P. Coloby

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.

Comprehensive evaluation of bladder and urethral dysfunction symptoms: development and psychometric validation of the Urinary Symptom Profile (USP) questionnaire.

OBJECTIVES To develop and validate a standardized tool assessing urinary symptoms among men and women with stress, urge, frequency, or urinary obstructive symptoms for use in clinical practice to complement clinical measures and diagnosis. METHODS After development by an advisory committee and comprehension testing with patients, the Urinary Symptoms Profile (USP) item content and validity were evaluated by clinicians. Patients with urinary symptoms (n = 253) and without symptoms (n = 75) completed the final questionnaire at day 0 and day 7. Psychometric properties were assessed, including construct and clinical validity, reliability, and predictive ability for detection of and differentiation between urinary disorders. RESULTS Principal Component Analysis with Varimax Rotation confirmed the final USP structure of 13 items in 3 dimensions: stress urinary incontinence (SUI), overactive bladder (OAB), and low stream (LS). Internal consistency reliability (Cronbachs alpha ranging from 0.69 to 0.94) and concurrent validity (Spearman correlation coefficients between International Consultation on Incontinence Questionnaire and SUI and OAB dimensions of 0.73 and 0.62, respectively) were good. Test-retest reproducibility over 7 days was excellent in stable patients (Intraclass Correlation Coefficients from 0.84 to 0.91). USP clinical validity was demonstrated by comparing micturition diary with USP scores. USP dimension scores were excellent predictors of urinary disorder presence and identification. CONCLUSIONS USP is the first valid and reliable questionnaire providing comprehensive evaluation of all urinary disorders and their severity in both men and women with SUI, OAB, and LS. It allows the screening and contributes to the differential diagnosis of these symptoms. The USP is a valuable tool for use in clinical practice.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk

PURPOSE We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer. MATERIALS AND METHODS Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk. RESULTS The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92). CONCLUSIONS The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Projection de l’incidence et de la mortalité par cancer urologique en France en 2012

OBJECTIVES: Present national estimations of the incidence and mortality trends in urological cancers in France between 1980 and 2012. MATERIAL AND METHODS: Francim database and French Register of Cancers. RESULTS: Analysis of the current data shows a regular increase of the incidence of renal cancer in men and women (7,781 cases in men and 3,792 in women in 2012). For bladder cancer, trends are divergent. There is a small reduction in incidence for men and an increase for women (9,549 cases in men and 2,416 in women in 2012). Testicular cancer is still increasing slightly (2,317 incidental cases in 2012). The incidence of prostate cancer experienced a huge increase up until 2005, and thereafter it decreased sharply, though it is difficult to discern whether this drop (which was observed up until 2008) continued at the same rate after that point (56,841 incidences in 2012 based on the rates calculated for 2009). CONCLUSION: The analyses by organ database show that there are significant variations in the incidence of urological cancers, particularly for prostate cancer, which shows that both the natural history of urological tumours and the methods of detection have an impact on incidence.OBJECTIVES Present national estimations of the incidence and mortality trends in urological cancers in France between 1980 and 2012. MATERIAL AND METHODS Francim database and French Register of Cancers. RESULTS Analysis of the current data shows a regular increase of the incidence of renal cancer in men and women (7,781 cases in men and 3,792 in women in 2012). For bladder cancer, trends are divergent. There is a small reduction in incidence for men and an increase for women (9,549 cases in men and 2,416 in women in 2012). Testicular cancer is still increasing slightly (2,317 incidental cases in 2012). The incidence of prostate cancer experienced a huge increase up until 2005, and thereafter it decreased sharply, though it is difficult to discern whether this drop (which was observed up until 2008) continued at the same rate after that point (56,841 incidences in 2012 based on the rates calculated for 2009). CONCLUSION The analyses by organ database show that there are significant variations in the incidence of urological cancers, particularly for prostate cancer, which shows that both the natural history of urological tumours and the methods of detection have an impact on incidence.

Is an Extended 20-Core Prostate Biopsy Protocol More Efficient than the Standard 12-Core? A Randomized Multicenter Trial

PURPOSE We determined the impact of increasing the number of cores from 12 to 20 at initial prostate biopsy in men suspicious of prostate cancer. MATERIALS AND METHODS From December 2009 to November 2011, patients in 7 centers scheduled for a first prostate biopsy, with a prostate specific antigen less than 20 ng/ml and no nodule on digital rectal examination, were invited to participate in this superiority trial. Patients were randomized to a 12-core (PB12 group) or a 20-core (PB20 group) protocol. The primary end point was cancer detection rate. Secondary end points were cancer characteristics, rate of complications and patient tolerance assessed by a self-completed booklet before prostate biopsy and at day 5 and day 15. RESULTS A total of 339 patients were randomized. Preoperative variables were similar in both groups. Cancer was detected in 71 patients (42.0%) in PB12 group and in 81 patients (48.8%) in PB20 group, and the difference was not significant (p >0.2). Gleason score and cancer length measured on prostate biopsy cores were not significantly different between groups. Although the cancer detection rate was linked to prostate volume, this was not affected by the number of extracted cores (p >0.4). Complications number and seriousness were comparable in both arms. No significant difference was noted regarding side effects and tolerance as self-assessed by the patient at day 5 and day 15 after prostate biopsy. CONCLUSIONS Our findings suggest that there is no significant advantage in using a 20-core biopsy protocol vs 12-core protocol during an initial prostate biopsy.

One preoperative dose randomized against 3-day antibiotic prophylaxis for transrectal ultrasonography-guided prostate biopsy

To compare the incidence of infective events between a single dose and 3‐day antibiotic prophylaxis for transrectal ultrasonography (TRUS)‐guided prostate biopsy.

Antibioprophylaxie courte versus longue pour les biopsies prostatiques. Étude prospective randomisée multicentrique

OBJECTIVE We compared the incidence of the Urinary Tract Infection between a single preoperative dose and a three-day antibiotic prophylaxis regimen for transrectal ultrasound guided biopsy in randomized multicenter trial. MATERIAL AND METHODS Between February 2006 and December 2007, 322 men who underwent transrectal ultrasound-guided prostate biopsy were included in a multicentre prospective randomised study. Patients received antibiotic prophylaxis by ciprofloxacin orally, either 1g single dose two hours before the biopsy (Group 1: n=139) or a prolonged prophylaxis for three days (Group 2: n=149). Assessment five days before and five days following the biopsy included a clinical examination, biological tests and a self-questionnaire. RESULTS Two patients developed prostatitis, one in each group: 0.75% of the first group, 0.69% of the second. Twelve developed asymptomatic bacteriuria, six in each group: 4.51% of the first group and 4.19% of the second. There was no significant difference between the two groups (Fisher test; p>0.9). CONCLUSIONS There was no significant difference between the two antibiotic prophylaxis regimen (one single dose or three days) for patients undergoing TRUS guided biopsies. Therefore, the single preoperative dose should be the preferred option.

Prostatites aiguësAcute prostatitis

A urinary infection in a febrile man is classiquely defined as a prostatitis. Investigation exams look for complicating factors or post voiding residual which should be drained. Antibiotic treatment should begin with a fluroquinolone or cephalosporin gr 3 for 3 to 6 weeks.

Recommandations du comité d’infectiologie de l’AFU. Diagnostic, traitement et suivi des candiduries

The candiduria are frequently encountered in urology. We present the recommendations of the Infectious Diseases Committee of the French Association of Urology for diagnosis, treatment and monitoring of urinary tract infections. C. albicans is the most frequently isolated species, representing 60% of the isolates. Immunosuppression, diabetes mellitus, age extremes of life, the presence of catheters or procedures on the urinary tract are risk factors for Candida urinary tract infection. The candiduria is usually asymptomatic and does not need treatment. Only 4-14% of patients with candiduria have symptoms of urinary infection. It is necessary before choosing candiduria isolated on a first urinalysis to eliminate contamination by conducting a second harvest. In patients surveyed, the removal of the material allows the resolution of the candiduria nearly half the time and represents the first step of management. Oral fluconazole is the recommended treatment for cystitis (400 mg on day 1 and 200 mg daily for 7 to 14 days). In cases of pyelonephritis without associated candidemia, the first-line therapy is fluconazole (3-6 mg/kg/day) for 14 days or amphotericin B at a dose of 0.5 to 0.7 mg/kg/day with or not associated to flucytosine when potentially resistant strain (C. glabrata).

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.