[Interest of a systematic assessment of the treatment of the lower urinary tract symptoms in the management of benign prostatic hypertrophy in general practice (1380 patients) - Study EVALURO]. / Intérêt d'une évaluation systématique du traitement des symptômes du bas appareil urinaire dans la prise en charge d'une hypertrophie bénigne de la prostate en médecine générale (1380 patients) ­ Étude EVALURO.

OBJECTIVE: To evaluate the efficacy of a modification or initiation of treatment by a α-blocker in patients already medically treated for BPH-related LUTS, with persistent urinary symptoms. METHODS: This is a prospective observational study among general practitioners in France. Included patients were over 60 years of age with BPH-related LUTS who had been medically treated for at least 6 months. A treatment by an α-blocker was initiated or modified if the PGI-I (Patient Global Impression of Improvement) did not objective any improvement under treatment and the IPSS (International Prostate Symptom Score) was≥8. Patients were followed up between 1 and 3 months after inclusion. The primary endpoint was the frequency of unsatisfactory progression of patients, assessed by persistence of urinary symptoms under treatment (IPSS≥8 and PGI-I unchanged or worsened). Progress of LUTS (IPSS and PGI-I) following modification of treatment with α-blocker was also assessed at the follow-up visit. RESULTS: Three hundred and fifty-three physicians included 1449 patients between February 2, 2016 and March 9, 2017 (1380 patients were analyzed): the average age was 70.0±6.9 years ; the duration of the LUTS was 4.1±4.2 years; at inclusion, they received mainly plants (n=744; 53.9%) and α-blockers (n=463; 33.6%); the mean IPSS score was 16.4±6.7, it was not correlated with duration of SBAU; the mean PGi-I was 2.6±1.2. In total, 48.8% (612/1255) of patients had a non-satisfactory evaluation of the LUTS; 42.8% (591/1380) of patients had a modification of treatment according to the protocol: 385 (65.6%) had an initiation of a α-blocker, 202 (34.4%) had a modification of treatment by α-blocker (4 missing data). The α-blocker was monotherapy for 484 (81.9%) patients. At the follow-up visit (1 to 3 months), the average IPSS score was 7.7±4.8, significantly lower (18.7±6.1 at inclusion); the average PGI-I of 1.2±0.7 was significantly lower (3.5±0.8 at inclusion); the quality of life (Q8-IPSS) was significantly improved. For the 345 patients under plant extracts having changed for one α-blocker, as well as for the 67 patients under α-blocker having changed for another α-blocker, the 3 scores had decreased significantly. CONCLUSION: A systematic evaluation of medical treatment for BPH showed that 48.8% of patients medically treated for at least 6 months were not improved. A modification of treatment by an α-blocker (initiation or modification) can then significantly improve the LUTS.

[Surgical treatment of BPO: Standard and innovations]. / Traitements chirurgicaux de l'obstruction prostatique bénigne : standards et innovations.

INTRODUCTION AND OBJECTIVE: Surgical management of benign prostatic hyperplasia has dramatically changed in the recent years towards higher proportion of endoscopic treatment and fewer perioperative complications. Nevertheless the question of urinary and sexual quality of life after surgical treatment remains partially unresolved with a high proportion of retrograde ejaculation after conventional surgical treatments. Therefore mini-invasive alternatives to conventional surgery have been proposed. The objective of this literature review was to provide an overview of the alternatives to monopolar TURP currently available in France. MATERIAL AND METHOD: A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review. A synthesis is proposed for each alternative technique mentioning its level of clinical development, but also its potential advantages and disadvantages compared to conventional surgical techniques. RESULTS: The quality of life of patients after surgical or interventional management has become the main priority of urologists since the risks of perioperative complication have been reduced by the use of laser or bipolar endoscopic techniques. Thanks to the development of minimally invasive alternatives that are better and better evaluated by randomized trials versus interventional simulation and conventional surgical treatment, more personalized care is possible. Patients' expectations and their individual risk factors can thus be placed at the center of the therapeutic decision and the preoperative information. CONCLUSION: The surgical and interventional management of LUTS due to BPH has evolved to lower perioperative morbidity with the help of numerous technological developments. Mini-invasive alternatives to standard treatment have also been proposed in order to improve the quality of postoperative sexual life. These alternatives provide significant improvement in LUTS that remains lower than after conventional treatments. Somme of these alternative are also not fully supported by clinical trials, which should urge urologists to act with caution when proposing these alternatives in daily clinical practice.

Evaluation of bleeding risk in patients on anticoagulation for mechanical cardiac valve operated for benign prostatic obstruction.

OBJECTIVE: To evaluate bleeding risk in patients on anticoagulation for mechanical cardiac valve operated for benign prostatic obstruction (BPO). MATERIAL AND METHOD: Fifty-eight patients operated between 1998 and 2014, in seven French departments of Urology were included. Forty-five patients were operated by conventional surgery (transurethral resection of the prostate 38, open simple prostatectomies 7), and 13 patients were operated by Greenlight™ photovaporization of the prostate (PVP). In order to assess bleeding risk, blood transfusion was considered as the primary outcome. RESULTS: Fifteen (26%) patients received blood transfusion in the postoperative period. Mean duration of hospitalization was 8.5 days. Secondary surgery was required in 12 cases (21%), including endoscopic clot removal under general anaesthesia in 10 patients, and suprapubic haemostasis in 3 patients. One patient died 72hours after transurethral resection of the prostate because of a massive pulmonary embolism. Two independent predictors of blood transfusion were identified: conventional surgery use versus PVP, and high preoperative PSA. Blood transfusion rate was significantly lower in the group of patients operated by PVP compared to conventional surgery (0% versus 33%, P=0.010). In addition, the laser surgery was associated with shorter duration of hospitalization (3.4 days versus 9.9 days, P=0.014). However, it was not found any significant difference between patients operated by PVP compared to conventional surgery in terms of secondary bleeding (3/13 vs 8/45, P=0.7), or second surgery (2/13 vs 10/45, P=0.5). CONCLUSION: Bleeding risk of BPO surgery in patients with mechanical cardiac valve is high. The PVP seems to decrease significantly the early haemorrhagic risk compared to classic surgical procedures for patients with mechanical cardiac valve. LEVEL OF EVIDENCE: 4.

[Serious and unexpected complications of benign prostatic obstruction surgery: Results of the LUTS Committee survey from urologists of the French Urological Association]. / Complications graves et inattendues de la chirurgie de l'hyperplasie bénigne de prostate : résultats de l'enquête du CTMH auprès des urologues de l'AFU.

PURPOSE: Rare and severe complications of benign prostatic hyperplasia (BPH) surgery are poorly documented in the literature. Our purpose was to make an inventory of severe and unexpected complications of BPH faced by urologists of the French Association of Urology (AFU). MATERIAL AND METHODS: A declarative 13-question survey was sent by e-mail 2 months before the 108th French Congress of Urology to the urologist's members of the AFU. Complications were split in complications due to material and complications directly related to the surgery. RESULTS: Overall, 216 (16.2%) urologists surveyed but only 85 forms were usable. Complications related to the material was divided into: excessive temperature of the serum irrigation leading to urethral and bladder burns (n=5), material default leading to interruption of the procedure (n=1) or incomplete hemostasis (n=2) and endoscope rupture (n=1). Peroperative complications related to surgery were divided into surgical complications: haemorrhage (n=7), urethral wounds (n=6), perforation and/or explosion (n=16), rectal wounds (n=11), obstructive renal failure (n=1); and medical complications: TURP syndrome (n=2), cardiovascular (n=5) and septic shock (n=6). CONCLUSION: This is the first French declarative study having allowed the identification of severe and unexpected complications of BPH surgery. The recorded occurred complications were very eclectic and secondary to all types of techniques used.

[Negative effects on sexual function of medications for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia]. / Effets négatifs sur la sexualité des traitements médicamenteux des symptômes du bas appareil urinaire liés a l'hypertrophie bénigne de la prostate.

PURPOSE: The aim of this review is to discuss the negative effects on sexual function of medications for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS-BPH). METHODS: An international non-systematic literature review was performed. It included randomized trials of seven drugs of interest and the summaries of the characteristics of these products. This work did not aim comparison between the drugs. RESULTS: Only maximal reported frequencies are presented in this abstract. With prolonged-release alfuzosin, they were 2.8% vs. 1.3% for erectile dysfunction, compared to placebo and 1% vs. 0% for ejaculatory dysfunction. With doxazosin, the incidence was 5.8% vs. 3.3% for erectile dysfunction, 3.6% vs. 1.9% for reduced libido and 0.4% vs. 1.4% for ejaculatory disorders. The incidence of ejaculatory disorders with tamsulosin, was 11% vs. <1% with the placebo and with silodosin, it was 28.1% vs. 1.1%. With finasteride, at 12 months, the highest frequency was 9% vs. 5% for erectile dysfunction, 4.4% vs. 1.5% for ejaculatory disorders and 6.4% vs. 3.4% for reduced libido. At 24 months, for dutatsteride, frequencies were 7.3% vs. 4.0% for erectile dysfunction, 2.2% vs. 0.8% for ejaculatory disorders and 4.2% vs. 2.1% for reduced libido. For tadalafil, a phosphodiesterase-5 inhibitor, and tolerodine, an anticholinergic drug, no negative effect on ejaculation or libido has been reported. For plant extracts, no sexual adverse effects (AEs) were reported among the most common AEs. CONCLUSION: The medications for LUTS-BPH may alter erection, ejaculation or libido. A greater knowledge of the adverse effects of each of these drugs could guide physicians in the clinical management of men with BPH-LUTS.

[Clinical impact of the intravesical prostatic protrusion: a review by the LUTS committee of the French Urological Association]. / Impact en pratique clinique de l'indice de protrusion prostatique intravésicale: une revue de la littérature du CTMH de l'AFU.

INTRODUCTION: Intravesical prostatic protrusion (IPP) is a protrusion of the lateral and/or median prostatic lobes into the bladder lumen. IPP can be estimated by suprapubic ultrasound. METHODS: A literature search was conducted in Pubmed/MEDLINE database using the following keywords: intravesical prostatic protrusion; benign prostatic enlargement; treatment outcome; ultrasonography. RESULTS: There are 3 grades of IPP: grade 1, 2 and 3 respectively if IPP ≤ 5mm, if 5-10mm, and if >10mm. IPP was a better prognosis factor than PSA and prostate volume for bladder outlet obstruction (BOO) with a sensibility of 80% and a sensitivity of 68% for grade 3. The progression risk of BOO increased with IPP (grade 1: OR=5.1 [95%CI: 1.6-16.2] and grade ≥ 2 OR=10.4 [95%CI: 3.3-33.4]). IPP was a predictive marker of failure of trial off catheter in patients with acute urinary retention with a 6 folds higher risk for grades ≥ 2. IPP was a prognosis factor for tamsulosine efficacy: 78% of patients with grade ≤ 2 had an improvement >35% of the IPSS-score versus 58% for grade >3 (P<0.01). Patients with grade >3 and a PV< 40cc had a poorer response to tamsulosine. After TURP, IPSS was more improved for grade ≥ 1 with an OR=3.43 (95%CI: 1.03-11.44, P=0.045). CONCLUSION: IPP can be a useful marker for the management of LUTS/BPH.

[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.

[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.

[Medical treatment of BPH]. / Traitement médical de l'hyperplasie bénigne de prostate.

Four therapeutic classes can be used for the treatment of BPH: alphablockers, 5 alpha reductase inhibitors (5ARI), muscrinic receptor antagonists, and plant extracts. Two combination therapies have been proven to be efficient: 5ARI - alphablockers, and muscarinic receptor antagonists - alphablockers. Alphablockers have the advantage to be efficient quickly. 5ARI decrease prostate volume. Efficacy of plant extracts is still discussed, but their tolerance is excellent. Muscrinic receptor antagonists can be a viable treatment option for men with predominantly bladder storage symptoms but without bladder outlet obstruction.

[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.

[Study of urinary continence after radical prostatectomy. Comparison between laparoscopic and retropubic prostatectomy based on a series of 251 cases]. / Etude de la continence urinaire après prostatectomie radicale. Comparaison entre prostatectomie rétropubienne et coelioscopique à propos de 251 cas.

INTRODUCTION: The objective of this study was to compare the results in terms of continence and quality of life between retropubic radical prostatectomy and laparoscopic radical prostatectomy, performed according to the same principle of retrograde dissection from the apex. MATERIAL AND METHOD: The series was composed of 120 patients undergoing retropubic radical prostatectomy and 131 patients undergoing laparoscopic radical prostatectomy performed in the Limoges hospital, urology and andrology department, between January 2002 and September 2005. Continence was evaluated by anonymous self-administered questionnaire sent to the patient's home. Pain was evaluated by visual analogue scale and narcotic consumption. Predictive factors of continence were analysed. RESULTS: The two groups were comparable in terms of pathological stage, Gleason score and age. The laparoscopy group comprised more patients with a history of transurethral resection of the prostate and more obese patients. No significant difference was observed between laparoscopy and laparotomy for degree of continence (71% versus 76%; p>0.05), time to return of continence (13 weeks versus nine weeks; p>0.05) and rate of mild (14% versus 13%), moderate (7% versus 6%) and severe (7% versus 5%) urinary incontinence. The anastomosis secondary stenosis rate was also identical in the two groups. Age was found to be a predictive factor for continence, especially for the mean time to return periods of continence. The patient's weight, prostate weight and TNM stage were not predictive factors for incontinence. The incontinence rate was 40% for salvage prostatectomies after radiotherapy. The mean duration of bladder catheterization was 6.9 days in the laparoscopy group and 7.2 days in the laparotomy group. Narcotic consumption was significantly lower in the laparoscopy group (21 mg versus 36 mg; p<0.05). CONCLUSION: Laparoscopic radical prostatectomy appears to give the same results in terms of continence as retropubic radical prostatectomy. However, these procedures were the first laparoscopic prostatectomies performed in the department, suggesting that, with greater experience, the results of laparoscopy could become superior to those of laparotomy. The laparoscopic technique also appeared to provide better patient comfort by decreasing postoperative pain.