Laurence Peyrat

The AdVance Transobturator Male Sling for Postprostatectomy Incontinence: Clinical Results of a Prospective Evaluation after a Minimum Follow-up of 6 Months

BACKGROUNDnTransobturator male slings have been proposed to manage stress urinary incontinence (SUI) after prostatic surgery, but data are still lacking.nnnOBJECTIVEnTo determine the safety and prospectively evaluate the clinical outcome after management of SUI after prostatic surgery by placement of a transobturator male sling.nnnDESIGN, SETTING, AND PARTICIPANTSnWe conducted a prospective evaluation on 102 patients treated in a single center between 2007 and 2009 for mild to moderate SUI following prostatic surgery.nnnINTERVENTIONSnPlacement of a suburethral transobturator sling and clinical follow-up.nnnMEASUREMENTSnPatients were evaluated by medical history, preoperative urodynamics, maximum flow rate measurement, 24-h pad test, and daily pad use. During follow-up, data on patients pad use, complications, and answers to the Patient Global Impression of Improvement (PGI-I) questionnaire were collected. Cure was defined as no pad usage or one pad for security reasons and improvement as reduction of pads≥50%. Median follow-up was 13 mo (range: 6-26).nnnRESULTS AND LIMITATIONSnMost patients (95%) presented post-radical prostatectomy incontinence (PRPI). Hospital stay was 2 d in 97 cases, and all patients were catheterized for 24h except two (48 h). Of 102 patients, 64 were cured, 18 were improved, and 20 were not improved. According to the PGI-I questionnaire, 85%, 11%, and 4% of patients described a respectively better, unchanged, and worse urinary tract condition, respectively. Previous radiation was associated with higher rate of failure (p=0.039). Neither severe complication nor postoperative urinary obstruction was noted during follow-up.nnnCONCLUSIONSnPlacement of a transobturator sling is a safe and effective procedure, giving durable results after >1 yr of follow-up. Further evaluation and high-quality controlled, randomized studies are needed to assess long-term efficacy and precise indications of this procedure for post-prostatic-surgery SUI management.

Mid-term evaluation of the transobturator male sling for post-prostatectomy incontinence: focus on prognostic factors.

Study Type – Therapy (outcomes research)

Midterm Prospective Evaluation of TVT-Secur Reveals High Failure Rate

BACKGROUNDnTVT-Secur has been described as a new minimally invasive sling for womens stress urinary incontinence (SUI) management, showing promising results in short-term studies.nnnOBJECTIVEnOur goal was to evaluate the outcome of this procedure after a midterm follow-up.nnnDESIGN, SETTING, AND PARTICIPANTSnA prospective evaluation involved 45 consecutive patients presenting SUI associated with urethral hypermobility. Fourteen patients preoperatively reported overactive bladder (OAB) symptoms, but none had objective detrusor overactivity. Eight patients had low maximal urethral closure pressure (MUCP). Four patients had pelvic organ prolapse (POP).nnnINTERVENTIONnPatients with POP were treated under general anesthesia by Prolift and TVT-Secur procedure. The 41 other patients received TVT-Secur under local anesthesia on an outpatient basis. All interventions were made by the same surgeon.nnnMEASUREMENTSnPostoperative assessment included pad count, bladder diary, clinical examination with stress test, evaluation of satisfaction with the Patient Global Impression of Improvement (PGI-I) scale, and evaluation of side effects. Patients were classified as cured if they used no pads, had no leakage, and had a PGI-I score < or = 2; as improved in case of reduction of SUI symptoms >50% and PGI-I score < or = 3; and as failure otherwise.nnnRESULTS AND LIMITATIONSnMean postoperative follow-up was 30.2 +/- 9.8 mo (range: 11-40 mo). Short-term evaluation showed a 93.5% success rate, but, at last follow-up, only 18 (40%) patients were cured, while 8 (18%) were improved, and 19 (42%) failed. Twelve patients underwent implantation of TVT or transobturator tape during follow-up. Age, MUCP, or OAB were not associated with failure. Side effects were limited to five cases of de novo OAB and three cases of urinary tract infection. This work is limited by the absence of a comparison group.nnnCONCLUSIONSnOur experience shows that despite its good short-term efficacy, TVT-Secur is associated with a high recurrence rate of SUI. Therefore, TVT-Secur does not seem appropriate for SUI first-line management in women.

Duloxetine for Mild to Moderate Postprostatectomy Incontinence: Preliminary Results of a Randomised, Placebo-Controlled Trial

BACKGROUNDnDuloxetine is effective in the management of stress urinary incontinence (SUI) in women but has been poorly evaluated in the treatment of SUI following radical prostatectomy (RP).nnnOBJECTIVEnTo establish the superiority of duloxetine over placebo in SUI after RP.nnnDESIGN, SETTING, AND PARTICIPANTSnWe conducted a prospective, randomised, placebo-controlled, double-blind, monocentric superiority trial. After a placebo run-in period of 2 wk, patients with SUI after RP were randomised to receive either 80mg of duloxetine daily or matching placebo for 3 mo.nnnMEASUREMENTSnThe primary outcome measure was the relative variation in incontinence episodes frequency (IEF) at the end of study compared to baseline. Secondary outcomes included quality of life (QoL) measures (Incontinence Impact Questionnaire Short Form [IIQ-SF], Urogenital Distress Inventory Short Form [UDI-SF], Incontinence Quality of Life [I-QoL]), symptom scores (Urinary Symptom Profile [USP] questionnaire, International Consultation on Incontinence/World Health Organisation Short Form questionnaire [ICIQ-SF], the Beck Depression Inventory [BDI-II] questionnaire), 1-h pad test, and assessment of adverse events.nnnRESULTS AND LIMITATIONSnThirty-one patients were randomised to either the treatment (n=16) or control group (n=15). Reduction in IEF was significant with duloxetine compared to placebo (mean±standard deviation [SD] variation: -52.2%±38.6 [range: -100 to +46] vs +19.0%±43.5 [range: -53 to +104]; mean difference: 71.2%; 95% confidence interval [CI] for the difference: 41.0-101.4; p<0.0001). IIQ-SF total score, UDI-SF total score, SUI subscore of the USP questionnaire, and question 3 of the ICIQ-SF questionnaire showed improvement in the duloxetine group (p=0.006, p=0.02, p=0.0004, and p=0.003, respectively). Both treatments were well tolerated throughout the study period.nnnCONCLUSIONSnDuloxetine is effective in the treatment of incontinence symptoms and improves QoL in patients with SUI after RP.

Transcorporal artificial urinary sphincter implantation as a salvage surgical procedure for challenging cases of male stress urinary incontinence: surgical technique and functional outcomes in a contemporary series.

To describe the surgical technique of transcorporal artificial urinary sphincter (AUS) implantation. To assess the efficacy of the AUS on continence and erectile function.

Repeat mid-urethral sling for recurrent female stress urinary incontinence.

Introduction and hypothesisThe aim of the study was to assess the effectiveness of repeat mid-urethral sling after a failed primary sling for stress urinary incontinence.MethodsA total of 112 women with recurrent stress incontinence after primary mid-urethral sling underwent a repeat procedure between 2000 and 2011. All patients had a preoperative clinical and urodynamic evaluation. Outcomes were divided into three groups: cured (no more leaks), improved (decrease of leaks), or failed.ResultsAll patients had urethral hypermobility and 12.9xa0% had intrinsic sphincter deficiency [maximum urethral closure pressure (MUCP)u2009≤u200920xa0cmH2O]. Median MUCP was 41xa0cmH20. Overactive bladder was found in 5.7xa0% of women. The second sling placed was one of the following: retropubic Tension-free Vaginal Tape (49xa0%), transobturator tape (48xa0%), or mini-sling (3xa0%). No intraoperative morbidity was reported. After the second sling was placed, 68 (60.7xa0%) patients were subjectively cured and 18 (16.1xa0%) improved (76.8xa0% success overall) with a mean follow-up of 21xa0months. Success rates were 72.2 and 81.8xa0% for transobturator and retropubic slings, respectively, with no significant difference. Multivariable analysis showed higher odds of cure and improvement with the retropubic approach after adjusting for MUCP. Late complication rates were comparable to those observed after a first sling. Urodynamic parameters were not associated with postoperative success.ConclusionsRepeat mid-urethral sling for recurrent female stress urinary incontinence is nearly 77xa0% successful u202ain a group of patients with persistent urethral hypermobility. u202cA retropubic approach might be preferred for patients with low urethral closure pressures.

Ajust single incision transobturator sling procedure for stress urinary incontinence: results after 1-year follow-up.

Introduction and hypothesisData on the Ajust™, a new single-incision sling procedure for female stress urinary incontinence (SUI) management, remain scarce and limited to a 1-year follow-up. Our goal was to assess the efficacy of this procedure after a 1-year follow-up.MethodsThis prospective evaluation involved 95 consecutive patients implanted with AjustTM at a single centre. All patients had SUI on urodynamics due to urethral hypermobility, 33xa0% had preoperative overactive bladder (OAB) symptoms and none had detrusor overactivity. Ninety-two patients were treated on an outpatient basis, and 3 patients had general anaesthesia. Postoperative assessment was conducted at 1, 6, 12xa0months, and yearly thereafter. The main outcome measure was pad usage. Secondary parameters were self-reported SUI episodes, OAB symptoms, data of clinical examination, satisfaction using the Patient Global Impression of Improvement (PGI-I) scale, postoperative pain, and adverse events.ResultsAfter a mean follow-up of 21u2009±u20096xa0months (12–32), 76 out of 95 patients used no pads or one dry security pad, showing a success rate of 80xa0%. Seventy-nine out of 95 patients had no more SUI-related leakage. Only 6 patients experienced late recurrence of SUI after 6xa0months’ follow-up. Perioperative complications included 1 case of vaginal hematoma, 1 case of acute urinary retention, 2 cases of urinary tract infection, all managed conservatively. Half of the patients had no pain after day 1, free of medications. Late complications were vaginal erosion in 1 case, and pain during exertion in 2 cases.ConclusionsThe AjustTM single incision transobturator sling is a safe and effective procedure, with durable results after 1xa0year.

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

OBJECTIVEnAmbulatory 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.nnnMATERIALnA 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.nnnRESULTSnIn 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.nnnCONCLUSIONnAn important part of urological procedures has been done on an outpatient basis without compromising quality of care and patient satisfaction.

Update in Management of Vaginal Mesh Erosion

Mesh erosion is one of the major complications of prolapse surgery conducted by transvaginal approach. Following the extensive use of meshes and warning about potential complications, a new classification of mesh-related adverse events has been proposed. Due to the wide scope of clinical features, no standardized approach has been proposed. Surgery is required after failure of conservative management, mostly based on mesh partial or total excision by transvaginal route, following the classic rules of re-do vaginal surgery. Complex cases are best managed in tertiary reference centers.

Update in management of male urinary incontinence: injectables, balloons, minimally invasive approaches.

Purpose of review The surgical armamentarium for stress urinary incontinence in men ranges from minimally invasive endoscopic procedures to artificial urinary sphincter implantation. In this rapidly moving field, respective indications of surgical options are also evolving, as evidence for the use of innovative devices is growing. This review is focused on recent data about injectables, stem cells and periurethral balloons implantation. Recent findings Periurethral injections are probably the most minimally invasive options, but are considered of low efficacy, with a high recurrence rate in the short term. Reinjections are often needed. However, the market share of periurethral bulking is decreasing relatively slowly. Innovative, so-called regenerative therapies, including injection of biological material, stem cells, myoblasts and muscle strings implantation have shown promising results but did not yet reach maturity for daily use in the clinic. Periurethral balloons implantation shows an acceptable success rate at mid-term follow-up, but are associated with a high rate of complications and reoperations. Summary Indications of periurethral bulking are decreasing. Regenerative therapies are still under investigation in men, and long-term studies are still required. Comparative studies against male slings and other compression devices are still awaited to accurately determine the role of periurethral balloons implantation.