Sacral neuromodulation in the management of non-obstructive urinary retention: Test phase and predictive factors.

AIM: The aim of this study is to evaluate the success of the test phase of sacral neuromodulation in management of chronic non-obstructive urinary retention and the factors predictive of good response. MATERIALS AND METHODS: This is a retrospective study carried out on a cohort of patients followed up in a tertiary University Hospital in France. Fifty-two patients with chronic non-obstructive urinary retention were included in this study. These patients were seen over the past 20 years, from the year 2000 to 2020. The initial evaluation of patients included a summary of medical and surgical history, age, BMI, history of pelvic floor disorders, initial voiding pattern, physical examination, voiding diary, initial uroflowmetry and a urodynamic study. Postoperative follow-up and analysis of complications were also carried out. RESULTS: A total of 52 patients were included in this study, 13 males and 39 females. Out of these patients, 17 patients (32.7%) with a median age of 47.3 years±18.1 benefited from definitive implantation of the sacral neuromodulation. The univariate analysis showed that age was the only significant variable in this study and the optimal age threshold was<58.5 years. CONCLUSION: SNM is a therapy with significant clinical benefits and low morbidity for patients with chronic non-obstructive urinary retention. The results obtained need to be confirmed with a prospective study with a larger number of patients.

Analysing the learning curve of prostate enucleation with the Holmium laser: A retrospective, single-center experience.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is a proven surgical technique for the treatment of benign prostatic hyperplasia (BPH). However, its challenging learning curve prevents its widespread adoption by urologists. The aim of this study was to analyse the learning curve of HoLEP and to determine the factors accelerating it. METHODS: This was a retrospective, monocentric cohort study of the first 60 cases of HoLEP performed by three operators. The primary outcome measure was operative efficiency, defined as the ratio of preoperative prostate volume estimated by trans-abdominal ultrasound (TAUS)to total surgical time in minutes. The studied learning curve parameters included the number of previously performed cases (NPPCs) and monthly case density (CD) (number of monthly performed cases before the studied one). RESULTS: Overall, 180 patients with a mean age of 71 (±9) years and a mean prostate volume (g) of 80.4 (±41) were included. The mean operative efficiency in the population was 0.74 (±0.37) g/min. Operative efficiency was increased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 0.66 (±0.27) g/min vs. CD ≥3: 0.79 (±0.43) g/min; P=0.012). At 3months, 46 patients (29%) developed stress urinary incontinence (SUI). Early SUI was significantly decreased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 37%, (n=26) vs CD ≥3: 22%, (n=20); P=0.045). CONCLUSIONS: A high frequency HoLEP procedures, set as one case per week, appeared to accelerate learning curves by improving operative efficiency. A high CD was also associated with reduced rates of early SUI. LEVEL OF PROOF: 5.

[Voiding dysfunction after TVT: A 20-year experience TVT-placement under local anesthesia and sedation]. / Troubles mictionnelles après pose de TVT : 20 ans d'expérience de pose sous diazanalgésie et anesthésie locale.

BACKGROUND: Trans-vaginal tape has become the gold standard for the cure of urinary stress incontinence, but post-operative voiding dysfunction is frequently reported. The purpose of this study is to assess the incidence of voiding dysfunction, dysuria, chronic urinary retention, and necessity of reoperation after retropubic TVT placement under local anaesthesia and sedation. MATERIAL AND METHOD: We perform a retrospective study of a cohort of patient treated with the placement of a retropubic TVT under local anaesthesia and sedation between 1999 and 2019 for a SUI. Post-operative voiding dysfunction and necessity of reoperation were reviewed to access the principal aim of this study. RESULTS: Three hundred and two patients who met the eligibility criteria were included in the study. At 3 months, the dysuria rate and chronic urinary retention rate was 4.3% and 1%. At 12 months it was 2.6% and 0.3% respectively. The 12-month sling section rate was 1% and long-term self-catherization rate was 0.3%. The objective cure rate was 93% and subjective cure was 92%. CONCLUSION: TVT placement under local anaesthesia and sedation resulted in few voiding dysfunctions at medium/long-term, necessity of re-operation for refractory obstructive disorder and well functional results. Even if these results support more frequent use of this type of anaesthesia, it would be interesting to be able to follow them in a prospective study to conclude. LEVEL OF EVIDENCE: 4.

[Initial assessment, follow-up and treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: guidelines of the LUTS committee of the French Urological Association]. / Bilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l'AFU.

AIM: To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH). METHOD: A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique. RESULTS: Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate. CONCLUSION: Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

[Surgical management of benign prostatic hyperplasia by thermotherapy and other emerging techniques: A review of the literature by the LUTS committee of the French Urological Association]. / Traitement chirurgical de l'hyperplasie bénigne de la prostate par thermothérapie et autres techniques émergentes : revue de littérature du CTMH de l'AFU.

PURPOSE: To perform an update on mini-invasive surgical treatment of benign prostatic hyperplasia (BPH) by thermotherapy and other emerging techniques. METHOD: A systematic review of literature was performed in Pubmed database for the period running from 1980 to 2011. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS: Monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Thermotherapy using transurethral microwaves or needle ablation is an alternative to medical management. Urethral stents should only be proposed in exceptional cases of surgical contra-indication, because of their related complications. Botulinium toxin and ethanol intra-prostatic injections are currently under evaluation.

[Benign prostatic hyperplasia medical treatment: systematic review of the literature by the CTMH/AFU]. / Traitement médical de l'hyperplasie bénigne de la prostate: revue de littérature par le CTMH/AFU.

INTRODUCTION AND OBJECTIVES: The medical treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (LUTS-BPH) has dramatically evolved within the last years: new drugs have been commercialized and others that used to be contra-indicated may now be prescribed. Our objective was to provide with an updated review of the scientific literature on the medical treatment of LUTS-BPH. PATIENT AND METHOD: A systematic review of the most recent scientific literature was performed. The query was addressed to the PubMed database using the following keywords: "benign prostatic hyperplasia" and "medical treatment". A very large amount of publications, from year 1990 until 2011, were reviewed to select the publications with level of evidence 1 and 2. These publications were analysed and the 30 most relevant were selected to serve as references for this article. RESULTS: There are many randomized clinical trials in the field of LUTS-BPH medical treatment. Recently, anti-muscarinic agents have been assessed and have proven their efficacy and tolerance as long as the storage symptoms are predominant over the voiding symptoms. Combination therapies using alpha-blockers and 5-alpha reductase (5-ARI) inhibitors, but also anti-muscarinic agents and PDEF-5 inhibitors may also be prescribed depending on the patient' complaint. CONCLUSION: The publication of recent randomized clinical trials allows the urologists to use new drugs and new combination therapies in the medical treatment of LUTS-BPH. In 2011, the medical treatment decision-making may better integrate the patient' complaint and medical history.

[Sacral neuromodulation with InterStim™ system: Results from the French national register]. / Neuromodulation sacrée avec le système InterStim™ : résultats du registre national français.

AIM: To analyse current practice patterns and to evaluate (long-term) effectiveness and adverse events of sacral neuromodulation with InterStim™ Therapy based on data collected in a national register and to discuss the strengths and weaknesses of the register. PATIENTS AND METHODS: This is a French multicenter prospective observational trial including patients with a permanent implant (2003-2009). Voiding diary variables and patient satisfaction were analysed based on last follow-up visit since implantation. RESULTS: One thousand four hundred and eighteen patients (median age: 63 years, 1206 females) were included in the database (median follow-up: 12 months). One thousand and eighty-nine patients had non-neurological disease. The principal diagnosis was overactive bladder syndrome ([OAB], n=1170) and retention (n=151). Implantation occurred in 1358 patients; 1172 patients had greater than or equal to one registered follow-up. Clinical improvement of greater than or equal to 50% was seen in 447/527 patients with OAB at 12 months follow-up (median number of voids per 24 hours decreased from 15 at baseline to 8 at 12 months) and in 42/54 of patients with retention (median number of catheterization per 24 hours dropped from 5 at baseline to 0 at 12 months). Clinical improvement remained relatively stable up to 60 months. Median patient satisfaction with treatment was between 60 and 80%. Five hundred and twenty-four patients had at least one adverse event; loss of efficacy (n=244) occurred most frequently. CONCLUSIONS: In this large database sacral neuromodulation with InterStim™ Therapy seems to be an effective treatment through routine practice in the long-term (up to 60 months) for patients refractory to medical treatment.

[Benign prostatic hyperplasia surgery and anticoagulant therapy: review of the literature by the French Association of Urology]. / Chirurgie de l'hyperplasie bénigne de la prostate et traitements anticoagulants: état des lieux par le Comité des troubles mictionnels de l'homme de l'Association française d'urologie (CTMH-AFU).

INTRODUCTION: The prescription of a long-term oral anticoagulant may pose several problems for the endoscopic surgery of benign prostatic hyperplasia (BPH). Questions regarding the length of its interruption, what it can be replaced by and the date oral treatment can be resumed must be asked at preoperative stage to avoid haemorrhaging or cardiovascular accidents. While the number of patients concerned by this type of prescription continues to grow, surgical hemostasis techniques continue to progress and recommendations for good practice are evolving. It is therefore interesting to bring up to date the knowledge and recommendations for surgery of BHP while being treated with anticoagulants. MATERIAL AND METHOD: A systematic revue of publications and of recommendations by knowledgeable bodies in cardiology and anesthesia were carried out. RESULTS: The transurethral resection of the prostate (TURP) is an intervention which carries an intermediate risk of haemorrhaging. Whenever possible, it is recommended to briefly interrupt the anticoagulant treatment in the perioperative period. For antivitamins K, heparinotherapy takes over, which, thanks to a short half-life, allows for a quicker management of the anticoagulation. For antiplatelets, the tendency is towards proposing an interruption for 4 to 5 days before the intervention. In all cases, the anticoagulant must be reintroduced as quickly as possible because cardiovascular risks are in proportion to the length of time of interruption. CONCLUSION: The strategy for treatment of patients taking oral anticoagulants is complex. It must be defined in consultation with the anesthetist, the cardiologist or hemostatis specialist. Nevertheless, the urologist remains at the center of the decision for treatment because he/she is the only one who can weigh up the risk of haemorrhaging, the cardiovascular risks and the necessity of an operation and technique used.

[Management of patients under anticoagulants for transurethral resection of the prostate: a multicentric study by the CTMH-AFU]. / Prise en charge des patients sous traitement antithrombotique dans la résection transurétrale de prostate: étude multicentrique du CTMH de l'Afu.

OBJECTIVE: To determine how are managed patients with anticoagulation treatments who are operated by transuretral resection of the prostate (TURP), and to evaluate the morbidity associated to these treatments. MATERIALS AND METHODS: This is a retrospective study on 226 patients operated consecutively in six french hospitals between January 2007 and August 2008 by TURP for symptomatic benign prostatic hypertrophy (BPH). RESULTS: Eighty-three patients (37%) operated by TURP were under anticoagulation treatment before hospitalization. (23 cases under coumarin derivatives, 57 cases under platelet aggregation inhibitors, and three cases under low molecular weight heparin). Management of anticoagulation for the operative period was very heterogenic. Overall, patients under anticoagulation treatment had significantly longer hospitalization period (5.8 versus 4.9 days, p = 0.003) and were more frequently re-hospitalized for hematuria (14.5% versus 1.4%, p < 0.001). Considering early and late morbidity, no significant difference was observed between patients under coumarin derivatives and those under platelet aggregation inhibitors. CONCLUSIONS: This study assessed the risk of anticoagulants in BPH surgery, and showed the necessity of establishing protocols and recommendations for the management of patients under anticoagulation treatment requiring BPH surgery.

[Localized hyperthermia of the prostate via the rectum in chronic inoperable urinary retention]. / L'hyperthermie localisée de la prostate par voie rectale dans les rétentions urinaires chroniques inopérables.

Local transrectal hyperthermia of the prostate was used to treat 16 poor surgical risk patients who had an indwelling catheter because of chronic urinary retention caused by benign prostatic hypertrophy. We used the Brucker (Prost-care) model with a rectal applicator, a water cooling system and a microwave generator operating at 915 MHz. Intraprostatic temperatures of 42 degrees to 44 degrees C were measured by a radiometric system. 12 patients received a complete treatment which consists in 6 to 10 sessions of one hour and was controlled at least one month later. 8 of them no longer need a catheter. Uroflowmetry was between 7.5 and 17.6 ml/sec and residual urine appreciate by ultrasounds was less than 60 cm3.