Base bibliographique

Complication vasculaire d'une pyélonéphrite aiguë
2013
- Réf : Prog Urol, 2013, 5, 23, 364-367


Introduction



This article reports a rare case of acute pyelonephritis with bacteriemia due to non-tiphoidal Salmonella associated with a mycotic aneurysm. The patient was a 75-year-old woman without histories of immunosuppression or urologic deformation. It was about a patient presenting a feverish access and urinary symptoms. Blood culture and urine culture showed Salmonella enteritidis ; in spite of a prolonged antibiotic treatment, the multiple bacteriological explorations remained positive. The research for this infection source allowed the discovery of a thoracic aorta aneurysm with hypermetabolism in the PET-scan carrying the diagnosis of mycotic aneurysm. Urinary salmonellosis represents 0.07% (Tena et al., 2007 [11

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]) of the urinary tract infections. They are rarely found in healthy patients; their eradication can turn out to be difficult when the infection source persists.

Mots clés:
Salmonellose / Infection urinaire haute / Anévrisme mycotique / pyélonéphrite
Mots-clés:
Salmonellosis / urinary tract infection / Mycotic aneurysm / pyelonephritis
Cystoscope flexible à gaine stérile à usage unique : impact organisationnel et économique et sécurité bactériologique
2013
- Réf : Prog Urol, 2013, 5, 23, 356-363


Introduction



Purpose

To assess both economical and organizational impact as well as bacteriologic safety of a flexible cystoscope with sterile disposable sheath (FCSDS) compared to standard flexible cystoscopy (SFC) in two French urologic academic units.


Patients

Two-center prospective study, comparing the use of the FCSDS to the SFC on two consecutive periods of time. Two hundred and five patients were included and divided into each group. Duration procedures and costs were analysed in the two techniques. The urinary tract infection rate was also described. A dedicated sheaths leaks test after use was performed systematically.


Results

The preparation time of the fibroscope was longer for the sheathed cystoscopy group: 16.2minutes versus 10.9minutes for the standard group. The mean duration of disinfection was significantly shorter for the sheathed cystoscopy group: 53.8minutes saved compared to the standard group; 99.01% of the tested sheaths, after their use, had no breaches. Urinary tract infections rate were similar in the two groups. The average cost of a sheathed cystoscopy compared to the standard was significantly cheaper in Lyon and almost equivalent in Marseille.


Conclusion

The FCSDS allows significant saving over the disinfection duration, consumable costs and staff costs, while ensuring patient bacteriologic safety similar to SFC.

Mots clés:
Cystoscopes / Analyse économique / Techniques bactériologiques / infection urinaire / Sécurité des équipements
Mots-clés:
Cystoscopes / Cost analysis / Bacteriologic techniques / urinary tract infection / Device safety
Effets des inhibiteurs de la phosphodiestérase de type 5 sur les symptômes du bas appareil urinaire associés à une hypertrophie bénigne de la prostate
2013
- Réf : Prog Urol, 2013, 5, 23, 283-295


Introduction



Purpose

The objective of this literature review was to report currently available clinical data on the effects of phosphodiesterase type 5 inhibitors (PDE5I) on lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).


Methods

An international literature review was carried out in February 2012 from the Medline database (National Library of Medicine, United States). Studies on the effects of PDE5I on LUTS secondary to BPH published within the last 15years (1997 to 2012) were extracted. In total, 12 studies were selected: four studies on sildenafil including one randomized, controlled, double-blind study; one randomized, controlled, double-blind study on vardenafil; and seven studies on tadalafil including five randomized, controlled, double-blind studies and a 1-year open-label extension study.


Results

PDE5Is significantly improve the overall International Prostatic Symptom Score (IPSS) compared to placebo. Most often, the maximum urinary flow rate (Qmax) was not significantly increased versus placebo. A statistically significant improvement of Qmax was nevertheless observed in certain studies.


Conclusion

The available clinical data assessing the efficacy of PDE5 inhibition in LUTS secondary to BPH are convincing. PDE5Is thus are a new therapeutic class in the treatment of this disease and are especially interesting in patients suffering from both LUTS and erectile dysfunction (ED), two frequently associated diseases.

Mots clés:
Symptômes du bas appareil urinaire / miction / Débit urinaire / Essais cliniques randomisés
Mots-clés:
Lower urinary tract symptoms / micturition / Urinary flow / Randomized clinical trials
Impact de l'utilisation d'un agent hémostatique sur les complications périopératoires de la néphrectomie partielle
2013
- Réf : Prog Urol, 2013, 5, 23, 317-322


Introduction



Objective

To evaluate impact of the use of haemostatic agent in partial nephrectomy on perioperative outcomes.


Material and methods

We reviewed the files of patients candidates for partial nephrectomy in our center between 2005 and 2010. The use of haemostatic agent and surgical procedure data were noted. Perioperative outcomes in haemostatic agent group were compared with perioperative outcomes in conventional surgical haemostasis group.


Results

Among the 131 patients included, haemostatic agent was used in 91 cases (69.5%). There was no statistically difference between the two groups on age, sex, BMI, ASA score, tumor size and RENAL score. The use of haemostatic agent was more frequent for patients operated with laparoscopy (10.7%, P =0.04). Concerning perioperative outcomes, there was no difference between the two groups on surgical complications, transfusions, conversion to radical nephrectomy and hospital stay. Median warm ischaemia time was comparable into the two groups. In multivariate analysis, haemorrhage, complications and transfusions were not predicted by the use of haemostatic agent.


Conclusion

Use of haemostatic agent in partial nephrectomy had no benefice on perioperative outcomes in our series. Rapport between utility and cost for these agents must be discussed in partial nephrectomy.

Mots clés:
cancer du rein / Néphrectomie partielle / Hémostatique / Complications
Mots-clés:
Renal cancer / partial nephrectomy / Haemostatic / Complications
Le parcours de l'opéré en neuro-urologie : de la programmation opératoire à la convalescence. L'avis d'expert du Comité de neuro-urologie de l'AFU
2013
- Réf : Prog Urol, 2013, 5, 23, 309-316


Abréviations



The surgical care pathway of neurologic patients has two aims: preventing urinary morbidity and mortality and improving their quality of life. It requires taking into account the specificities of disabilities in domains of body functions: circulatory, ventilation and digestive physiology, motor functions, sensory functions, mental functions, and skin fragility which are responsible of dependencies in this heterogeneous group of patients. This management is necessarily multidisciplinary to be optimal and through specific clinical care pathway, providing guidance to the surgical procedure: preparation of the surgery, its realization, and post-operative rehabilitation. The indication for surgery must be coordinated and validated in neuro-urology multidisciplinary staff. Preoperative stay in a physical and rehabilitation medicine center may be useful to ensure a complete assessment and anticipate problems related to surgery. The patient will be hospitalized in the urology department in a single room suited to their disabilities and handicaps. The chronic treatments should be not modified if possible. The lack of sensitivity does not dispense anesthesia to prevent autonomic hyperreflexia, the most severe complication after high complete spinal cord injury. The laparoscopy and sub-peritoneal surgery, the early removal nasogastric tube and early refeeding make it possible to early resumption of intestinal transit. In many cases, the patients should be transferred to a physical and rehabilitation medicine during post-operative period where the nursing care will be most suitable. A quickly adapted rehabilitation must be able to reduce loss of function and physical dependence.

Mots clés:
Neuro-Urologie / Chirurgie / Anesthésie / Parcours de soins / Médecine physique et de réadaptation
Mots-clés:
Neurogenic bladder / Surgery / Anesthesia / Physical medicine rehabilitation / Clinical care pathway
Les anévrismes artériels anastomotiques après la transplantation rénale et pancréatique : diagnostic et traitement
2013
- Réf : Prog Urol, 2013, 5, 23, 329-335


Introduction



Objective

The objective of our study was to assess the frequency, circumstances of diagnosis and treatment of anastomotic arterial aneurysms and compare them to the literature.


Material and method

A single-center series of 3000 kidney transplants and 126 pancreas transplants between 1974 and 2010 was studied retrospectively. Ten patients had anastomotic arterial aneurysms: eight after kidney transplantation and two after pancreas-kidney transplantation. Diagnosis was based on the association Doppler ultrasonography–angioscanner.


Results

Ten arterial anastomotic aneurysms were identified. The circumstances of discovery were clinical in eight cases, half of them by hemodynamic collapsus. A majority of our patients (60%) were diagnosed in the year following the transplantation and two cases were discovered after transplantectomy. Pancreas-kidney transplantation had a high risk for arterial anastomotic aneurysm. Candida albicans was isolated in preoperative samples in four cases. The management consisted to transplantectomy in seven patients, revascularization of the lower limb in six patients and one renal transplant preservation. We found two lower limb ischemia and two deaths by a fatal intraoperative haemorrhage and vascular cerebral haemorrhage. No recurrence was identified after in the follow-up ranged from 20months to 12years.


Conclusion

Arterial anastomotic aneurysm was in our study a serious complication that requires emergency surgery. The transplantectomy followed by revascularization of the limb is the treatment of choice associated to an appropriate antifungal or antibiotic treatment.

Mots clés:
Transplantation rénale / Transplantation pancréatique / Anévrisme mycotique / /
Mots-clés:
Mycotic aneurysm / Transplantation / /
Néphrectomie partielle laparoscopique assistée par robot : analyse monocentrique et rétrospective sur cinq ans
2013
- Réf : Prog Urol, 2013, 5, 23, 323-328


Introduction



Introduction

The aim of this study is to assess perioperative outcomes in a large series of robotic partial nephrectomy.


Patients and methods

We performed a retrospective analysis of 413 patients undergoing a robotic partial nephrectomy in a single center between June 2006 and December 2011. We analyzed demographic characteristics, operative and postoperative outcomes.


Results

Mean age was 58.6±11.9 years, body mass index was 30.5±7.1kg/m2 and median ASA score 3. Mean tumor size was 3.2±1.66cm and was divided in low, moderate and high RENAL nephrometry score respectively in 40%, 44% and 16%. Operative time and warm ischemia time were respectively 191 and 21min. Mean estimated blood loss was 200mL and there were 4.3% major complications (Clavien-Dindo System). Mean length of stay was 3.6 days. The latest estimated glomerular filtration rate (eGFR) was 74.84mL/min×1.73m2 with a mean decrease of 8.6%. In multivariate analysis, Charlson comorbidity index (P =0.005), preoperative eGFR (P <0.001) and warm ischemia time (P =0.0025) were found to be independent predictors of latest postoperative renal function.


Conclusion

Robotic partial nephrectomy is feasible and safe in experienced hands. In our study preoperative renal function, Charlson comorbidity index and warm ischemia time were independent predictors of latest eGFR.

Mots clés:
Néphrectomie partielle / Robot / Cancer rénal / Fonction rénale
Mots-clés:
partial nephrectomy / Kidney cancer / Robot / Renal function
Prise en charge du cancer de la prostate : analyse rétrospective de 808 hommes biopsiés en France
2013
- Réf : Prog Urol, 2013, 5, 23, 347-355


Introduction



Objective

We explored the characteristics of a sample of men who had undergone a biopsy in clinical practice in France and evaluated initial treatment choice in men with a positive biopsy.


Methods

This was a multi-centre, retrospective chart review including men who had undergone a biopsy in France. Clinical variables were collected using an electronic data capture system.


Results

Eight hundred and eight men were included; 632 men (78%) had an initial biopsy and 176 men (22%) had one or more repeat biopsy. The mean age was 64 years and 9% of men were 75 years or more. The mean (median) PSA was 11.6 (7.0) ng/mL; 25% of men had a PSA greater than 10ng/mL. Twenty-eight percent of men had a suspicious DRE. A total of 52% of men had a positive initial and 26% a positive repeat biopsy. One hundred and eleven patients (34%) had low-risk PCa (stage T1c-2a, PSA<10ng/mL, Gleason sum<7) and 195 (59%) were at intermediate/high risk of disease progression. The most common treatment was radical therapy (54% of patients), even in men with low-risk PCa (40% of patients). A total of 38% of low-risk patients chose active surveillance.


Conclusions

The French biopsy sample appeared to be at a relatively high risk of having PCa at initial biopsy. Radical therapy was the most common treatment choice in men with a positive biopsy. In patients with low-risk PCa, radical therapy and active surveillance were used most often and to the same extent.

Mots clés:
Surveillance active / Biopsie / Pratique clinique / France
Mots-clés:
Active surveillance / Biopsy / Clinical practice / France
Traitement d'entretien par BCG-thérapie des tumeurs de vessie n'infiltrant pas le muscle (TVNIM) : résultats à un an de l'étude multicentrique URO-BCG-4
2013
- Réf : Prog Urol, 2013, 5, 23, 336-346


Introduction



Introduction

Intravesical instillations of BCG remains the gold standard for intermediate and high risk NMIBC management. Maintenance treatment is recommended, however, the frequency of side effects responsible for the discontinuation of maintenance therapy over four out of five patients before the third year suggest a reduction or even spacing instillations. The objective of the study URO-BCG-4 was the evaluation of a new maintenance schedule by intravesical instillations of BCG combined reduced dose (third dose) and a decrease number of instillations per cycle (two or three).


Material and methods

Multicenter study of the French Association Oncologic Committee (12 university hospital centers), randomized, prospective, comparing reference diagram of BCG maintenance therapy one third of usual dose (group I) to a regimen combining third dose and decrease the number of instillations per cycle (two instead of three) (group II). We present the preliminary results at 1year of this Program of Clinical Research (CHU Rouen Promoter 2003-081).


Results

The rate of recurrence was respectively 9 and 7% (P =0.678) in groups I and II. The rate of tumor progression are 3 and 2.8% in groups I and II (P =1). Tolerance of intravesical instillations of BCG scored according to the WHO classification (Geneva 1979) was similar in the two groups.


Conclusion

The decrease in the BCG dose (third dose) and the changes in the number and rate of instillations did not alter free tumor recurrence survival. The toxicity of intravesical instillations of BCG was identical in both groups. The use of the WHO classification has shown its limitations in the study of side effects of BCG as too complex and often not exhaustive. The rate of increase muscle was comparable in the two groups; however, a larger clinical experience is required.

Mots clés:
TVNIM / instillations de BCG / Traitement d’entretien
Mots-clés:
Urinary bladder neoplasm / BCG instillations / Maintenance treatment
Troubles vésicosphinctériens des syndromes parkinsoniens : une revue du comité de neuro-urologie de l'Association française d'urologie
2013
- Réf : Prog Urol, 2013, 5, 23, 296-308


Introduction



Introduction

Lower urinary tract disorders (LUTD) are common in Parkinson’s disease (PD) and other parkinsonian syndromes (PS). They are responsible for a significant morbidity and mortality and impair patients’ quality of life. The therapeutic management of these LUTD requires to know how to distinguish the PD from other PS and their epidemiology and pathophysiology.


Objective

To provide a diagnostic and therapeutic management of LUTD in patients with PS.


Method

A review of litterature using PubMed library was performed using the following keywords: Parkinson’s disease, multiple system atrophy, lower urinary tract disorders, neurogenic bladder, overactive bladder, obstruction, anticholinergics, dopamine, prostate surgery.


Results

Sometimes revealing the neurological disease, LUTD in PS raise a diagnostic problem because they occur at an age when various urogynecological disorders can be intricated with neurogenic bladder dysfunction. The differential diagnosis between PD and multiple system atrophy is important to know by the urologist. The distinction is based on the semiological analysis, the clinical response to dopaminergic therapy and the clinical outcome but also on data from urodynamic explorations. The therapeutic management of these LUTD cannot be easy due to the difficulty of use of some pharmacological treatments and the risk of deterioration after inappropriate surgery. The different treatments include the careful use of anticholinergics, posterior tibial nerve stimulation, deep thalamic stimulation and low-dose intradetrusor injections of botulinum toxin without approval. The decision to perform prostate surgery will be taken with caution after proving the bladder obstruction.


Conclusion

When analysing LUTD in PS, the urologist must know to question the initial diagnosis of PD. Treatments in order to reduce morbidity and mortality of these LUTD and to improve the quality of life of patients suffering from these degenerative diseases, will be proposed after multidisciplinary neuro-urologic concertation. The decision to perform prostate surgery must be taken with caution after proving sub-vesical obstruction.

Mots clés:
Maladie de Parkinson / Atrophie multisystématisée / Troubles vésicosphinctériens / Vessie neurogène / vessie hyperactive
Mots-clés:
Parkinson’s disease / Multiple system atrophy / Lower urinary tract disorders / Neurogenic bladder / Overactive bladder