[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. / Recommandations sur la gestion du risque et la prise en charge urologique du patient adulte atteint de dysraphisme spinal (spina bifida).

INTRODUCTION: Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS: National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS: Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION: Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

[Autologous fascia pubovaginal slings in women with stress urinary incontinence at high risk of mesh/device-related complications]. / Bandelette aponévrotique pubovaginale pour incontinence urinaire d'effort chez les femmes à risque de complications prothétiques.

INTRODUCTION: Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population. MATERIAL AND METHODS: The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months. RESULTS: Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%). CONCLUSION: The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes. LEVEL OF PROOF: 4.

[Urodynamics: All the nurse needs to know]. / Bilan urodynamique : tout ce que l'infirmier(e) doit savoir.

Urodynamic (UD) is an exam intended to explore the mechanisms underlying lower urinary tract symptoms (LUTS) or urinary incontinence (UI). It involves the measurement of bladder and sphincter pressures using uretrovesical and rectal catheters with pressure transducers, but also the measurement of urinary flow and bladder sensation during filling. UD is far from being systematic in the assessment of LUTS or UI and must seek to tackle a specific clinical or therapeutic question. Thus, history taking, physical examination, voiding diary and questionnaires are essential prerequisites to UD per se. UD steps include a free (unintubated) uroflowmetry, a cystometry, post-void residual measurement±an urethral profilometry, a pressure-flow study or sensitization tests. The pressures are set to zero before to start the study and the validity of the equipment is tested. This control is continued throughout the procedure to ensure the quality of the recording. Any event (e.g., urine leakage, change of position, urgency) is noted during the study. A final report is made by the doctor. The competence of the nurse ensures the reliability, reproducibility and interpretability of the UD study and the nurse's humanity guarantee f an atmosphere as favourable as possible for this uncomfortable and invasive test.

Prognostic factors after adrenalectomy for adrenal metastasis.

PURPOSE: Very few studies have sought prognostic factors after adrenalectomy for metastasis. The aim of this study was to assess prognostic factors for oncological outcomes after adrenalectomy for adrenal metastasis. METHODS: All adrenalectomies for metastases performed in seven centers between 2006 and 2016 were included in a retrospective study. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Prognostic factors for CSS and RFS were sought by Cox regression analyses. RESULTS: 106 patients were included. The primary tumors were mostly renal (47.7%) and pulmonary (32.3%). RFS and CSS estimated rates at 5 years were 20.7% and 63.7%, respectively. In univariate analysis, tumor size (HR 3.83; p = 0.04) and the metastasis timing (synchronous vs. metachronous; HR 0.47; p = 0.02) were associated with RFS. In multivariate analysis, tumor size (HR 8.28; p = 0.01) and metastasis timing (HR 18.60; p = 0.002) were significant factors for RFS. In univariate analysis, the renal origin of the primary tumor (HR 0.1; p < 0.001) and the disease-free interval (DFI; HR 0.12; p = 0.02) were associated with better CSS, positive surgical margins with poorer CSS (HR 3.4; p = 0.01). In multivariate analysis, the renal origin of the primary tumor vs. pulmonary (HR 0.13; p = 0.03) and vs. other origins (HR 0.10; p = 00.4) and the DFI (HR 0.01; p = 0.009) were prognostic factors for CSS. CONCLUSION: In this study, tumor size and synchronous occurrence of the adrenal metastasis were associated with poorer RFS. Renal origin of the primary tumor and longer DFI were associated with better CSS. These prognostic factors might help for treatment decision in the management of adrenal metastasis.

[Safety and feasibility of outpatient flexible ureteroscopy for urinary stones: A retrospective single-center study]. / Faisabilité de l'urétéroscopie souple en ambulatoire pour la prise en charge des calculs urinaires : une étude rétrospective monocentrique.

AIM: Management of urolithiasis has changed over the past decades. Outpatient surgery has become a major issue for healthcare systems. The aim of this study was to assess the feasibility of outpatient flexible ureteroscopy. METHODS: A single-center retrospective study has been conducted including all patients who underwent an outpatient flexible ureteroscopy between January 2012 and December 2013. Failure of outpatient management was defined as length of hospital stay>12 hours or readmission within 48 hours after discharge. Univariate analysis was performed to seek for predictors of failure of outpatient management. RESULTS: One hundred and fifty-seven patients who underwent a total of 174 procedures were included. They were mostly men (57.5 %), with a mean body mass index of 25.2kg/m2 (±4.3). The stones were mostly unique (64.3 %), with a mean size of 14.2mm (±11.2). Eighty patients had a double J stent preoperatively (46.5 %), and mean operative time was 64.2 minutes (±34.1). An ureteral access sheath was used in 39 procedures (22.4 %). A double J stent was left postoperatively in 103 patients (59.1 %). In total, 165 procedures (94.8 %) were performed successfully as outpatient surgery. On postoperative imaging, the stone-free rate was 69.5 %. Postoperative complications occurred in 3.4 % of cases and were mostly minor (i.e. Clavien 1-2; 83.3 %). Predictive factors of failed outpatient management were male gender (P=0.04), BMI (P=0.03), and anticoagulants intake (P=0.003). CONCLUSION: Outpatient flexible ureteroscopy for urinary stones is feasible and its low failure and complications rate may allow a wider spread of its use. LEVEL OF EVIDENCE: 4.

Routine enema before urodynamics has no impact on the quality of abdominal pressure curves: Results of a prospective controlled study.

AIMS: The presence of stools in the rectum might affect the quality of the abdominal pressure curve during filling cystometry, but, to date, no study has evaluated the impact of bowel preparation before urodynamics. We evaluated the influence of a sodium phosphate enema before urodynamics on the quality of the abdominal pressure curve. METHODS: A prospective, controlled, single-blind study was conducted in a single center from May to June 2013. The patients were divided into 2 consecutive groups: patients seen in outpatient clinics during the first 6 weeks (group A) who underwent urodynamics without bowel preparation and patients seen in outpatient clinics during the second 6 weeks (group B) who had a prescription of sodium phosphate enema before urodynamics. The primary endpoint was the quality of the abdominal pressure curve evaluated independently by three physicians who were blinded to the study group. The following data were also collected: age, gender, the presence of a neurological disorder, complicated nature of urodynamics and bother related to preparation for it, assessed using a Likert scale (0 to 10), and the equipment used. A per protocol analysis and an intent-to-treat analysis were conducted. RESULTS: One hundred and thirty-nine patients were included: 54 in group A and 85 in group B. One-third of patients had neurological conditions. 14 patients in group B did not perform their scheduled enema. Thus, 68 patients performed an enema before urodynamics and 71 did not. There was no difference between groups A and B regarding the complicated nature of urodynamics (Likert scale: 3.12 vs. 3.18; P=0.91) or bother related to preparation for it (Likert scale: 3.46 vs. 2.97; P=0.43). In the per protocol analysis, the abdominal pressure curve was considered perfectly interpretable (PI) in 69% of patients who did not receive an enema before urodynamics and in 65% of patients who did (P=0.61). The between-group difference was not statistically significant in intent-to-treat analysis (P=0.99). In patients who did not receive an enema before urodynamics, the only factors statistically associated with better quality of abdominal pressure curves were age <60years (P=0.001) and the urodynamic equipment used (Dantec®>Laborie®; P=0.01). CONCLUSION: In this prospective study, routine enema before urodynamics did not improve the quality of the abdominal pressure curve and did not increase the complicated nature of urodynamics or the bother of preparation for it. LEVEL OF EVIDENCE: 3.

[Oncologic and perioperative outcomes of robot-assisted radical cystectomy: A single-center prospective series]. / Résultats oncologiques et périopératoires de la cystectomie totale robot-assistée pour cancer : une série prospective monocentrique.

INTRODUCTION: The aim of this study was to report perioperative and oncological outcomes of robot-assisted radical cystectomy (RARC) in a single-center series and to evaluate the impact of the experience on perioperative outcomes. METHODS: Between March 2012 and January 2016, 41 patients underwent RARC associated with extended pelvic lymphadenectomy for muscle-invasive bladder cancer. All RARC included were performed by a single-surgeon in one center. Perioperative and oncological datas were collected prospectively. Recurrence-free (RFS), overall (OS) and cancer-specific survivals (CSS) were estimated using the Kaplan-Meier Method. The impact of the experience on perioperative data was estimated using Spearman's correlation test. RESULTS: Mean age was 67,7years (±10.6). Most patients underwent neoadjuvant chemotherapy (73.2%). Mean operative time and mean estimated blood loss were respectively 319.5minutes (±85.3) and 662.5mL (±360.9). Eight patients needed perioperative blood transfusion (19.5%). Conversion to open surgery was necessary in 3 cases (7.3%). Ileal neobladder was performed in 26.8% of the cases (54.5% being performed intracorporeal), and non-continent urinary diversion in 73.2%. Mean nodal yield was 17.7 (±9.3). Positive surgical margins were observed in 1 patient (2.3%). Mean length of stay was 13.2 days (±9.8). Postoperative complication rate was 46,3%. After a median follow-up of 16months, estimated 2 year-OS and CSS were respectively 62 and 76.1%. Estimated 2-year RFS was 67.6%. Perioperative outcomes improved with experience with a significant decrease in operative time (P=0.04) and a significant increase of nodal yield (P=0.05). CONCLUSION: In this single-center prospective study, satisfactory perioperative and oncological outcomes after RARC were observed despite the learning curve. Perioperative outcomes improved with surgeon's experience. Further studies are needed to confirm these findings. LEVEL OF EVIDENCE: 4.

[Impact of robotic assistance on the use and the outcomes of nephron-sparing surgery: A single center experience]. / Impact de l'assistance robotique sur la pratique et les résultats de la chirurgie rénale conservatrice : une expérience monocentrique.

INTRODUCTION: The aim of this study was to assess the impact of the acquisition of a Da Vinci® robot on the use and outcomes of partial nephrectomy (PN). PATIENTS AND METHODS: It was a single center retrospective study including 280 patients who underwent PN from January 2006 to May 2013. The number of PN, tumors and patients' characteristics and perioperative outcomes have been assessed over 3 periods defined according to the main surgical approach: 2006-2008 (open PN), 2008-2010 (laparoscopic PN) and 2010-2013 (robotic PN). RESULTS: Over the study period, the surgical approach has changed significantly in favor of minimally-invasive surgery and especially robotic approach. The PN/nephrectomy rate has also evolved to a higher proportion of PN over radical nephrectomy (P=0.002). No significant difference was noted between the three periods in terms of tumor size but there was a higher rate of highly complex tumors (RENAL score≥10) during the last period (10.7%; 18.6% and 33.2%; P=0.04). Warm ischemia time increased from 2006-2008 to 2008-2010 (26 vs. 23minutes) but decreased thereafter during the robotic era (14.5minutes; P<0.001). Regarding postoperative outcomes, the only change was a decreased length of stay over time (P=0.003). CONCLUSION: In this single center series, the robotic approach was associated with a spread of PN and with an improvement of nephron-sparing surgery outcomes. LEVEL OF EVIDENCE: 4.

[Management of overactive bladder in women]. / Prise en charge de l'hyperactivité vésicale chez la femme.

Overactive bladder (OAB) is defined as urgency, with or without urge incontinence, usually with frequency and nocturia. OAB has been reported in 9 to 43% of female patients. It is usually idiopathic. The diagnosis is clinical but an initial work-up may be needed to exclude an underlying cause (bladder tumor, stone, cystitis, neurological disorder…) using urinary tract ultrasound, urine culture or cystoscopy. The initial assessment may also include a frequency-volume chart and urodynamics. Behavioral therapy is the first line treatment. In case of failure, antimuscarinics are recommended. Nowadays, three treatment options are available for OAB refractory to antimuscarinics: sacral neuromodulation, peripheral tibial nerve stimulation and intra-detrusor injections of botulinum toxin. Surgical procedures such as augmentation cystoplasty are very rarely required.

[Risk of rectal perforation during intention to treat laser photovaporization of prostate with transrectal ultrasound guidance: a report of 4 cases]. / Risque de perforation rectale liée à l'utilisation de l'échographie endorectale au cours de la photovaporisation prostatique au laser en intention de traiter : à propos de 4 cas.

CONTEXT: Transrectal ultrasound guidance (TUG) during prostate endoscopic surgery can optimize the procedure by reducing the risk of capsular perforation and ascertain the treatment completeness. TUG is proposed during photoselective vaporisation of prostate (PVP). OBJECTIVE: To report four cases of rectal perforations during PVP with TUG and assess their occurrence. MATERIALS AND METHODS: This is a retrospective study including prostate endoscopic surgeries with TUG, performed in two centers between November 2011 and May 2013. Rectal perforations were identified. Surgical data, treatment modalities and postoperative outcomes of rectal perforations were analysed. RESULTS: Four rectal perforations were identified among 450 surgical procedures. Median age and prostate volume were 80 years old [62-91] and 40mL [13-150], respectively. Two perforations occurred during PVP with Greenlight(®) XPS 180W. Two perforations occurred during transurethral resection of prostate or cervicoprostatic incision. Patients were treated by systematic urinary drainage associated with colostomy or direct suture. Two patients died from this complication and two patients have satisfying functional outcomes at one year. CONCLUSION: TUG during prostate endoscopic surgery could lead to rectal perforation by protusion of the prostate and therefore should be used cautiously. LEVEL OF EVIDENCE: 5.

[The role of urinary markers in the assessment and follow-up of lower urinary tract disorders: a literature review]. / Place des biomarqueurs urinaires dans le diagnostic et le suivi des troubles du bas appareil urinaire: une revue de la littérature.

OBJECTIVES: To conduct a literature review on the role of urinary biomarkers in the initial assessment and follow-up of lower urinary tract symptoms. METHODS: A literature review was conducted in August 2014 using the Medline/Pubmed database limiting the search to work in English or French. RESULTS: Most studies were of level of evidence 2 or 3 (prospective cohort, controlled or not) and mainly about overactive bladder and bladder pain syndrome. Nerve Growth Factor (NGF) was the most studied and apparently the most promising in the evaluation of overactive bladder (OAB) and neurogenic detrusor overactivity (NDO). Urinary levels of ATP, prostaglandin E2 (PGE2), Brain-Derived Neurotrophic Factor (BDNF) and some cytokines were also significantly higher in most studies in patients with NDO or OAB. Epidermal Growth Factor (EGF), Heparin-Binding EGF (HBEGF) and Antiproliferative Factor (APF) were the most studied urinary markers in bladder pain syndrome, with a significant increase (EGF APF) or decrease (HBEGF) in cases of interstitial cystitis (compared to healthy controls). The urinary N-terminal-telopeptide (NTx) could be predictive of a failed mid-urethral sling. However, few studies reported the diagnostic values of the markers, their association with urodynamic parameters were rarely evaluated and the existence of a publication bias is likely. No randomized controlled study has so far compared the urinary markers to urodynamic evaluation. CONCLUSION: In the future, urinary markers could complete or replace urodynamic examination. However, to date, there is no high level of evidence study comparing these markers to urodynamics and their use can therefore not be recommended in daily practice.

[Adrenalectomy for adrenal metastases: is the laparoscopic approach beneficial for all patients?]. / Surrénalectomie pour métastases surrénaliennes: la voie d'abord laparoscopique est-elle bénéfique pour tous les patients ?

INTRODUCTION: Laparoscopy has become the gold-standard approach for excision of benign adrenal tumors but the question of its safety for malignant lesions is still controversial. Our aim was to evaluate the oncologic outcome of laparoscopic adrenalectomy for adrenal metastasis and to look for predictors of a negative surgical outcome. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent laparoscopic adrenalectomy for suspicion of adrenal metastasis between 2007 and 2013 at a single academic institution. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Univariate analysis was performed to determine risk factors of negative surgical outcome (positive surgical margins, complications, conversion, significant blood loss) and predictors of RFS and CSS. RESULTS: Thirteen patients underwent 14 laparoscopic adrenalectomies. All patients were operated by a single highly experienced surgeon. Complications occurred in 2 patients (15%): 2 blood transfusions (Clavien-score=2). There were 3 positive surgical margins (21%). Mean length of hospital stay was 4.3 days. Unadjusted RFS and CSS were respectively 48.4% and 83.3% at 1 year, 39.5% and 66.7% at 5 years. In univariate analysis, tumor size was the only risk factor of complication (P=.009) and conversion (P=0.009). Capsule invasion and tumor size were risk factors of positive surgical margins (P=0.01 and P<0.0001). One hundred percent of complications, conversion and positive surgical margins occurred in tumor>7.5 cm on preoperative CT-scan. No predictors of RFS and CSS was found in univariate analysis. CONCLUSION: Laparoscopic adrenalectomy for adrenal metastasis achieves good surgical and oncologic outcomes. When performed by highly experienced surgeon, complications and positive surgical margins occur only in tumors>7.5 cm. These patients may benefit from an open surgical approach.

[Comparative study of histological results between resection and biopsy of the prostate]. / Étude comparée des résultats histologiques de résection et de biopsies de prostate.

PURPOSE: To evaluate the histological correlation between transuretral resection chips and biopsy cores within a population of patients who underwent resection of prostate (TURP) and prostate biopsies (BPx). PATIENTS AND METHODS: Clinical and tumoral data of 77 patients who had both procedures simultaneously or with a slight delay were collected. According to the presence of prostate cancer (Pca), 4 groups were defined: group 1 (TURP and BPx negative), group 2 (TURP positive, BPx negative), group 3 (TURP negative, BPx positive), group 4 (TURP and BPx positive). Means and proportions were compared using Anova and χ(2) test, respectively. RESULTS: The patients were older in groups 3 and 4 (79 and 76 respectively, P=0.65). The PSA was higher in the groups 3 and 4 (64 and 55 ng/mL) than the groups 1 and 2 (10.6 et 16 respectively, P=0.23). The number of positive biopsy was higher in the group 4 than the group 3 (5.6 vs. 4.6, P<0.0001), the chips were more invaded in the group 4 than the group 2 (41% vs. 11% P<0.0001), the Gleason score at TURP was higher in the group 4 than the group 2 (7.5 vs. 6.2 P<0.0001). CONCLUSION: Our study underlines that the Pca of transition and peripheral zones seems to have distinct characteristics. When chips of TURP and BPx were both invaded, it was due to an aggressive cancer. The decision to explore the peripheral zone in the case of positive TURP must take clinical context into consideration.

Robotic-assisted laparoendoscopic single-site radical nephrectomy: first experience with the novel Da Vinci single-site platform.

PURPOSE: To report our first cases of robotic laparoendoscopic single-site (R-LESS) radical nephrectomy with the novel Da Vinci R-LESS platform (Intuitive Surgical, Sunnyvale, CA). METHODS: Six radical nephrectomies were performed with R-LESS Da Vinci single-site port and instruments. Data concerning patients characteristics, indication of surgery, operative and postoperative outcomes were collected. RESULTS: All procedures were completed successfully. Two patients required the placement of an additional port. Median operative, docking and console times were 179 min (range 120-318), 19 min (range 15-24) and 129 min (range 100-264), respectively. Median blood loss was 100 ml (range 50-800). No significant robotic-related problem was noticed during the procedures. There was no operative or major postoperative (Clavien >2) complication. Median length of hospital stay was 3 days. CONCLUSION: Our initial experience of R-LESS radical nephrectomies with the novel Da Vinci platform shows that the procedure is feasible. Indications, safety and place of the technique will be confirmed with growing experience.