Accuracy of the preoperative PSA level for predicting clinically significant incidental transitional zone-prostate cancer before endoscopic enucleation of very large adenoma.

OBJECTIVE: To analyse the accuracy of high preoperative PSA levels for predicting transitional zone incidental PCa (TZ-PCa) in men with very large prostates. MATERIALS AND METHODS: Perioperative data from 375 consecutive patients who underwent endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction between July 2013 and December 2018 were retrospectively reviewed. Patients were stratified into three groups according to the preoperative PSA level: low-PSA (< 4 ng/mL), intermediate-PSA (4 ≤ PSA < 10 ng/mL) and high-PSA (≥ 10 ng/mL). Men in each group were propensity score matched by age, 5α-reductase inhibitor (5-ARI) use, prostate volume and mpMRI. The TZ-PCa incidence rate was retrospectively compared by preoperative PSA level in a propensity score model including all predetermined variables. RESULTS: Age, prostate volume, 5-ARI use were similar between patient groups. The median PSA levels in the low-, intermediate- and high-PSA groups were 3 [2.3; 3.4], 6.6 [5.3; 8.1] and 12.7 [11; 16.7] ng/mL, respectively. The median prostate volume was > 100 grams in all groups (108, 105 and 120 cc, respectively). The T1a-Gleason 6 incidental TZ-PCa rate was statistically comparable between the three groups (3.4, 5.1 and 8.6% in the low-, intermediate- and high-PSA groups, respectively). The detection rate of clinically significant TZ-PCa was low for preoperative PSA levels > 4 ng/mL (1.7%); with no difference between the intermediate- and high-PSA groups. CONCLUSION: In men with large glands, the clinically significant incidental TZ-PCa detection rate was similar regardless of the preoperative PSA level stratum. Such details may help with patient counselling during BPH surgical management.

Does mechanical morcellation of large glands compromise incidental prostate cancer detection on specimen analysis? A pathological comparison with open simple prostatectomy.

OBJECTIVE: This study sought to compare the incidental prostate cancer (iPCa) detection rate between pathological specimens from green laser enucleation of the prostate (GreenLEP) and open simple prostatectomy (OSP). MATERIALS AND METHODS: In two institutions, the charts of all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and the data of all consecutive patients who underwent GreenLEP with tissue morcellation between July 2013 and January 2018 were also collected. Preoperative demographics and pathological findings were recorded. iPCa detection rate was retrospectively compared between the GreenLEP and OSP groups in a propensity score model, including all predetermined variables: Age, preoperative PSA level and prostate volume. RESULTS: Of 738 patients, 402 were included in the propensity-score matching analysis, and they were equally distributed among groups. The overall iPCa detection rates were similar in both groups (9.9% vs. 8.5%; p = 0.73), and there were no statistically significant differences in terms of tumour stage, Gleason score or the rate of clinically significant iPCa, although the number of cassettes analysed was significantly higher in the morcellation group than in the OSP group. No predictive factors for iPCa were identified. CONCLUSIONS: The results of the present study suggest that the mechanical morcellation of large glands had no influence on iPCa detection. Compared with a specimen from standard OSP, a large morcellated tissue sample allows adequate pathological evaluation and does not alter a pathologist's ability to detect iPCa.

Comparison between open simple prostatectomy and green laser enucleation of the prostate for treating large benign prostatic hyperplasia: a single-centre experience.

PURPOSE: This study sought to compare perioperative outcomes and morbidities for open simple prostatectomy (OSP) and endoscopic green laser enucleation of the prostate (GreenLEP). METHODS: In a single department, all consecutive patients who underwent OSP between January 2005 and December 2010 were retrospectively reviewed, and all consecutive patients undergoing GreenLEP between July 2013 and January 2017 were prospectively enrolled. Perioperative data, information regarding early postoperative complications for up to 6 months and outcomes were collected and retrospectively compared. RESULTS: Overall, 204 patients were enrolled in each group. The baseline characteristics of patients in both groups were comparable. Intraoperative time was significantly longer for the OSP group than for the GreenLEP group (67 versus 60 min; p < 0.0001). The OSP group had significantly longer catheterisation (5 versus 2 days; p < 0.0001) and hospitalisation times (7 versus 2 days; p < 0.0001) than the GreenLEP group. The overall rate of complications was significantly higher after OSP than after GreenLEP (37.2 versus 20.6%; p = 0.0003); both Clavien-Dindo grade 3a complications (8.8 versus 0.98%) and Clavien-Dindo grade 3b complications (2.4 versus 3.4%) were observed. The transfusion rate was higher after OSP than after GreenLEP (8.3 versus 0.5%; p = 0.0001). The rehospitalisation rate was similar for both groups (7.8 versus 8.3%; p = 0.99). CONCLUSIONS: The results of this single-centre cohort study confirm those of similar prior investigations addressing endoscopic enucleation of the prostate. Compared with OSP, GreenLEP may have a more desirable perioperative profile with lower morbidity. In contrast, GreenLEP and OSP were associated with similar 6-month rehospitalisation rates.

Efficacy and safety of the first and repeated intradetrusor injections of abobotulinum toxin A 750 U for treating neurological detrusor overactivity.

PURPOSE: To assess clinical and urodynamic efficacy of the first and repeated intradetrusor injections of abobotulinum toxin A (Dysport(®), Ipsen(®), France) in patients with neurogenic detrusor overactivity (NDO) refractory to anticholinergic treatment. METHODS: A single-center retrospective study was conducted in 81 consecutive patients who had never received any botulinum toxin intradetrusor injections. They were treated with at least one 750 U intradetrusor injection of abobotulinum toxin A. All patients performed clean intermittent self-catheterization (CIC) before injections. Success was defined as a combination of no incontinence episode, a number of catheterization <8 reported in a 3-day bladder diary and the lack of detrusor overactivity. RESULTS: Six weeks after the first injection, the success rate was 64.2 %. The proportion of continent patients was 80.2 %, the mean number of CIC per 24 h reduced (-3.55, p < 0.0001) and the mean catheterization volume increased (+237.3 ml, p < 0.0001). Regarding urodynamics, mean maximum cystometric capacity and mean volume at the first uninhibited contraction increased (+132.7 ml, p < 0.0001 and +180 ml, p < 0.0001, respectively) and mean maximum bladder pressure decreased significantly (-21.5 cm H2O, p < 0.0001). Mean reinjection number was 3.9 and mean interval between reinjection was 8.8 ± 3 months. The clinical efficacy rate after each reinjection (up to fourteen) was at least 86.7 %. Out of 55 patients who underwent repeated injections, secondary resistance was noted in 2 (3.6 %). CONCLUSION: The results of the present study are in favor of a long-term safety and efficacy of abobotulinum toxin A 750 U for NDO.

Preliminary results of botulinum toxin A switch after first detrusor injection failure as a treatment of neurogenic detrusor overactivity.

AIMS: To assess the results of onabotulinum toxin detrusor injections when abobotulinum toxin detrusor injection failed. METHODS: Twenty-six patients, 15 women and 11 men, mean age 40.8 ± 12.7 years old, in whom a first injection of 750 U abobotulinum toxin in 20 sites failed in treating neurogenic detrusor overactivity, received onabotulinum toxin 300 U detrusor injections in 30 sites. Neurologic conditions were spinal cord injury in 14 cases, multiple sclerosis in nine, myelomeningocele in two and myelitis in one. Mean time between the two injections was 5.6 ± 1.4 months. Before and 6 weeks after each injection, patients carried out a 3-day bladder diary and had urodynamics. The success was defined as the combination of a clean intermittent self-catheterization number under 8 per 24 hr, urgency, urinary incontinence and detrusor overactivity relief. RESULTS: Out of 26 patients, the second injection was successful in 15 (57.7%). While the first injection of 750 U abobotulinum toxin had no impact at all, after 300 U onabotulinum toxin injection, the number of clean intermittent self-catheterization decreased significantly (11.3 ± 2.1 vs. 6.4 ± 1.9, P = 0.01), 17/26 (65.4%) patients achieved continence, urgency was relieved in 18/26 (69.2%) and detrusor overactivity in 15/26 (57.7%). CONCLUSIONS: In case of failure after a first detrusor injection of abobotulinum toxin, switching for onabotulinum toxin is efficient. Further investigations should be performed to assess whether the replacement of onabotulinum toxin by abobotulinum toxin provides the same results.

Urinary complications and risk factors in symptomatic multiple sclerosis patients. Study of a cohort of 328 patients.

AIMS: Lower urinary tract dysfunctions (LUTD) are very common in Multiple Sclerosis (MS), have a significant social impact, while the organic impact is discussed. We studied urinary complications and their risk factors in our cohort of MS patients, in order to improve the management of LUTD in MS. METHODS: Between 2004 and 2009, all patients affected by MS and managed for LUTD were included in a retrospective study. We studied the epidemiological data (age, gender), the clinical data (duration of MS, EDSS score, progression of MS) and the paraclinical data (urinary creatinine clearance, urine culture, urinary tract ultrasonography and in some cases urodynamic assessment and cystography). We then identified the urinary complications and their risk factors. RESULTS: Three hundred twenty eight patients, mean age 49.9 ± 12.3 years, with a MS for 14.3 ± 10 years on average and with a median EDSS score equal to 6 (1-9), were managed for LUTD. One hundred seventy eight (54%) patients developed one or more urinary complications. We identified duration of MS greater than 8.5 years and an EDSS above 7 as risk factors. CONCLUSION: Urinary complications are common in symptomatic MS, these results imply screening and specialized care to limit the impact on the quality of life but also to prevent urinary complications.

Assessment of the learning curves for photoselective vaporization of the prostate using GreenLight™ 180-Watt-XPS laser therapy: defining the intra-operative parameters within a prospective cohort.

PURPOSE: To assess the learning curves for the intra-operative parameters of the GreenLight™ 180-W XPS for photoselective vaporization of the prostate (PVP). METHODS: A prospective study was conducted on 200 men who underwent PVP using the GreenLight™ 180-W XPS over 20 months. The population was divided into four consecutive equal groups. Evolution of lasing parameters was the main endpoint to reach an average energy of 5 kJ per prostate volume and to reach a lasing time/operative time (LT/OT) ratio of 66-80 %. Changes in the IPSS and prostate volume were also evaluated 12 weeks later. RESULTS: Total energy delivered (energy/ml of prostate) and the LT/OT ratio significantly increased over time (p < 0.05). Urinary function significantly improved from baseline in all groups. The first lasing parameter endpoint was reached after the 75th patient (group 1) and the second endpoint (LT/OT ratio) after the 125th patient (group 3). Only the PSA level (p = 0.04) and prostate volume (p < 0.0001) decreased significantly in the 3rd and the 4th group. Post-operative complications occurred in 20 % of patients, which were primarily Clavien-Dindo grades 1 and 2, though there were no statistical differences between the four groups (p = 0.62). In-hospital stay and time to catheter removal were significantly shorter in the 3rd and 4th group. CONCLUSIONS: The current study assessed the PVP learning curves within multiple intra-operative parameters. The PVP learning curves required at least 120 procedures until it met all intra-operative parameters of experts in this field.

Robot-assisted Partial Nephrectomy for Hilar and Nonhilar Renal Masses: Comparison of Perioperative, Oncological, and Functional Results in a Multicentre Prospective Cohort (NEPRAH Study, UroCCR 175).

BACKGROUND AND OBJECTIVE: A hilar location for a renal tumour is sometimes viewed as a limiting factor for safe partial nephrectomy. Our aim was to evaluate perioperative, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) for hilar tumours (RAPN-H) in comparison to RAPN for nonhilar tumours (RAPN-NH). METHODS: We conducted an observational, multicentre cohort study using prospectively collected data from the French Research Network on Kidney Cancer (UroCCR). The registry includes data for 3551 patients who underwent RAPN for localised or locally advanced renal masses between 2010 and 2023 in 29 hospitals in France. We studied the impact of a hilar location on surgery, postoperative renal function, tumour characteristics, and survival. We also compared rates of trifecta achievement (warm ischaemia time [WIT] <25 min, negative surgical margins, and no perioperative complications) between the groups. Finally, we performed a subgroup analysis of RAPN without vascular clamping. Variables were compared in univariable analysis and using multivariable linear, logistic, and Cox proportional-hazards models adjusted for relevant patient and tumour covariates. KEY FINDINGS AND LIMITATIONS: The analytical population included 3451 patients, of whom 2773 underwent RAPN-NH and 678 underwent RAPN-H. Longer WIT (ß = 2.4 min; p < 0.01), longer operative time (ß = 11.4 min; p < 0.01) and a higher risk of postoperative complications (odds ratio 1.33; p = 0.05) were observed in the hilar group. Blood loss, the perioperative transfusion rate, postoperative changes in the estimated glomerular filtration rate, and trifecta achievement rates were comparable between the groups (p > 0.05). At mean follow-up of 31.9 mo, there was no significant difference in recurrence-free survival (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.58-1.2; p = 0.3), cancer-specific survival (HR 1.1, 95% CI 0.48-2.6; p = 0.79), or overall survival (HR 0.89, 95% CI 0.52-1.53; p = 0.69). CONCLUSIONS AND CLINICAL IMPLICATIONS: Patient and tumour characteristics rather than just hilar location should be the main determinants of the optimal surgical strategy for hilar tumours. PATIENT SUMMARY: We found that kidney tumours located close to major kidney blood vessels led to a longer operation and a higher risk of complications during robot-assisted surgery to remove the tumour. However, tumours in these locations were not related to a higher risk of kidney function loss, cancer recurrence, or death.

Preparing for the Worst: Management and Predictive Factors of Open Conversion During Minimally Invasive Renal Tumor Surgery (UroCCR-135 Study).

Background and objective: Data regarding open conversion (OC) during minimally invasive surgery (MIS) for renal tumors are reported from big databases, without precise description of the reason and management of OC. The objective of this study was to describe the rate, reasons, and perioperative outcomes of OC in a cohort of patients who underwent MIS for renal tumor initially. The secondary objective was to find the factors associated with OC. Methods: Between 2008 and 2022, of the 8566 patients included in the UroCCR project prospective database (NCT03293563), who underwent laparoscopic or robot-assisted minimally invasive partial (MIPN) or radical (MIRN) nephrectomy, 163 experienced OC. Each center was contacted to enlighten the context of OC: "emergency OC" implied an immediate life-threatening situation not reasonably manageable with MIS, otherwise "elective OC". To evaluate the predictive factors of OC, a 2:1 paired cohort on the UroCCR database was used. Key findings and limitations: The incidence rate of OC was 1.9% for all cases of MIS, 2.9% for MIRN, and 1.4% for MIPN. OC procedures were mostly elective (82.2%). The main reason for OC was a failure to progress due to anatomical difficulties (42.9%). Five patients (3.1%) died within 90 d after surgery. Increased body mass index (BMI; odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, p = 0.009) and cT stage (OR: 2.22, 95% CI: 1.24-4.25, p = 0.008) were independent predictive factors of OC. Conclusions and clinical implications: In MIS for renal tumors, OC was a rare event (1.9%), caused by various situations, leading to impaired perioperative outcomes. Emergency OC occurred once every 300 procedures. Increased BMI and cT stage were independent predictive factors of OC. Patient summary: The incidence rate of open conversion (OC) in minimally invasive surgery for renal tumors is low. Only 20% of OC procedures occur in case of emergency, and others are caused by various situations. Increased body mass index and cT stage were independent predictive factors of OC.

Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience.

PURPOSE: Adrenocortical carcinoma (ACC) is a rare and clinically aggressive cancer. Previous studies reported increased recurrence rates associated with laparoscopic adrenalectomy (LA). We evaluated a single-center experience of LA versus open adrenalectomy (OA) for the management of ACC. METHODS: Between 1993 and 2011, 44 consecutive patients with primary ACC were treated at our institution. Baseline patient characteristics and surgical and pathological outcomes were compared between OA and LA groups. Multivariable Cox proportional hazards analysis was used to estimate the association between OA versus LA with recurrence-free and overall survival. RESULTS: Eighteen and 26 patients underwent LA and OA, respectively. Patients who underwent OA had larger tumors and more advanced clinical stage compared with LA group. During a median follow-up of 22 months, 22 recurrences and 26 deaths were observed. The 2-year, recurrence-free and overall survivals for OA and LA were 60 vs. 39 % (P = 0.7) and 54 vs. 58 % (P = 0.6), respectively. After adjusting for clinical stage, OA was associated with lower risk of recurrence (hazard ratio (HR) 0.4; 95 % confidence interval (CI) 0.2-1.2; P = 0.099) and improved overall survival (HR 0.5; 95 % CI 0.2-1.2; P = 0.122) compared with LA, although differences were not statistically significant. CONCLUSIONS: A nonstatistically significant increase in recurrence and death was observed among patients undergoing LA versus OA after adjusting for clinical stage. The rarity of this disease limits the ability to assess for significant differences in a single-institution series. Patients with suspected ACC should be considered for OA.

Impact of lymphovascular invasion on oncological outcomes in patients with upper tract urothelial carcinoma after radical nephroureterectomy.

OBJECTIVES: To assess the impact of lymphovascular invasion (LVI) on upper urinary tract urothelial carcinomas (UTUCs) in a multicentre study on cancer-specific survival (CSS), recurrence-free survival and metastasis-free survival (MFS). To show the negative impact of LVI for patients with pN0/x disease and to stratify these patients into risk groups for metastatic relapse. PATIENTS AND METHODS: A multicentre retrospective study was performed on patients who underwent radical nephroureterectomy between 1995 and 2010. LVI status was evaluated as a prognostic factor for survival using univariate and multivariate Cox regression analysis. RESULTS: Overall, 551 patients were included and were divided into two groups: those without LVI (LVI-), n = 388 and those with LVI (LVI+), n = 163. LVI+ status was associated with high stage and grade UTUC and lymph node metastasis (P < 0.001). The 5-year CSS and MFS rates were significantly worse in the LVI+ group than in LVI- group (52.2 vs 84.5%, P < 0.001 and 43.8 vs 82.7%, P < 0.001, respectively). In multivariate analysis, LVI+ status was an independent prognostic factor for CSS and MFS (P = 0.04 and P < 0.001). These findings were confirmed for the pN0/x patient subgroup (n = 504, P < 0.001). In the pN0/x patient subgroup, we described a prognostic tool for MFS based on independent factors that permitted us to stratify patients into groups of high, intermediate or low risk of metastasis relapse. CONCLUSIONS: The presence of LVI was a strong predictor of a poor outcome for UTUC. When a lymphadenectomy has not been achieved, the report of LVI status is crucial to identfiy those patients at higher risk for metastatic relapse.

Assessment of oncologic control obtained after open versus laparoscopic nephroureterectomy for upper urinary tract urothelial carcinomas (UUT-UCs): results from a large French multicenter collaborative study.

BACKGROUND: The purpose of this study was to compare the postsurgical survival of UUT-UC patients treated with ONU and LNU. METHODS: Using a multi-institutional, national, retrospective database, we identified patients with UUT-UC who underwent radical nephroureterectomy by open access (ONU) or by the minimally invasive alternative (LNU). Survival curves were estimated using Kaplan-Meier method. A multivariate Cox model was used to evaluate the association between surgical approach and disease recurrence. RESULTS: Overall, 609 patients were included (ONU = 459 and LNU = 150). The median age was 69.8 years (range 61.9-76), and the male-to-female ratio was 2:1. Postoperative complications occurred in 80 patients, with no significant difference between ONU and LNU on the whole (P = 0.64). The median follow-up was 27 months. There was no difference between the 2 procedures in the 5-year CSS or 5-year RFS. Moreover, the 5-year CSS (P = 0.053) and 5-year RFS (P = 0.9) for cases with locally advanced disease (pT3/pT4) were similar between ONU and LNU. In the multivariate analysis, the surgical procedure used was not found to be associated with survival. The main limitation of the study is its retrospective design, which is the result of the rarity of the disease. CONCLUSIONS: There is no evidence that oncological outcomes for LNU are inferior to those for open surgery, provided that the appropriate precautionary measures are taken.

Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study.

UNLABELLED: What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT-UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the 'gold-standard' treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT-UCs. Due to the paucity of cases of UUT-UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi-institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5-year probability of cancer-specific survival, recurrence-free survival and metastasis-free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases. OBJECTIVE: To compare recurrence-free survival (RFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT-UC) located in the ureter. PATIENTS AND METHODS: We performed a multi-institutional retrospective review of patients with UUT-UC who had undergone RNU or SU between 1995 and 2010. Type of surgery, Tumour-Node-Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival. RESULTS: In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow-up was 26 (10-48) months. The 5-year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P = 0.99); 37% and 47.9%, respectively (P = 0.48); 81.9% and 85.4%, respectively (P = 0.51). In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P = 0.94, 0.42 and 0.53, respectively). In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P = 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P = 0.001, 0.04, 0.009 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of the disease. CONCLUSIONS: Short-term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases and should be considered an option. In every other case, RNU still represents the 'gold standard' for the treatment of UUT-UC.

Access techniques, platforms and instruments for LESS.

OBJECTIVES: To summarize the available tools available for performing LaparoEndoscopic Single-Site surgery in Urology. METHOD: A comprehensive electronic literature search was conducted in May 2011 using the Medline database to identify all publications relating to NOTES and LESS in urology and information on devices were also obtained by accessing company Websites. RESULTS: Multiple access ports are available and allow to insert several instruments through multiple channels inside a larger single port. Due to lack of triangulation intracorporally, companies developed various articulating and bent instruments, limiting clashing and allowing increased working space. The ideal endoscope for LESS should remove the light cord and camera head from the operative field. Articulating and low profile scopes are now available. Furthermore, surgeons can use extra-long scopes. CONCLUSION: Various tools currently are available for single-site surgery. Randomized studies are needed to determine the Platform selection.

Prospective study of the impact on quality of life of cystectomy with ileal conduit urinary diversion for neurogenic bladder dysfunction.

OBJECTIVES: Neurogenic bladder dysfunction has a negative impact on the patient's quality of life (QoL). Cystectomy with ileal conduit urinary diversion is a treatment option in patients in failure after conservative management. The objective of this study was to evaluate the impact of ileal conduit urinary diversion on the QoL of patients with neurogenic bladder dysfunction. MATERIALS AND METHODS: From March 2004 to November 2010, 48 patients (36 women and 12 men with a mean age of 50.6 ± 11.8 years) treated by cystectomy with ileal conduit urinary diversion for neurogenic bladder dysfunction, prospectively completed, before and after surgery, two self-administered QoL questionnaires. Neurological diseases were multiple sclerosis in 38 cases, spinal cord injury in 7 cases, and other neurological disease in 3 cases. Cystectomy was performed by laparoscopy in all patients. QoL was measured by using two self-administered questionnaires, one questionnaire specific for urinary disorders validated in neurological patients, Qualiveen®, and the generic SF36-v2® questionnaire. Data were compared by Student's t test. RESULTS: Comparison of the Qualiveen® self-administered questionnaire scores and indices before and after surgery showed that, after surgery, patients presented a significant reduction of limitations (0.57 ± 0.64 vs. 1.55 ± 1.35, P < 0.001), constraints (2.12 ± 0.83 vs. 2.64 ± 1.12, P = 0.046) scores and the SIUP index (1.29 ± 0.65 vs. 1.79 ± 0.95, P = 0.015). No significant change in SF36-v2® scores was observed postoperatively. CONCLUSIONS: Ileal conduit urinary diversion improves the urinary QoL of patients with neurogenic bladder dysfunction by decreasing limitations and constraints induced by urinary disorders, but has no impact on general QoL.

Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study.

PURPOSE: The efficacy of sacral neuromodulation for treating refractory idiopathic lower urinary tract dysfunction is now well established. Nevertheless, results of this technique in neurological patients are still controversial. The aim of this retrospective study was to assess the results of sacral neuromodulation in neurogenic bladder dysfunction. MATERIALS AND METHODS: Between 1998 and 2008, a percutaneous nerve evaluation or a two-stage technique was performed in 62 patients (mean age 50.5 ± 14.8 years) with neurogenic lower urinary tract dysfunction. Before and during the temporary stimulation, each patient had a urodynamic evaluation and performed a bladder diary. The test was considered positive if the clinical and urodynamic improvement was over 50% and if the symptoms reappeared after turning the stimulation off. RESULTS: Lower urinary tract dysfunction was detrusor overactivity in 34 cases and chronic urinary retention in 28 cases. A detrusor-sphincter dyssynergia (DSD) was associated in nine cases. Out of the 62 patients, 41 patients (66.1%) had more than 50% improvement on urodynamic evaluation and bladder diary and 37 were implanted. With a mean follow-up of 4.3 ± 3.7 years, results remained similar to the evaluation phase in 28 cases (75.7%), were partially altered in three cases (8.1%) and lost in six cases (16.2%). In these six cases, neuromodulation failed on average 12.0 ± 12.4 months after implantation. CONCLUSION: Sacral neuromodulation seems to constitute a serious therapeutic option for patients with neurogenic lower urinary tract dysfunction. However, its results depend on the type of the underlying neurologic disease and in particular, whether it may progress or not.

Risk of urinary tract infection after detrusor botulinum toxin A injections for refractory neurogenic detrusor overactivity in patients with no antibiotic treatment.

OBJECTIVE: To determine if antibiotic prophylaxis is required for intradetrusor botulinum toxin A (BoNT-A) injections. PATIENTS AND METHODS: This was a prospective non-randomized study. Inclusion criteria were adult patients with neurogenic detrusor overactivity who failed anticholinergic-based first-line treatment and had sterile urine culture 7 days before injections, a negative dipstick test on the day of the injections, and were performing clean intermittent self-catheterization. Injections were performed using a rigid cystoscope, under local anaesthetic. Patients received BoNT-A as either Botox® (Allergan Inc., Irvine, CA, USA) 300 U in 30 sites or Dysport® (Ipsen Ltd, Ipsen, Paris, France) 750 U in 20 sites. Urine culture was done 6 days and 6 weeks after the injections. If urinary tract infection (UTI) was suspected, a physician performed a complete physical examination. The primary outcome criterion was the occurrence of UTI during the first week after injections. RESULTS: In all, 42 patients (22 women, 20 men) with a mean (sd) age 45.3 (16.4) years were included. A symptomatic UTI occurred during the first week after the injections in three patients (7.1%). The urinary colonization rate was 31% and 26% at 6 days and 6 weeks after injection, respectively. The most common bacterium was Escherichia coli (62.5%). There were no differences between 20 and 30 injection sites or between the sexes. CONCLUSION: The rate of UTI after intradetrusor injections of BoNT-A was 7.1%. The most frequent bacterium involved was Escherichia coli. These results indicate that antibiotic prophylaxis for intradetrusor BoNT-A injections seems necessary.

Radical cystectomy for bladder cancer: morbidity of laparoscopic versus open surgery.

PURPOSE: We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. MATERIALS AND METHODS: This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. RESULTS: Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. CONCLUSIONS: Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Comparison of Outcomes Obtained After Regular Surgery Versus Live Operative Surgical Cases: Single-centre Experience with Green Laser Enucleation of the Prostate.

BACKGROUND: Live surgery remains controversial. Although it may improve surgical training and accelerate the dissemination of technical steps of surgical procedures, controversy exists regarding patient safety in live surgery. OBJECTIVE: To compare the perioperative outcomes of "en bloc" green laser enucleation of the prostate (GreenLEP) performed in workshops during live case demonstration (LCD) and in standard conditions (SCs). DESIGN, SETTING, AND PARTICIPANTS: Between June 2015 and January 2017, all consecutive patients who underwent GreenLEP for benign prostatic obstruction performed by a single surgeon were prospectively enrolled. Perioperative data and early postoperative complications according to Clavien-Dindo classification were collected. Workshop programmes started locally according to the European Association of Urology policy on live surgical events in June 2015 to enrol small groups of urologists in the GreenLEP technique. INTERVENTION: Endoscopic enucleation of the prostate using a GreenLight fibre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Outcomes were compared between the LCD and SC groups. RESULTS AND LIMITATIONS: Of the 126 performed procedures, 37 were performed live during 17 LCDs with a median attendee number of 3. The patients' baseline characteristics were similar in both groups. Intraoperative parameters were comparable: total energy of 62 [53; 77] versus 56kJ [44; 69] (p=0.068), operative time of 61 [53; 71] versus 55min [45; 66] (p=0.1), and morcellating time of 3 [3; 5] versus 4min [2; 6] (p=0.82) in the LCD versus SC group. The catheterisation time (2d [1; 2]) and length of hospital stay (2d [2; 3]) were similar. The overall complication rate was comparable in the LCD (18.9%) and SC (24.7%) groups (p=0.64). Preoperative parameters significantly improved from baseline without any significant differences between the two groups. Limitations included a small number of attendees/workshop, and case selections were made by the surgeon himself. CONCLUSIONS: GreenLEP was safe and provided satisfactory functional outcomes in both conditions. From this preliminary study, it seems that LCD did not jeopardise the surgeon's skill or technique. Similar studies are required to further assess patient safety and outcomes associated with live surgical events. PATIENT SUMMARY: According to the surgeon expertise, endoscopic enucleation of the prostate performed during live case demonstration provided similar functional outcomes to that performed in standard condition and could therefore be considered a safe potential educational tool.

[Laparoscopic cystectomy and transileal ureterostomy for neurogenic vesicosphincteric disorders. Evaluation of morbidity]. / Cystectomie laparoscopique et urétérostomie transiléale pour troubles vésico-sphinctériens d'origine neurologique. Evaluation de la morbidité.

OBJECTIVES: To evaluate the morbidity and mortality of laparoscopic cystectomy combined with transileal ureterostomy to treat neurogenic vesicosphincteric disorders. MATERIAL: Prospective study performed between february 2004 and april 2006 on 26 consecutive patients with a mean age of 55.0 +/- 12.7 years treated by laparoscopic cystectomy for neurogenic vesicosphincteric disorders. The underlying neurological disease was multiple sclerosis (MS) in 20 cases, spinal cord injury in 4 cases and transverse myelitis in 2 cases. The median preoperative ASA score was 3 (range: 2-3). RESULTS: No open conversion was necessary. One intraoperative complication was observed (vascular injury). No perioperative death was observed. The nasogastric tube was maintained postoperatively for an average of 8.69 +/- 5.9 hours. The mean time to resumption of oral fluids was 1.4 +/- 0.7 days and mean time to resumption of solids was 2.6 +/- 1.0 days. The mean time to resumption of bowel movements was 3.8 +/- 3.2 days. The mean intensive care stay was 3.9 +/- 1.1 days. Two postoperative complications were observed in the same patient (ileus and bronchial congestion). Postoperative narcotic analgesics were necessary in 60% of cases. The mean hospital stay was 10.3 +/- 4.1 days. Two late postoperative complications were observed in the same patient (two episodes of pyelonephritis). CONCLUSION: Laparoscopic cystectomy has a low morbidity in neurological patients, allowing early return of feeding and a moderate length of hospital stay.