P. Paparel

Technique of Injection of Hyaluronic Acid as a Prostatic Spacer and Fiducials Before Hypofractionated External Beam Radiotherapy for Prostate Cancer

OBJECTIVEnTo describe a technique combining the implantation of fiducials and a prostatic spacer (hyaluronic acid [HA]) to decrease the rectal toxicity after an image-guided external beam radiotherapy (EBRT) with hypofractionation for prostate cancer and to assess the tolerance and the learning curve of the procedure.nnnMATERIALS AND METHODSnThirty patients with prostate cancer at low or intermediate risk were included in a phase II trial: image-guided EBRT of 62u2009Gy in 20 fractions of 3.1u2009Gy with intensity-modulated radiotherapy. A transrectal implantation of 3 fiducials and transperineal injection of 10u2009cc of HA (NASHA gel spacer, Q-Med AB, Uppsala, Sweden) between the rectum and the prostate was performed by 1 operator. The thickness of HA was measured at 10 points on magnetic resonance imaging to establish a quality score of the injection (maximum scoreu2009=u200910) and determine the learning curve of the procedure.nnnRESULTSnThe quality score increased from patients 1-10, 11-20, to 21-30 with respective median scores: 7 [2-10], 5 [4-7], and 8 [3-10]. The average thicknesses of HA between the base, middle part, and apex of the prostate and the rectum were the following: 15.1u2009mm [6.4-29], 9.8u2009mm [5-21.2], and 9.9u2009mm [3.2-21.5]. The injection of the HA induced a median pain score of 4 [1-8] and no residual pain at mid-long term.nnnCONCLUSIONnCreating an interface between the rectum and the prostate and the implantation of fiducials were feasible under local anesthesia with a short learning curve and could become a standard procedure before a hypofractionated EBRT for prostate cancer.

Patient-reported long-term sexual outcomes following plication surgery for penile curvature: A retrospective 58-patient study

OBJECTIVEnTo evaluate long-term sexual function results following plication surgery for the correction of penile curvature using patient questionnaires.nnnMETHODSnWe performed a single-center, retrospective study in a cohort of patients with Peyronies disease or congenital penile curvature. All patients who underwent plication surgery on the convex aspect using the Nesbit, Yachia or diamond-shaped techniques were included. At a mean 34 months after the interventions, the patients were asked to respond to the IIEF5 questionnaire and a 19-item questionnaire.nnnRESULTSnForty-six patients operated for Peyronies disease and 12 for congenital curvature (total: 58) were included in the study. The questionnaire response rate was 69% (40/58). The shortened penis bothered 47.5% of patients in their sexuality at least regularly. Involuntary exit from the vagina occurred for 35% of the patients in at least one out of two sexual intercourse sessions. Postoperative sexual life was as good as or better than preoperative sexual life for 35% of the patients and 95% stated that they could achieve erection at least sometimes, in coherence with the mean IIEF5 result of 19.3/25.nnnCONCLUSIONnOur study suggests that even when successful, a relatively high rate of patients may be unsatisfied with the results of plication surgery, and there may be a relatively low rate of maintenance or improvement of postoperative sexual life. Furthermore, our in-house questionnaire, although not validated, shed light on how bothersome the loss of penis length is in postoperative sexuality, an aspect the IIEF5 and its sole evaluation of erectile quality cannot detect.nnnLEVEL OF EVIDENCEn4.

Le score PCA3 et l’IRM prostatique permettent-ils de sélectionner les patients candidats a une première série de biopsies prostatiques ?

INTRODUCTIONnDeterminate if the adjunction of PCA3 score and/or prostatic MRI can improve the selection of the patients who have an indication of first prostate biopsy.nnnPATIENTS AND METHODSnMultiparametric prostatic MRI and PCA3 score were made before biopsy to men scheduled for initial prostate biopsy for abnormal digital rectal examination and/or PSA superior to 4 ng/mL. T2-weighted imaging, diffusion-weighted imaging and dynamic contrast-enhanced imaging looked for suspect target classified on a scale of four. It was a prospective, single centre study. The diagnostic accuracy of PCA3 score and MRI was to evaluate in comparison with biopsy results.nnnRESULTSnSixty-eight patients were included, median PSA was 5.2 ng/mL (3.2-28). Negative predictive value (NPV) of MRI score 0, 1 and 2 were respectively 80%, 43% and 69%. Positive predictive value (PPV) of MRI score 3 and 4 were 50% and 81%. The PCA3 cutoff with best accuracy was 21 (Se: 0.91; Sp: 0.50). Only one patient with positive biopsy (0.5mm of Gleason score 3+3) had negative MRI and PCA3 inferior to 21.nnnCONCLUSIONnMRI and PCA3 score in association allowed, in this study, to consider reduction of unnecessary initial biopsy without ignoring potential aggressive tumor.

Comparaison de l’IPSS et de l’ICS male SF dans le bilan initial des troubles urinaires☆

UNLABELLEDnThe IPSS is considered to be the standard questionnaire for evaluation of lower urinary tract voiding disorders in men with benign prostatic hyperplasia (BPH). However, the absence of questions concerning urinary incontinence can be considered to be a weakness of this tool in view of the symptom profile of these patients. The ICS male SF, which comprises a supplementary domain of urinary incontinence, was compared to the IPSS in the context of the initial assessment of men with BPH.nnnMETHODSnOne hundred and fifty-eight patients with voiding disorders associated with BPH completed the two questionnaires on two occasions at an interval of two weeks.nnnRESULTSnThe prevalence of urinary incontinence symptoms was very low (3.7%) and these symptoms were not independent of the symptoms of the urinary frequency domain.nnnCONCLUSIONnDespite the addition of a urinary incontinence domain, the ICS male SF does not provide any decisive advantage compared to the IPSS for the initial assessment of urinary disorders related to BPH.

Angiomyolipome épithélioïde du rein : à propos d’une observation et discussion des critères de malignité

Renal epithelioid angiomyolipoma (E-AML) is a rare mesenchymal tumor of the kidney included in the family of tumor with perivascular epithelioid cell differentiation (PEComas) and is frequently associated with tuberous sclerosis complex. Since its clinical and radiological features are not specific, the diagnosis remained mostly pathological. Microscopically, E-AML demonstrate proliferation of more than 80% of epithelioid cells with atypia, often associated with necrosis, hemorrhage, mitotic activity and vascular invasion. Tumors cells are immunohistochemically positive for melanocytic and smooth muscle markers. The pathologic prognostic predictors are not well known and the malignancy remained based on the identification of distant metastasis. We herein report a case of E-AML diagnosed in a 58-year-old woman and review analysis in the literature to discuss the prognostic indicators of malignancy useful for risk stratification of E-AML and to manage the patients.

Genitourinary injuries following traffic accidents: analysis of a registry of 162,690 victims

BACKGROUND Traffic accidents are the most frequent cause of genitourinary injuries (GUI). Kidney injuries after trauma have been well described. However, there exists a paucity of data on other traumatic GUI after traffic accidents. The objective of this study was to analyze the frequency and type of all GUI, by user category, after traffic accidents. METHODS Patient cases were extracted from the trauma registry of the French department of Rhone from 1996 to 2013. We assessed the urogenital injuries presented by each of road user’s categories. Severity injuries were coded with the Abbreviated Injury Scale and the Injury Severity Score. Kidney trauma was mapped with the classification of the American Association for the Surgery of Trauma. Multivariate prediction models were used for analysis of data. RESULTS Of 162,690 victims, 963 presented with GUI (0.59%). 47% were motorcyclists, 22% were in a car, 18% on bicycles, and 9% were pedestrians. The most common organ injury was kidney (41%) followed by testicular (23%). Among the 208 motorists with a GUI, kidney (70%), bladder (10%), and adrenal gland (9%) were the most frequent lesions. Among the 453 motorcyclist victims with GUI, kidney (35%) and testicular (38%) traumas were the most frequent and 62% of injuries involved external genitalia. There were 175 cyclists with GUI, 70% of injuries involved external genitalia; penile traumas (23%) were the most frequent. In total, there were 395 kidney injuries, most being low grade. According to the American Association for the Surgery of Trauma kidney injuries were grade I, 59%; grade II, 11%; grade III, 16%; grade IV, 9%; grade V, 3%; and indeterminate, 2%. CONCLUSION GUI is an infrequent trauma after traffic accidents, with kidneys being the most commonly injured. Physicians must maintain a high awareness for external genitalia injuries in motorcyclists and cyclists. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

[Impact of anastomotic strictures on treatment of post-prostatectomy stress incontinence by artificial urinary sphincter].

INTRODUCTIONnStress urinary incontinence (SUI) is a degradation of the quality of life factor in the consequences of radical prostatectomy. Artificial urinary sphincter (AUS) is the standard treatment. Screening and preoperative treatment of anastomotic strictures (AS) is an essential step for the success of the intervention. The objective of the study was to assess the impact of AS on the results of AUA.nnnMETHODSnWe retrospectively studied 147 AUS settlements from 2005 to 2013 in the urology department of the Centre Hospitalier Lyon by three operators. The demographic characteristics, the irradiation history, the severity of incontinence, the complications of AUS, the continence rate and the postoperative satisfaction were collected. Wilcoxon statistical tests and Fischer and a Kaplan-Meier curve were used to compare the two control groups and AS. Logistic regression analysis looked for predictors of surgical reintervention.nnnRESULTSnOf the 147 patients included, 24 (16.3%) had a history of AS. Of these, 21 (87.5%) were treated with endoscopic urethrotomy. Patients in the AS group had more severe incontinence (P<0.05) than in the control group. Explantation rates, recurrence of incontinence and reoperation was 12.5%, 8.3% and 33.3% in the AS group against 4.9%, 15.4% and 27.6% in the control group. In logistic regression, history of AS has not been found as reoperation risk factor. Continents and satisfied patients rate were 77.8% and 76.5%, respectively in the AS group against 91.1% and 81.1% in the control group.nnnCONCLUSIONnThe history of AS does not appear to be predictive of poor outcome after implementation of a AUS. Larger cohort studies are needed to confirm these results.nnnLEVEL OF EVIDENCEn4.

Urinary PCA3 to predict prostate cancer in a cohort of 1015 patients

AIMnTo evaluate the performance of urinary PCA3 test to predict prostate biopsy outcome in a large French cohort.nnnPATIENTS AND METHODSnA urine sample was prospectively obtained from 1015xa0patients undergoing prostate biopsies to determine the PCA3 score. The predictive value of PCA3 was explored using receiver operating characteristic curve analysis (ROC), multivariable logistic regression analysis and decision curve analysis.nnnRESULTSnThe median PCA3 score was significantly higher in patients with positive biopsies. The PCA3 score AUC was 0.76 (0.73-0.79), significantly higher than that of PSA (0.55; 0.51-0.58). At the cutoff of 35, sensitivity was 68%, specificity 71%, positive and negative predictive values 67% and 71%, and accuracy 69%. Using multivariate analysis, PCA3 score appeared as an independent predictor of biopsy outcome and its addition to a base model including usual clinicobiological parameters resulted in a significant increase in predictive accuracy. At the cutoff of 20, about 1/2 of the ultimately unnecessary biopsies would have been avoided while ignoring 7% of cancers with Gleason scorexa0≥xa07. PCA3 score did not correlate with Gleason score but did correlate with tumor volume (proportion of positive cores).nnnCONCLUSIONnUrinary PCA3 is a useful test with high diagnostic performances for early prostate cancer diagnosis. Its correlation with cancer aggressiveness seems rather represented by a link to prostate volume than Gleason score.nnnLEVEL OF EVIDENCEn5.

Résultats chirurgicaux des poses d’implants péniens après phalloplastie : analyse rétrospective de 95 procédures

Objectifs La creation d’un neophallus est une chirurgie complexe devant repondre a des objectifs esthetiques et fonctionnels. C’est un long et exigeant processus chirurgical dont l’etape finale reside en l’implantation d’une prothese rigide ou gonflable permettant de reproduire une erection. Les donnees de la litterature a ce sujet sont rares et peu developpees. L’objectif de notre etude etait d’analyser les resultats chirurgicaux des patients operes d’une pose de prothese penienne apres phalloplastie selon une technique chirurgicale standardisee. Methodes Tous les patients consecutifs operes d’une pose de prothese penienne apres phalloplastie de mars 2007xa0a mars 2015xa0ont ete inclus. Les facteurs associes aux complications ont fait l’objet d’analyse multivariee. Les donnees ont ete recueillies retrospectivement dans le dossier medical informatise, incluant les complications precoces survenant au cours du premier mois postoperatoire et les complications tardives (erosion, infection, malposition et dysfonction mecanique). Resultats Soixante-neuf patients ont ete inclus et 95xa0procedures analysees. Apres un suivi moyen de 4xa0ans, 43xa0patients (62,3xa0%) avaient toujours leur implant originel en place. Les patients etaient operes d’une phalloplastie pour transsexualisme ( n xa0=xa062, 89,9xa0%), malformation ( n xa0=xa04, 5,8xa0%), ou traumatisme ( n xa0=xa03, 4,3xa0%). Les phalloplasties realisees etaient a 58xa0% des lambeaux libres antebrachiaux ( n xa0=xa040), 33xa0% des phalloplasties suprapubiennes ( n xa0=xa023), ou autres (7xa0%, n xa0=xa06). Les protheses erectiles utilisees etaient des AMS Ambicor ( n xa0=xa071, 74,7xa0%), des AMS Ambicor avec embout de prothese vasculaire ( n xa0=xa019, 20,0xa0%), et autres ( n xa0=xa05, 5,2xa0%). Il n’y a pas eu de complications precoces dans 89xa0procedures (93,7xa0%) et si presentes il s’agissait principalement d’infection ( n xa0=xa04, 4,2xa0%). Les complications tardives etaient des erosions ( n xa0=xa04, 4,2xa0%), infections ( n xa0=xa04, 4,2xa0%), dysfonctionnement mecanique ( n xa0=xa010, 10,5xa0%) et des malpositions ( n xa0=xa012, 12,6xa0%) ( Fig. 1 ) ( Tableau 1 , Tableau 2 ). Conclusion Cette etude presente les resultats chirurgicaux apres l’implantation de prothese penienne des patients operes d’une phalloplastie. Des etudes multicentriques sont necessaires afin de preciser les facteurs de risque de survenue de complication ainsi qu’etudier la satisfaction des patients.

Évaluation par questionnaire d’un programme de réhabilitation anticipée (RAAC) après tumorectomie rénale robot assistée pour cancer du rein

Objectifs Plusieurs programmes de rehabilitation precoce apres chirurgie (RAAC) ont montre une reelle efficacite sur les suites postoperatoires des patients avec une meilleure recuperation postoperatoire permettant des sorties d’hospitalisation precoces et en securite. Un protocole de RAAC apres tumorectomie renale robot assiste (NPRA) a ete developpe dans notre service. L’objectif de cette etude est d’evaluer la satisfaction des patients ayant beneficie du protocole de RAAC. Methodes Un questionnaire valide EORTC IN-PATSATxa032, evaluant la satisfaction des patients sur l’hospitalisation, associe a un questionnaire specifique evaluant la satisfaction du patient sur la RAAC ont ete envoye aux 42xa0premiers patients inclus dans le protocole RAAC de NPRA. Tous les patients avaient deja eu leur consultation postoperatoire a 1xa0mois. Les calculs des scores de satisfaction du questionnaire EORTC ont ete effectues pour chaque dimension par la methode de Likert. Les scores ont ensuite ete transformes lineairement en une echelle variant de 0xa0a 100, ou 100xa0represente le meilleur niveau de satisfaction sur les soins (methode EORTC). Resultats Au total, 21xa0patients ont renvoye les questionnaires (50xa0% de reponses). Les reponses des patients etaient anonymes. Les scores de satisfaction du questionnaire EORTC IN-PATSATxa032xa0sont presentes dans le Tableau 1 . L’analyse des resultats du questionnaire specifique sur la satisfaction des patients sur le protocole de rehabilitation precoce apres chirurgie de tumorectomie renale robot assistee est presentee dans le Tableau 2 . Conclusion Les patients ayant beneficie du protocole de rehabilitation precoce apres chirurgie de tumorectomie renale robot assistee semblent tres satisfaits de leur prise en charge pre-, per- et postoperatoire. Etant donne la satisfaction des patients, la sortie precoce d’hospitalisation, la securite du patient et l’avantage medico-economique, ces protocoles de rehabilitation precoce apres chirurgie sont a developper et evaluer.