Jean-François Hermieu

Efficacy and Safety of Low Doses of OnabotulinumtoxinA for the Treatment of Refractory Idiopathic Overactive Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled Dose-Ranging Study

BACKGROUNDnIn the treatment of patients with idiopathic overactive bladder (iOAB), high doses of botulinum toxin type A (BoNTA) were often associated with complications resulting from high postvoid residuals (PVR), leading to clean intermittent catheterisation (CIC) and urinary tract infections (UTI).nnnOBJECTIVEnEvaluate the efficacy and tolerability of low doses of onabotulinumtoxinA compared to placebo in patients with iOAB.nnnDESIGN, SETTING, AND PARTICIPANTSnBetween 2005 and 2009, adults with persistent iOAB were included in a prospective, randomised, double-blind, placebo-controlled comparative trial.nnnINTERVENTIONnPatients were randomised to undergo a single intradetrusor injection procedure of either placebo or onabotulinumtoxinA (50 U, 100 U or 150 U).nnnMEASUREMENTSnThe initial evaluations (ie, clinical and urodynamic variables as well as quality of life [QoL]) were repeated at day 8 and months 1, 3, 5, and 6.nnnRESULTS AND LIMITATIONSnNinety-nine patients were included in the efficacy analysis. Three months after the procedure, we observed>50% improvement versus baseline in urgency and urge urinary incontinence (UUI) in 65% and 56% of patients who respectively received 100 U (p=0.086) and 150 U (p=0.261) BoNTA injections and >75% improvement in 40% of patients of both groups (100 U [p=0.058] and 150 U [p=0.022]). Complete continence was observed in 55% and 50% patients after 100 U and 150 U BoNTA treatment, respectively, at month 3. Frequency symptoms and QoL improved up to the 6-mo visit. We observed only three patients with a PVR>200 ml in the 150 U group and a few UTIs.nnnCONCLUSIONSn100 U and 150 U BoNTA injections were well tolerated and have both shown to improve symptoms and QoL in patients with iOAB. Nevertheless, 100 U injections showed a reasonable efficacy, with a lower risk of high PVR.nnnTRIAL REGISTRATIONnClinicalTrials.gov NCT00231491.

A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study.

Study Type – Therapy (prospective cohort)

Diagnostic Value of Ten Systematic TRUS-Guided Prostate Biopsies

Objective: To evaluate the improvement in the rate of detection of prostate cancer using an extensive protocol involving ten transrectal biopsies. Methods: A total of 162 patients submitted to transrectal ultrasound-guided biopsy for elevated prostate-specific antigen (PSA) and/or abnormality on digital rectal examination were studied consecutively and prospectively. Five biopsies were performed in each lobe: between the three standard biopsies on each side, two additional biopsy specimens were taken in the same plane and at the same 45° angle. Results: The complication rate with the ten-biopsy protocol was 1.85%. Prostate cancer was detected in 40.1% of the patients. In the overall series, the percentage of diagnostic improvement brought about by this ten-biopsy protocol was +3.1%. The percentage improvement was greatest (+4.9%) in patients with PSA ≤10 ng/ml. Conclusion: Increasing the number of biopsy cores without altering the angle of biopsy and/or the zone sampled does not lead to a significant improvement in the detection of prostate cancer.

Urolithiasis and the Protease Inhibitor Indinavir

Objective: To evaluate specific urological abnormalities in patients treated with the protease inhibitor indinavir. Methods: A series of 155 consecutive human immunodeficiency virus-positive patients were treated with indinavir 800 mg p.o. three times a day. Of these, 14 (9%) treated for 1–321 (average 110) days experienced severe flank pain and were subjected to clinical and laboratory examinations. Results: Abdominal X-ray was consistently negative for stones. Ultrasonography showed upper-tract dilatation in 12 patients. Intravenous urography showed obstruction above a radiolucent obstacle in 7 patients; in 2 cases, there was a marked delay in urine excretion on the obstructed side. The mean urine pH was 6. Urine culture was negative. Serum uric acid, phosphorus, and calcium levels were normal. In 8 patients there was slight renal insufficiency, and 4 patients required ureteral stenting. In all cases, hyperhydration and oral analgesia led to a favorable outcome. In 3 patients, chemical analysis of the stone demonstrated monohydrate indinavir crystals. Conclusions: In our experience, indinavir therapy is associated with urolithiasis in 9% of the cases. Hydration, analgesia, and acidification of the urine usually lead to a favorable clinical outcome. Prophylactic hydration and acidification of the urine are extremely important.

Prostate Specimen Reevaluation in Patients With Organ Confined Prostate Cancer and Postoperative Biological Recurrence

PURPOSEnWe evaluated whether detectable levels of prostate specific antigen after radical prostatectomy for stage P2 disease are associated with unconfined cancer overlooked at pathological examination.nnnMATERIALS AND METHODSnAmong 129 patients with stages T1 and T2 prostate cancer treated with radical prostatectomy 60 had stage P2 disease. The initial slides from the 7 patients with biological failure were carefully reviewed and, if necessary, the embedded blocks were sectioned every 2 mm.nnnRESULTSnThe disease was upstaged histologically from P2 to P3 in 6 of 7 patients by reinspecting the initial slides (3) and examining new slides (3).nnnCONCLUSIONSnA postoperative detectable prostate specific antigen level in cases of stage P2 cancer reflects the presence of unconfined disease that may be overlooked by histopathological examination.

The Learning Curve of Transrectal Ultrasound-guided Prostate Biopsies: Implications for Training Programs

OBJECTIVEnTo assess the quality of specimens obtained from prostate biopsies performed by urology residents and evaluate the number of procedures required to perform high-quality transrectal ultrasound (TRUS)-guided prostate biopsies.nnnMATERIALS AND METHODSnBetween 2006 and 2009, 770 patients underwent TRUS-guided prostate biopsies in our academic center. During the 6 semesters of this period, 24 residents (4 per semester) performed 1 session of 5.6±1.5 procedures each month for a total of 33.6±9 procedures during the study. The first session was performed with a senior urologist. Prostate cancer detection rate and standards of quality (average length of prostatic core biopsy specimens and absence of prostatic tissue) were retrospectively studied between the beginning and the end of each semester.nnnRESULTSnA total of 12,760 biopsy cores were performed for 770 procedures. Mean patient age (64.5±6.1 years), and median prostate-specific antigen (8.7±3.7 ng/mL) were comparable between the study periods. The average length of biopsy cores significantly improved (+10%) from the first (12±2.7 mm) to the last month (13.2±2.1 mm) with a plateau after 12 procedures. Overall, cancer detection rate was 47% and was stable during the semester (41.3% the first month vs 44.1% the last month; P=.39). On univariate and multivariate analysis the mean length of biopsy specimens was associated with the number of procedures (P<.001) and the number of cores performed (P<.001).nnnCONCLUSIONnTwelve procedures are necessary to perform high-quality TRUS-guided prostate biopsies without compromising prostate cancer detection. In current training programs, we strongly recommend that residents have direct supervision for a minimum of 12 cases before they are allowed to perform TRUS-guided biopsies with indirect supervision.

A case report of reninoma: radiological and pathological features of the tumour and characterization of tumour-derived juxtaglomerular cells in culture.

Case report: A 20-year-old woman presented with malignant hypertension associated with hypokalemia, metabolic alkalosis and elevated plasma renin and aldosterone levels. Computed tomography angiography (CTA) evidenced a 22u200amm tissular mass in the posterior cortex of the left kidney, and 18F-flurodeoxyglucose PET (18-FDG PET) imaging showed no hypermetabolism of the tumour. Following nephron-sparing surgery, blood pressure and potassium levels rapidly normalized, allowing interruption of all treatments within 2 weeks. Discussion: Reninoma is a rare juxtaglomerular cell tumour (JGCT) producing excessive amounts of renin resulting in severe hypertension. Pathological studies revealed that tumoural cells highly expressed renin and contained electron-dense structures, typical of renin-containing granules. Tumoural cells also exhibited the vascular cell surface marker CD34, but, in contrast with previous reports, did not express the tyrosine-protein kinase Kit (cKit or CD117). Dissociation of the tumour allowed to obtain confluent cultures of elongated smooth muscle actin (SMA)-positive cells producing high amounts of renin. However, after the first passage, subcultured human juxtaglomerular cells rapidly lost renin and CD34 expressions and their ability to produce renin. Conclusion: The present case of reninoma emphasizes the need for CTA in the etiologic work up of otherwise unexplained severe hypertension. 18-FDG PET imaging showed no hypermetabolism of the tumour, in accordance with its reported benignity. Pathological studies further emphasized that high expressions of renin and CD34 are typical hallmarks of reninoma. Although CD117 has been proposed to represent a reliable marker of JGCT, the present findings indicate that reninomas may not always express this marker.

L’uréthroplastie par résection-anastomose en un temps : le mécanisme lésionnel impacte-t-il les résultats ?

Objectifs L’urethroplastie par resection-anastomose (URA) en un seul temps est une des differentes options de reparation des stenoses de l’uretre. Cependant, les resultats sont aleatoires y compris dans des centres referents. Notre objectif etait d’evaluer les resultats de cette technique en fonction du mecanisme lesionnel. Methodes Entre janvier 2004xa0et janvier 2015, 97xa0patients ont eu une URA pour une stenose de l’uretre. Les mecanismes lesionnels etaient regroupes en 3xa0classesxa0: fracture du bassin ( n xa0=xa023), traumatisme iatrogenique endouretral ( n xa0=xa024) et idiopathique ( n xa0=xa050). Les complications postoperatoires, la debimetrie, le taux de recidive et de reintervention ont ete compares en fonction de mecanisme lesionnel initial. Resultats Les patients qui avaient des fractures du bassin etaient plus jeunes que les deux autres groupes ( p Tableau 1 ). Apres un suivi moyen de 25xa0±xa024 (intervallexa0: 1–102) mois, 27 (27,8xa0%) patients ont recidives. Le risque de recidive etait superieur dans le groupe (log rank p Fig. 1 ). Conclusion Cette etude retrospective suggere que les resultats de l’urethroplastie par resection anastomose avaient des resultats moins perennes dans le cas des fractures du bassin compare aux lesions iatrogene endourologique ou idiopathiques.

Mise en place progressive de la photo-vaporisation de prostate en ambulatoire : expérience sur les 100 premiers patients

Objectifs La photo-vaporisation de la prostate (PVP) est une option therapeutique de plus en plus repandue dans la chirurgie mini-invasive de l’hypertrophie benigne de la prostate. Notre objectif etait de rapporter notre experience d’introduction de la PVP dans un service hospitalo-universitaire et d’analyser les limites a la chirurgie ambulatoire dans cette indication. Methodes Depuis le mois de mai 2014, la PVP au laser GreenLight XPS™ (AMS, Minnetonka, USA) a ete introduite dans notre service. Un registre prospectif a ete ouvert pour la collection des donnees demographiques, les caracteristiques de la maladie ainsi que les complications per- et postoperatoires (classification de Clavien). Les 4xa0operateurs ont eu une journee de «xa0proctoringxa0» par un urologue experimente. Nous rapportons les complications perioperatoires, la duree de sejour et les modalites d’hospitalisation (traditionnelle versus ambulatoire) des 100xa0premiers patients. Resultats Les caracteristiques pre- et peroperatoires de la cohorte sont resumees dans le Tableau 1 . La conversion a une resection monopolaire, a ete necessaire dans 6xa0% des cas. Au total, 21xa0% des patients ont necessite un sondagexa0>xa024xa0heures (6xa0% de conversion, 6xa0% hematurie, 1xa0% de fausse route, 8xa0% de retention chronique). Apres un suivi moyen de 6xa0mois (medianexa0: 5xa0mois), 3xa0patients ont eu une deuxieme PVP (prostates de 50, 117xa0et 178xa0mL). Il a ete rapporte 5xa0% et 1xa0% de complications de grade (I–IIxa0: 3xa0retentions d’urine, une transfusion et une prostatite) et (III–IVxa0: un sepsis severe) respectivement. L’implementation et les limites a chirurgie sont resumees dans la Fig. 1 . Conclusion L’introduction progressive de la photo-vaporisation de la prostate a permis d’obtenir des resultats satisfaisants et d’atteindre un plateau en termes de resultats en moins de 100xa0interventions en moins d’un an. Apres 8xa0mois, 80xa0% des interventions etaient realisee en ambulatoire.

L’IRM dans la maladie de Lapeyronie : un outil performant pour la cartographie clinique et infra-clinique et pour la caractérisation des plaques

Objectifs L’IRM semble etre un examen sensible et reproductible pour detection et la caracterisation des plaques fibreuses de la maladie de Lapeyronie. L’objectif de cette etude etait d’evaluer l’utilite de l’IRM dans la prise en charge de la maladie de Lapeyronie. Methodes Entre 2012 et 2013, 21xa0patients consecutifs qui ont ete adresses a notre institution pour une deformation de la verge avec diagnostic clinique de maladie de Lapeyronie ont eu une IRM du penis selon un protocole identiquexa0: 1,5xa0T avec des sequencesxa0T1 sans et avec injection de gadolinium, une sequence T2 et une reconstruction en 3D de la cartographie des plaques. Toutes les IRM ont ete realisees et interpretees par un Uro-radiologue dediexa0(PF). Les caracteristiques cliniques et radiologiques des plaques ont ete rapportees. En particulier, la distinction entre les plaques actives (phase inflammatoire) et les plaques fixees (phase fibreuse) a ete recherchee. Resultats L’âge moyen de la cohorte etait de 52xa0ans (intervallexa0: 24–70). Sur l’ensemble de la cohorte, 30xa0plaques ont ete detectees avec 20xa0% es plaques non palpables. Une IRM etait non exploitable du fait du positionnement du penis lors de l’examen (premier patient de la serie). Dans les autres cas, l’IRM a permis de detecter toutes les plaques a l’origine de la deformation clinique y compris chez les patients chez lesquels la plaque n’etait pas palpee ( Tableau 1 ). Chez 3xa0patients, l’IRM a revele la coexistence d’autres plaques non palpees. Deux grandes categories de plaques ont ete caracteriseesxa0: la premiere fixee en hyposignalxa0T1 et T2 sans rehaussement ( Fig. 1 A), la deuxieme active en hypersignalxa0T1 et T2 avec un rehaussement apres injection de gadolinium ( Fig. 1 B). Conclusion Cette etude a mis en evidence l’excellente sensibilite et specificite de l’IRM dans la cartographie et la caracterisation des plaques responsables de la deformation meme lorsqu’elles ne sont pas cliniquement palpables. Ses elements constituent une aide precieuse lors de l’information du patient et la decision therapeutique (collagenase ou chirurgie versus abstention therapeutique) d’interets.