified because of results of prospective studies and new therapeutics. They allowed precise treatments for each specific clinical situation. In the future, multidisciplinary treatments for high risk tumors, time of adjuvant treatment and sequencies of new hormonal treatment had to be defined.

[Status and medicolegal implications in France pT0 stage of prostate cancer: a study by the CC-AFU]. / État des lieux et implications médico-légales en France du stade pT0 du cancer de la prostate : une étude du CC-AFU.

OBJECTIVE: To assess the frequency, circumstances, and possible medico-legal consequences of the pT0 prostate cancer, defined by the absence of tumor in a radical prostatectomy specimen. METHODS: Six centers retrospectively identified all cases of pT0 and selectionned those that occurred without prior hormone therapy or prostate resection. Preoperative data, histological report and clinical and biological outcome were analyzed. The lawsuits' registry in pathology were consulted at insurance companies. RESULTS: Thirty cases of pT0 prostate cancer (0.4%) were reported on 7693 patients. The median age was 63years, PSA 7.4ng/mL. The number of positive preoperative biopsies ranged from one to four for a median tumor length of 1mm (0.3 to 18mm). The biopsy Gleason score was 3+3 for 23 patients, less than 5 for six others and included a contingent of grade 4 in two patients. With a median follow-up of 82months, no clinical or biochemical recurrence was observed. One patient complaint for pT0 prostate was found in the insurances registry. CONCLUSION: The occurrence of a prostate pT0 called into question all the diagnostic procedures and surgical indication. To avoid a forensic procedure, urologists should inform patients of the possibility of this situation before radical prostatectomy.

[Obliterative vaginal surgery for genital prolapse: a retrospective cases series]. / Colpocléisis selon la technique de Lefort : une série rétrospective.

OBJECTIVE: Treatments of pelvic organ prolapse are pelvic floor rehabilitation, surgery by abdominal or vaginal route, with or without prosthesis, and pessaries. Since last decade, increasing elderly patients seen for pelvic organ prolapse require to redefine the place of the obliterative vaginal surgery, among the existent surgical procedures. Our objectives were to describe the morbidity associated with colpocleisis, to determine the anatomical results of colpocleisis, and patient's satisfaction. PATIENTS AND METHODS: Retrospective case series of 27 patients who underwent a vaginal closure (Lefort) between 2004 and 2010. RESULTS: Twenty-seven patients underwent an obliterative vaginal surgery for genital prolapse. The mean age was 79 years (range 74.5-82.5). The mean surgical time was 70 minutes (range: 60-87.5). We did not notice any per-surgical complication. During follow-up (median: 3 years, extremes: 1-10 years), the global satisfaction rate was 94%. Objective cure rate, defined as the absence of prolapse to the hymen, was 96% (26/27). Only one (3.7%) case of pelvic organ prolapse recurrence occurred and needed surgery. CONCLUSION: The current study showed that Lefort colpocleisis technique was associated with a good patients' satisfaction and functional results in a population aged over 75.

[Sipuleucel-T: a prostate cancer vaccine: "instructions for use" for urologists]. / Sipuleucel-T : un vaccin contre le cancer de la prostate : « mode d'emploi ¼ pour les urologues.

Sipuleucel-T is the first approved vaccine for prostate cancer, opening the pathway for this new treatment approach. The treatment process consists in isolating the patient dentritic cells via leukapherisis, stimulate and infuse them into the patient. These enhanced cells are then able to stimulate patient T lymphocytes to target the tumour cells. The median survival in the pivotal study, IMPACT, as well as in the previously reported randomised trials, was 4.1 months longer in the sipuleucel-T group. The estimated probability of survival 36 months after randomisation was 31.7% in the sipuleucel-T group and 23.0% in the placebo group. However, the median time to objective disease progression was similar in the two groups (hazard ratio: 0.95; 95% CI, 0.77 to 1.17; P=0.63). We report herein, the treatment modalities, side effects and results in the light of recently published randomised trials.

[New concepts in management of NMIBC in 2010]. / Actualités concernant la prise en charge et le suivi des tumeurs vésicales n'infiltrant pas le muscle en 2010.

The aim of this article is to make a synthesis of news headlines concerning the follow-up and the management of non-muscle invasive bladder tumors. The diagnosis and the follow-up of non-muscle invasive bladder are based on flexible cystoscopy associated with urinary cytology. At present time, no molecular marker, and no imaging allows to reduce the rhythm and the modalities of surveillance such as defined by the guidelines. Early cystectomy is the current option for BCG-refractory high risk bladder tumor. Rarely, some conservative options, such as endovesical chemotherapy, could be discussed at an individual level.

[Transvaginal repair of genital prolapse using the Prolift technique: a prospective study]. / Traitement du prolapsus génital par renfort transvaginal Prolift: une étude prospective.

OBJECTIVE: To evaluate the efficacy and to report the follow-up of transvaginal repair of genital prolapse using a tension free vaginal mesh. PATIENTS AND METHODS: Twenty-eight women were treated for genital prolapse with the Prolift technique and followed prospectively. Preoperative prolapse treatment, associated treatment, complications were reported. Postoperatively, efficacy and complications were reported. Patients were examined at one, three, six and 12 months then yearly. Treatment failure defined as Pelvic Organ Prolapse Quantification (POP-Q) stage II or more. RESULTS: The mean age was 68 years. The median follow-up was 12 months. Ten (35%) and 14 (50%) patients had a stage II and III/IV cystocele respectively. Nineteen (67%) patients had stage II/III rectocele. We reported one bladder injury (3.5%) sutured during surgery and one haematoma (3.5%) requiring secondary management. Important buttock pain appeared in two patients (7%) treated with a total mesh on day 1 and 6 weeks after surgery respectively. They were both relieved after cutting one posterior arm of the mesh. De novo stress incontinence appeared in one (3.5%) patient and urgency in two (7%) patients. Mesh exposure occurred in one (3.5%) patient requiring a minimal surgical management. One patient (3.5%) declared dyspareunia. Success was reached in 96.5% patients. CONCLUSION: The transvaginal mesh was a safe and efficient technique to treat genital prolapse.