[Intravesical instillations for inflammatory and sensory chronic bladder diseases: Literature review and guide to clinical practice]. / Instillations endovésicales pour les cystopathies chroniques inflammatoires et douloureuses : revue de la littérature et guide de la pratique clinique.

INTRODUCTION: Inflammatory and sensory chronic bladder diseases have a significant impact on quality of life. These pathologies share alteration of the layer between urine and urothelium, making the use of topical agents appropriate. OBJECTIVES: Review the efficacy and tolerance of intravesical treatments for these pathologies. Give practical guidelines for the use of agents currently available in France. METHOD: A narrative review was performed in March 2021 using PubMed/MEDLINE, Google Scholar and the international guidelines. Pharmaceutical companies and pharmacies were interviewed. RESULTS: Although numerous molecules were tested over the last 5 decades, only dimethylsulfoxyde and glycosaminoglycans are available in France today. Results are promising: response rates are up to 95% and 84% respectively in bladder pain syndrome. In urinary tract infections, glycosaminoglycans could decrease annual number of cystitis by 2.56 (95% confidence interval (CI) -3.86, -1.26; P<0.001) and increase the time to first cystitis recurrence by 130 days (95% CI: 5.84 - 254.26; P=0.04). In radiation cystitis, results could be comparable to hyperbaric oxygen regarding pain and frequency of voiding (-1.31±1.3 visual analogic scale et -1.5±1.4 voiding per day, respectively, at 12 months, P<0.01). However, literature has a low level of evidence. CONCLUSION: Chronic bladder diseases have limited treatment options. Intravesical agents are a good alternative, although their cost is significant and their outcome uncertain.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence.

OBJECTIVE: To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]. / Complications des bandelettes sous urétrales : une revue de la littérature par le Comité d'urologie et pelvipérinéologie de la femme de l'Association française d'urologie.

INTRODUCTION: Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term. OBJECTIVES: In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected. RESULTS: Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women. CONCLUSION: Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

[Vaginal LASER therapy for genito-urinary disorders: A systematic review and statement from the Committee for Female Urology and Pelviperineology of the French Association of Urology]. / Utilisation du LASER vaginal pour le traitement des pathologies génito-urinaires : revue systématique de la littérature et position du CUROPF.

INTRODUCTION: Vaginal LASER therapy is increasingly used in the field of urogynecology, but several points remain unclear. Our goal was to produce a systematic review of available evidence and provide a critical appraisal of available data. METHODS: A systematic review until march 2020 was conducted using PubMed/MEDLINE, Cochrane and Embase databases. All studies about vaginal LASER use in the field of urogynecology were included. RESULTS: Forty studies have been included (8 for genitourinary syndrome of menopause, 19 for stress urinary incontinence, 3 for overactive bladder, 7 for urogenital prolapse, 3 for other indications). Data were heterogeneous, and level of evidence was weak or very weak. Few studies were comparative, and only 3 were randomized). Mild improvement of symptoms and quality of life and limited satisfaction were seen for genitourinary syndrome, stress urinary incontinence, overactive bladder and prolapse. Few adverse events were reported. However, major methodological biases were noted regarding efficacy and safety evaluation. No long-term results were available. CONCLUSIONS: While Vaginal LASER therapy seem to provide encouraging results, the level of evidence supporting its use was weak, especially regarding long-term outcomes. Studies of better quality are warranted before any recommendation can be made. Current use should be limited to clinical research.

[Intrinsic sphincter deficiency and female urinary incontinence]. / Insuffisance sphinctérienne et incontinence urinaire de la femme.

OBJECTIVE: Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. MATERIAL AND METHODS: This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. RESULTS: Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. CONCLUSION: Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

Technical aspects of botulinum toxin type A injection in the bladder to treat urinary incontinence: reviewing the procedure.

AIMS: Standardise the injection technique with botulinum toxin type A (BoNT A) in the bladder of patients with overactive bladder (OAB) [idiopathic overactive bladder (iOAB) or neurogenic overactive bladder (nOAB) with urinary incontinence], using a literature review and a survey of an International expert panel. METHODS: PubMed literature searches of BoNT A in adults with iOAB/nOAB together with a survey of 13 experts from 10 countries. RESULTS: Data from 21 articles and completed questionnaires were collated. The procedure can be carried out in an out-/inpatient setting. Dose used in clinical studies vs. clinical practice was 300 and 200 U for nOAB and 200 and 100 U for iOAB. Recent studies have also demonstrated that there are no clinically relevant benefits between 100 and 150 U in iOAB or between 300 and 200 U in nOAB, though adverse effects are increased with higher doses. Usually, 30 sites for nOAB (range: 6.7-10 U/ml) and 20-30 sites for iOAB (range: 5-10 U/ml) are injected in clinical studies vs. 20-30 sites of 1 ml/injection for 200 U in nOAB and 10-20 sites of 0.5-1 ml/injection for 100 U in iOAB in clinical practice. BoNT A is usually injected directly into the detrusor, sparing the trigone. Flexible or rigid cystoscopes are used. The needle should be typically 22-27 gauge and 4 mm in length and should have a stopper to avoid any leakage or perforation of the bladder wall while ensuring a targeted injection. CONCLUSION: Based on the literature and survey analysis, recommendations are proposed for the standardisation of the injection procedure.

[Mini-sling for management of stress urinary incontinence in women: a literature review]. / Mini-bandelettes pour le traitement de l'incontinence urinaire d'effort féminine : revue de la littérature.

AIM: To conduct a review about the use of single incision mini-slings (SIMS) to manage non-neurogenic stress urinary incontinence in women. METHODS: Literature search in Pubmed/MEdline database until june 2013. TVT-Secur™ was excluded because this device is not anymore marketed. RESULTS: Ajust™ and Mini-Arc™ were the two main SIMS evaluated in the literature. Studies about Mini-Arc™ generated heterogeneous results, with a success rate between 44% and 91% after 1 year. Ajust™ was the most promising device with 80% efficacy after mid-term follow-up. All evaluated SIMS had a low rate of immediate complications. Two randomized controlled trials comparing SIMS and traditional mid-urethral slings were identified, as well as one meta-analysis; they all concluded to non-superiority or inferiority for the mini-sling versus traditional slings. CONCLUSION: Due to short follow-up, limited evidence and heterogeneous data, SIMS are not yet standard of care and further research is warranted.

Repeat mid-urethral sling for recurrent female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence. METHODS: A total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed. RESULTS: All patients had urethral hypermobility and 12.9 % had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP) ≤ 20 cmH2O]. Median MUCP was 41 cmH20. Overactive bladder was found in 5.7 % of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49 %), transobturator tape (48 %), or mini-sling (3 %). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7 %) patients were subjectively cured and 18 (16.1 %) improved (76.8 % success overall) with a mean follow-up of 21 months. Success rates were 72.2 and 81.8 % for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success. CONCLUSIONS: Repeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77 % successful in a group of patients with persistent urethral hypermobility. A retropubic approach might be preferred for patients with low urethral closure pressures.

[Salvage therapy with artificial urinary sphincter after Advance™ male sling failure for post-prostatectomy incontinence: a first clinical experience]. / Thérapie de sauvetage par implantation d'un sphincter artificiel urinaire après échec de bandelette Advance™ pour incontinence urinaire après prostatectomie : une expérience monocentrique.

OBJECTIVES: To assess the clinical outcome following artificial urinary sphincter (AUS) implantation after failure of Advance™ sub-urethral male sling for post-prostatectomy incontinence (PPI). METHODS: A prospective evaluation was conducted about consecutive patients who received an AUS after failure of Advance™ therapy in one tertiary reference center. Evaluation included medical history, pad use and operative data (duration, cuff size, technical difficulties). Follow-up was scheduled at 1, 6, 12 months and yearly thereafter. Clinical outcome was evaluated by pad use, patient global impression of improvement (PGI-I) scale and assessment of side effects. Cure was defined as no pad usage. RESULTS: Twelve patients were included in this evaluation. Median follow-up was 20 months (12-43). No patient was lost to follow-up. Four patients had a history of radiation therapy and all patients had mild or moderate PPI with previous failed Advance™ surgery. Median (range) operative time was 47 minutes (40-60). No technical problem occurred during AUS implantation. Hospital stay duration and catheterization duration were respectively 2 days and 24 hours in all but one case. At last follow-up, 10/12 patients (83%) were cured and fully satisfied. Two were improved, wearing only one pad per day. Postoperative complications were noted in two cases (17%) (one case of cutaneous erosion and one case of superficial iliac wound infection). CONCLUSIONS: AUS implantation is feasible in patients who have undergone Advance™ male sling implantation. Mid-term results of this procedure are comparable to those obtained after first line AUS implantation.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients.

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77% of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46% of the patients were in the "full success" group. 31% of the patients had a partial improvement. 23% of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46% of the cases, BTX-A injection therapy failed to treat refractory NDO in 23% of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anti cholinergic drugs fail to reduce NDO.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77 percent of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46 percent of the patients were in the "full success" group. 31 percent of the patients had a partial improvement. 23 percent of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46 percent of the cases, BTX-A injection therapy failed to treat refractory NDO in 23 percent of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anticholinergic drugs fail to reduce NDO.

[Initial experience combinating transobturator male sling and penile implant after radical prostatectomy]. / Chirurgie combinée par bandelette transobturatrice Advance et prothèse pénienne après prostatectomie totale: une première expérience.

PURPOSE: Stress urinary incontinence (SUI) and erectile dysfunction (ED) are two major complications following radical prostatectomy (RP). In case of failure of medical treatment, Advance™ retrourethral male sling and penile implant are validated options to manage respectively SUI and ED. Our goal was to assess the feasibility and results of the combination of these two devices. PATIENTS AND METHODS: Four patients were treated for SUI and DE following RP in our institution by retrourethral sling and penile prosthesis, after failure of medical management. Each patient was preoperatively evaluated by age, complete medical history, ASA score, endoscopy, pad-test, and urodynamics. The first two patients were implanted with the two devices in a two-stage procedure: retrourethral sling then penile prosthesis for one, and penile prosthesis then retrourethral sling for the other. The two other patients underwent a one-stage procedure: one received the two devices, and the other had retrourethral sling implantation and replacement of a penile prosthesis. Post-operative follow-up was focused on complications and efficacy (evaluated by pad use and PGI-I questionnaire for continence, and patient auto-evaluation for sexual function). RESULTS: No perioperative complication occurred. After a minimum of 6 months follow-up, all the four patients were pad-free with no leakage reported, feeling very much better after the procedure according to the PGI-I. The four patients were fully satisfied of the penile implant device. CONCLUSIONS: According to our initial experience, surgery combining the transobturator Advance male sling and a penile prosthesis is feasible, successively or simultaneously, and leads to excellent functional results with no complications.

[Evaluation of urologic activity in ambulatory surgery: a single centre experience]. / Évaluation de la pratique de la chirurgie ambulatoire en urologie: expérience d'un centre.

OBJECTIVE: Ambulatory surgery is an alternative to traditional hospitalisation and an opportunity for savings for the healthcare system. Here, we analyze our experience in outpatient surgery in urology over a year. MATERIAL: A prospective database concerning outpatient activity was established in 2009, gathering age, ASA score, type of intervention, discharge and recovery for each patient. An individual questionnaire was sent retrospectively in February 2010, to collect data about history of outpatient surgery, overall satisfaction, preference for traditional hospitalization and emergency department visits within 48 hours after surgery. RESULTS: In 2009, 465 patients aged of 52±16 years (15-98) underwent urologic surgery on an outpatient basis. Median ASA score was 2 (1-3). Types of intervention were mainly endo-urology (44.5%), surgery for urinary incontinence (32.5%), and circumcision (12.3%). The postoperative hospitalization rate was 4.5%. The questionnaire response rate was 28%. Forty-six percent of the patients had already been supported in ambulatory, overall satisfaction was 3.3 out of 4 (±1.06) and 24% of patients would have preferred a traditional hospitalization. 11% of patients required emergency department care within 48 hours whatever the surgery undergone. CONCLUSION: An important part of urological procedures has been done on an outpatient basis without compromising quality of care and patient satisfaction.

[Guidelines for treatment of urinary incontinence in women due to refractory idiopathic vesical hyperactivity with botulinum toxin A]. / Recommandations pour le traitement de l'incontinence urinaire féminine par hyperactivité vésicale idiopathique réfractaire par la toxine botulique A.

The data reported in the literature today show that botulinum toxin A may have a certain value in the therapeutic arsenal for non-neurological vesical hyperactivity. However, the use of botulinum toxin cannot be recommended in daily practice of non-neurological vesical hyperactivity incontinence treatment. In patients presenting non-neurological vesical hyperactivity, the use of botulinum toxin A (which in 2009 did not have market authorization for this indication, even in neurological patients) should be reserved for highly targeted, second- and third-line indications (failure or intolerance of recommended treatments), and certainly at first within clinical research or in specialized units.

[Synthesis of the guidelines for the treatment of non-neurological urinary incontinence in women]. / Synthèse des recommandations pour le traitement de l'incontinence urinaire féminine non neurologique.

The last two decades have brought about new medical and surgical treatments revolutionizing care for non-neurological urinary incontinence in women. Many studies, often randomized prospective studies with sufficient follow-up, have validated the therapeutic choices and shown them not to be part of a fad or marketing pressures. The French Association of Urology (L'Association Française d'Urologie), through its Committee on Women's Urology and Pelviperineology (Comité d'Urologie et de Pelvipérinéologie de la Femme), proposes its recommendations. These were established by an expert group of specialists (urologists, gynecologists, and physical therapists), based on a review of the literature but taking into account the daily practices in academic and private practice settings. Between evidence-based medicine and reality in the field, these recommendations attempt to propose realistic and applicable strategies.

Prevalence and risk factors of urinary incontinence in young and middle-aged women.

Objective To assess the prevalence of and risk factors for urinary incontinence (UI) in young and middle-aged women. Subjects and methods During 1998 the prevalence of overall, stress, urge and mixed UI was assessed in women working in a French academic hospital. Women (2800) received a questionnaire at the same time as their yearly interview with a staff physician in occupational medicine. The usual risk factors for constitutional events, i.e. increasing age, obesity (defined as a body mass index of > or = 25), obstetric events (pregnancy, previous Caesarean delivery, previous vaginal delivery, postpartum incontinence) and gynaecological events (hysterectomy) were evaluated. Results Of the 1700 women (mean age 40.0 years) who returned the questionnaire, 467 (27.5%, 95% confidence interval, CI, 25.4-29.7) reported UI, comprising 210 (12.4%, 10.8-14.0) with stress UI, 28 (1.6%, 1.1-2.4) with urge UI and 229 (13.5%, 11.9-15.2) with mixed UI. Thirty-eight women (8.1%) had frequent urinary leakage, comprising one (0.5%), four (14.3%) and 33 (14.4%) with stress, urge and mixed UI. The prevalence of UI increased significantly with age > or = 40 years, with a relative risk (95% CI) of 2.16 (1.86-2.57), and with pregnancy (2.22, 1.71-2.87), previous vaginal delivery (2.15, 1.72-2.69), postpartum incontinence (2.57, 2.22-2.97), and hysterectomy (1.52, 1.11-2.08). Obesity (1.14, 0.99-1.32) and previous Caesarean delivery (2.15, 1.72-2.69) did not significantly increase the risk of UI. The risk factors for stress UI were age > or = 40 years, pregnancy, previous vaginal delivery, postpartum incontinence and hysterectomy, but there was no relationship between stress UI and obesity or previous Caesarean delivery. Conclusion There was a high prevalence of UI among young adult and middle-aged women hospital workers who had easy access to medical resources. Gynaecological and obstetric events (pregnancy, particularly previous vaginal delivery and hysterectomy) were the most prominent risk factors, especially for stress UI.