[Effectiveness of sacral neuromodulation in patients with Parkinson's disease]

INTRODUCTION

The urinary disorders of the patients with Parkinson's disease are complex and have a negative impact on their quality of life. None of therapy is considered effective ; whether drug or surgical. Sacral neuromodulation, recommended in other neurological pathologies such as multiple sclerosis, has never been studied in the patients with Parkinson's disease. The objective of our study is to assess the efficacy of sacral neuromodulation in the patients with Parkinson's disease.

MATERIAL AND METHOD

Multicentric retrospective cohort study, of 22 parkinsonian patients who underwent a sacral neuromodulation test. Epidemiological, clinical and urodynamic data were collected for each patient. A long-term effectiveness telephone survey was conducted.

RESULTS

Twenty two patients with Parkinson's disease had a sacral neuromodulation test. 17/22 (77%) had Idiopathic Parkinson's Disease and 5/22 (23%) had Systematized Multi Atrophy. Clinically, the indication for the sacral neuromodulation test was overactive bladder in 68% of the cases. Urodynamically, detrusor hyperactivity is found in 12 patients (8 MPI, 4 AMS). Sacral neuromodulation was effective in only 7 patients (6 MPI and 1 AMS). Rather, the profile of the patient in whom NMS is effective is female, mature, and with PID. The long-term effectiveness of NMS is disappointing. Only 2 permanently implanted patients retained urinary benefit.

CONCLUSION

NMS improves urinary symptoms in the patients with Parkinson's disease in 32% of cases. It fluctuates over time and loses its effectiveness in the long term.

LEVEL OF EVIDENCE

3.

[Penile prosthesis for erectile dysfunction in the neurological patient, indication, complications and satisfaction: Retrospective study on 27 patients]

INTRODUCTION

Penile prosthesis for erectile dysfunction in patients with spinal cord injury or multiple sclerosis is sometimes discussed after failure of drug or instrumental treatments (vacuum). The objective of this study was to evaluate the complications, evolution and patient satisfaction after the implantation of a penile prosthesis in the neurological patient.

MATERIALS AND METHODS

Multi-center retrospective study of 27 consecutive patients including 18 spinal cord injured patients and 9 patients with multiple sclerosis benefiting from the implantation of a penile prosthesis for erectile dysfunction purposes in two French centers between 2009 and 2019. Post-implantation complications, evolution of the use of the prosthesis and global patient satisfaction were evaluated using the standardized questionnaire Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) during a telephone call between March and May 2020.

RESULTS

The average age of implantation was 46.4 years (±12.74). The length of follow-up to date of call was 6.05 years (±2.86). 8/27 patients (29.6 %) had at least one complication of any Clavien-Dindo grade included 2 infection. 2/27 (7,4 %) patients had a mechanical prosthesis injury during follow-up. The patient's dexterity with inflation of the prosthesis was perfect in 85 % of cases, and 75 % for deflation. The satisfaction rate for prosthesis use at the time of the call was 75.36/100pts for the patient and 66.88/100pts for the partner.

CONCLUSION

This study found an increased rate of prothesis infection compared to the general population in the neurologic patient, but patient and partner satisfaction remain sustainable after more than 5 years of implantation. Dexterity was maintained over the long term, demonstrating a good selection of indications. These data invite to favorably consider the installation of a penile prosthesis in neurological patients who have failed first-line treatments.

LEVEL OF EVIDENCE

4.

[Cystocele repair by a light tension-free vaginal mesh: results after 6 years of follow-up]

INTRODUCTION

The objective of this study was to evaluate the long-term anatomical and functional efficacy, but also the safety of tension-free vaginal mesh in cystocele repair.

METHODS

This retrospective and monocentric study included 90 women who underwent a prolapse repair between June 2006 and November 2008. A light-weight polypropylene vaginal mesh (22g/m2, Novasilk COLOPLAST®) was used without any fixation. Females were followed at 1 month, 1 year, 3 years and 6 years. Only long-term results are presented in this study. The anatomical result was assessed by the POP-Q classification and the functional results by standardized symptoms (PFDI-20), sexuality (PISQ-12) and quality of life (PFIQ-7) questionnaires.

RESULTS

6 years after surgery, the follow-up rate was 74%. Anatomically, the prolapse recurrence rate (Ba≥0) was 17% (n=8). Functionally, the overall patient satisfaction rate was 89%. Quality of life and symptoms scores (4,11±8.45 vs. 17.5±14.4 and 35.8±15.9 vs 94±23.4 respectively) were significantly improved (p<0.001). Concerning the prevalence of the complication, the retraction and exposition rate was 1.7% (n=1) and a re-intervention rate was 6.7% (n=4). The rate of de novo dyspareunia was 1.7% (n=1).

CONCLUSION

In this short retrospective series of vaginal mesh interposition for cystocele repair, the prevalence of medium-term patient satisfaction was high.

[Results of conservative surgical management of ureteral injuries]

INTRODUCTION

The ureter is a retroperitoneal organ. Ureteral injuries are rare, with a prevalence of 0.083% of surgical interventions over 10 years. The objective of this study was to evaluate the surgical management of ureteric injuries according to the time of discovery, their size and their location. We also evaluated the results of this management on the renal repercussion as well as the predictive factors of the severity of the ureteric injuries.

MATERIAL AND METHODS

This was a monocentric retrospective study carried out on the basis of a systematic review of the CHU surgery files.

RESULTS

The average follow-up was 30 months. The average hospital stay was 8 days. Thirty-four patients (73.9%) underwent initial endoscopic management by attempting a double J probe. Only 20 patients received this double J probe and only 11 patients (55%) did not recidivate the ureteral injury with a median duration of maintenance of the double J probe of 90 days (28-240). Thirty-five patients received open surgical management (76.1%). We found 57% ureterovesical reimplantations (n=20), corresponding to pelvic ureteral injuries (n=32). We also found 20% of nephrectomies. No patient had recurrence of the ureteral injury. Eight patients had secondary dilatation of the pyelocalicious cavities (28.57%). The success of surgical treatment was therefore 57%.

CONCLUSION

The management of surgically treated ureter injuries provides good results but remains relatively diversified due to the different lesion levels. It was effective in 57% of cases including nephrectomies as failure of treatment.

LEVEL OF EVIDENCE

4.

[Endoscopic management of postoperative ureteral wound. Retrospective unicentric study from October 2003 to June 2014]

BACKGROUND

Ureteral wounds are rare with an incidence of 0.5 to 1% of pelvic surgeries. Their supports and their prognosis remain dependant of the period of support and the level of ureteral lesion. The importance of early treatment reduces morbidity and improves patient prognosis.

METHODS

A retrospective study from October 2003 to June 2014 was performed in a university hospital using a systematic chart review of patients' urology, digestive surgery, vascular surgery and gynecology.

RESULTS

Forty-six wounds were found in 43 patients. The majority of the ureteral wound was found at the pelvic ureter, i.e. 69.6% of the study population (n=32). The main cause was gynecological surgery (n=25). In the simple wound group, endoscopic treatment was effective in nearly 90% of cases (n=6). In the other two groups, the efficacy was only 30% and imposed a surgical treatment as second-line.

CONCLUSION

The management is based primarily on early detection or intraoperative, and on a correct initial knowledge of the location and size of the lesion. Endoscopic treatment can in most cases treated with a simple and minimally invasive operation an ureteral wound with nearly 90% success rate. In more complex wounds, endoscopy remains a step in the management with about 30% success rate in our study.

LEVEL OF EVIDENCE

5.

[Pain evaluation during extracorporeal lithotropsy]

OBJECTIVE

The aim of this study was to demonstrate the feasibility of extracorporeal lithotripsy using lithotripter Sortz MODULITH SLK(®) without analgesics.

MATERIALS AND METHODS

An anonymous self-administered questionnaire was sent to 854 patients post-shock wave lithotripsy for urinary lithiasis. No patient had pain medication. The questionnaire included seven questions to assess the pain symptoms due to treatment. After 15 days, a reminder letter was sent.

RESULTS

The response rate was 69% (591/854). The extracorporeal lithotripsy without analgesic treatment was generally well tolerated. About 70% of patients felt just a few or no pain and average pain assessment was 3.6/10 on VAS. The pain was often considered to be multifactorial, related to the treatment itself, the duration of the session and the position on the table. Anxiety seemed to play an equally important role in pain relief with an average VAS 4.5 against 2.9 for non-anxious patients. If a new session of extracorporeal lithotripsy was necessary, 53% of patients would require no pain medication.

CONCLUSIONS

The extracorporeal lithotripsy could easily be done without systematic analgesics allowing for outpatient care. In contrast, anxiety seemed to be an important predictor of poor tolerance of sessions so the idea of a prophylactic anxiolytic treatment based on psychological profile of the patient should allow less aggressive and less costly management of urolithiasis.

[Non-antibiotic anti-infectious treatments in urology]

OBJECTIVE

To define the terms of use of pesticides, antifungal, antiviral and antiseptic treatments in urology.

MATERIALS AND METHODS

A literature search was conducted on MEDLINE for all these treatments used in urology. The molecules were classified by family. Modes of action, indications in urology and adverse effects have been detailed. Authorisation files were consulted and then complemented by a literature analysis.

RESULTS

Although parasitic or viral diseases are uncommon in urology, their specific treatment deserves a thorough knowledge of pesticide and antiviral molecules. Antifungal treatments are regularly used in urology with special features to know to improve the efficacy/safety ratio. Antiseptics are used daily in urology and a better understanding of these molecules allows better use.

CONCLUSION

Beyond antibiotics, antiviral, antiparasitic and antifungal deserve a thorough knowledge. Antiseptic although used daily have features little known.

[Anti-infectious treatments in urology: general remarks]

OBJECTIVE

To define the general use of anti-infectious treatments in urology.

MATERIALS AND METHODS

A review of national guidelines and articles published on the subject in the Medline database, selected by keywords, depending on the scientific relevance was performed.

RESULTS

While the epidemiology clearly shows the non-reduction of the anti-infectious treatments use in France, the resistance increases to highlight foo-resistant germs. Urology is not an exception to this observation, and different means are set to improve the prescription made by urologists.

CONCLUSION

The epidemiological observation confirms the urgent need to improve the prescription of anti-infectious treatments particularly in urology.

[Chemotherapy in male external genital organs (testicular and penile cancer)]

AIM

To describe drugs used in the chemotherapy of testis and penis neoplasms.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

Nowadays, the chemotherapy is perfectly codified in adjuvant treatment or in first-line treatment of metastatic testis cancer. A single dose of carboplatin for seminoma testicular (stage I) in adjuvant treatment situation is one of the latest advances. Concerning penis cancer, the optimal protocols validated by a high level of evidence are missing.

CONCLUSION

The chemotherapy in testis and penis neoplasms knew few advances in recent years. So, it is necessary to include patients in clinical research protocols.

[Drug therapy of urethral diseases]

AIM

To describe drugs targeting urethra and prostate to treat dysfunctions such LUTS related to BPH, primary bladder neck obstruction (PBNO), detrusor sphincter dyssynergia (DSD) or sphincter deficiency (SD).

METHOD

Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM).

RESULTS

To treat LUTS related to BPH alpha-blockers (AB) and 5-alpha reductase inhibitors (5ARIs) have a clearer efficacy than plant extract. Daily Phosphodiesterase 5 inhibitors (PDE5Is) alone or in association with AB also demonstrate efficacy in this indication. AB are an option in PBNO and DSD related to multiple sclerosis. Although Botulinum toxin A derived molecules decrease urethral pressure in patient with DSD related to spinal cord injury or multiple sclerosis, efficiency remains to be demonstrated. Duloxetine a serotonin reuptake inhibitor increases urethral sphincter pressure and reduce stress urinary incontinence in women and men. Nevertheless, moderate efficacy combine with frequent side effects lead French regulation agency to reject its agreement.

CONCLUSION

Armamenterium to treat urethral dysfunctions has recently increases. Two new therapeutic classes emerge: PDE5Is to treat LUTS related to BPH and an SRIs (Duloxetine) to treat stress urinary incontinence. Efficacy and safety evaluation of all the possible associations between drugs targeting urethra and/or bladder is needed to a subtler and more efficient pharmacologic modulation of lower urinary tract dysfunction.

[Medical treatment of bladder carcinoma]

AIM

To describe drugs used in bladder carcinoma.

METHOD

Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM).

RESULTS

The drugs used in the treatment of bladder cancer are represented by the products referred to diagnosis (hexyl aminolevulinate), the intravesical instillations for the treatment of tumors not infiltrating the muscle and the infiltrating tumor chemotherapy (neo-adjuvant treatment or metastatic tumors). The hexyl aminolevulinate cystoscopy allows to identify a significantly greater number of lesions, including carcinoma in situ, compared to conventional white light cystoscopy. For intravesical instillations, BCG has a superior efficacy to mitomycin C with a lower tolerance. The chemotherapies for invasive tumors are effective in metastatic disease in 15-20% of cases with a mean survival of 12 to 14 months.

CONCLUSION

Except the use of hexyl aminolevulinate for improving the diagnosis, there was no emergence in recent years of new drugs for the treatment of bladder cancer. Targeted therapies currently available for many neoplasms were ineffective for bladder cancer.

[Hormonal treatment in prostate cancer]

AIM

To describe drugs used in the hormonal treatment (hormonotherapy) of prostate cancer.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

LHRH analogs and the antiandrogens remain the cornerstone in the treatment of locally advanced and metastatic prostate cancer. New therapeutic classes emerged recently (inhibitor of the synthesis of the androgen, the new antiandrogens) and allowed to grow again the limits of the hormone resistance and define the concept castration-resistant prostate cancer.

CONCLUSION

The hormonal treatment of the prostate cancer grew rich of new therapeutic classes which are going to change the medical care of the prostate cancer in the coming years and the urologist must play its full part.

[The non-hormonal treatment of metastatic prostate cancer]

AIM

To describe drugs used in the non-hormonal treatment of metastatic prostate cancer.

MATERIAL

Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned.

RESULTS

The metabolic radiotherapy although under-used for this indication, kept a place at the beginning of the disease. Radium-223 chloride seems to have to occupy an important place in the coming years. The chemotherapy, the only recourse until very recently in the castration-resistant prostate cancer, must redefine its place partially. The denosumab provide an interesting alternative to bisphosphonates.

CONCLUSION

The non-hormonal treatment of the metastatic disease of the prostate cancer is changing rapidly with the emergence of new molecules. Urologist must know perfectly these new drugs.

[Prostate cancer in elderly subjects: how diagnosis should be made, why and how geriatric assessment should be implemented]

Managing an elderly subject with prostate cancer brings into play the notion of likelihood of survival before any diagnostic or therapeutic decision can be made. The diagnostic strategy must be specified for each patient in accordance with the clinical presentation so as to determine whether prostate biopsies are indicated in this elderly population. To estimate the likelihood of survival, one must make use of geriatric assessment techniques comprising medical strategies ranging from screening for frailty to detailed geriatric evaluation for the most complex patients. The many tools available for estimating the likelihood of survival requires a critical review of their advantages and disadvantages in daily clinical practice.

De novo kidney graft tumors: results from a multicentric retrospective national study

De novo tumors in renal allografts are rare and their prevalence is underestimated. We therefore analyzed renal cell carcinomas arising in renal allografts through a retrospective French renal transplant cohort. We performed a retrospective, multicentric survey by sending questionnaires to all French kidney transplantation centers. All graft tumors diagnosed after transplantation were considered as de novo tumors. Thirty-two centers participated in this study. Seventy-nine tumors were identified among 41 806 recipients (Incidence 0.19%). Patients were 54 men and 25 women with a mean age of 47 years old at the time of diagnosis. Mean tumor size was 27.8 mm. Seventy-four (93.6%), 53 (67%) and 44 tumors (55.6%) were organ confined (T1-2), low grade (G1-2) and papillary carcinomas, respectively. Four patients died of renal cell carcinomas (5%). The mean time lapse between transplantation and RCC diagnosis was 131.7 months. Thirty-five patients underwent conservative surgery by partial nephrectomy (n = 35, 44.3%) or radiofrequency (n = 5; 6.3%). The estimated 5 years cancer specific survival rate was 94%. Most of these tumors were small and incidental. Most tumors were papillary carcinoma, low stage and low grade carcinomas. Conservative treatment has been preferred each time it was feasible in order to avoid a return to dialysis.