A. Ruffion

Salvage radiotherapy with or without short-term hormone therapy for rising prostate-specific antigen concentration after radical prostatectomy (GETUG-AFU 16): a randomised, multicentre, open-label phase 3 trial

BACKGROUNDnHow best to treat rising prostate-specific antigen (PSA) concentration after radical prostatectomy is an urgent clinical question. Salvage radiotherapy delays the need for more aggressive treatment such as long-term androgen suppression, but fewer than half of patients benefit from it. We aimed to establish the effect of adding short-term androgen suppression at the time of salvage radiotherapy on biochemical outcome and overall survival in men with rising PSA following radical prostatectomy.nnnMETHODSnThis open-label, multicentre, phase 3, randomised controlled trial, was done in 43 French study centres. We enrolled men (aged ≥18 years) who had received previous treatment for a histologically confirmed adenocarcinoma of the prostate (but no previous androgen deprivation therapy or pelvic radiotherapy), and who had stage pT2, pT3, or pT4a (bladder neck involvement only) in patients who had rising PSA of 0·2 to less than 2·0 μg/L following radical prostatectomy, without evidence of clinical disease. Patients were randomly assigned (1:1) centrally via an interactive web response system to standard salvage radiotherapy (three-dimensional [3D] conformal radiotherapy or intensity modulated radiotherapy, of 66 Gy in 33 fractions 5 days a week for 7 weeks) or radiotherapy plus short-term androgen suppression using 10·8 mg goserelin by subcutaneous injection on the first day of irradiation and 3 months later. Randomisation was stratified using a permuted block method according to investigational site, radiotherapy modality, and prognosis. The primary endpoint was progression-free survival, analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT00423475.nnnFINDINGSnBetween Oct 19, 2006, and March 30, 2010, 743 patients were randomly assigned, 374 to radiotherapy alone and 369 to radiotherapy plus goserelin. Patients assigned to radiotherapy plus goserelin were significantly more likely than patients in the radiotherapy alone group to be free of biochemical progression or clinical progression at 5 years (80% [95% CI 75-84] vs 62% [57-67]; hazard ratio [HR] 0·50, 95% CI 0·38-0·66; p<0·0001). No additional late adverse events occurred in patients receiving short-term androgen suppression compared with those who received radiotherapy alone. The most frequently occuring acute adverse events related to goserelin were hot flushes, sweating, or both (30 [8%] of 366 patients had a grade 2 or worse event; 30 patients [8%] had hot flushes and five patients [1%] had sweating in the radiotherapy plus goserelin group vs none of 372 patients in the radiotherapy alone group). Three (8%) of 366 patients had grade 3 or worse hot flushes and one patient had grade 3 or worse sweating in the radiotherapy plus goserelin group versus none of 372 patients in the radiotherapy alone group. The most common late adverse events of grade 3 or worse were genitourinary events (29 [8%] in the radiotherapy alone group vs 26 [7%] in the radiotherapy plus goserelin group) and sexual disorders (20 [5%] vs 30 [8%]). No treatment-related deaths occurred.nnnINTERPRETATIONnAdding short-term androgen suppression to salvage radiotherapy benefits men who have had radical prostatectomy and whose PSA rises after a postsurgical period when it is undetectable. Radiotherapy combined with short-term androgen suppression could be considered as a reasonable option in this population.nnnFUNDINGnFrench Ministry of Health, AstraZeneca, and La Ligue Contre le Cancer.

Surgical Outcomes and Patients' Satisfaction with Suprapubic Phalloplasty

INTRODUCTIONnMany techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives.nnnAIMnThe aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty.nnnMETHODSnMedical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being.nnnMAIN OUTCOME MEASURESnMedical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables.nnnRESULTSnDuration of surgery and of hospital stay was relatively short in the first (1u2009hour 30u2009minutes; 3 days) and last (1u2009hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2u2009hour 15u2009minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Meanu2009=u200912.83u2009cm), and 71% with the circumference (Meanu2009=u200910.83u2009cm) of their neophallus. Satisfactory appearance was significantly correlated (Pu2009<u20090.01) with penile length (ru2009=u20090.69) and diameter (ru2009=u20090.77). Sexual satisfaction was significantly correlated with penile diameter (ru2009=u20090.758), frequency of orgasm (ru2009=u20090.71), perceived importance of voiding while standing (ru2009=u20090.56), presurgery satisfaction with sexuality (ru2009=u20090.58), current masculine-feminine scale (ru2009=u20090.58), attractive-unattractive scale (ru2009=u20090.69), and happy-depressed scale (ru2009=u20090.63).nnnCONCLUSIONnSuprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme

Study Type – Therapy (data synthesis)

RENAL ARTERIOVENOUS MALFORMATION REQUIRING SURGERY IN RENDU-OSLER-WEBER DISEASE (HEREDITARY HEMORRHAGIC TELANGIECTASIA)

Hereditary hemorrhagic telangiectasia is a rare disorder of vascular structure, inherited as an autosomal dominant condition. Vascular malformations may involve many organs but rarely the urinary tract. To our knowledge we report the second case of an intrarenal lesion but the first to require surgery.

Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: preliminary findings

Study Type – Therapy (case series)

TNF‐α‐related apoptosis‐inducing ligand decoy receptor DcR2 is targeted by androgen action in the rat ventral prostate

The apoptotic cell death process in the prostate is known to be under the control of androgens. Tumor necrosis factor‐α (TNF‐α)‐related apoptosis‐inducing ligand (TRAIL) is a member of the TNF‐α family of cytokines, known to induce apoptosis upon binding to its death domain‐containing receptors, DR4/TRAIL‐R1 and DR5/TRAIL‐R2. Two additional TRAIL receptors, DcR1/TRAIL‐R3 and DcR2/TRAIL‐R4, lack functional death domains and act as decoy receptors for TRAIL. In this study, we examined whether TRAIL and cellular receptors expression was targeted by androgens during the apoptotic cell death process in the hormone sensitive ventral prostate. The role of androgens was investigated using two sets of experiment. (1) Androgen deprivation associated with an apoptotic process resulted in a decrease in DcR2 mRNA and protein expression in the ventral prostate 3 days after castration. Testosterone administration to castrated adult rats prevented the decrease in DcR2 mRNA and protein levels in the ventral prostate. In contrast, DcR2 expression was modified, neither in the dorsolateral nor in the anterior prostate following castration. No changes were observed in DR4, DR5, DcR1, and TRAIL mRNA and protein levels in prostate after castration. (2) A specific decrease in DcR2 expression was observed in the ventral prostate after treatment of rats with the anti‐androgen flutamide. Together, the present results suggest that testosterone specifically controls DcR2 expression in the adult rat ventral prostate. Androgen withdrawal, by reducing DcR2 expression, might leave the cells vulnerable to cell death signals generated by TRAIL via its functional receptors. J.Cell.Physiol.

Surgical Staff Radiation Protection During Fluoroscopy-Guided Urologic Interventions.

INTRODUCTIONnOver the past 20 years, the use of fluoroscopy to guide urologic surgical interventions has been constantly growing. Thus, in their daily practice, urologists and other operating room (OR) staff are exposed to X-radiation increasingly frequently. This raises questions as to the risks they encounter and the actions needed to reduce them.nnnOBJECTIVEnEvaluate X-ray dose exposure in the members of the surgical team and determine urologist radioprotection knowledge and practices.nnnMATERIALS AND METHODSnA prospective bicenter study was conducted within AFUF (French urology resident association) and in association with The French Nuclear Safety Authority/The Institute for Radiological Protection and Nuclear Safety (ASN/IRSN). Radiation exposure was measured on 12 operators using dosimeters (seven per operator), in staff-occupied locations in the OR using ionization chambers, and on anthropomorphic phantoms. A survey was used to gather information on radiation knowledge and safety practices of the AFUF members.nnnRESULTSnAnnual whole-body radiation doses were low (0.1-0.8 millisieverts [mSv], mostly at around 0.3 mSv), and equivalent doses were low for the fingers (0.7-15 mSv, mostly at around 2.5 mSv), and low for the lens of the eye (0.3-2.3 mSv, mostly at around 0.7 mSv). In percutaneous nephrolithotomy, extremity doses were lower when the patient was placed in dorsal decubitus compared with ventral decubitus. Pulsed fluoroscopy reduced radiation dose exposure by a factor of 3 compared with continuous fluoroscopy with no image quality loss. Radiation safety practices were poor: only 15% of urologists wore dosimeters and only 5% had been trained in the handling of X-ray generators.nnnCONCLUSIONnIn the present study, radiation exposure for urologists was low, but so was knowledge of radiation safety and optimization practices. This absence of training for radiation safety and reduction, teamed with novel techniques involving long fluoroscopy-guided interventions, could result in unnecessarily high exposure for patients and OR personnel.

Genital Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty in Male-to-Female Transgender Women

INTRODUCTIONnGender-affirming surgery is common for the treatment of gender dysphoria, but its effect on genital sensitivity is not well known.nnnAIMSnTo investigate genital sensory detection thresholds in male-to-female transgender women postoperatively and their relation to psychological well-being and variables of satisfaction.nnnMETHODSnProspective study on 28 transgender women at least 18 years old operated on at least 3 months before the study by a single surgeon (N.M.J.).nnnMAIN OUTCOME MEASURESnMedical complications; sensory detection thresholds for light touch, pressure, and vibration; and questionnaires on general and sexual satisfaction, sexual function, depression, and psychological well-being.nnnRESULTSnSensory detection thresholds ranged from 0.07 to 2.82 g for light touch, with the neck being most sensitive; from 20.23 to 34.64 g for pressure, with similar results for the neck and clitoris; and from 0.0052 to 0.0111 V for vibration, with similar findings for all stimulation points. Satisfaction with the appearance of the labia, vulva, clitoris, and sexual function was good to very good. Frequency of sexual activities increased significantly postoperatively for orogenital stimulation and decreased significantly for frequency of fantasies (txa0=xa0-4.81; P < .0001). Orgasmic function was reported by 80% of participants. Psychological adjustment was good to very good, with low depression scores. Sexual satisfaction was statistically and positively correlated with vaginal function and depth, clitoral sensation, appearance of the vulva and labia minora, and natural lubrication and negatively correlated with depression scores.nnnCONCLUSIONnGender-affirming surgery yields good results for satisfaction with appearance and function. Genital sensitivity showed the best results with pressure and vibration.

Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex

BACKGROUNDnThe bladder exstrophy-epispadias complex is a rare congenital malformation associated with severe dysfunction of the genital and urinary tracts and requiring a staged surgical reconstruction.nnnAIMnThe primary aims of this study were to report the sexuality, infertility, and urinary incontinence outcomes in a cohort of men born with bladder exstrophy-epispadias complex. The secondary aim was to highlight some predictive factors of infertility in this population.nnnMETHODSnWe conducted a descriptive, cross-sectional study of men diagnosed with classic presentations of bladder exstrophy or epispadias.nnnOUTCOMESnPatients were asked to complete 4 validated questionnaires: the International Index of Erectile Function (IIEF)-5, the Erection Hardness Score (EHS), the Self-Esteem and Relationship, and the International Consultation Incontinence modular Questionnaire-Short Form. Fertility potential was assessed with semen analysis and a non-validated questionnaire.nnnRESULTSn38 Patients 18-64 years old (M [mean]xa0= 32.2) completed the questionnaires. The average IIEF-5 score was 18.1/25 (ranging from 3-25; SExa0= 7.62), with results indicating that 55% of the sample had normal erectile function. Results also showed higher scores for patients with normal spermatozoa concentration (Mxa0= 22.75, SExa0= 1.89, Pxa0= .08) than for those with oligospermia (Mxa0= 17.30, SExa0= 8.53, Pxa0= .08). Results on the IIEF-5 also indicated higher scores for patients who conceived children without assisted reproductive technologies (ART) (Mxa0= 22.83, SExa0= 2.317, Pxa0= .02) than for patients without children (Mxa0= 15.76, SExa0= 8.342, Pxa0= .02). The average EHS was 3.43/4 (ranging from 1-4, SExa0= 0.9). EHS was higher for patients who had reconstruction than for patients who had cystectomy (Mxa0= 3.88, SExa0= 1.07 and 2.78, SExa0= 1.09, Pxa0= .02). The average total Self-Esteem and Relationship score was 67.04/100 (ranging from 10.71-96.43, SExa0= 22.11). The average total International Consultation Incontinence modular Questionnaire-Short Form score was 4.97/21 (ranging from 0-18, SExa0= 5.44), higher score indicating more urinary incontinence. Among the patients surveyed, 31.6% were parents at the time of study and 50% of them benefited from ART. With regards to the 14 semen analyses performed, only 7.1% produced normal results and 44.7% indicated that ejaculation was weak and dribbling.nnnCLINICAL TRANSLATIONnErectile function appears to be decreased and psychological aspects of sexuality indicate low self-esteem about sexual relationship. Although ethical problems could not allow prospective spermograms, our cohort is large enough to provide significant data.nnnCONCLUSIONSnEarly sperm storage for future ART, sexual medicine management, and complementary genital reconstruction in adulthood constitute potential treatment options for this population. Reynaud N, Courtois F, Mouriquand P, etxa0al. Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex. J Sex Med 2017;15:314-323.

Utilisation de lambeaux scrotaux pédiculés pour reconstruire les défects de peau du fourreau de la verge : technique et résultats

Objectifs Les plasties peniennes pour defects cutanes du fourreau de la verge, toutes etiologies confondues, restent actuellement des procedures delicates et peu communes, qui doivent repondre a des attentes esthetiques et fonctionnelles. La technique la plus communement pratiquee est la greffe de peau, avec des resultats imparfaits. Notre objectif est de decrire la technique et les resultats de la plastie penienne par rotation de lambeaux scrotaux pedicules. Methodes L’ensemble des patients ayant beneficie d’une plastie penienne par lambeaux scrotaux dans notre centre entre 2009xa0et 2016xa0a ete inclus. Les donnees concernant les patients et les procedures ont ete collectees retrospectivement ( Tableau 1 , Tableau 2 ). La technique consiste a prelever des lambeaux de scrotum bilateraux, pedicules sur les vaisseaux iliaques externes superficiels, comprenant le fascia de Dartos, qui sont disseques et separes de la vaginale testiculaire puis pivotes le long de la verge, au contact du fascia de Buck. Ces lambeaux sont ensuite sutures longitudinalement entre eux sur les faces ventrale et dorsale de la verge, et coronalement a la muqueuse du sillon balano-prepucial. Resultats Vingt-deux patients ont beneficie de cette intervention avec un suivi median de 10,5xa0mois. Les indications etaient iatrogenes, verges enfouies, lesions tumorales et dermatosiques ou injections de produits sclerosants. La duree moyenne d’intervention etait de 150,3xa0min et la duree d’hospitalisation de 4,6xa0jours. Les complications precoces comprenaient 36,4xa0% de desunions cicatricielles, 9,1xa0% d’infections et 9,1xa0% d’hematomes, sans aucune reprise chirurgicale. Plus tardivement, 27,3xa0% des patients ont presente une ascension testiculaire, 31,8xa0% une retraction cutanee, 9,1xa0% un aspect pyramidal de la verge, 13,6xa0% un raccourcissement de la verge, avec au total 36,4xa0% de reinterventions. Conclusion Dans notre experience, la plastie penienne par rotation de lambeaux scrotaux pedicules est une technique simple, sure et efficace pour reconstruire les defects cutanes de fourreau de la verge. Cette technique pourrait concurrencer la greffe de peau libre, encore tres largement utilisee dans cette indication.