[Impact of the COVID-19 pandemic on surgical activity within academic urological departments in Paris]. / Impact de la pandémie de COVID-19 sur l'activité chirurgicale au sein des services d'urologie de l'Assistance Publique ­ Hôpitaux de Paris.

INTRODUCTION: As a result of the COVID-19 pandemic in France, all non-emergency surgical activity has been cancelled since March 12, 2020. In order to anticipate the reinstatement of delayed interventions, surgical activity reduction analysis is essential. The objective of this study was to evaluate the reduction of urological surgery in adult during the COVID-19 pandemic compared to 2019. MATERIAL: The data regarding urological procedures realized in the 8 academic urological departments of Parisians centres (AP-HP) were compared over two similar periods (14-29 March 2019 and 12-27 March 2020) using the centralized surgical planning software shared by these centres. Procedure title, type of surgery and outpatient ratio were collected. The interventions were sorted into 16 major families of urological interventions. RESULTS: Overall, a 55% decrease was observed concerning urological procedures over the same period between 2019 and 2020 (995 and 444 procedures respectively). Oncology activity and emergencies decreased by 31% and 44%. The number of kidney transplantations decreased from 39 to 3 (-92%). Functional, andrological and genital surgical procedures were the most impacted among the non-oncological procedures (-85%, -81% and -71%, respectively). Approximatively, 1033 hours of surgery have been delayed during this 16-day period. CONCLUSION: Lockdown and postponement of non-urgent scheduled urological procedures decisions has led to a drastic decrease in surgical activity in AP-HP. Isolated kidney transplantation has been stopped (national statement). Urologists must anticipate for lockdown exit in order to catch-up delayed surgeries. LEVEL OF EVIDENCE: 3.

[Multidisciplinary and systematic preoperatory-assessment in geriatric urologic oncology surgery: Feasibility and results]. / Évaluation pluridisciplinaire préopératoire systématique en chirurgie cancérologique urologique gériatrique : faisabilité et résultats.

INTRODUCTION: The incidence of cancer increases with age, especially for urological cancers. The frailty of the elderly persons may expose them to more postoperative complications resulting in prolonged hospitalization, increased morbidity or even increased mortality, and delayed or impossible return to normal life. In such cases, the benefit of surgery and therefore its realization can be questioned. PATIENTS AND METHOD: This article reports the experience of a pre-operative risk assessment in a population of elderly patients treated for urologic cancer. This retrospective study aims to report the feasibility and the main results of this systematic preoperative multi-professional evaluation. RESULTS: Between April 2016 and February 2017, 31 elderly patients were evaluated. The evaluation revealed: moderate to severe malnutrition in 59 % of cases, a patient judged from a geriatric point of view fit, intermediate or fragile in respectively 25 %, 35 % and 40 % of cases. This evaluation led to propose a modification of an element of care for 66 % of patients and to propose therapeutic abstention for only 3 patients. CONCLUSION: An evaluation whose purpose is to adapt to the physiological age of patients and their overall state of health, surgical treatment and postoperative management is feasible and seems to help unmask elements of fragility usually not detected. LEVEL OF EVIDENCE: 4.

Study of the intra-prostatic arterial anatomy and implications for arterial embolization of benign prostatic hyperplasia.

INTRODUCTION: Prostatic arterial embolization (PAE) is an experimental therapy for benign prostatic hyperplasia. Its feasibility is based on the knowledge of the pelvic arterial anatomy, and more specifically the prostate. The aim of this study was to describe the prostatic arterial supply: origins, distribution and variability. MATERIAL AND METHODS: We reviewed retrospectively, with two radiologists, 40 arteriographies of patients who underwent PAE in our center. With these observations of 80 hemipelvics, we described the number of prostatic arteries, their origins, their distributions and eventually their anastomoses with other pelvic arteries. RESULTS: There was one prostatic artery in 70% of the cases. It came from a common trunk for the prostate and the bladder in 55% of the cases, from the obturator artery in 17.5% of the cases, from the pudendal artery in 25% of the cases, from the intern iliac artery in 1% of the cases, and from the superior gluteal artery in 1% of the cases. The prostatic artery splitted in two branches (medial and lateral), with no anastomoses in 37% of the cases. Anastomoses with penile and rectal arteries were observed in 29% of the cases. CONCLUSIONS: For our 40 patients, we observed many variations of arterial prostatic anatomy. We proposed a classification in order to increase security and efficacy of PAE, and it should be validated with more patients. LEVEL OF EVIDENCE: 2.

[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.

[Urinary incontinence after HOLEP: Incidence, evolution and predictive factors]. / Incontinence urinaire après énucléation endoscopique de la prostate au laser Holmium : fréquence, évolution, et facteurs prédictifs de survenue.

OBJECTIVE: Assess the early morbidity after HOLEP, the urinary incontinence in particular, and specify its different types, evolution, and predictive factors. PATIENTS AND METHODS: We conducted an observational, analytical, retrospective, monocentric study including all patients undergoing surgery for benign prostatic hypertrophy (HBP) by HoLEP between November 2015 and January 2017. The data were collected pre-, per- and postoperatively. The follow-up was for 6 months. RESULTS: One hundred and seventy one patients were included. 23 patients (14.6%) had a complication according to Clavien-Dindo classification [4]: 19 (83%) Clavien 2, 1 (4%) Clavien 3b et 3 (13%) Clavien 4. At one month of the surgery, 64 (42.7%) patients had urinary incontinence of which 55 (86.1%) presented pure stress urinary incontinence. 18 (32.7%) were still incontinent at 6 months of the surgery. The delivered amount of energy during the surgery and the preoperative IIEF5 score were statistically significantly associated with the occurrence rate of stress urinary incontinence. There was no correlation between the surgeon's learning curve and the occurrence of incontinence. CONCLUSION: The occurrence rate of urinary incontinence post HoLEP might be related to the adopted surgical technique ; It is crucial to keep the patient well informed of the risk of this complication postoperatively. LEVEL OF EVIDENCE: 4.

The HIV-1 viral synapse signals human foreskin keratinocytes to secrete thymic stromal lymphopoietin facilitating HIV-1 foreskin entry.

The complexity of signal transduction resulting from the contact of human immunodeficiency virus type 1 (HIV-1)-infected cells and mucosal cells has hampered our comprehension of HIV-1 mucosal entry. Such process is driven efficiently only by viral synapse contacts, whereas cell-free HIV-1 remains poorly infectious. Using CD4+ T-cells expressing only HIV-1 envelope inoculated on human adult foreskin tissues, we designed methodologies to identify the signals transduced in foreskin keratinocytes following HIV-1-envelope-dependent viral synapse formation. We find that the viral synapse activates the MyD88-independent TLR-4-nuclear factor (NfκB) signaling pathway in keratinocytes and the subsequent secretion of cytokines including thymic stromal lymphopoietin (TSLP), a cytokine linking innate and T-helper type 2-adaptive immune responses. Moreover, the viral synapse upregulates the non-coding microRNA miR-375, known to control TSLP, and transfection of keratinocytes with anti-miR-375 blocks significantly TSLP secretion. Thus, the secretion of TSLP by keratinocytes is induced by the viral synapse in a miR-375 controlled manner. At the tissue level, these signals translate into the epidermal redistribution of Langerhans cells and formation of conjugates with T-cells, recapitulating the initial events observed in human foreskin infection by HIV-1. These results open new possibilities for designing strategies to block mucosal HIV-1 transmission, the major pathway by which HIV-1 spreads worldwide.

[Validation of visual prostate symptom score, VPSS, in the evaluation of lower urinary tract symptoms associated with benign prostatic hyperplasia (550 patients)]. / Validation du score visuel prostatique en images SVPI dans l'évaluation des symptômes du bas appareil urinaire associés à une hyperplasie bénigne de la prostate (550 patients).

OBJECTIVES: Our objective was to validate the VPSS (visual prostatic symptom score) score in the French language for the identification and monitoring of BPH-related LUTS in urological practice. METHODS: A prospective observational survey was carried out between September the 15th 2014 and July the 30th 2015 in urology practices. The first 4 consecutive patients aged over 60 years, with BPH-related LUTS requiring prescription of an alpha-blocker, were enrolled. We translated a "visual prostatic symptom score" (VPSS) into French and adapted it slightly. At the first visit and follow-up visit (1-3 months after the first visit), the patient completed 2 questionnaires: the French language version of the IPSS and the VPSS. RESULTS: Of the urologists contacted, 169 enrolled at least one patient and returned information; 550 questionnaires were included in the statistical analysis. The median IPSS and VPSS total scores, subscores and quality of life scores all decreased significantly (P<0.0001) between enrolment and the follow-up visit 1-3 months later. Correlations between the IPSS and VPSS at enrolment and the follow-up visit and their variation were all significant. Total VPSS was significantly correlated with total IPSS, as were the irritative, obstructive and quality of life subscores evaluated on the corresponding pictograms. CONCLUSIONS: This study showed the VPSS to be a simple and useful tool for identifying and monitoring BPH-related LUTS. LEVEL OF EVIDENCE: 4.

Relation between plasma trough concentration of abiraterone and prostate-specific antigen response in metastatic castration-resistant prostate cancer patients.

BACKGROUND: Abiraterone (ABI) is a major oral agent for the treatment of metastatic castration-resistant prostate cancer (mCRPC) patients but its systemic exposure is subject to a large inter-individual variability. We aimed to explore the relationship between ABI trough plasma concentration and prostate-specific antigen (PSA) response in mCRPC patients and to identify the critical determinants for its activity. PATIENTS AND METHODS: This is a monocentric prospective observational study in mCRPC patients treated with ABI. The plasmatic concentration of ABI at steady state was measured using liquid chromatography with fluorescence detection. The primary objective was to study the relationship between mean ABI plasma exposure (ABI Cmin) and 3-month PSA response. RESULTS: From 2012 to 2016, 61 mCRPC patients were eligible for pharmacokinetic/pharmacodynamic assessment. Thirty-eight patients experienced PSA response (62%, [confidence interval {CI} 95% 50-78]). In univariate analysis, ABI Cmin was 1.5-fold higher in responders: 12.0 ng/mL (CI 95% 9.4-15.6) versus 8.0 ng/mL (CI 95% 5.8-11.6; P = 0.0015). In multivariate analysis, only ABI Cmin was independently associated with PSA response (odds ratio = 1.12 [CI 95% 1.01-1.25], P = 0.004). By receiver operating characteristic analysis, the optimal threshold for ABI Cmin was 8.4 ng/mL. Progression-free survival (PFS) was significantly higher in patients with ABI Cmin above 8.4 ng/mL (hazard ratio 0.55, [CI 95% 0.31-0.99], 12.2 [CI 95% 9.2-19.5] versus 7.4 [CI 95% 5.5-14.7] months otherwise, P = 0.044). CONCLUSIONS: We showed that ABI trough concentration correlates with PSA response and PFS. Moreover, we could determine a cut-off value of plasmatic concentration for PSA response. Altogether, ABI concentration monitoring appears as a new approach to improve clinical outcome in mCPRC patients.

[Negative prognostic impact of female gender on oncological outcomes following radical cystectomy]. / Impact pronostique du genre féminin sur le devenir oncologique des patients traités par cystectomie totale.

OBJECTIVE: To confirm gender specific differences in pathologic factors and survival rates of urothelial bladder cancer patients treated with radical cystectomy. PATIENTS AND METHODS: We conducted a retrospective monocentric study on 701 patients treated with radical cystectomy and pelvic lymphadenectomy for muscle invasive bladder cancer. Impact of gender on recurrence rate, specific and non-specific mortality rate were evaluated using Cox regression models in univariate and multivariate analysis. RESULTS: We collected data on 553 males (78.9%) and 148 females (21.1%) between 1998 and 2011. Both groups were comparable at inclusion regarding age, pathologic stage, nodal status and lymphovascular invasion. Mean follow-up time was 45 months (interquartile 23-73) and by that time, 163 patients (23.3%) had recurrence of their tumor and 127 (18.1%) died from their disease. In multivariable Cox regression analyses, female gender was independently associated with disease recurrence (RR: 1.73; 95% CI 1.22-2.47; P=0.02) and cancer-specific mortality (RR=2.50, 95% CI=1.71-3.68; P<0.001). CONCLUSION: We confirmed female gender to be an independent negative prognosis factor for patients following a radical cystectomy and lymphadenectomy for an invasive muscle bladder cancer.

[Pronostic value of parenchyma renal invasion of pT3 upper tract urinary carcinoma]. / Impact pronostique de l'envahissement du parenchyme rénal dans la population des tumeurs de la voie excrétrice urinaire supérieure de stade pT3.

INTRODUCTION: Upper tract urinary carcinoma (UTUC) pT3 tumors are a heterogeneous entity including tumors invading the renal parenchyma, tumors with peripelvic fat invasion or peri-ureteral fat invasion. The aim of this study was to evaluate the prognostic significance of these three different groups of pT3 tumors. PATIENTS AND METHODS: Between 1998 and 2012, 205 patients with UTUC were operated in two centers, including 52 patients with pT3 tumor stage. pT3 tumors were divided into three groups: peri-ureteral fat invasion (pT3U, n = 16), peripelvic fat invasion (pT3G, n = 21), and renal parenchyma invasion (pT3P, n = 15). The prognostic significance of the type of tumor infiltration was evaluated on specific and disease-free survival. RESULTS: Median follow-up was 18.9 months [6-133.4]. In univariate analysis, renal parenchyma invasion was associated with a better prognostic in both specific (P = 0.026) and disease-free survival (P = 0.031) compared with peripelvic or peri-ureteral fat invasion. Mutivariate analysis retained the pT3 subgroup as an independant prognostic factor in both specific and disease-free survival (P = 0.02). CONCLUSION: pT3 tumors with renal parenchyma invasion had a better prognosis than those with peripelvic or peri-ureteral fat invasion. The heterogeneity of the pT3 group should be taken into account to improve the care of patients.

[Evolution of lower urinary tract symptoms under silodosin: factors influencing patients' satisfaction]. / Évolution des symptômes du bas appareil urinaire sous silodosine: facteurs influençant la satisfaction des patients.

UNLABELLED: The objective of this study was to analyze the efficacy and safety of silodosin in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) in current urologic practice. METHOD: This was a prospective observational study conducted by 272 urologists on patients treated by silodosin for BPH. The parameters evaluated were the weighted IPSS score, the IPSS question 8 related to quality of life, the USP score and the Athens Insomnia Scale (AIS) measured at treatment initiation and after 3 months. RESULTS: Nine hundred and fourteen patients whose average age was 66 years with LUTS for 3.3 years were analyzed. After 3 months of treatment, a significant decrease in IPSS (from 16.2 ± 6.1 to 9.7 ± 5.5, P<0.0001) and USP score (from 10.6 ± 5.1 to 6 0 ± 4.6, P<0.0001) were observed, quality of life (from 67.1% to 14.4% of unsatisfied patients, P<0.0001) and sleep were significantly improved (from 49.2% to 28.9% patients with insomnia, P<0.0001). Among the patients, 21.2% experienced at least one adverse event. The most frequent were abnormal ejaculation (17.2%). And 7.1% discontinued the treatment for this reason. After 3 months of treatment silodosin was continued in 86.9% of patients. CONCLUSION: This large study confirmed the efficacy of silodosin in LUTS associated with BPH with a safety profile that does not affect patient satisfaction.