[Pelvic radiotherapy and artificial urinary sphincter in women]

OBJECTIVES

A retrospective evaluation of artificial urinary sphincter (AUS) implantation in women with previous pelvic radiotherapy (PR).

POPULATION AND METHODS

From May 1987 to December 2009, on the 215 women implanted with AUS, nine (4.2%) had previous PR. We compared two groups of women, the first one without PR (group 1; n=206) and the other group with PR (group 2; n=9). Previous preop. urodynamics were realized. Patients using more than one pad per day at the end of follow-up were considered in failure.

RESULTS

Mean follow-up for these two groups was 6 years (SD: 5.6 years), with a mean age of 62.8 years. Mean delay between PR and surgery was 14 years. PR was indicated for cervix cancer in 78% (7/9), endometrial cancer and ovarian cancer in 9% (1/9) each. PR was responsible of an increased rate of AUS erosion and explantation (P<0.001). In group 2, more than half of women had AUS failure and 60% for AUS erosion, versus 22% and 26% respectively in group 1. In group 2, all the AUS eroded were explanted, one third of women, with a mean delay of 59.8 months (4-140) with AUS implantation.

CONCLUSION

AUS implantation in a female population with previous PR is not necessary inconsistent, but the failure rate is high. This difficult surgery should be reserved for specialized centres.

[Postchemotherapy retroperitoneal lymphadenectomy for testicular cancer. Literature review by the Oncology Committee of the French Association of Urology, External Genitalia Group]

INTRODUCTION

Postchemotherapy retroperitoneal lymphadenectomy (PC RPLDN) leads to an overall survival rate for testicular cancer exceeding 75%. Several questions still persist concerning: preoperative assessment of residual masses, reducing templates of dissection, choosing surgical approaches or including RPLND in high-risk patients' management.

METHOD

The main series in the literature of the past 20 years were analyzed and selected to address these issues and reach a consensual diagnostic and therapeutic approach.

RESULTS

Forty-eight original articles (1992 to 2011) were selected. They confirm that no preoperative tool can predict the histological nature of residual masses. The unilateral modified template is a valid option for selected patients but the full bilateral dissection remains the standard but more morbid. The laparoscopic approach is being evaluated. The LDNRP PC is indicated in "high risk" situations especially after salvage chemotherapy.

CONCLUSION

The bilateral lymphadenectomy by laparotomy of any supracentimeter residual mass, 6 weeks after chemotherapy, for germ cell tumors of the testicle is a standard of care.

[Pancreas transplantation and venous thrombosis: multivariate analysis of risk factors]

OBJECTIVE

Portal veinous thrombosis (VT) in the pancreatic transplant (6 to 20% of the cases) is the first cause of early loss of the transplant. Our objective was to identify the risk factors of VT in our experiment.

METHOD

The sample group includes 106 patients who underwent pancreas transplantation (portal venous drainage, enteric-drained pancreas) within our institute of transplantation from 2004 until 2010. We completed a portal vein extension graft in 25% of the cases. First of all, risk factors were selected from preoperative and operative data with an univariate analysis. We then carried out a multivariate analysis of these factors (binary logistic regression). The threshold P was 0.05.

RESULTS

Sixteen patients (15%) showed a VT. Eight of them developed a total thrombosis and required a transplantectomy. Three risk factors of VT were isolated by the multivariate analysis: a BMI of the receiver>25kg/m(2) (Odds Ratio [OR]=6.977), a portal vein extension graft (OR=4.1) and an age of the donor>45 years (OR=4.432).

CONCLUSIONS

The knowledge of these risk factors of thrombosis allows the implementation of preventive measures (selection of the donor, nutritional support of the receiver in the registration if BMI>25kg/m(2)). The portal lengthening should be avoided by an attentive retrieval of the transplant (without shorter section of the portal vein). Nevertheless, the presence of one of these risk factors in a transplant patient should lead to start an antithrombotic treatment.

Minimally invasive ventral mesh rectopexy for complex rectocoele: impact on anorectal and sexual function

AIM

Minimally invasive surgery for pelvic floor prolapse has recently been shown to be feasible and safe. This study presents the results of robotic-assisted and laparoscopic rectopexy for complex rectocoele, focusing on less frequently reported outcomes of bowel and sexual function.

METHOD

We prospectively assessed 41 consecutive patients who underwent ventral mesh rectopexy (robotic-assisted or laparoscopic) for a symptomatic complex rectocoele from January 2009 to January 2010. Complex rectocoele was defined as having one or more of the following features: larger than 3 cm, an enterocoele or internal rectal prolapse. Patients with cystocoele underwent bladder suspension concurrently. Both groups were assessed for anatomical recurrence and function, comparing preoperative and postoperative faecal incontinence, obstructive defaecation syndrome and Gastrointestinal Quality-of-life Index scores, as well as vaginal discomfort and sexual function.

RESULTS

Forty-one women underwent the procedure (16 robotic-assisted), with four (10.5%) having minor complications and two developing anatomical recurrence. There was significant relief of the commonest predominant symptoms of vaginal bulge/fullness (P<0.0001) and sexual dysfunction (P=0.02). There were three conversions to laparotomy (one robotic-assisted) and five patients declined postoperative functional assessment. In the remaining 33 patients [follow-up median 12 (8-21) months], analysis revealed no significant difference in overall functional score (P>0.740) or between patients with one or two meshes inserted (P>0.486). Only patients with a preoperative obstructive defaecation syndrome score >6 had a significant improvement postoperatively (P=0.030).

CONCLUSION

Minimally invasive ventral mesh rectopexy for complex rectocoele offers satisfactory anatomical correction and functional results, with the potential for alleviating symptoms of outlet obstruction and improving vaginal comfort and sexual dysfunction.

[Imperative partial nephrectomy for renal cell carcinoma: oncological and functional results]

OBJECTIVES

To study oncological results and functional results after partial nephrectomy in imperative indication for the treatment of renal cell carcinoma.

PATIENTS AND METHODS

From January 1990 to December 2009, 65 partial nephrectomies in 61 patients were performed in imperative indication for renal cell carcinoma.

RESULTS

The mean age of patients was 59.3 years. The mean follow-up was 47.4 months. The tumours were asymptomatic in 87.5%. The average tumour diameter was 4.3 cm. Twenty-nine percent of patients relapsed after a mean time of 27.4 months. The morbidity was 38.5%. Preoperative and endpoint serum creatinine and renal clearance were respectively 119 μmol/L and 63.1 mL/min versus 137 μmol/L and 50.9 mL/min (P=0.0003; 0.0002). Overall survival at one, three, five and ten years was 98.4%, 91.2%, 91.2% and 51.9%.

CONCLUSION

Partial nephrectomy in imperative indication for renal cell carcinoma has helped preserve renal function but has a significant morbidity and recurrence rate.

[Natural history and management of retroperitoneal sarcoma: Review of the literature by the Oncology committee of the French association of urology]

INTRODUCTION

The objective of this article of review is to precise the natural history and rules of treatment of retroperitoneal sarcoma. These elements are sometimes ignored of the urologists.

MATERIAL AND METHOD

A systematic review of the literature over the 15 last years was carried out on Medline database.

RESULTS

The sarcomas of the rétropéritoine are found with diagnosis delay because they don't have specific symptoms. The imagery is sometimes characteristic but only percutaneous biopsy is able to confirm the diagnosis. Retroperitoneal sarcomas are characterized by the high rate of local recurrence, which is related to the survival rate. The main prognostic factors are negative margins and grade of the tumor. The role of adjuvant radiotherapy is limited by the radio sensitivity of the abdominal viscera and the postoperative rehandlings. Today, the role of the neoadjuvant radiotherapy is in evaluation in prospective study. The effectiveness of chemotherapy is limited.

CONCLUSION

Complete compartmental surgery without tumor rupture is the cornerstone of treatment. This complex surgery should be performed in a high-volume center.

[Laparoscopic sacrocolpopexy results contingent on mesh position]

OBJECTIVES

Do the number and the position of meshes in laparoscopic sacrocolpopexy influence anatomical or functional postoperative results in genital prolapse treatment?

PATIENTS AND METHODS

Ninety patients were treated for genital prolapse by laparoscopic sacrocolpopexy between January 1998 and 2007. Eleven had an anterior single mesh, 36 a single posterior mesh and 43 a double mesh.

RESULTS

Four patients with late postoperative complications needed a new surgical procedure. Three of them had a double mesh. Thirteen anatomical recurrences (14 %) were found. Eleven recurrences had a single posterior mesh and eight needed a new surgical procedure. Two other recurrences had a double mesh. Only one needed a new surgical procedure. No recurrence was noticed in the anterior single mesh group. The observed pelvic floor dysfunction rates were respectively for the single anterior mesh group, posterior single mesh group and double mesh group: constipation 20 % 64 % 35 %, anal incontinence 0 % 14 %/2 %, urgency 0 %/8 %/12 %, stress urinary incontinence 27 % 14 %/31 %.

CONCLUSION

Double mesh reduced anatomical recurrence, but increased surgical complications and postoperative dysfunctions.

[Clinical interview and clinical examination of patients with chronic pelvic and perineal pain]

INTRODUCTION

Patients with chronic pelvic and perineal pain sometimes report major complaints with no objective value that help to "validate" this pain other than by the patient's own interpretation of the pain. The purpose of this article is to describe the essential elements of the clinical interview and clinical examination in the diagnostic approach to patients with chronic pelvic and perineal pain.

PATIENTS AND METHODS

A review of the literature and a description of our experience was performed to describe the clinical interview and clinical examination of patients with chronic pelvic and perineal pain.

RESULTS

Clinical interview of the patient is designed to define the characteristics of the pain: mode of installation, topography, irradiation, type, remission, nocturnal waking, and aggravating or limiting factors. It must also look for associated clinical signs: urinary, gastrointestinal, gynaecological, sexual, cutaneous and neurological. The intensity of the pain is evaluated on an analogue scale. A complete clinical examination of the pelvis and perineum must be performed looking for an organic cause: neurological, dermatological, urogenital, spinal, myofascial and sympathetic nervous system. Digital rectal and vaginal (pelvic) examinations play an important role in the detection of trigger points.

CONCLUSION

A well-conducted clinical interview and clinical examination can help to elucidate a large proportion of cases of chronic pelvic and perineal pain and are an essential in part of the diagnostic approach.

[Pelvic sexual pain]

OBJECTIVE

To colligate the clinical and ethiopathogenical elements to take into account in the assessment of sexual activity-related chronic pelvic and perineal pain, in the male as well as in the female subject.

SUBJECTS AND METHODS

Review of articles and consensus conferences published on this subject in the Medline (Pubmed) database, selected according to their scientific relevance.

RESULTS

In the female subject, only dyspareunia has benefitted from a consensual definition. Deep dyspareunia must start investigations in search of pelvic organs disorders, endometriosis, painful bladder syndrome adhesions. Superficial dyspareunia can be a part of provoked vestibulodynia. Vaginismus can be linked to a local disorder, but can also be caused by an excess of nociception. In the male subject, painful ejaculation must start investigation in search of a local urological disorder. It can also be of iatrogenous origin, or be included in a chronic pelvic pain syndrome. Although less documented, other pelvic and perineal pain syndrome, coitus-related or not, exist in the male subject.

CONCLUSION

Assessment of these sexual dysfunctions is primarily based on history taking and clinical examination. In the absence of systematically researched organic disorder, these pains can be part of functional disorders, in which case a global assessment must be undergone, by taking into account all aspects of the pain, including emotional aspects.

[Symptomatic approach to chronic penile pain]

OBJECTIVE

To describe the aetiologies of non-cancer chronic penile pain.

MATERIAL AND METHODS

A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either medical subject heading (MeSH) keywords (pain, penis, penile diseases) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time.

RESULTS

Clinical interview and physical examination are essential elements of the assessment of chronic penile pain. The aetiologies of chronic penile pain include local diseases, referred pain, neuropathic pain, psychological or psychiatric disorders and penile pain syndrome. Neuropathic pain is related to compression of the dorsal nerve of the penis, derived from the pudendal nerve, at the inferior border of the pubis. This nerve compression syndrome, often associated with cycling, can also be responsible for decreased sensitivity of the glans and penis, genital paraesthesia (numbness) and sometimes erectile dysfunction. Penile pain syndrome, defined as pain located in the penis, but not due to an urethral cause, documented infection or another clinically apparent disease, is a diagnosis of exclusion.

CONCLUSION

The diagnosis of non-cancer chronic penile pain is essentially clinical. Compression of the dorsal nerve of the penis is part of the context of penile pain syndrome, corresponding to a diagnosis of exclusion.

[Specific treatments for chronic bacterial prostatitis and chronic pelvic pain syndrome]

OBJECTIVE

To review the treatment of chronic bacterial prostatitis and chronic pelvic pain syndrome (CPPS).

MATERIAL AND METHODS

A review of the literature was performed by searching the Medline database (National Library of Medicine). Search terms were either Medical subject heading (MeSH) keywords (antibacterial agents, pelvic pain, placebos, prostatitis, treatment) or terms derived from the title or abstract. Search terms were used alone or in combinations by using the "AND" operator. The literature search was conducted from 1990 to the present time.

RESULTS

The treatment of chronic bacterial prostatitis is based on the use of antibiotics, primarily fluoroquinolones, for 4 to 6 weeks, but no consensus has been reached concerning the standard treatment of CP/CPPS. A review of the literature failed to identify any recognized and validated treatments for CP/CPPS, but several conclusions can be drawn: placebo gives satisfactory results in a considerable number of patients; antibiotics are not recommended; alpha-blocking agents may be effective in recently diagnosed, previously untreated patients, provided they are prescribed for 12 weeks to 6 months; invasive surgery of the prostate and bladder neck is not recommended.

CONCLUSION

Progress in the treatment of CP/CPPS will require more extensive basic and clinical research. Only randomized, placebo-controlled clinical trials including a large number of patients, and using the NIH-Chronic Prostatitis Symptom Index questionnaire (NIH-CPSI) as evaluation tool will be able to provide reliable conclusions. The use of patient subgroups selected according to the predominant symptoms could be contributive.

[Treatment algorithms for the management of chronic pelvic and perineal pain: from syndrome to treatment]

INTRODUCTION

The treatment of patients with chronic pelvic and perineal pain is often complex and involves a number of different parameters. The purpose of this article is to propose a series of treatment algorithms to facilitate the therapeutic management of patients with chronic pelvic and perineal pain.

MATERIAL AND METHODS

A review of the literature was performed by searching Pubmed for articles on treatment of chronic pelvic and perineal pain. Treatment algorithms were established for each type of pain syndrome.

RESULTS

Treatment algorithms were defined for the various types of chronic pain syndrome: pudendal nerve entrapment syndrome, chronic pelvic pain syndrome, painful bladder syndrome, vulvar pain syndrome, epididymotesticular pain syndrome, complex pelvic pain syndrome. Therapeutic management is proposed for each algorithm.

CONCLUSION

The proposed algorithms are designed to be a clinical aid and do not constitute a comprehensive approach to the management of patients with chronic pelvic and perineal pain.

[Specific treatments for painful bladder syndrome]

INTRODUCTION

Painful bladder syndrome is defined as chronic pelvic pain present for more than 6 months, causing discomfort perceived as being related to the bladder and accompanied by a persistent and strong urge to urinate or urinary frequency. The purpose of this article is to review the treatment of painful bladder syndrome.

MATERIAL AND METHODS

A comprehensive review of the literature was performed by searching PUBMED for articles on specific treatments for painful bladder syndrome.

RESULTS

Many treatments have been proposed for the management of painful bladder syndrome: local intravesical treatments (glucosaminoglycan [pentosan polysulfate], dimethylsulfoxide [DMSO], heparin, bacillus Calmette-Guérin [BCG], anticholinergic agents [oxybutynin, etc.] or oral treatments [glucosaminoglycan (pentosan polysulfate), antihistamines, antidepressants, immunosuppressives, etc.]) with an action on the pathophysiology of this syndrome. The efficacy of these various treatments has been limited, with trials based on small numbers of patients and not always conducted according to a randomized, prospective design. Other salvage treatments (neuromodulation, botulinum toxin, surgery, etc.) have also been reported with limited efficacy, but allowing salvage of treatment failures.

CONCLUSION

The therapeutic management of painful bladder syndrome is complex. The large number of proposed treatment modalities present a limited efficacy with discordant results from one study to another making comparisons and analyses difficult.

[The doctor-patient relationship in chronic pelvic and perineal pain]

OBJECTIVE

To analyse the doctor-patient relationship from the patient's point of view and from the doctor's point of view.

MATERIAL AND METHODS

Experience of a chairman of a chronic pelvic and perineal pain patient association (AFAP-NP) and experience of doctors specialized in chronic pelvic and perineal pain.

RESULTS

Management of a patient with chronic pelvic and perineal pain requires knowledge and understanding of the patient's trajectory disease, the history of the disease and the patient's hopes and disappointments, and evaluation of the patient's personality and family, social and work environment.

CONCLUSION

As pain is an emotional experience, the type of doctor-patient relationship determines the quality of subsequent management. A number of basic principles should be applied: believe the patient, avoid making the patient feel responsible for failure, avoid overestimating the secondary benefits, avoid making the patient passive and dependent, learn to reinterpret the patient's symptoms, ask "how" does the pain persist rather than "why", clearly define the patient's demand and adapt management to realistic and accessible objectives.

[Therapeutic management of chronic intrascrotal pain]

OBJECTIVE

To resume available therapeutic options for intra scrotal chronic pain, including surgical procedures, and to analyze their efficiency through a review of published data.

MATERIAL AND METHODS

Review of articles published on this topic in the Medline (PubMed) database, selected according to their scientific relevance.

RESULTS

Initial treatment of epididydimal and testicular pain should always be conservative. Mean success rates of the different therapeutic options varies from 27% to 90%. Surgery on the scrotal content should be considered only if: (1) Pain can be explained by a local intra scrotal cause; (2) Medical and conservative treatments have failed; (3) Nerve block has been tried and is efficient in relieving pain; (4) Patients are informed of the risk of failure. Conservative surgical procedure (epididymectomy, vasovasostomy) have a success rate of 50-70%. Microsurgical spermatic cord denervation yields better results, while preserving testis and epididymis integrity. Failure is still possible (15%). Orchidectomy should be avoided if possible.

CONCLUSIONS

Levels of evidence concerning indications and efficiency of these surgical procedures are low. Patients suffering from recurring or implacable chronic testicular and epididymal pain require a multidisciplinary care.

[Management of chronic pelvic and perineal pain after suburethral tape placement for urinary incontinence]

INTRODUCTION

The surgical treatment of stress urinary incontinence is essentially based on TVT or TOT suburethral tape placement. The purpose of this article is to review the literature on the diagnostic and therapeutic approach to chronic pelvic and perineal pain following suburethral tape placement for urinary incontinence.

MATERIAL AND METHODS

A comprehensive review of the literature was performed by searching Pubmed for articles on pelvic and perineal pain following suburethral tape placement.

RESULTS

The role of suburethral tape in the pathogenesis of pain is essentially based on the fact that pain occurs immediately or over the days following tape placement. The clinical features are usually fairly nonspecific, with pelvic myofascial pain, possibly associated with direct or indirect nerve lesions (obturator nerve or pudendal nerve). Local infiltration of anaesthetic along the tape is performed for diagnostic purposes to confirm the aetiology of the pain and can also have a temporary therapeutic efficacy. Surgical removal of the tape was performed with satisfactory intermediate-term results in about two out of three cases.

CONCLUSION

The frequency of chronic pelvic and perineal pain following suburethral tape placement appears to be underestimated. The diagnostic approach is based on complete clinical examination and infiltration along the tape and any nerves involved. Surgical removal of the tape provides the best intermediate-term analgesic results.

[General principles of the diagnostic approach to chronic postoperative pelvic and perineal pain]

INTRODUCTION

Chronic postoperative pain has been defined as pain arising after a surgical operation, present for at least 2 months, with no organic (active cancer or chronic infection) or pre-existing cause. The purpose of this article is to review the aetiological and diagnostic assessment of chronic postoperative pelvic and perineal pain.

MATERIAL AND METHODS

A review of the literature was performed by searching PUBMED for articles on the diagnostic approach to chronic postoperative pelvic and perineal pain.

RESULTS

The chronology of the symptoms, i.e., rapid onset of pain following a surgical procedure that does not subsequently resolve, is a leading argument to incriminate the surgical procedure in the pathogenesis of the pain. Clinical examination of the scars and detailed analysis of the topography and type of pain are essential elements in the analysis of this pain. The primary objective of complementary investigations (imaging, EMG, etc.) is to eliminate a differential diagnosis, as they are normal in the case of chronic postoperative pain. A test block of a nerve or trigger point is the main test performed to determine the level of the lesion responsible for pain.

CONCLUSION

The aetiological and diagnostic assessment of chronic postoperative pelvic and perineal pain requires a detailed clinical analysis based on examination of the scars and analysis of the clinical signs of muscle and nerve lesions. A local test block confirms the level of the lesion.