Base bibliographique

Aim

To elaborate guidelines for the diagnosis, the follow-up, and the treatment of benign prostatic hyperplasia (BPH).

Method

A systematic review of the literature was conducted to select more relevant publications. The level of evidence was evaluated. Graded recommendations were written by a working group, and then reviewed by a reviewer group according to the formalized consensus technique.

Results

Terminology of the International Continence Society was used. Initial assessment has several aims: making sure that lower urinary tract symptoms (LUTS) are related to BPH, assessing bother related to LUTS and checking for a possible complicated bladder outlet obstruction (BOO). Initial assessment should include: medical history, LUTS assessment using a symptomatic score, physical examination including digital rectal examination, urinalysis, flow rate recording, and residual urine volume. Frequency volume chart is recommended when storage symptoms are predominant. Serum PSA should be done when the diagnosis of prostate cancer can modify the management. When a surgical treatment is discussed, serum PSA, serum creatinine and ultrasonography of the urinary tract are recommended. BPH patients should be informed of the benign and possibly progressive patterns of the disease. When LUTS cause no bother, annual follow-up should be planned. Medical treatment includes some phytotherapy agents, alpha-blockers and 5-alpha reductase inhibitors. The last two can be associated. The association of antimuscarinics and alpha-blockers can be offered to patients with residual storage symptoms when already under alpha-blockers therapy, after checking for the absence of severe BOO (residual volume more than 200mL or max urinary flow less than 10mL/s). Phosphodiesterase-5 inhibitors could be used in patients complaining for both LUTS and erectile dysfunction. In case of complication, or when medical treatment is inefficient or not tolerated, then a surgical treatment should be discussed. Treatment decision should be done according to type of LUTS and related bother, prostate anatomy, level of obstruction and its consequences on urinary tract, patient co-morbidities, experience of practitioner, and choice of patient. Surgical treatments with the higher level of evidence of efficacy include monopolar or bipolar transurethral resection of the prostate, open prostatectomy, transurethral incision of the prostate, photoselective vaporization of the prostate, and Holmium laser enuclation of the prostate.

Conclusion

Here are the first guidelines of the French Urological Association for the initial assessment, the follow-up and the treatment of urinary disorders related to BPH.

Introduction

Intravesical BCG immuno-therapy with maintenance therapy is considered as the standard treatment for non-muscle invasive bladder cancer with high risk of recurrence and progression. In practice, adverse events (AEs) of BCG therapy could restrict its prescription by urologists. The aim of this article was to present a review of these AEs and of their management.

Materials and methods

A bibliographic research in French and English using Medline^® and Embase^® with the keywords “BCG”, “bladder”, “complication”, “toxicity”, “adverse reaction”, “prevention” and “treatment” was performed.

Results

The main mechanism of AEs of BCG are infectious (cystitis, fever), immuno-allergic (granulomatous prostatitis, epididymo-orchitis, and granulomatous reactions) and auto-immune (arthralgies, rash). Management of AEs is based on their pathophysiological mechanisms. Classifications of BCG therapy AEs based on clinical features allow to adapt their treatments.

Conclusion

The combination of antibiotics directed against BCG, steroid or non-steroidal anti-inflammatory medication and symptomatic treatment is currently the triad on which is set up the appropriate treatment of severe AEs. Reductions of BCG doses and ofloxacin medication after instillation decrease the frequency and severity of minor and moderate AEs. Severe or more than 7 days long infectious AEs, immuno-allergic AEs or auto-immune during more than 7 days impose cessation of BCG immuno-therapy.

Objective

To assess the frequency, circumstances, and possible medico-legal consequences of the pT0 prostate cancer, defined by the absence of tumor in a radical prostatectomy specimen.

Methods

Six centers retrospectively identified all cases of pT0 and selectionned those that occurred without prior hormone therapy or prostate resection. Preoperative data, histological report and clinical and biological outcome were analyzed. The lawsuits’ registry in pathology were consulted at insurance companies.

Results

Thirty cases of pT0 prostate cancer (0.4%) were reported on 7693 patients. The median age was 63years, PSA 7.4ng/mL. The number of positive preoperative biopsies ranged from one to four for a median tumor length of 1mm (0.3 to 18mm). The biopsy Gleason score was 3+3 for 23 patients, less than 5 for six others and included a contingent of grade 4 in two patients. With a median follow-up of 82months, no clinical or biochemical recurrence was observed. One patient complaint for pT0 prostate was found in the insurances registry.

Conclusion

The occurrence of a prostate pT0 called into question all the diagnostic procedures and surgical indication. To avoid a forensic procedure, urologists should inform patients of the possibility of this situation before radical prostatectomy.

Introduction

Urinary symptoms occur in 50 to 80% of patients with Multiple Sclerosis (MS). This study was conducted to determine prevalence of renal failure during MS follow-up and to investigate the correlation of these complications with disease characteristics and urodynamic findings.

Methods

One hundred and twenty-one consecutive patients have been followed for (MS) (61 men and 60 women) between 1995 and 2009 in our institution. The demographic findings of patients were documented. The history was obtained and a detailed neurological and urological physical examination was performed for all patients. Urological symptoms (urgency, frequency, urge incontinence, dysuria), urinary scores (UPS and International Consultation on Incontinence Questionnaire [ICIQ]) and renal failure were recorded. All patients underwent ultrasound imaging of the bladder during their follow-up and on the last evaluation. Expanded Disability Status Scale (EDSS) was evaluated during neurologic follow-up. For each patient mean onset age of disease, mean onset age of micturation disorders, mean illness duration and mean urological follow-up duration were recorded. Urodynamic investigation was performed for all patients. Urodynamic assessment was carried out according to the International Continence Society (ICS) standards (detrusor overactivity, detrusor/sphincteric dyssynergia and low bladder compliance).

Results

Mean illness duration was 13.8 years (1–50). According to the history and clinical findings, 21 patients had primary-progressive (PPMS), 59 relapsing-remitting (RRMS) and 41 secondary-progressive multiple sclerosis (SPMS). Four patients have shown renal failure during their follow-up (3.3% - three men and one woman). Renal failure was associated with disease characteristic (SPMS - EDSS score >6.5), mean illness duration (30 years [12–48]) and low bladder compliance (17 [7–23]) (P =0.03; P =0.02; P =0.049).

Conclusion

Relationship between renal failure, disease characteristics and urodynamic findings was suggested in our study. More accurate follow-up might be used for SPMS (EDSS >6.5), longer mean illness duration (>30 years), and low bladder compliance (<30).

Hydatid disease is endemic in some Mediterranean countries. Kidney is a relatively rare site, representing 2 to 3 % of all visceral sites. The diagnosis of hydatid cyst of the kidney is suspected in epidemiological, clinical, radiological and biological arguments. It remains clinically silent for a long time and only presents at the stage of complications. Ultrasound can suspect the hydatid nature of the lesion in 50 % of cases. Computed tomography and magnetic resonance imaging are helpful in the event of problem of differential diagnosis. The standard treatment for renal hydatid cyst is resection of the prominent dome and nephrectomy is indicated in cases of destroyed kidney.

Objectives

To evaluate the results of Anderson-Hynes open pyeloplasty in our institution. And then to compare them to those of laparoscopic procedure and identify what can be considered now as the indications of the open procedure.

Patients and methods

It was a retrospective study on 30 cases of ureteropelvic junction syndrome managed by Anderson-Hynes open procedure. The clinical, biological and radiologic characteristics of the patients as well as the surgical technique and its results were taken into account. The patients were classified, according to Valdeyer and Cendron classification as type II in eight cases (26.7%), type III in ten cases (33.3%) and type IV in four cases (13.3%). There were also eight cases of giant hydronephrosis (26.7%). The operating time, the length of hospital stay and the outcomes were studied and compared with those of the laparoscopic pyeloplasty found in the medical literature.

Results

The mean operating time was 115±33.4minutes (90–230min). The mean length of hospital stay was 10.4±5.1days. Six patients (20%) had postoperative complications. After a mean follow-up of 28±13.7months (13–48months), our first-hand success rate was 90% (n =27).

Conclusion

Anderson-Hynes open pyeloplasty reached good results but nowadays its indications can be limited to laparoscopic contraindications, severe hydronephrosis (grade IV or giant hydronephrosis) and second-hand cases. The two latter indications depend on the surgeon experience in laparoscopic surgery.

Objective

With PSA screening, the incidence of prostate cancer (PCa) has increased. Moreover, age and clinical stage have decreased as a result of earlier diagnosis. In this context, the risk of over-treatment including surgery may be important. The objective was to assess the evolution of pathological stages of radical prostatectomy (PR) to 5years apart.

Materials and methods

Nine hundred and six PR were conducted in two French centers (503 in 2005 and 403 in 2010). Preoperative data (age, PSA, clinical stage, number of biopsies, Gleason score) and postoperative (pTNM, Gleason score, prostate weight) were analyzed and compared (Student test and Chi²).

Results

In 2005 and 2010, the median age was respectively 62.85 and 62.52years (NS). The median PSA was 8.55 and 8.99ng/ml (NS). The number of positive biopsies increased significantly (2.30 to 2.88, P <0.0001), but not the biopsy Gleason score (6.34 to 6.43, NS). Clinical stage was significantly changed with T1c: 77.8 to 73%, T2a: 16.6 to 14.2%, T2b: 4 to 7.8%, T2c: 0 to 1%, T3: 1 to 3.9% T4: 0.4 to 0% in 2005 and 2010, respectively (P <0.0006). The average weight of prostate decreased significantly (55.6g versus 48.8g, P <0.0001), pathological Gleason score was unchanged (6.86 versus 6.80, NS). However, the pathological stage has changed significantly to tumours with higher stages pT2: 66.5 to 51.8% and pT3 33.5 to 48.1% (15%) (P =0.02).

Conclusion

These results have shown that the number of PT performed for pT3 tumours has increased. This increase in patients with high-risk disease has been probably due to change in the selection of patients (surgery for more advanced clinical stages) and allows to consider the radical prostatectomy as a treatment of high risk PCa.

Introduction

Approximately, 30% of kidney cancers are diagnosed in patients over 75 years, mostly by fortuitously. This review had identified the indications of ablative treatment among others options for kidney cancer in these elderly patients.

Materials and methods

A bibliographic research in French and English using Medline^® with the keywords “tumor”; “kidney”; “radio frequency” and “cryoablation” was performed.

Results

The expected benefits were less morbidity, reduced hospital stay and preservation of renal function. Ablative techniques have allowed a satisfactory cancer control but lower than that obtained by surgical excision at the cost of a lower morbidity. Cryoablation has allowed better oncological results than the radiofrequency. A decision tree for management of small renal tumors in patients defining a role for these treatments depending on the patient’s life expectancy, its comorbidities (Charlson index) and tumor size was proposed.

Conclusion

The preferential indications for cryoablation and radiofrequency treatments in elderly patients are tumors under 3cm and less than 4cm respectively, when life expectancy is between 3 and 7 years.

Objective of the study

Feasibility and efficiency study of mesh readjustment in suburethral slings by overcoat plication in case of persisting of recurring stress urinary incontinence in patients with suburethral slings.

Methods

Retrospective and monocentric study including patients that present with a failure or recurring incontinency after suburethral slings surgery. The eligibility was evaluated after a complete clinical and paraclinical statement, proving the recurrence of the incontinence and its mechanism. Surgery consisted in a plication in an overcoat.

Results

Nineteen patients were included. The medium delay between initial surgery and the plication was 23.4months (ds=25.5). Results were evaluated subjectively by the MHU questionnaire and objectively by the urodynamic appraisal. The medium survey was 27.2months (ds=37.3). The procedure lasts about 30minutes. According to MHU, 73.7% of patients were cured and for 10.3% the symptoms were lessened. The difference in the MHU score of stress urinary incontinence before and after mesh readjustment was significant (P =0.0005) and get down from 2.31 (ds=0.75) to 0.56 (ds=0.92) as an average. There was no complication during surgery. There were two cases of postoperative acute urinary retention which were reoperated by simply cutting a thread allowing the sling to relax without losing the benefit of the plicature. There was no significant increase in urge incontinence or dysuria.

Conclusion

The results of this study confirmed the feasibility, the efficiency and the low morbidity of mesh readjustment for the suburethral sling.

This case report describes an exceptional case of ectopic adrenal cortex tissue (EACT) in the spermatic cord associated with ipsilateral cryptorchidism in an adult. While both EACT and cryptorchidism are fairly common congenital anomalies in boys, adult cases are uncommon. Although the spermatic cord is a known site of EACT, the reports of its association with cryptorchidism have been limited to child cases. During surgery, undescended testis was discovered and incidentally ectopic adrenal tissue along the spermatic cord was also identified. This combination of developmental aberrations in the adult has not been described, and the clinicopathological findings are reported with a brief literature review.