Respiratory Complications after Cystectomy with Urinary Diversion: Avoidable Complications or Ineluctable Destiny?

Background: Cystectomy with urinary diversion (CUD) is a highly morbid surgery. Despite implementing an enhanced recovery after surgery (ERAS®) protocol, postoperative respiratory complications (PRC) within 30 days after surgery remain frequent. This study aims to identify patients at higher risk of developing PRC after CUD. Methods: We conducted a retrospective analysis of 242 patients who underwent CUD at Lausanne University Hospital from 2012 to 2022, adhering to ERAS® guidelines. Data on postoperative complications, including pneumonia, respiratory failure, pulmonary embolism, lobar atelectasis, and pleural effusion, were analyzed. Chi-square and Mann-Whitney U tests compared patients with and without PRC. A multivariable Cox model identified independent prognostic factors. Results: PRC occurred in 41 patients (17%). Those with PRC experienced longer hospital stays and higher 30-day mortality rates. Poor ERAS® compliance was a significant risk factor. Multivariable analysis showed pneumonia was associated with postoperative ileus, while pulmonary embolism correlated with infectious and cardiovascular complications. Conclusions: PRC result in extended hospitalization and decreased survival. Rigorous adherence to ERAS® protocols, including early mobilization, respiratory physiotherapy, and avoiding nasogastric tubes, is essential for preventing PRC.

Impact of Enhanced Recovery after Surgery® Protocol Compliance on Length of Stay, Bowel Recovery and Complications after Radical Cystectomy.

BACKGROUND: Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC). METHODS: Data from consecutive patients undergoing RC for BC within an ERAS® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS® compliance was extracted from the ERAS® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI. RESULTS: After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS® protocol and age > 75 years were significant independent predictors of POI. CONCLUSIONS: Our study provides further evidence to support the beneficial effect of the ERAS® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.

[Robotic-assisted laparoscopic surgeries in functional and reconstructive urology]. / Chirurgie robot-assistée en urologie fonctionnelle et reconstructive.

The adoption of robotic-assisted laparoscopic surgery in urology is becoming increasingly frequent. Initially, its use was essentially limited to oncological surgery, such as radical prostatectomy. Its success lies in the enhanced dexterity, the three-dimensional vision, and the ability to easily suture intracorporeally. All these advantages have enabled many pioneer surgeons to develop techniques in the field of functional surgery, such as artificial urinary sphincter implantation and sacrocolpopexy, and as for reconstructive surgery, ureteral reconstructions and enterocystoplasties. This article provides a brief yet rich review of the recently innovated techniques and the now minimally invasive feasibility of previously highly complex procedures in conventional laparoscopy.

L'utilisation de l'assistance robotique en chirurgie laparoscopique est une pratique croissante en urologie, qui s'est généralisée notamment en oncologie. Son succès s'explique par une meilleure ergonomie, une meilleure vision et la capacité à suturer aisément en intracorporel. Ces avantages ont permis à plusieurs équipes de développer des techniques pour des indications de chirurgie fonctionnelle, notamment la pose de sphincter urinaire artificiel, la promontofixation, ainsi qu'en chirurgie reconstructive, par exemple pour les reconstructions urétérales et les entérocystoplasties d'agrandissement. Cet article propose un survol condensé des innovations techniques récentes et de la faisabilité désormais minimalement invasive d'interventions jusqu'à présent hautement complexes en laparoscopie conventionnelle.

bTUNED: transcutaneous tibial nerve stimulation for neurogenic lower urinary tract dysfunction.

OBJECTIVE: To present the protocol for a randomized controlled trial (RCT) evaluating the efficacy and safety of transcutaneous tibial nerve stimulation (TTNS) for refractory neurogenic lower urinary tract dysfunction (NLUTD). STUDY DESIGN AND RESULTS: bTUNED (bladder and TranscUtaneous tibial Nerve stimulation for nEurogenic lower urinary tract Dysfunction) is an international multicentre, sham-controlled, double-blind RCT investigating the efficacy and safety of TTNS. The primary outcome is success of TTNS, defined as improvements in key bladder diary variables at study end compared to baseline values. The focus of the treatment is defined by the Self-Assessment Goal Achievement (SAGA) questionnaire. Secondary outcomes are the effect of TTNS on urodynamic, neurophysiological, and bowel function outcome measures, as well as the safety of TTNS. CONCLUSIONS: A total of 240 patients with refractory NLUTD will be included and randomized 1:1 into the verum or sham TTNS group from March 2020 until August 2026. TTNS will be performed twice a week for 30 min during 6 weeks. The patients will attend baseline assessments, 12 treatment visits and follow-up assessments at the study end.

Is EDSS Enough to Predict Risk of Upper Urinary Tract Damage in Patients with Multiple Sclerosis?

Lower urinary tract dysfunction is often observed in patients with multiple sclerosis (MS) and may be responsible for an increased risk of upper urinary tract (UUT) damage. Although there are well-known urodynamic risk factors for UUT damage, no clinical prediction parameters are clearly identified. We aimed to confirm the accuracy of the Expanded Disability Status Scale (EDSS) in predicting urodynamic risk factors for UUT deterioration and to assess other clinical parameters potentially predicting urodynamic risk factors. We retrospectively reviewed 201 patients with MS referred for primary neuro-urological work-up, including a video-urodynamic study (VUDS) from August 2009 to February 2020. Multivariate modeling revealed EDSS, male gender, and a number of LUTS as clinical parameters significantly associated with urodynamic risk factors for UUT damage (p = 0.06, p = 0.01, p = 0.02, respectively). A nomogram combining EDSS, male gender, and a number of different LUTS was created to predict the presence of at least one urodynamic risk factor for UUT damage. In conclusion, the presence of high EDSS combined with male gender and several different LUTS is significantly associated with urodynamic risk factors and can be used to stratify MS patients for further neuro-urological assessment and treatment.

[Urinary tract infections in patients with neurogenic lower urinary tract dysfunction]. / Infections urinaires chez les patients avec dysfonction neurogène du bas appareil urinaire.

Urinary tract infections (UTIs) are one of the main causes of morbidity and mortality in patients with neurogenic lower urinary tract dysfunction (nLUTD). In most cases, these are patients whose symptoms manifest differently from non-neurological patients, and it can be difficult to decide whether the infection should be treated or whether it is asymptomatic bacteriuria for which treatment is not indicated. Recurrent urinary tract infections should be investigated for an underlying urological cause. This article reviews the diagnosis and management of urinary tract infections in adults with neurogenic lower urinary tract dysfunction.

Les infections urinaires sont l'une des principales causes de morbidité et mortalité chez les patients souffrant d'une dysfonction neurogène du bas appareil urinaire (nLUTD) d'origine médullaire. Dans la plupart des cas, les symptômes se manifestent différemment des patients non neurologiques. Il peut être difficile de décider si l'infection doit être traitée ou s'il s'agit d'une bactériurie asymptomatique pour laquelle le traitement n'est pas indiqué. Les infections urinaires récidivantes doivent faire rechercher une cause urologique sous-jacente. Cet article revoit le diagnostic et la prise en charge des infections urinaires de l'adulte atteint d'un dysfonctionnement neurogène du bas appareil urinaire.

[Sacral neuromodulation in urology: Indications, advancements and outcomes]. / Neuromodulation sacrée en urologie : indications, développements et résultats.

Emerging in the last decades, sacral neuromodulation remains an underknown therapy in the general population and even in the medical field. It has proven itself in the treatment of urinary dysfunctions, such as overactive bladder syndrome and chronic non-obstructive urinary retention. Numerous applications are currently being validated and the innovations made open up encouraging prospects. This article aims to introduce the modalities of the intervention and to present the established and future medical indications of sacral neuromodulation.

Émergeant au cours des dernières décennies, la neuromodulation sacrée reste une thérapie méconnue de la population et de la plupart du corps médical. Pourtant, elle a bien fait ses preuves dans la prise en charge des dysfonctionnements vésico-sphinctériens, comme le syndrome de la vessie hyperactive et la rétention urinaire chronique non obstructive. De nombreuses autres applications sont en cours de validation et les innovations apportées ouvrent des perspectives encourageantes. Cet article a pour objectif de présenter les modalités de l'intervention ainsi que les indications médicales établies et futures de la neuromodulation sacrée.

[Surgical treatments for male stress urinary incontinence]. / Traitement chirurgical de l'incontinence urinaire d'effort chez l'homme.

Stress urinary incontinence (SUI) in men is common, radical prostatectomy (RP) remaining its main cause. Despite improvements in surgical techniques, SUI rates range from 5 % to 48 %. Management begins with non-invasive and conservative methods. Surgical treatment includes implantation of an artificial urinary sphincter, a suburethral sling or periurethral balloons. This article summarizes the surgical treatments for male SUI.

L'incontinence urinaire d'effort (IUE) chez l'homme est fréquente et a comme cause principale la prostatectomie radicale (PR). Malgré les progrès des techniques chirurgicales, les taux d'IUE se situent entre 5 et 48 %. La prise en charge débute par des méthodes non invasives et conservatrices. Le traitement chirurgical comprend l'implantation d'un sphincter urinaire artificiel, d'une bandelette sous-urétrale ou de ballonnets péri-urétraux. Dans cet article, nous résumons les traitements chirurgicaux de l'IUE chez l'homme.

ERAS® protocol improves survival after radical cystectomy: A single-center cohort study.

INTRODUCTION: To evaluate Enhanced recovery after surgery (ERAS®) protocol on oncological outcomes for patients treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). METHODS: A prospectively maintained single-institutional database comprising 160 consecutive UCB patients who underwent open RC from 2012 to 2020 was analyzed. Patients receiving chemotherapy and those with a urinary diversion other than ileal conduit were excluded. Patients were divided into two groups according to the perioperative management (ERAS® and pre-ERAS®). The study aimed to evaluate the impact of the ERAS® protocol on survival at five years after surgery using a Kaplan-Meier log-rank test. A multivariable Cox proportional hazards model was used to identify prognostic factors for cancer-specific (CSS) and overall survival (OS). RESULTS: Of the 107 patients considered for the final analysis, 74 (69%) were included in the ERAS® group. Median follow-up for patients alive at last follow-up was 28 months (interquartile range [IQR] 12-48). Five-years CSS rate was 74% for ERAS® patients, compared to 48% for the control population (P = 0.02), while 5-years OS was 31% higher in the ERAS® (67% vs. 36%, P = .003). In the multivariable analysis, ERAS® protocol and tumor stage were independent factors of CSS, while ERAS®, tumor stage so as total blood loss were independent factors for OS. DISCUSSION: A dedicated ERAS® protocol for UCB patients treated with RC has a significant impact on survival. Reduction of stress after a major surgery and its potential improvement of perioperative patient's immunity may explain these data.

Body contouring abdominoplasty for augmentation enterocystoplasty with continent cutaneous urinary diversion in an obese adolescent patient: A case report.

Bladder exstrophy requires staged reconstruction to achieve control over bladder function. In case of failure, bladder neck closure with augmentation enterocystoplasty and appendicovesicostomy is a good surgical option. We report the case of a girl born with bladder exstrophy who, despite multiple surgical reconstructions in childhood, developed severe stress incontinence with contracted bladder and recurrent urinary tract infections during adolescence. The patient had a large abdominal pannus and in order to realize the appendicovesicostomy, we combined this intervention with a body contouring abdominoplasty to achieve tension free closure.

[Urinary incontinence: a good diagnosis as a basis for treatment]. / Incontinence urinaire: un bon diagnostic comme base de traitement.

Urinary incontinence: a good diagnosis as a basis for treatment Abstract. Abtract: Everyone has experienced incontinence at an early age. However, it also affects approximately 200 million people worldwide at the adult age. This common condition is frequently underreported by patients but can dramatically limit their social life. Subject to appropriate differential diagnosis, urinary incontinence is a condition that can be treated with good results in the majority of patients. This article provides a review of the essential symptomatology and current treatments, so that clinicians confronted with the problem may adopt the appropriate management.

Résumé. Tout le monde a connu l'incontinence, dès le plus jeune âge. Elle affecterait cependant encore 200 millions de personnes dans le monde à l'âge adulte. Cette pathologie du quotidien est relativement peu rapportée des patient(e)s, mais limite la vie sociale de façon parfois dramatique. Sous réserve d'un sous-diagnostic pertinent, l'incontinence urinaire est une pathologie traitable avec des résultats élevés. Cet article propose une revue de la sémiologie essentielle ainsi que des traitements actuels afin que tout clinicien confronté au problème adopte une prise en charge adéquate.

Robot-assisted Supratrigonal Cystectomy and Augmentation Cystoplasty with Totally Intracorporeal Reconstruction in Neurourological Patients: Technique Description and Preliminary Results.

BACKGROUND: Augmentation cystoplasty as a third-line therapy for neurogenic detrusor overactivity performed by an open approach has long been studied. Few laparoscopic and robot-assisted series have been reported. OBJECTIVE: To evaluate the feasibility, safety, and functional outcomes of completely intracorporeal robot-assisted supratrigonal cystectomy and augmentation cystoplasty (RASCAC) in patients with refractory neurogenic detrusor overactivity. DESIGN, SETTING, AND PARTICIPANTS: We identified all patients undergoing RASCAC, as treatment for refractory neurogenic detrusor overactivity, from August 2016 to April 2018. SURGICAL PROCEDURE: RASCAC was performed in all cases using a standardized technique with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) in a four-arm configuration. MEASUREMENTS: Perioperative data, and functional and urodynamic results at 1-yr follow-up were assessed. Statistical analysis was performed using Stata version 15.1. RESULTS AND LIMITATIONS: Ten patients were identified. No conversion to open surgery was needed. The median operative time was 250 (interquartile range 210-268) min, the median estimated blood loss was 75 (50-255) ml, and the median hospitalization time was 12 (10.5-13) d. The 30-d major complication rate was 10%. Two patients presented a late urinary fistula; in one of the cases, surgical revision was needed. In both cases, low compliance to intermittent self-catheterization was identified. At 1-yr follow-up, functional and urodynamic outcomes were excellent. CONCLUSIONS: Robot-assisted augmentation cystoplasty has been shown to be safe and feasible, with a reasonable operative time and low complication rate in experienced hands. A higher number of patients and longer follow-up are, however, warranted to draw definitive conclusions. PATIENT SUMMARY: In this report, we look at the outcomes of robot-assisted supratrigonal cystectomy and augmentation cystoplasty in neurourological patients. Perioperative, functional, and urodynamic results are promising. Further studies with a longer follow-up are needed to confirm these findings.

Performance and Safety of the Artificial Urinary Sphincter (AMS 800) for Non-neurogenic Women with Urinary Incontinence Secondary to Intrinsic Sphincter Deficiency: A Systematic Review.

CONTEXT: The use of the artificial urinary sphincter (AUS) for female non-neurogenic severe stress urinary incontinence (SUI) due to sphincter deficiency is either not specifically registered and/or reimbursed in some countries worldwide, as opposed to males, in whom it is considered the gold standard. With waning popularity of synthetic midurethral slings for the treatment of SUI, evidence-based assessment of AUS performance and safety is mandatory for patient counselling. OBJECTIVE: To conduct a systematic review of studies evaluating short- to long-term AUS performance and safety outcomes in non-neurogenic adult females with severe SUI. EVIDENCE ACQUISITION: PubMed/Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched, from 1987 to 2018, without language restriction. Included studies had to report outcomes after AUS implantation in at least five adult women with non-neurogenic SUI, after a minimum follow-up of 6 months. EVIDENCE SYNTHESIS: Twelve articles collecting data from 886 patients were identified, no study being randomised or prospective. The reported zero pad rates ranged from 42% to 86%, revision rates from 6% to 44%, and mechanical failure rates from 2% to 41%. Procedure serious adverse event rates ranged from 2% to 54% and rates of serious adverse device effects such as explantation ranged from 2% to 27%. CONCLUSIONS: The level of evidence supporting the use of an AUS for non-neurogenic SUI in women is very low. AUS outcome assessments necessitate well-designed randomised trials, in accordance with current evidence-based medicine requirements. PATIENT SUMMARY: In this article, reviewing the scientific literature over the last 30 yr, we looked at the short- to long-term efficacy and safety of the artificial urinary sphincter in adult women for the treatment of severe urine leakage. We conclude that the data analysed provide very low evidence and that further well-conducted trials with large populations are required.

[Current surgical treatments for women with stress urinary incontinence]. / Actualité du traitement chirurgical de l'incontinence urinaire d'effort chez la femme.

Surgical treatments for female stress urinary incontinence is in perpetual evolution. This article reviews the current surgical treatments for stress urinary incontinence in female. Bulking agents, Burch colposuspension, autologous sling, midurethral slings, single incision slings, artificial urinary sphincter and adjustable continence therapy (ACT) are discussed.

Les traitements chirurgicaux de l'incontinence urinaire d'effort chez la femme sont en perpétuelle évolution. Cet article passe en revue les options actuelles de traitement chirurgical de l'incontinence urinaire d'effort chez la femme. Les injections péri-urétrales d'agents de comblement, la colposuspension selon Burch, la bandelette sous-urétrale aponévrotique, les bandelettes sous-urétrales synthétiques, les mini-bandelettes (single incision sling), le sphincter urinaire artificiel et les ballonnets péri-urétraux (ACT) y sont présentés.

[Nocturia in aged patient: in practice]. / Nycturie du patient âgé : en pratique.

Nocturia is defined as the complaint that the individual has to wake at night to urinate. In older persons, this urinary functional disorder is most often of multifactorial origin and/or the symptom (sometimes the unique one) of a chronic disease. Nocturia is very annoying and its impact on health and quality of life is related to the disturbance of sleep cycles. In aged patients, who are often polymorbide and polymedicated, the interaction between nocturia and geriatric syndromes as well as comorbidities has to be more particularly underlined. The impact on informal caregiver's health and the decision for institutional admission are also to be considered. An adapted management of nocturia improves quality of life and reduces morbidity in aged patients.

La nycturie se définit comme la plainte d'avoir à se réveiller la nuit en raison d'une envie d'uriner. Chez les personnes âgées, ce trouble urinaire est le plus souvent d'origine multifactorielle et/ou le symptôme (parfois même unique) d'une maladie chronique. La nycturie est très gênante, et son impact sur la santé et la qualité de vie est lié à la perturbation du cycle de sommeil. Chez le patient âgé, souvent polypathologique et polymédiqué, l'interaction de la nycturie avec les syndromes gériatriques et les comorbidités doit être plus particulièrement soulignée. L'impact sur la santé du proche aidant et la décision d'une entrée en institution sont aussi à considérer. Une prise en charge adaptée de la nycturie améliore la qualité de vie et réduit la morbidité chez les patients âgés.

[Common medications and prostate cancer : what is the association ?] / Médicaments usuels en médecine de premier recours et cancer de la prostate : quelle relation ?

A possible association between prostate cancer and metabolic syndrome has recently been observed. Further, multiple experimental and epidemiologic studies have recently reported a probable association between common medications and prostate cancer. In this article, we summarize the results of those studies that explore the role of aspirin, oral antidiabetic medication and statins.

Une possible association entre le cancer de la prostate et le syndrome métabolique a récemment été mise en évidence. Plusieurs récentes études expérimentales et épidémiologiques ont suggéré un rôle protecteur de plusieurs médicaments largement utilisés en médecine de premier recours dans le cancer de la prostate. Nous résumons ici les résultats de ces études, en particulier pour l'aspirine, les antidiabétiques oraux et les statines.

[Management of genitourinary trauma]. / Prise en charge des traumatismes urogénitaux.

Urogenital trauma often occurs in the context of polytrauma patients. In this article, aimed at primary care practitioners and emergency physicians, we summarise the epidemiology and aetiology of these traumas as well as their management. The goal is to allow primary healthcare professionals to become acquainted with diagnostic and therapeutic strategies in genitourinary trauma patients.

Les traumatismes des organes génitaux externes et du système urinaire chez l'adulte se rencontrent souvent dans le contexte de patients polytraumatisés. Dans cet article, qui s'adresse aux médecins de premiers recours ainsi qu'aux membres des services d'urgences, nous résumons les caractéristiques épidémiologiques et étiologiques de ces lésions ainsi que les dernières recommandations concernant leur prise en charge. Le but est de permettre aux différents intervenants de se familiariser avec les stratégies diagnostiques et thérapeutiques face à un patient présentant un traumatisme urogénital.