[Efficacy and safety of available therapies in the management of idiopathic overactive bladder: A systematic review of the literature]. / Hyperactivité vésicale idiopathique : efficacité et tolérance des traitements pharmacologiques : revue de la littérature.

OBJECTIVE: Study the efficacy and adverse events of different pharmacological lines in the treatment of idiopathic overactive bladder (iOAB). METHODS: PubMed research on meta-analyses and randomized controlled trials (RCT) focused on the efficacy and adverse effects of anticholinergics, botulinum toxin and mirabegron since 2005. RESULTS: Ten meta-analyses of anticholinergics were selected; 16 randomized controlled trials (ERC) comparing botulinum toxin A to either anticholinergic or placebo and 10 ERC studying mirabegron. All the molecules studied showed efficacy compared to placebo in the treatment of iOAB. Anticholinergics remain the first-line pharmacological treatment allowing a significant reduction in the number (nb) of incontinence (-5/week) and in the number of urination (-4/week) as well as a perception of subjective improvement of the symptoms reported by 56 % of the patients treated against 41 % for the placebo group (RR: 1.39 [95 % CI: 1.28-1.51]). The most commonly reported side effect is dry mouth (30 % vs. 8 % in the placebo group). Injections of botulinum toxin A appear to be relatively comparable to anticholinergics in the first line with a decrease in urinary emergency incontinence (UTI) of 3.3/d in the toxin group versus 3.4/d in the anticholinergic group (P=0.81). There was also a higher rate of complete resolution of urinary incontinence in the toxin group (27 % vs. 13 % P=0.03) but significant adverse effects such as lower urinary tract infections (33 % vs. 13 % P>0.01). And the risk of using self-catheterization (5 % vs. 0 % P=0.01). In view of the invasive character of the toxin injections and their side effects, this treatment remains a 2nd line therapy. The same is true for mirabegron: similar efficacy (IUU number in the mirabegron group 50mg -1.74 vs. -1.53 In the solifenacin group 5mg, P>0.5) but different side effects with arterial hypertension (the oral dryness rate being comparable to that in the placebo group). The choice of use of anticholinergic or mirabegron should be based on the balance of efficacy/tolerance to be estimated for each patient. CONCLUSION: The different molecules have shown their efficacy in the treatment of iOAB with acceptable tolerance. There is a lack of direct comparisons between treatments available. Further studies are needed to evaluate the possible interest of a combination of these molecules as well as the search for predictive factors of response to these different therapies.

[Contribution of clinical biology in the etiological exploration and follow-up of urolithiasis]. / Apport de la biologie clinique dans l'exploration étiologique et le suivi de l'urolithiase.

Urolithiasis is a frequent pathology with a constantly increasing prevalence in industrial countries. The relapse frequency is around 50 % with a risk of complications. The laboratory input is essential in the determination of the etiology and in the therapeutic monitoring. The morphoconstitutional analysis of the stone is the most important element. It comprises the examination of the stone with binocular loupes and the simultaneous analysis of its crystalline composition. This can be done by different techniques but infrared spectrophotometry is the most powerful. The chemical analysis should be definitely proscribed. The analysis of crystalluria includes the search, the identification and the counting of crystals in fresh morning urines. It is useful for the diagnosis and for the patient follow-up. Finally, the biochemical analyses in urine and serum, in first line or on the basis of the stone composition, are an important part of the etiological exploration and therapeutic monitoring.

A two-consultant approach is a safe and efficient strategy to adopt during the learning curve for laparoscopic Roux-en-Y gastric bypass: our results in the first 100 procedures.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) can be technically challenging. It is imperative that patient morbidity and mortality are minimized while teams are on the learning curve for this procedure. METHODS: This retrospective study evaluated the peri-operative risk of LRYGBP utilizing a two-consultant surgeon approach in a newly established bariatric service. 100 consecutive patients undergoing LRYGBP were included. Two consultants participated in each procedure. RESULTS: Median operative duration was 113 minutes (range 80-240) and fell with increasing experience [127 minutes (range 90-240) in cases 1-50 and 105 minutes (range 80-210) in cases 51-100; P=0.009]. Multivariate analysis found operation time correlated only with number of procedures performed (P<0.001). There were no conversions to laparotomy. Intra-operatively, 2 patients had hand-assisted completion of the jejuno-jejunostomy, and 2 underwent laparoscopic revision of the reconstruction. Postoperative complications were observed in 8 patients on the operative admission. Median stay was 4 days (range 3-7). 4 patients required readmission. There was no mortality. Percentage of excess BMI loss was 47%, 53% and 70% at 3, 6 and 12 months respectively. CONCLUSION: A learning curve for LRYGBP is evidenced in this series by reduction in operative time with increasing experience. Complication rates in line with large published series can be achieved by adopting a two-surgeon approach, which we propose as a safe method to adopt in the development of new bariatric services.

[Dutasteride (Avodart): a novel 5-alpha reductase inhibitor for treatment of benign prostate hypertrophy]. / Dutasteride (Avodart): un nouvel inhibiteur de la 5-alpha réductase pour traiter l'hypertrophie bénigne de la prostate.

Dutasteride (Avodart), a novel dual 5-alpha reductase inhibitor is effective for the treatment of benign prostate hypertrophy, of more than 30 cc because the reduction of the level of dihydrotestosterone. By reducing prostatic volume, dutasteride improves moderate to severe symptoms and flow rate. It allows a reduction of disease progression by reducing the rate of acute urinary retention and need for surgery.

[The urology department]. / Le Service d'Urologie.

The Department of Urology of Erasme Hspital, University of Brussels, has participated to the development and implementation of new technologies that have significantly transformed the specialty in the last 25 years. The minimally invasive treatment of benign prostatic hypertrophia was developed by the use of Trans-Urethral Needle Ablation (TUNA) and new pharmacological treatments. Treatment of urinary stones by extracorporeal shockwaves lithotripsy and Endourology has allowed to avoid operating hundred of patients each year. In the field of prostate cancer, an original laparoscopic prostatectomy technique by the extraperitoneal approach was developed in our unit. The prevention of prostate cancer and the influence of various nutritional factors and its early diagnosis by the use of different markers have been the subject of numerous publications and have contributed to improve our knowledge in this field. Different prognostic factors of bladder cancer have been evaluated and in particular their place with the use of intravesical BCG. A better understanding of the different mechanisms involved in erectile dysfunction has been the subject of numerous studies during the last 20 years and the department is internationally recognised as a reference centre in this field.

Extraperitoneal laparoscopic radical prostatectomy. Results after 50 cases.

INTRODUCTION: After an initial experience using transperitoneal laparoscopic radical prostatectomy as described by Vallancien and Guillonneau, we developed a pure extraperitoneal approach. This approach seems more comparable to the open technique and avoid potential risks of specific complications due to the transperitoneal approach. We evaluated the perioperative parameters (blood loss, operating time, transfusion rate) and postoperative results (oncological results, continence and potency) after our first 50 cases. MATERIAL AND METHOD: Between September 1999 and September 2000, we performed 50 laparoscopic radical prostatectomy. On average, patients were 63.3 years old (range 47-71), had preoperative mean PSA values of 9.14 ng/ml (1.1-23). Median Gleason score was 6 (4-10) with 2.5 (1-6) positive biopsies for a mean prostate volume of 40 cm(3) (17.5-95.0). Clinical stage was T1, T2a, T2b and T3 in 46.3, 41.5, 9.8 and 2.4% of the cases, respectively. We used a pure extraperitoneal approach and we performed a descending technique starting with the dissection at the bladder neck. The seminal vesicles dissection is comparable to the open approach. RESULTS: 42 extraperitoneal and 8 transperitoneal procedures were performed (2 in the initial experience, 3 because of previous abdominal surgery and 3 because of incidental peritoneal opening). Mean operative time was 317 min, mean blood loss 680 cm(3), transfusion rate of 13%. 1 patient/50 was converted to an open procedure. Pathological stage was pT1a, pT2a, pT2b, pT2c, pT3a and pT3b in 2.2, 8.5, 42.5, 2.2, 34 and 10.6% of cases, respectively. Positive surgical margins were observed in 22% of cases. The potency rate after neurovascular bilateral bundle preservation was 43% at 3 months (n = 7) and 67% at 6 months and (n = 6) without any further treatment. The continence rate (no pad) was 39% at 3 months and 85% at 6 months. Detectable postoperative PSA at 3 month was observed in 2 patients only. Two major complications occurred: one acute transient renal failure one uretrorectal fistula at day 20. CONCLUSIONS: The extraperitoneal laparoscopic radical prostatectomy results seem comparable to transperitoneal laparoscopic radical prostatectomy or open surgery. This approach is reproducible and seems to avoid the potential risks of intraperitoneal injury. Long-term follow up and comparative series are however necessary to further evaluate these new techniques.

Persisting active and proliferative intrinsic ureteral endometriosis under GNRH agonists therapy: a case with immunohistological study.

We report the case of a 30-year-old patient who underwent a segmental ureteral resection with ureteroureterostomy because of the presence of a left ureterohydronephrosis caused by an intrinsic ureteral endometriotic lesion. Preoperatively, the patient received a 3 months course of GNRH agonists. The serum estradiol level was at 12 pg/ml at the moment of surgery. Histology and immunohistochemistry performed on the resected specimen showed the presence of numerous large haemorrhagic endometriotic foci containing very high levels of alpha-estrogen and progesterone nuclear receptors, a high Ki-67 labeling index and a strong positivity for EGF-receptor. This is the first report of immunohistochemical study performed on ureteral endometriosis preoperatively treated with GNRH agonists. Because hormonal treatments are often prescribed in the treatment of ureteral endometriosis, clinicians should be aware of the possibility of persisting very active and proliferative ureteral endometriotic lesions even under treatment with GNRH agonists and very low levels of circulating estradiol.

[Cancer of the prostate: what treatment for what stage?]. / Cancer de la prostate: quel traitement pour quel stade?

The treatment of locally advanced prostatic cancer is the most controversial subject in urological oncology. Localized disease is best treated by radical prostatectomy or radiotherapy. Metastatic cancer is treated by surgical or medical castration. Second line therapeutics will be overviewed. Each treatment decision is based upon the pathological stage and differentiation of the tumour, the life expectancy and comorbidity of the patient.

[Infectious pathologies of the prostate]. / Les pathologies infectieuses de la prostate.

Prostatitis represents an heterogenic disease: we describe acute bacterial prostatitis, chronic bacterial prostatitis, chronic abacterial prostatitis and prostatodynia. Acute bacterial prostatitis is treated easily as an acute infection since chronic prostatitis needs a long and difficult treatment. In both cases, fluoroquinolones are the antibiotics of choice. Prostatodynia is treated by alpha-blockers. Granulomatous prostatitis is evocated in terms of differential diagnosis.

Hyperthermia and thermotherapy of benign prostatic hyperplasia: a critical review.

The indications, risks and benefits of surgical treatment of benign prostatic hyperplasia (BPH) have recently been scrutinized, and interest in the development of less invasive alternative nonsurgical approaches has emerged. Among the nonsurgical alternatives, thermal treatments have been clinically introduced for a few years but are still under evaluation. Microwaves and radiofrequency waves are generated by various devices applied by the transrectal or transurethral approach, with different treatment and temperature schedules. Results achieved with the various devices did not show large significant differences. Improvement is mainly observed by a decrease in irritative symptoms rather than by modifications of obstructive parameters. The placebo effect must not be underestimated in all these new alternative methods. Fifty percent of patients in retention and unfit for anesthesia voided satisfactorily after thermal treatment. Pathological studies of operative specimens after transurethral thermotherapy showed coagulative necrosis with destruction of smooth muscle and glandular components. The destruction of alpha-receptors or sensory nerves in the prostate stroma is a possible explanation for the reduction of irritative symptoms. No significant histological lesions were found however after transrectal hyperthermia. Various factors such as differences in tissue thermosensitivity, tissular architecture and thermoregulation related to variation in the prostate blood supply may all play a part in the final heating effect and determine the clinical response for a given patient. Better understanding of these various factors may improve patient selection. Although thermal treatment of BPH cannot be seen as a substitution for surgery, it may represent an alternative option in selected patients essentially to alleviate irritative symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effects of mepartricin on the symptomatology of prostatic hypertrophy--double-blind controlled trial]. / Etude de l'effect de la mépartricine sur la symptomatologie de l'hypertrophie prostatique--expérimentation contrôlée en double aveugle.

Seventy one patients were treated with mepartricin or placebo in three urological centres for a mean duration of 102 days (extremes: 60 and 142 days). An analysis of the results was carried out for 34 patients in the placebo group and 36 patients in the mepartricin group. The results indicate a significant improvement in both the placebo group and the mepartricin group. The irritative and obstructive symptoms are improved in the active treatment group with a response rate of the order of 70%, compared to approx. 45% in the placebo group. An improvement of the values on the flow meter, though not statistically significant, is observed following treatment with mepartricin, compared to the placebo group. There were no significant differences in the evolution of the prostate gland volume, determined by ultrasound in the placebo group and the active treatment group. Side-effects were minor and only one patient reported epigastric pain.

Shockwave treatment of ureteric stones in situ with second-generation lithotriptor.

During a 17-month period we treated in situ 334 patients with ureteric stones with a second-generation electromagnetic lithotriptor. Anxiety and discomfort were relieved with diazepam and pethidine chloride only. Ureteral stenting was used in 8.1% of upper, 36.4% of mid- and 5.7% of lower ureteric stones. The retreatment rate was 15%, but no patient had more than 3 sessions. The success rate of the treatment at 3 months was 88% for upper, 65% for mid- and 83% for lower ureteric stones. Open surgery had to be performed in 5 cases and ureteroscopies in 6 cases.

Shock wave monotherapy of staghorn calculi.

From June 1987 to October 1988, 52 staghorn calculi were treated without anesthesia by shock wave lithotripsy with the second-generation lithotriptor, Lithostar Siemens. 36 calculi were evaluated. Multiple sessions (n = 1-6) were necessary according to the size of the stone. The mean hospital stay for complete treatment was 7 days. Double-J stenting was used in 45% of the patients with calculi of less than 40 mm and in 81% of the patients with calculi of greater than 40 mm. After 3 months, 50% of the patients with calculi of less than 40 mm were free of stones, as were 43% of the patients with calculi greater than 40 mm. After 9 months, the stone-free rate rose to 75%. At 3 months, the success rate (stone free or residual fragments of less than 4 mm) is 87.5% and rose to 92% at 9 months. Two severe complications were observed: one patient with acute infected hydronephrosis with sepsis and one with perirenal hematoma. Shock wave lithotripsy monotherapy of staghorn calculi is possible in multiple treatment sessions. Double-J stenting is mandatory in most of the cases but, even in this condition, anesthesia is not necessary.

Transrectal ultrasound in the diagnosis and staging of prostatic carcinoma.

In this retrospective study we try to evaluate the benefit of transrectal ultrasonography of the prostate in the diagnostic, the screening and the preoperative staging of prostatic carcinoma. Five hundred and sixty-six patients with histologically proved prostatic carcinoma were evaluated. For the diagnosis, our specificity was 80%. The specificity of preoperative staging was 85% concerning the extraprostatic extension of the tumor. The screening seems to be of poor interest.

[Reliability of endorectal echography of the prostate in the screening and staging of prostatic cancer]. / Fiabilité de l'échographie endorectale de la prostate dans le dépistage et le staging du cancer prostatique.

1433 transrectal ultrasonographies were performed for prostatic disease. In 453 cases, histopathologic correlation was obtained and compared to digital rectal examination and transrectal ultrasonography done after the clinical examination. The sensitivity of digital rectal examination was 91% and the specificity was 85%. The sensitivity and the specificity of ultrasonography were respectively 95 and 81%. 4 prostatic cancers, not suspected by digital rectal examination, were diagnosed by ultrasound (0,9%). The total number of subclinical cancer was 9 (2%). Interest of ultrasound compared to digital rectal examination concerns less than 1% of the total number of controlled patients. The staging of local extension of prostatic cancer is better by ultrasound than by the digital rectal examination. On 9 cases of clinical unsuspected extracapsular invasion, 6 were diagnosed by ultrasound.