N. Barry Delongchamps

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.

Article originalGuide de prise en charge en médecine générale des symptômes du bas appareil urinaire de l’homme liés à une hyperplasie bénigne de la prostateGuide dedicated to general practitioner for the management of lower urinary tract symptoms related to benign prostatic hyperplasia

OBJECTIVE To establish a guide dedicated to general practitioner for the diagnosis, the follow-up, and the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH). METHOD Guidelines already published for urologists were modified to make them relevant for general practitioners. The role of specialists referral was defined. The whole content of the document was submitted to the formal consensus process in which urologists and general medicine teachers were involved. RESULTS Initial assessment has several aims: making sure that LUTS are related to BPH, assessing bother related to LUTS, and checking for a possible complication. Initial assessment should include: medical history, physical examination with digital rectal examination, and urinalysis. Some other explorations such as frequency volume chart, serum PSA or creatinine, and ultrasonography of the urinary tract were found optional, meaning they are necessary only in specific situations. Referring to urologist is justified when LUTS might not be related to BPH (particularly when urgencies are predominant), or when a severe bladder outlet obstruction is suspected (severe symptoms, palpable bladder, post-voiding residual volume>100ml), or when a complication is assessed. Follow-up without treatment is justified for patients with no bothersome symptoms related to not complicated BPH. Several drugs are available for the treatment of bothersome symptoms related to BPH. Alpha-blockers and plants extracts might be offered as monotherapy. Five alpha reductase inhibitors might be offered to patients with LUTS related to a significant prostate hypertrophy (>40 ml) ; they might be given for a minimum duration of one year, alone or in association with alpha-blocker. The association of antimuscarinic and alpha-blocker might be used in patients with persistent storage LUTS in spite of alpha-blocker treatment. Phosphodiesterase 5 inhibitors might be offered to patients with erectile dysfunction associated with LUTS related to BPH. In case of complicated BPH, or when medical treatment is not efficacious or not tolerated, a surgical option should be discussed. CONCLUSION The male lower urinary tract symptom committee of the French Urological Association and general practitioner present the first guide for the management of LUTS related to BPH dedicated to general practitioner. LEVEL OF EVIDENCE 5.

Cancer de la prostate de stade pT3N0 traité par prostatectomie radicale en monothérapie : résultats carcinologiques et facteurs prédictifs de récidive

OBJECTIVES To evaluate biological free survival in patients with locally advanced prostate cancer treated with radical prostatectomy (RP) as sole treatment, and to analyse predictive factors of recurrence. PATIENTS AND METHOD We retrospectively studied patients treated between 1996 and 2006 for a pT3N0 prostate cancer with RP without any adjuvant treatment. The main endpoint was PSA relapse, defined as two successive elevations of PSA>0.2 ng/mL. An association between PSA free survival and PSA, Gleason score, pathological stage and surgical margins status was statistically assessed. RESULTS A total of 147 patients were included. Median preoperative PSA was of 10 ng/mL. Pathological stage was pT3b in 30% of the cases and surgical margins showed cancer involvement in 63% of the cases. Gleason score was ≥3+4 in 74% of the cases. Postoperative PSA was undetectable in 121 (82%) patients. Median follow up following RP was of 5 years. The 5-year-PSA free survival was of 48%. Multivariate analysis showed that preoperative and postoperative PSA, as well as Gleason score were predictors of PSA relapse (P<0.05). In patients with undetectable postoperative PSA, 5-year-PSA free survival was of 56%. Seminal vesicle involvement and Gleason score ≥3+4 were the only independent predictors of PSA relapse. CONCLUSIONS After RP for pT3N0 prostate cancer, the only predictive factors of recurrence were postoperative PSA and Gleason score. In case of undetectable postoperative PSA, surveillance seems acceptable if Gleason score is <3+4 and in the absence of seminal vesicle involvement.

Caractéristiques anatomopathologiques des tumeurs apparentes et non apparentes en IRM multiparamétrique de la prostate avant prostatectomie totale

INTRODUCTION As urologists are questioned about the overtreatment of localized prostate cancer, multiparametric MRI can diagnose significant prostate cancer thanks to targeted biopsies. However, some tumors cannot be detected by MRI. What are the pathological characteristics of those tumors? MATERIALS AND METHODS We have selected 144 consecutive patients treated with radical prostatectomy for clinically localized prostate cancer diagnosed on systematic and targeted biopsies (Koelis®) according to multiparametric MRI findings. On MRI, each suspicious area was graded according to the PI-RADS score v1.0. On radical prostatectomy specimen, tumor foci with a Gleason score greater than 3+3 and/or a tumor volume greater than 0,5cm3 were considered significant. The grade-four tumoral volume was calculated by multiplying the tumoral volume by grade 4 tumoral percentage. RESULTS Two hundred and seventy seven tumors were identified. A hundred and thirty nine were non-visible on MRI. They had a significantly lower volume (0.15cm3 versus 1.45cm3, P<0.0001) and a Gleason score significantly lower (P<0.0001) than apparent tumors. 17.3% of non-apparent tumors were significant. Moreover, the grade-four tumoral volume of significant non-apparent tumors was significantly lower than that of significant apparent tumors (0.11cm3 versus 0.66cm3, P<0.0001). CONCLUSION Non-apparent prostate tumors on multiparametric MRI have a Gleason score, a tumor volume - and consequently - a grade 4 tumor volume significantly lower than apparent tumors. LEVEL OF PROOF 4.

Cystectomie totale chez les octogénaires

des greffons était diminué à 1 h et à 3mois après la transplantation. Dans le cortex total des greffons, il a été mis en évidence une augmentation du nombre de bifurcations des segments vasculaires et le développement d’un tissu fibreux qui participe au remodelage vasculaire (Fig. 1d). Conclusion Ce travail apporte des indications sur le spectre lésionnel de l’ischémie reperfusion rénale et permettra de développer des futures thérapies dans le but d’améliorer la préservation du réseau microvasculaire du greffon rénal.