M. Galiano

The Current Status of Laparoscopic Sacrocolpopexy: A Review

CONTEXTnPelvic organ prolapse (POP) is a common problem in women that causes morbidity and a decreased quality of life. Sacrocolpopexy can treat women with vaginal vault prolapse (VVP), multicompartmental POP, and/or a history of failed prolapse procedures. Abdominal sacrocolpopexy (ASC) is the gold standard for VVP and is superior to vaginal sacrocolpopexy, with fewer recurrent prolapses and less dyspareunia. Vaginal prolapse repairs, however, are often faster and offer patients a shorter recovery time. Laparoscopic sacrocolpopexy (LSC) aims to bridge this gap and to provide the outcomes of ASC with decreased morbidity.nnnOBJECTIVEnThis review evaluates the recent literature on LSC as a therapy for POP.nnnEVIDENCE ACQUISITIONnA PubMed search of the available English literature on LSC was performed. The reference lists of selected articles were reviewed, and additional on-topic articles were included. Some 50 articles were screened, 22 articles were selected, and the reported outcomes from 11 series are presented in this review.nnnEVIDENCE SYNTHESISnLaparoscopic experience with POP has advanced tremendously, and LSC results from >1000 patients in 11 series support this. Conversion rates and operative times have decreased with increased experience. Mean operative time was 158 min (range: 96-286 min) with a 2.7% conversion rate (range: 0-11%) and a 1.6% early reoperation rate (range: 0-3.9%). With a mean follow-up of 24.6 mo (range: 11.4-66 mo), there was, on average, a 94.4% satisfaction rate, a 6.2% prolapse reoperation rate, and a 2.7% mesh erosion rate. Several centers have demonstrated that excellent outcomes with LSC are reproducible in terms of operative parameters, durable results, minimal complications, and high levels of patient satisfaction.nnnCONCLUSIONSnLSC upholds the outcomes of the gold standard ASC with minimal morbidity. Longer prospective and randomized trials are needed to confirm these results.

Focal therapy with high-intensity focused ultrasound for prostate cancer in the elderly: a feasibility study with 10 years follow-up

PURPOSEnTo evaluate the long-term efficacy of prostate cancer control and complication rates, in the elderly, after focal therapy with high-intensity focused ultrasound (HIFU).nnnMATERIALS AND METHODSnBetween June 1997 and March 2000, patients with localized prostate cancer were included into a focal therapy protocol. Inclusion criteria were: PSA ≤ 10 ng/mL, ≤ 3 positive biopsies with only 1 lobe involved, clinical stage ≤ T2a, Gleason score ≤ 7 (3+4), negative CT scan and bone scan. Hemi-ablation of the prostate was performed with the Ablatherm® device. Survival, complication rates and urinary continence were evaluated. Control biopsies were performed at 1 year. Treatment failure was defined as a positive biopsy or need for salvage therapy.nnnRESULTSnTwelve patients with a mean age 70 years were included. Median follow-up was 10 years. Control prostate biopsies were negative in 11/12 (91%) patients. Overall survival was 83% (10/12) and cancer specific survival was 100% at 10 years. Two patients died from other causes. Recurrence free survival was 90% (95% CI; 0.71-1) at 5 years, and 38% (95% CI; 0.04-0.73) at 10 years. Five patients had salvage therapy with repeat HIFU (n = 1) or hormonal therapy (n = 4) and all salvage patients were alive at 10 years. No patients developed lymph node or bone metastasis. No patients suffered from urinary incontinence. International Prostate Symptom Score was stable at 1 year. Complications included two urinary tract infections and one episode of acute urinary retention.nnnCONCLUSIONSnHemi-prostate ablation with HIFU can be safely performed in selected elderly patients with adequate long-term cancer control and low complication rates. Results from larger prospective studies using improved imaging techniques and extensive biopsy protocols are awaited.

Focal High-intensity Focused Ultrasound Targeted Hemiablation for Unilateral Prostate Cancer: A Prospective Evaluation of Oncologic and Functional Outcomes

BACKGROUNDnIn selected patients with unilateral, organ-confined prostate cancer (PCa), hemiablation of the affected lobe might be feasible to achieve acceptable cancer control with fewer complications.nnnOBJECTIVESnTo assess the oncologic and functional outcomes of focal high-intensity focused ultrasound (HIFU) hemiablation in unilateral organ-confined PCa.nnnDESIGN, SETTING AND PATIENTSnSingle-center prospective evaluation of HIFU hemiablation for unilateral organ-confined PCa was performed from July 2009 through December 2013.nnnINTERVENTIONnCancer localization was done with transrectal ultrasound-guided biopsy and multiparametric magnetic resonance imaging followed by HIFU hemiablation.nnnOUTCOME MEASUREMENT AND STATISTICAL ANALYSISnOncologic outcomes were analyzed with control biopsies and prostate-specific antigen (PSA) measurement. Functional outcomes were assessed with validated questionnaires for genitourinary symptoms.nnnRESULTS AND LIMITATIONSnOf 71 HIFU hemiablation patients, 67 completed the study protocol. The mean age was 70.2 yr (standard deviation: 6.8 yr), and median PSA was 6.1 ng/ml (interquartile range [IQR]: 1.6-15.5 ng/ml). Median maximum cancer-core length was 3 mm (IQR: 2-10 mm), and total cancer length was 6.5 mm (IQR: 2-24 mm). Gleason score was 6 (3+3) in 58 patients (86.6%) and 7 (3+4) in 9 patients (13.4%). Median follow-up was 12 mo (IQR: 6-50 mo), and at 12 mo, 56 of 67 patients had a negative control biopsy in the treated lobe. At 3 mo, all patients were continent, and potency was maintained in 11 of 21 preoperatively potent patients (confidence interval, 0.18-0.69). Complications included 8% Clavien-Dindo grade 2 and 2.8% grade 3 events.nnnCONCLUSIONSnFocal HIFU hemiablation appears to achieve acceptable oncologic outcomes with low morbidity and minimal functional changes. Longer follow-up will establish future considerations.nnnPATIENT SUMMARYnThis study showed that high-intensity focused ultrasound hemiablation in selected patients with unilateral organ-confined prostate cancer can be used for satisfactory cancer control with minimal effect on genitourinary functions.

Focal cryoablation: a treatment option for unilateral low‐risk prostate cancer

To assess oncological (biochemical and histological recurrence) and functional (urinary and potency) outcomes in patients with unilateral low‐risk organ‐confined prostate cancer (PCa) treated with focal cryoablation (FC).

Comparison of the rate, location and size of positive surgical margins after laparoscopic and robot-assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series)

Laparoscopic radical prostatectomy is feasible and effective in 'fit' senior men with localized prostate cancer.

Study Type – Therapy (case series)u2028Level of Evidenceu20034

Implants péniens hydrauliques: résultats, complications et facteurs pronostiques

OBJECTIVEnTo identify the main prognostic factors influencing the immediate and long-term results of inflatable penile prosthesis implantation.nnnPATIENTS AND METHODSnBetween February 1999 and December 2007, 118 inflatable penile prostheses were implanted, by the same operator, on 96 patients with a mean age of 54.4 years. One third of the implanted patients had had previous penile surgery. Three different penile implants were used: TITAN alpha1 (N = 32), EXCEL (N = 6), and TITAN RESIST (N = 80).nnnRESULTSnMedian follow-up was 25 months [6-114]. One patient with sickle-cell disease died from a massive pulmonary embolism. Seven patients (7.3%) had a postoperative scrotal haematoma. Eleven patients (11.5%) had a postoperative infection. Fourteen patients (14.6%) had a material migration. Sixteen patients (16.7%) had a surgical revision for mechanical dysfunctions after a mean period of 21 months. The rate of postoperative complications was significantly increased in case of prior penile surgery (p = 0.049) or in case of associated surgical procedure (p = 0.0095). The rate of migration was significantly more important in case of postpriapism erectile dysfunction (p = 0.00035). The risk of mechanical dysfunctions was significantly increased in case of Peyronies disease. In the end of the follow-up, 85% of patients (and 91% of first-time implantations) had a functional prosthesis.nnnCONCLUSIONnThe long-term functional results of inflatable penile prosthesis are suitable but the postoperative complications are frequent in case of prior penile surgery, associated surgical procedure, Peyronies disease, or postpriapism implantation.

Article originalImplants péniens hydrauliques : résultats, complications et facteurs pronostiquesInflatable penile prostheses: Results, complications and prognostic factors☆

OBJECTIVEnTo identify the main prognostic factors influencing the immediate and long-term results of inflatable penile prosthesis implantation.nnnPATIENTS AND METHODSnBetween February 1999 and December 2007, 118 inflatable penile prostheses were implanted, by the same operator, on 96 patients with a mean age of 54.4 years. One third of the implanted patients had had previous penile surgery. Three different penile implants were used: TITAN alpha1 (N = 32), EXCEL (N = 6), and TITAN RESIST (N = 80).nnnRESULTSnMedian follow-up was 25 months [6-114]. One patient with sickle-cell disease died from a massive pulmonary embolism. Seven patients (7.3%) had a postoperative scrotal haematoma. Eleven patients (11.5%) had a postoperative infection. Fourteen patients (14.6%) had a material migration. Sixteen patients (16.7%) had a surgical revision for mechanical dysfunctions after a mean period of 21 months. The rate of postoperative complications was significantly increased in case of prior penile surgery (p = 0.049) or in case of associated surgical procedure (p = 0.0095). The rate of migration was significantly more important in case of postpriapism erectile dysfunction (p = 0.00035). The risk of mechanical dysfunctions was significantly increased in case of Peyronies disease. In the end of the follow-up, 85% of patients (and 91% of first-time implantations) had a functional prosthesis.nnnCONCLUSIONnThe long-term functional results of inflatable penile prosthesis are suitable but the postoperative complications are frequent in case of prior penile surgery, associated surgical procedure, Peyronies disease, or postpriapism implantation.

Radical prostatectomy: evolution of surgical technique from the laparoscopic point of view

PURPOSEnTo review the literature and present a current picture of the evolution in radical prostatectomy from the laparoscopic point of view.nnnMATERIALS AND METHODSnWe conducted an extensive Medline literature search. Articles obtained regarding laparoscopic radical prostatectomy (LRP) and our experience at Institut Montsouris were used for reassessing anatomical and technical issues in radical prostatectomy.nnnRESULTSnLRP nuances were reassessed by surgical teams in order to verify possible weaknesses in their performance. Our basic approach was to carefully study the anatomy and pioneer open surgery descriptions in order to standardized and master a technique. The learning curve is presented in terms of an objective evaluation of outcomes for cancer control and functional results. In terms of technique-outcomes, there are several key elements in radical prostatectomy, such as dorsal vein control-apex exposure and nerve sparing with particular implications in oncological and functional results. Major variations among the surgical teams performance and follow-up prevented objective comparisons in radical prostatectomy. The remarkable evolution of LRP needs to be supported by comprehensive results.nnnCONCLUSIONSnRadical prostatectomy is a complex surgical operation with difficult objectives. Surgical technique should be standardized in order to allow an adequate and reliable performance in all settings, keeping in mind that cancer control remains the primary objective. Reassessing anatomy and a return to basics in surgical technique is the means to improve outcomes and overcome the difficult task of the learning curve, especially in minimally access urological surgery.

Dysfonction érectile et cellules endothéliales caverneuses

The physiopathology of erectile dysfunction (ED) is multifactorial. The recent discovery of the precise role of cavernosal endothelium in the functional regulation of the smooth muscle cells allowed to understand the physiological bases of erection. The purpose of this article is to make a synthesis of the current knowledge on the endothelial function and to allow a better understanding of the pathological responsible mechanisms of ED. Endothelium provides cavernosal smooth muscle cells relaxation by two main pathways: the NO/cGMP pathway induced by production of neural nitric oxide (NO) in cavernosal nerve terminals, and the AC/cAMP pathway which by-passes the NO route by using other mediators. This action allows the initiation and maintenance of erection. Risk factor-associated cavernosal endothelial alterations (diabetes mellitus, hypertension, hypercholesterolemia) are mostly induced by unifying mechanisms, including oxidative stress and accumulation of reactive oxygen species, alteration of NO production, or decrease of VEGF expression. The same cellular mechanisms can also be observed during aging. To a comprehensive appraisal of physiological bases of viable endothelium in erectile function, it is crucial to understand its biological activities. The hemodynamic evaluation of endothelial function and the current therapeutic implications will be later approached.