Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes.

OBJECTIVE: To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign prostatic hyperplasia. METHODS: 238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery. RESULTS: CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value. CONCLUSION: PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.

[Medical treatment of renal cell carcinoma]. / Les médicaments du cancer du rein.

AIM: To describe drugs used in renal cell carcinoma. METHOD: Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies websites (HAS and ANSM). RESULTS: Since 2007, a total of three different therapeutic classes in the management of metastatic renal cell carcinoma are available. These three classes are tyrosine kinase inhibitors with sunitinib and sorafenib, the anti-VEGF antibodies (bevacizumab which is associated with alpha interferon in the treatment of advanced kidney cancer) and mTOR inhibitors with temsirolimus and everolimus. These targeted therapies are a major progress in the treatment of patients with metastatic kidney cancer. The side effects encountered with these molecules are numerous but serious side effects are less than 5% of all reported side effects. CONCLUSIONS: A better understanding of molecular mechanisms has enabled the development of new therapies for the treatment of metastatic renal cell carcinoma. In the future, a personalized approach taking into account the biology of each tumor could be created to provide a more targeted treatment.

[Chemotherapy in male external genital organs (testicular and penile cancer)]. / Chimiothérapie des organes génitaux externes chez l'homme (cancer du testicule et du pénis).

AIM: To describe drugs used in the chemotherapy of testis and penis neoplasms. MATERIAL: Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned. RESULTS: Nowadays, the chemotherapy is perfectly codified in adjuvant treatment or in first-line treatment of metastatic testis cancer. A single dose of carboplatin for seminoma testicular (stage I) in adjuvant treatment situation is one of the latest advances. Concerning penis cancer, the optimal protocols validated by a high level of evidence are missing. CONCLUSION: The chemotherapy in testis and penis neoplasms knew few advances in recent years. So, it is necessary to include patients in clinical research protocols.

[Drug therapy of urethral diseases]. / Les médicaments de l'urètre.

AIM: To describe drugs targeting urethra and prostate to treat dysfunctions such LUTS related to BPH, primary bladder neck obstruction (PBNO), detrusor sphincter dyssynergia (DSD) or sphincter deficiency (SD). METHOD: Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM). RESULTS: To treat LUTS related to BPH alpha-blockers (AB) and 5-alpha reductase inhibitors (5ARIs) have a clearer efficacy than plant extract. Daily Phosphodiesterase 5 inhibitors (PDE5Is) alone or in association with AB also demonstrate efficacy in this indication. AB are an option in PBNO and DSD related to multiple sclerosis. Although Botulinum toxin A derived molecules decrease urethral pressure in patient with DSD related to spinal cord injury or multiple sclerosis, efficiency remains to be demonstrated. Duloxetine a serotonin reuptake inhibitor increases urethral sphincter pressure and reduce stress urinary incontinence in women and men. Nevertheless, moderate efficacy combine with frequent side effects lead French regulation agency to reject its agreement. CONCLUSION: Armamenterium to treat urethral dysfunctions has recently increases. Two new therapeutic classes emerge: PDE5Is to treat LUTS related to BPH and an SRIs (Duloxetine) to treat stress urinary incontinence. Efficacy and safety evaluation of all the possible associations between drugs targeting urethra and/or bladder is needed to a subtler and more efficient pharmacologic modulation of lower urinary tract dysfunction.

[Drugs for sexual medicine]. / Les médicaments de la médecine sexuelle.

AIM: To describe drugs used in sexual medicine. METHOD: Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM). RESULTS: 5PDIs and intracavernous injection of alprostadil are first- and second-line therapies of erectile dysfunction. Dapoxetine is the first specific and approved treatment of premature ejaculation. Androgene supplementation improves sexual desire among patient with hypogonadism as much as initial serum testosterone levels are low. Female sexual dysfunctions pharmacology is to date less developed, although candidate drugs reach phase III clinical studies. CONCLUSION: Pharmacology is one but not the only therapeutic avenue in sexual medicine. Despite real breakthrough such as 5PDIs for erectile dysfunction, incomplete knowledge and understanding of physiology, pathophysiology and pharmacology of human sexual function reduces its development particularly for women.

[Anti-infective treatments in urology]. / Les traitements anti-infectieux non médicamenteux en urologie.

OBJECTIVE: To define the terms of use of vaccines, probiotics, and cranberry in urology. MATERIALS AND METHODS: A literature search was conducted on MEDLINE for all these treatments used in urology. Modes of action, indications in urology and adverse effects have been detailed for each treatment. RESULTS: Vaccines have been published in urinary tract infections. Products for bacterial interference such as probiotics are also used, their properties are described. As for the cranberry widely used in recurrent urinary tract infections, efficacy and mode of action are discussed. CONCLUSION: The anti-E. coli vaccines, cranberry and probiotics may be useful in urinary tract infection.

[Guidelines from the Infectious Disease Committee of the French Association of Urology and The Neuro-Urology Committee of the AFU: antibiotic prophylaxis for sacral neuromodulation]. / Recommandations de bonnes pratiques cliniques : antibioprophylaxie et neuromodulation des racines sacrées par le Comité d'infectiologie de l'Association française d'urologie (CIAFU) et le Comité de neuro-urologie de l'AFU.

INTRODUCTION: In urology, antibiotic prophylaxis is advised by the French Association of anesthesiology (SFAR) and the Infectious Disease Committee of the French Association of urology guidelines published in 2010. No guideline exists concerning the implantation of neuromodulation implants. MATERIAL AND METHOD: A literature analysis was performed on sacral modulation and antibiotic prophylaxis. Then guidelines were discussed by reviewers. Items that showed no consensus were then discussed again to arrive at recommendations. RESULTS: Antibiotic prophylaxis is recommended during the test phase as well as in the case of installation of sacral neuromodulation (Grade C). Antibiotic recommended (Grade B) are: cefotetan or cefoxitin, 2g dose by slow intravenous injection or amoxicillin-clavulanic acid at a dose of 2 g, intravenously or, in the case of allergy vancomycin at a dose of 15 mg/kg or the clindamycin has 600 mg intravenously. CONCLUSIONS: Despite the lack of high level of evidence, antibiotic prophylaxis seems necessary when setting up of electrode case of sacral neuromodulation.

[Greenlight(®) photoselective vaporisation for benign prostatic hyperplasia: a systematic review]. / Traitement de l'hyperplasie bénigne de prostate par photovaporisation au laser Greenlight(®) : analyse de la littérature.

INTRODUCTION: Transurethral resection of the prostate (TURP) is the most common surgical procedure in urology and remains the gold standard treatment of complicated benign prostatic hyperplasia or refractory to medical treatment. Routinely used since the 2000s, prostate photoselective vaporization (PVP) with Greenlight(®) laser has been developed to improve the safety of hemostasis in elderly patients and/or with high surgical risk. The purpose of this study was to review the results of PVP from the international literature. MATERIAL AND METHODS: [corrected] A systematic review of the literature on the research base Pubmed (http://www.ncbi.nlm.nih.gov/) was performed using the keywords benign prostatic hyperplasia; greenlight; photovaporisation; Laser; IPSS score; endoscopicsurgery; morbidity; complication. Prospective and retrospective studies in English and French were selected from its first use in 1998. Finally, we looked for studies that reported at least one of the following items: surgical technique; operative data; complications; anatomical and functional results and/or direct comparison between PVP and TURP. RESULTS: Regardless the PVP technique used to treat adenoma and identify the limits of the prostatic capsule, some parameters are well defined (sweepspeed, angle and distance of the fiber with the tissue) but others are still debated (number of joules per volume, when do we have to stop the PVP) and are reported in a heterogeneous manner due to the different generators. Versus TURP, PVP would offer the same functional results in the medium term but with a lower risk of per- and postoperative bleeding. The study of the risk of erectile dysfunction (ED) after PVP is made difficult due to the heterogeneity of DE assessment and study populations. However, PVP does not seem associated with an increased risk of ED versus TURP. The lack of histological material should lead to preoperative individual screening of prostate. The economy generated by PVP regarding the decrease in average length of stay has been clearly identified in Australia, Canada, Switzerland and USA. Studies will be published soon on French economic model. CONCLUSION: PVP with Greenlight(®) laser appears to be a safe and effective technique. With the new generator XPS, the PVP technique reaches maturity. Its development will certainly lead to a long-term evaluation with high levels of evidence based.

[Photoselective vaporization of the prostate]. / La photovaporisation laser de la prostate.

Photoselective vaporization of the prostate is a minimal invasive endoscopic treatment of benign prostatic hyperplasia (BPH) obstruction. It uses the light energy produced by a laser source to destroy and remove urethral obstruction due to BPH. Its main advantage over transurethral resection of prostate is the minimal bleeding allowing a short urethral catheterization and hospital stay. It is useful in patients with bleeding disorders.

Is urine culture routinely necessary before prostate biopsy?

The objective of this study was to assess the value of a urine bacterial culture performed before prostate biopsy. We performed a prospective study on 353 patients who underwent prostate biopsy. All patients had a urine bacterial culture performed before biopsy. We compared the outcomes of patients with bacteriuria (left untreated) with those of patients without bacteriuria. Of the 353 men, 12 had a pre-biopsy-positive bacterial culture and underwent prostate biopsy without any infectious complication. Fifteen patients with a negative pre-biopsy culture developed a post-biopsy-positive bacterial culture, but remained asymptomatic without any treatment. Only four men from the group without pre-biopsy bacteriuria developed an infectious complication, requiring 3 weeks of antibiotic therapy. The complication rates were similar for both groups. Our results suggest that routine urine bacterial culture before prostate biopsy is not useful when antibiotic prophylaxis and enema are performed. We do, however, suggest performing a urine bacterial culture before prostate biopsy for patients with a previous history of urinary tract infections.

[Use of cranberry in chronic urinary tract infections]. / Utilisation de la canneberge dans les infections urinaires récidivantes.

OBJECTIVE: Chronic cystitis in women is frequent and difficult to treat. Up to now, an empirical prescription of antibiotics could decrease the frequency of acute episodes but with adverse effects and increasing risks of resistance. Studies have shown that cranberries should be used for that indication. We made a systematic review of literature to demonstrate how to use the cranberry. RESULTS: Randomized studies confirmed that the proanthocyanidin contained in cranberries can eliminate Escherichia coli adhesion to the urothelium. Clinical studies showed that the incidence of acute cystitis decreased when treated by cranberries. On the other hand, patients with a neurogenic bladder and intermittent catheterization do not seem to benefit from the fruit. We did not find any study on postcoital use of cranberries. Various substances and doses were used in these studies and we could not conclude on best galenic presentation to prescribe. CONCLUSION: Cranberries can inhibit E. coli adhesion to the urothelium and could be useful to treat urinary infections. Clinical studies confirm the probable benefit of this fruit as a prophylactic treatment for female cystitis. Prescriptions modalities remain to be defined.