J.-N. Cornu

Photoselective Vaporization of the Prostate with GreenLight 120-W Laser Compared with Monopolar Transurethral Resection of the Prostate: A Multicenter Randomized Controlled Trial

BACKGROUND Evidence supporting the widespread use of GreenLight High Performance System (HPS) 120-W photoselective vaporization of the prostate (PVP) is lacking. OBJECTIVE To assess the noninferiority of PVP compared with transurethral resection of the prostate (TURP) on urinary symptoms and the superiority of PVP over TURP on length of hospital stay. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized controlled trial was conducted. INTERVENTION Patients underwent monopolar TURP or PVP with the GreenLight HPS 120-W laser. MEASUREMENTS International Prostate Symptom Score (IPSS), Euro-QOL questionnaire, uroflowmetry, Danish Prostate Symptom Score Sexual Function Questionnaire, sexual satisfaction, and adverse events were collected at 1, 3, 6, and 12 mo. The two groups were compared using the 95% confidence interval (CI) of median difference for testing noninferiority of the IPSS at 12 mo and the student t test for testing the difference in length of hospital stay. RESULTS AND LIMITATIONS A total of 139 patients (70 vs 69 men in each group) were randomized. Median IPSS scores at 12-mo follow-up were 5 (interquartile range [IQR]: 3-8) for TURP versus 6 (IQR: 3-9) for PVP, and the 95% CI of the difference of the median was equal to -2 to 3. Because the upper limit of the 95% CI was >2 (the noninferiority margin), the hypothesis of noninferiority could not be considered demonstrated. Median length of stay was significantly shorter in the PVP group than in the TURP group, with a median of 1 (IQR: 1-2) versus 2.5 (IQR: 2-3.5), respectively (p<0.0001). Uroflowmetry parameters and complications were comparable in both groups. Sexual outcomes were slightly better in the PVP group without reaching statistical significance. CONCLUSIONS The present study failed to demonstrate the noninferiority of 120-W GreenLight PVP versus TURP on prostate symptoms at 1 yr but showed that PVP was associated with a shorter length of stay in the hospital. TRIAL REGISTRATION NCT01043588.

Systematic Review of Combination Drug Therapy for Non-neurogenic Male Lower Urinary Tract Symptoms

BACKGROUND Several drugs are approved for the treatment of lower urinary tract symptoms (LUTS) in men, but these are mostly used by clinicians as monotherapies. The combination of different compounds, each of which targets a different aspect of LUTS, seems appealing. However, only few clinical trials have evaluated the effects of combination therapies. OBJECTIVE This systematic review analyzes the efficacy and adverse events of combination therapies for male LUTS. EVIDENCE ACQUISITION PubMed and Cochrane databases were used to identify clinical trials and meta-analyses on male LUTS combination therapy. The search was restricted to studies of level of evidence ≥ 1b. A total of 49 papers published between January 1988 and March 2012 were identified. EVIDENCE SYNTHESIS The α1-adrenoceptor antagonist (α1-blocker)/5α-reductase inhibitor (5-ARI) combination provides the most data. This combination seems to be more efficacious in terms of several outcome variables in patients whose prostate volume is between 30 ml and 40 ml when treatment is maintained for >1 yr; when given for <1 yr, α1-blockers alone are just as effective. The combination of α1-blocker/5-ARI shows a slightly increased rate of adverse events. It remains unknown whether its safety and superiority over either drug as monotherapy are sustained after >6 yr. The α1-blocker/muscarinic receptor antagonist (antimuscarinic) combination was most frequently assessed as an add-on therapy to already existing α1-blocker therapy. Inconsistent data derive from heterogeneous study populations and different study designs. Currently, the α1-blocker/antimuscarinic combination appears to be a second-line add-on for patients with insufficient symptom relief after monotherapy. The combination seems to be safe in men with postvoid residual <200 ml. However, there are no trials >4 mo concerning safety and efficacy of this combination. The α1-blocker/phosphodiesterase type 5 inhibitor combination is a new treatment option with only preliminary reports. More studies are needed before definitive conclusions can be drawn. CONCLUSIONS An α1-blocker/5-ARI combination is beneficial for patients whose prostate volume is between 30 ml and 40 ml when medical treatment is intended for >1 yr. Based on short-term follow-up studies, add-on of antimuscarinics to α1-blockers is an option when postvoid residual is <200 ml.

Bilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l’AFU

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.

Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP)

To describe the step‐by‐step learning curve of the holmium laser enucleation of the prostate (HoLEP) surgical technique.

RecommandationBilan initial, suivi et traitement des troubles mictionnels en rapport avec hyperplasie bénigne de prostate : recommandations du CTMH de l’AFUInitial assessment, follow-up and treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: Guidelines of the LUTS committee of the French Urological Association

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.

Bilan initial et suivi de l’hyperplasie bénigne de prostate : revue de littérature du CTMH de l’AFU

PURPOSE To perform an update on the initial evaluation and follow-up of benign prostatic hyperplasia (BPH). METHOD A systematic review of recent literature was performed. Level of evidence of publications was evaluated. RESULTS AND CONCLUSIONS Objectives of the initial evaluation are to assess the link between low urinary tract symptoms (LUTS) and BPH, to evaluate the bother associated to LUTS, assess a complicated bladder outlet obstruction (BOO), diagnose an adenocarcinoma of the prostate if it modifies the therapeutic strategy, and establish an evolutive profile of the disease. Clinical assessment with digital rectal examination, evaluation of symptoms by a dedicated questionnaire and urine analysis are the first steps of BPH evaluation. Bladder diary is useful to objective storage symptoms. Uroflowmetry and post-void residual volume assessment are useful if BOO is suspected. Measure of serum creatinine and ultrasound exam of the urinary tract are second line explorations. Urine cytology, neurological evaluation, urethrocystoscopy, urodynamics with pressure-flow studies are useful if the link between LUTS and BPH is unclear. PSA dosage is used for prostate cancer screening or as a prognostic marker of BPH evolution.

Traitement chirurgical de l’hyperplasie bénigne de la prostate par laser : revue de littérature du CTMH de l’AFU

PURPOSE To perform an update on the surgical treatment of benign prostatic hyperplasia (BPH) by laser. METHOD A systematic review of recent literature was performed. The level of evidence of each report was evaluated, and only recent publications of high level of evidence were included. RESULTS AND CONCLUSIONS Monopolar transurethral resection of the prostate (TURP) and open prostatectomy remain the gold standards. Alternative endoscopic options are laser photoselective vaporisation, holmium enucleation and thulium resection. These techniques seem to show functional results similar to those obtained after TURP and open prostatectomy, as well as an advantage in terms of bleeding.

Trends in the Use of the GreenLight Laser in the Surgical Management of Benign Prostatic Obstruction in France Over the Past 10 Years

Photoselective vaporization of the prostate (PVP), introduced in the late 1990s, is now considered a valuable alternative to transurethral resection of the prostate (TURP) [1]. Although several studies conducted in Asia and North America have highlighted the expanding role of laser prostatectomy [2,3], specific epidemiological data in Europe are critically lacking. We describe the trends in the surgical management of benign prostatic obstruction (BPO) in France over the past 10 yr, with a specific focus on the use of the GreenLight laser. We analyzed data from a national comprehensive administrative claim database (previously described by Lukacs et al [4]) to estimate the number of endoscopic procedures (whatever the technique) and open prostatectomy surgeries performed each year between 2005 and 2014. We concurrently analyzed data from the manufacturer regarding use of the GreenLight laser fibers (American Medical Systems, Minnetonka, MN, USA) in France during the same period. PVP numbers were subtracted from the group of endoscopic procedures. Because enucleation was introduced in France only very recently, the remaining endoscopic procedures were hereafter designated as TURP. For the 2014 figures, data were extrapolated from those obtained for the period from January to September. The overall number of BPO surgical procedures in France remained stable during the study period (61 993 in 2005 and 60 184 in 2014). During the past decade, the share of PVP has dramatically increased from 0.2% in 2005 to 22.9% of all procedures in 2014, whereas the number of TURPs and open prostatectomies conducted per year decreased from 52 828 to 40 436 and from 9069 to 5948 (34.4% reduction), respectively (Fig. 1A). In 2014, TURP, open prostatectomy, and PVP accounted for 67.2%, 9.9%, and 22.9%, respectively, of all benign prostatic hyperplasia surgeries. The fibers used were mostly KTP 80 W between 2005 and 2006, HPS 120 W between 2007 and 2010, and XPS 180 W between 2011 and 2014 (Fig. 1B). The increased use of PVP thus mainly occurred during the XPS era. Our results are consistent with previous findings outside Europe [2,3,5]. However, in 2014, the rate of TURP remained

Évaluation de la pratique de la chirurgie ambulatoire en urologie : expérience d’un centre ☆

OBJECTIVE Ambulatory surgery is an alternative to traditional hospitalisation and an opportunity for savings for the healthcare system. Here, we analyze our experience in outpatient surgery in urology over a year. MATERIAL A prospective database concerning outpatient activity was established in 2009, gathering age, ASA score, type of intervention, discharge and recovery for each patient. An individual questionnaire was sent retrospectively in February 2010, to collect data about history of outpatient surgery, overall satisfaction, preference for traditional hospitalization and emergency department visits within 48 hours after surgery. RESULTS In 2009, 465 patients aged of 52±16 years (15-98) underwent urologic surgery on an outpatient basis. Median ASA score was 2 (1-3). Types of intervention were mainly endo-urology (44.5%), surgery for urinary incontinence (32.5%), and circumcision (12.3%). The postoperative hospitalization rate was 4.5%. The questionnaire response rate was 28%. Forty-six percent of the patients had already been supported in ambulatory, overall satisfaction was 3.3 out of 4 (±1.06) and 24% of patients would have preferred a traditional hospitalization. 11% of patients required emergency department care within 48 hours whatever the surgery undergone. CONCLUSION An important part of urological procedures has been done on an outpatient basis without compromising quality of care and patient satisfaction.

Les anti-angiogéniques : de nouveaux standards thérapeutiques dans le cancer du rein métastatique

Resume Depuis 2004, le traitement du cancer du rein au stade metastatique est en profonde mutation. Avant, la prise en charge reposait essentiellement sur l’utilisation des cytokines en association eventuelle a la nephrectomie elargie. Depuis, l’etude de nouvelles molecules aux proprietes anti-angiogeniques, agissant sur la voie pVHL-HIF, le VEGF, le PDGF ou leurs recepteurs de type tyrosine-kinase ont revolutionne la prise en charge des patients en situation metastatique. Les resultats des anti-angiogeniques concernent surtout l’amelioration de la survie sans progression que ce soit pour le sunitinib, en premiere ligne de traitement, ou pour le sorafenib en seconde ligne de traitement. Les inhibiteurs de m-TOR (temsirolimus), peuvent etre utilises avec un benefice sur la survie globale dans les cas de cancers du rein metastatiques de mauvais pronostic ou en cas de tumeurs non a cellules claires. Enfin, un anticorps monoclonal recombinant humanise, le bevacizumab, est capable de cibler le VEGF, quel que soit son isoforme. Les effets secondaires sont propres a chaque molecule. Toutefois, la place exacte de chaque molecule reste a definir dans la sequence du traitement.