[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. / Recommandations sur la gestion du risque et la prise en charge urologique du patient adulte atteint de dysraphisme spinal (spina bifida).

INTRODUCTION: Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS: National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS: Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION: Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Prognostic factors after adrenalectomy for adrenal metastasis.

PURPOSE: Very few studies have sought prognostic factors after adrenalectomy for metastasis. The aim of this study was to assess prognostic factors for oncological outcomes after adrenalectomy for adrenal metastasis. METHODS: All adrenalectomies for metastases performed in seven centers between 2006 and 2016 were included in a retrospective study. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Prognostic factors for CSS and RFS were sought by Cox regression analyses. RESULTS: 106 patients were included. The primary tumors were mostly renal (47.7%) and pulmonary (32.3%). RFS and CSS estimated rates at 5 years were 20.7% and 63.7%, respectively. In univariate analysis, tumor size (HR 3.83; p = 0.04) and the metastasis timing (synchronous vs. metachronous; HR 0.47; p = 0.02) were associated with RFS. In multivariate analysis, tumor size (HR 8.28; p = 0.01) and metastasis timing (HR 18.60; p = 0.002) were significant factors for RFS. In univariate analysis, the renal origin of the primary tumor (HR 0.1; p < 0.001) and the disease-free interval (DFI; HR 0.12; p = 0.02) were associated with better CSS, positive surgical margins with poorer CSS (HR 3.4; p = 0.01). In multivariate analysis, the renal origin of the primary tumor vs. pulmonary (HR 0.13; p = 0.03) and vs. other origins (HR 0.10; p = 00.4) and the DFI (HR 0.01; p = 0.009) were prognostic factors for CSS. CONCLUSION: In this study, tumor size and synchronous occurrence of the adrenal metastasis were associated with poorer RFS. Renal origin of the primary tumor and longer DFI were associated with better CSS. These prognostic factors might help for treatment decision in the management of adrenal metastasis.

Urethral pressure controlled balloon refilling or balloon change for artificial sphincter secondary procedure?

OBJECTIVES: To report our experience of inflating or changing pressure balloon to treat recurrent urinary incontinence after AMS800® implantation instead of changing all the devices. PATIENTS AND METHODS: A retrospective study was conducted in a tertiary reference center between 2005 and 2015. All patients, treated by AMS800® implantation for post-prostatectomy urinary incontinence and whom balloon was subsequently changed or inflated, were included. Main clinical end point was the need for another surgery. Secondary end points were urethral erosion, infection, and efficacy on pad test and pad use. RESULTS: Thirty-one patients were included. All had had a 61-70cm H20 balloon implanted, with a single cuff (13 with transcorporeal placement). Twenty-one patients had their balloon changed for a 71-80cm H20 type, while 10 patients had their balloon refilled (median 3mL [range 2-7]). Median follow-up was 23 months (range 1-129). Overall rate of another subsequent surgery was 48.3% (n=15). Erosion and atrophy occurred more frequently after balloon repressurizing than after balloon replacement (80% vs 33%, P=0.024). At last follow-up, median pad use was higher in repressurizing group (2 vs 1, P=0.033). CONCLUSION: Balloon repressurizing is associated with a higher erosion and reoperation rate than changing pressure balloon. Continence results seem better when PRB is changed. It could be an alternative instead of changing all devices in patients with frail urethra. LEVEL OF EVIDENCE: 4.

Long-term outcomes of I-Stop TOMS™ male sling implantation for post-prostatectomy incontinence management.

OBJECTIVES: To report long-term outcomes after I-Stop TOMS™ implantation for PPI. PATIENTS AND METHODS: A retrospective evaluation was conducted in three tertiary reference centers. All consecutive patients implanted with an I-Stop TOMS™ sling between 2007 and 2012 for mild to moderate PPI (24-hour Pad test<400g) without history of pelvic radiation therapy were included. Evaluation had been conducted preoperatively, at one and six months postoperative and yearly thereafter. The main outcome criterion was the number of pads per day. Secondary criteria were International Consultation on Incontinence Questionnaire (ICIQ), SF-36 questionnaire, and complications. RESULTS: A hundred patients were evaluated with a median follow-up of 58months [19-78]. Pad use was significantly reduced and quality of life improved at last follow-up (P<0.0001). The percentage of patients dry and socially continent (0 or 1 pad) were 40% and 77% at 1 year, then dropped to 15% and 22%, respectively after 5years. Twelve patients were treated by artificial urinary sphincter implantation, five by ProACT™ balloons and one by a re-do I-Stop TOMS™. No severe complications were recorded at last follow-up. CONCLUSIONS: I-Stop TOMS™ implantation is a safe and effective option in the short-term for mild to moderate PPI management. However, a significant trend to recurrence of leakage has been established after long-term follow-up. If confirmed by further studies, these results may substantially impact patient information before male sling implantation. LEVEL OF EVIDENCE: 4.

Sequential treatment with ProACT™ device implantation after male sling failure for male urinary incontinence.

OBJECTIVES: There is no strong evidence for second line therapy after male sling failure for post-prostatectomy urinary incontinence (PPUI). We report the outcomes after periurethral balloons implantation for persistence or recurrence of mild PPI symptoms after male sling implantation. METHODS: All patients implanted of a ProACT™ device (Uromedica, Inc., MN, USA) following I-STOP transobturator male sling (TOMS) failure, in a tertiary reference center between 2009 and 2016, were included. Patients were evaluated by 24-hour pad-test before and after implantation, and after each balloon repressurizing procedure. PGI-I and Likert scale patient satisfaction were estimated during a telephone interview conducted in 2016. Objective and subjective cure of urinary incontinence were defined by a 24-hour pad-test<8g and the use of zero or one pad per day, respectively. RESULTS: Fourteen patients were included. Median follow-up was 34months [4-89]. Objective and subjective cure were 29% (n=4) and 57% (n=8), respectively. Median pad-test decreased from 95g [IQR: 130] to 34g [IQR: 83] (P=0.022). ProACT™ significantly decreased median pad-test by a factor 2.73 [1.19-6.29]. Eighty-eight percent patients were feeling a little better, much better or very much better and 77% were satisfied or very satisfied at the end of follow-up. Reoperation rate was 28% (n=4): 3 balloons were changed for caudally migration (n=2) or deflation (n=1) and 1 had a urinary sphincter implanted for severe UI. CONCLUSIONS: ProACT™ is a safe and efficient treatment that can be used in second line therapy after TOMS failure for PPUI. LEVEL OF EVIDENCE: 4.

[Notice of expert for modality and prescriptions limits of local estrogenotherapy for urinairy inconfinence in women]. / Avis d'experts sur les modalités et limites de prescription des estrogènes locaux dans l'incontinence urinaire chez la femme.

OBJECTIVE: To develop a consensus of experts on the use of local estrogens in female urinary incontinence. MATERIAL AND METHOD: Following a formalized consensus method (DELPHI), a questionnaire was produced and sent to a first round and then to a second round of experts. The questionnaire consisted of proposals for recommendations for the use of local estrogens in the context of female urinary incontinence. The Survey Monkey® survey software allowed the questionnaire to be distributed and the answers obtained to be analyzed. RESULTS: Eight experts responded to the first round questionnaire. Seven formulations were deleted, 3 amended and 4 added to the first round questionnaire following expert advice. Twenty-six experts replied to the second round questionnaire, 24 of which were complete. Ten of the 21 proposals were approved at more than 80%, including five with strong agreement regarding the recognized benefit of local estrogens in urinary incontinence due to overactive bladder, the absence of data from the literature to demonstrate over-risk of hormone-dependent cancer under local estrogens and the need for follow-up of patients under this treatment. Six proposals were not the subject of a consensus and concerned the prescription modalities (maximum duration, effective minimum dose, prescription before surgery for incontinence). CONCLUSION: Although local estrogens did not have regulatory approval in urinary incontinence, more than 80% of these experts recognized their benefit in the management of urinary incontinence in women with vulvo-vaginal atrophy, particularly in the case of urinary urge incontinence. LEVEL OF PROOF: 4.

[Interest of surgical companionship during the training period of robot-assisted radical prostatectomy]. / Intérêt du compagnonnage chirurgical durant la période d'apprentissage de la prostatectomie radicale robot-assistée.

OBJECTIVE: Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification. PATIENTS AND METHODS: Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group. RESULTS: Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3. CONCLUSION: The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair. LEVEL OF EVIDENCE: 4.

[HoLEP learning curve: Toward a standardised formation and a team strategy]. / Apprentissage de l'HoLEP : vers une formation standardisée et une stratégie d'équipe.

AIM: Holmium laser enucleation of prostate (HoLEP) is renowned for the difficulty of its learning curve. Our aim was to evaluate the interest of a three-step tutorial in the HoLEP learning curve, in a university center. METHODS: It is a retrospective, monocentric study of the 82 first procedures done consecutively by the same operator with a proctoring in early experience and after 40 procedures. For all patients were noted: enucleation efficiency (g/min), morcellation efficiency (g/min), percentage of enucleated tissue (enucleated tissue/adenome weigth evaluated by ultrasonography. g/g), perioperative morbidity (Clavien), length of hospital stay, length of urinary drainage, functional outcomes at short and middle term (Qmax, post-void residual volume [PVR], QOL scores and IPSS at 3 and 6months). RESULTS: Enucleation and morcellation efficiency were significantly higher after the second proctoring (0.87 vs 0.44g/min; P<0.0001 and 4.2 vs 3.37g/min, P=0.038, respectively) so as the prostatic volume (43.5 vs 68.1mL, P=0.0001). Percentage of enucleated tissue was higher in the second group, however, the difference was not significant (69.5% vs 80.4%, P=0.03). Per- and postoperative complications, hospital length of stay, urinary drainage length and functional results at 3 and 6months were not significantly different. CONCLUSION: The learning curve did not interfere with functional results. The second proctoring was essential to us in order to grasp the technique. These data underlined the necessity of a pedagogic reflexion in order to built a standardized formation technique to the HoLEP. LEVEL OF EVIDENCE: 4.

[External sphincterotomy in neurological patients: A monocentric experience]. / Sphinctérotomie laser chez le patient porteur d'une vessie neurologique : une expérience monocentrique.

AIM: The aim of this study was to assess the feasibility, efficacy and tolerance of Greenlight™ and Holmium sphincterotomy for treating detrusor-sphincter dyssynergia. METHODS: All men treated with this two techniques between may 2012 and june 2015 were analyzed. Preoperative evaluation included kidney ultrasound scan, urodynamic, retrograde and voiding urethrocystography. Postoperative assessment was composed of a post-void residual volume measurement when the urethral catheter was removed and 1 year after the procedure, a retrograde and voiding urethrocystography at 3 months and telephonic Likert scale questionnaire. RESULTS: Twelve patients were operated with Greenlight™ and 12 with Holmium. Eleven had a memocath urethral stent preoperatively. Post-void residual volume median for both techniques was 285 cc preoperatively vs 137.5 cc postoperatively (P<0.001). Likert scale global satisfaction was 75%. Five stenosis (20.8%) were observed within a median of 4 months. CONCLUSION: Greenligth™ and Holmium procedures are efficient techniques with low morbidity. However, superiority toward monopolar incision remains to be demonstrated through complementary studies. LEVEL OF EVIDENCE: 4.

[Prevalence and initial management of overactive bladder in France: A cross-sectional study]. / Prévalence et prise en charge initiale de l'hyperactivité vésicale en France : une étude transversale.

AIMS: To determine the prevalence of overactive bladder (OAB) syndrome in France and gather data about initial patient trajectories in the healthcare system. METHODS: A dedicated questionnaire (41 questions) has been sent to a 12,000 sample of people representative of the global population. The following data were investigated: social and demographic features, medical history, Urinary Symptom Profile questionnaire, bother, history of symptoms, care seeking and treatments received. Patient were considered having OAB in case if presenting at least two episodes of urgency per week, or being under treatment of OAB. OAB prevalence was the main outcome, and associated factors were characterized by univariate and multivariate analysis. RESULTS: Based on 8842 available questionnaires, the global prevalence of OAB was estimated to be 14.4%. Prevalence was significantly higher in women, older age groups, as well as obesity, irritable bowel syndrome, urinary tract infections, enuresia, constipation, anxiety/depression, neurological diseases, sleep apnea syndrome, asthma, chronic obstructive pulmonary disease, diabetes and hypertension. Only 34.6% of patients with OAB had visited a health practitioner for this problem. General practitioners were most frequently implicated in patient primary care and evaluation. Seventy-two percent of patients with OAB had had additional investigations (mostly a urine culture) and only 6% of patients had to complete a bladder diary. The most frequent treatment option was oral antimuscarinics. Physical therapy and rehabilitation have been prescribed in 26% of cases, as well as dietary advice. CONCLUSIONS: OAB is a frequent syndrome. Its prevalence increases with age, and OAB frequently concern elderly frail people with many other associated diseases. LEVEL OF EVIDENCE: 3.

[Does urinary sacral neuromodulation improve bowel symptoms other than fecal incontinence: A systematic review]. / La neuromodulation sacrée urinaire a-t-elle un effet sur les troubles digestifs autre que l'incontinence fécale : revue de la littérature.

PURPOSE: To evaluate literature data about urinary sacral neuromodulation and its effects on bowel symptoms other than fecal incontinence. METHOD: A systematic review was conducted using PubMed/Medline with the following keywords: sacral neuromodulation, urinary incontinence, voiding symptoms, intestinal bowel syndrome, constipation, epidemiology. RESULTS: Urinary SNS seems to improve intestinal bowel symptoms scores (level of evidence 4). However, for constipation, there are more contrasting results. If symptoms scores seem to improve, QOL scores are not significantly changed. Furthermore, some people reported an aggravation of their constipation symptoms (level of evidence 4). Those contrasted results could be explained by the various causes of constipation which implies various pathophysiological pathways. CONCLUSIONS: A better evaluation of digestive symptoms in patient candidate to urinary SNS could help identifying patients able to be improve by SNS. LEVEL OF EVIDENCE: 4.

High bacterial titers in urine are predictive of abnormal postvoid residual urine in patients with urinary tract infection.

Urine bacterial titers (BTs) are influenced by bacterial and host factors. The impact of an abnormal postvoid residual (PVR) on BT in urine was investigated. A total of 103 inpatients with a urine growing Enterobacteriacae (≥ 10(2) CFU/mL) and a PVR measure were analyzed, mostly female (62%), elderly (mean age: 72 years), with urinary tract infection (25% of asymptomatic bacteriuria) due to Escherichia coli (85%). Fifty-two subjects (56%) had BT ≥ 10(6) CFU/mL; 48 (53%) had a PVR ≤ 100 mL, while 26 (25%) had a PVR >250 mL. PVR increased with BT, and a significant (P<0.0001) threshold was reached for 10(6) CFU/mL: 100mL mean PVR for patients with BT ≤ 10(5) CFU/mL versus 248 mL for patients with BT >10(5) CFU/mL. High PVR and BT were associated with complicated infections, concomitant bacteremia, and delayed apyrexia. Screening for patients with BT ≥ 10(6) CFU/mL is an easy way to identify patients at high risk for acute retention and voiding disorders.

Acute sacral nerve stimulation reduces visceral mechanosensitivity in Rat through spinal opioid pathway.

BACKGROUND: Sacral nerve stimulation (SNS) is an alternative surgical treatment of refractory urge incontinence and/or fecal incontinence. Despite its clinical efficacy, the mechanisms of action of SNS remain poorly understood. The aim of this experimental study was to evaluate the effect of SNS on visceral mechanosensitivity in rats. METHODS: Anesthetized Sprague-Dawley rats were treated with SNS or sham stimulation. SNS was performed by implanting an electrode close to the sacral nerve root S1. Rats were administered either a non-selective opioid receptor antagonist (naloxone) or a nitric oxide synthase inhibitor (L-NAME). Colonic mechanosensitivity was evaluated using the variation of arterial blood pressure as a spino-bulbar reflex in response to graded isobaric colorectal distension (CRD). C-fos immunoreactive neurons were quantified in spinal and supraspinal sites. µ-opioid receptor (MOR) internalization was counted in the sacral spinal cord with sham or effective SNS in response to CRD. KEY RESULTS: SNS reduced visceral mechanosensitivity in response to CRD. This effect was reversed by intrathecal and intraveinous naloxone administration. In both models, CRD induced increased c-fos immunoreactivity in the dorsal horn neurons of the sacral spinal cord and supraspinal areas. This increase was prevented by SNS. MOR internalization was significantly higher in stimulated group. CONCLUSIONS & INFERENCES: SNS impacts on visceral mechanosensitivity by decreasing the spino-bulbar reflex in response to CRD. Spinal opioid receptors are likely involved in this effect.

[Evaluation of the electromyography activity of pelvic floor muscle during postural exercises using the Wii Fit Plus©. Analysis and perspectives in rehabilitation]. / Évaluation de l'activité électromyographique des muscles du plancher pelvien pendant des exercices posturaux à l'aide du jeu vidéo virtuel Wii Fit Plus©. Analyses et perspectives en rééducation.

INTRODUCTION: The aim of this work was to evaluate the effect of postural awareness by using the Wii Fit Plus© on the quality of the baseline (automatic) activity of the pelvic floor muscles (PFM) measured by intravaginal surface electromyography (sEMG). METHODS: Four healthy continent female subjects, all able to perform a voluntary contraction, undertook 2 sets of 3 various exercises offered by the software Wii Fit Plus© using the Wii balance board© (WBB): one set without any visual control and the second set with postural control and sEMG visual feedback. Simultaneously, we recorded the sEMG activity of the PFM. RESULTS: Mean baseline activity of PFM in standing position at start was 2.87 mV, at submaximal voluntary contraction the sEMG activity raised at a mean of 14.43 mV (7.87-21.89). In the first set of exercises on the WBB without any visual feedback, the automatic activity of the PFM increased from 2.87 mV to 8.75 mV (7.96-9.59). In the second set, with visual postural and sEMG control, mean baseline sEMG activity even raised at 11.39 mV (10.17-11.58). CONCLUSION: Among women able of a voluntary contraction of PFM, visualisation of posture with the help of the WBB and of sEMG activity of the PFM during static and dynamic Wii Fit Plus© activities, may improve the automatic activation of the PFMs. LEVEL OF EVIDENCE: 4.

The efficacy of hemostatic radiotherapy for bladder cancer-related hematuria in patients unfit for surgery

Objective The aim of our study was to assess short and mid-term clinical efficacy of external beam radiation therapy to achieve hemostasis in patients with bladder-cancer related gross hematuria who were unfit for surgery. We also assessed hypofractionation as a possible alternative option for more severe patients. Patients and Methods Thirty-two patients were included for hemostatic radiation therapy, with two schedules based on Eastern Cooperative Oncology Group performance status. The standard treatment was 30 Gy in 10 fractions over 2 weeks. More severe patients underwent a hypofractionated regimen, with 20 Gy in 5 fractions over a one week period. Clinical evaluation was performed at 2 weeks and 6 months. Results At 2 weeks, 69% of patients were hematuria-free. Subgroup analysis showed that 79% of patients undergoing hypofractionated regimen were hematuria-free. A total of 54% were hematuria-free with the standard regimen. Based on tumor stage, hematuria was controlled at 2 weeks for 57% of non-muscle invasive tumors and 72% of muscle-invasive tumors. After 6 months, 69% of patients had relapsed, regardless of tumor stage or therapy schedules. Conclusions Hemostatic radiotherapy is an effective option for palliative-care hematuria related to bladder cancer in patients unfit for surgery. Although it appears to be rapidly effective, its effect is of limited duration. Hypofractionation also seems to be an effective option; however larger cohorts and prospective trials are needed to evaluate its efficacy compared to standard schedules. .