S. Beley

Évaluation prospective des effets du stage d’initiation pratique sur le recrutement des internes d’urologie à Paris : résultats définitifs

Resume Objectifs Evaluer les effets d’un stage d’initiation pratique a l’urologie sur le recrutement des internes parisiens depuis la mise en place de l’Examen National Classant (ENC). Materiels et methodes Depuis 2004, tous les internes nommes en chirurgie a Paris ont participe a un stage d’initiation a l’urologie avant de prendre leur fonction hospitaliere. Un questionnaire leur a ete remis. L’enquete prospective s’est interessee a : l’âge, le sexe, l’existence d’un stage d’urologie pendant l’externat et au souhait d’orientation au sein des 11 disciplines chirurgicales. Les internes ont ete recontactes annuellement pour connaitre l’evolution de leur orientation professionnelle. Resultats Population. Deux cent cinquante cinq internes ont participe dont 145 femmes (56,9%) et 110 hommes (43,1%). L’âge moyen etait de 24,6 ± 5 ans (22-31). 173 internes etaient issus d’un CHU parisien (67,8%) et 82 (32,2%) d’un CHU de province. Cinquante deux internes (21,2%) avaient effectue au moins un stage dans un service d’urologie pendant leur externat. Disciplines chirurgicales. L’orthopedie a ete le plus souvent citee (n=48; 28,9%). L’urologie a ete choisie par 32 internes (12,5%) qui avaient effectue un stage d’externe dans la specialite dans 28 cas. A la fin du stage, 18 internes etaient tentes par l’urologie. A un an, 31 internes134 (91,2%) ont confirme leur choix pour I’urologie. Conclusion La realisation d’un stage pratique intervenant tres tot dans la formation des jeunes chirurgiens est une bonne solution pour les initier a l’urologie. En beneficiant d’un choix eclaire, les internes les plus motives sont incites a rejoindre volontairement notre discipline.

Dysfonction érectile après prostatectomie totale: physiopathologie, évaluation et traitement

Radical prostatectomy (RP) is the gold standard treatment for localized prostate cancer; yet erectile dysfunction (ED) in selected series is still reported as high as 80% after this surgery. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of postoperative ED. Pharmacological treatment of postoperative ED, using either oral or local approaches, is effective and safe. Thus, most men need adjuvant treatments to be sexually active following RP. These include intracorporeal injections of vasoactive drugs, vacuum constriction devices and transurethral dilators, all of which have reported response rates of 50 to 70%. Unfortunately, long-term compliance is sub-optimal, with a discontinuation rate of nearly 50% at 1year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy (IPDE5) since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections is the gold standard for partients over 60years old and those who underwent non-sparing surgery. In younger patients and/or when preservation of nerve tissue was feasible, oral IPDE5 may be effective in promoting an earlier return of erectile function. Recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in cases of properly selected young patients treated with a bilateral nerve-sparing approach by experienced urologists.

Article de revueDysfonction érectile après prostatectomie totale : physiopathologie, évaluation et traitementErectile dysfunction after radical prostatectomy: Pathophysiology, evaluation and treatment

Radical prostatectomy (RP) is the gold standard treatment for localized prostate cancer; yet erectile dysfunction (ED) in selected series is still reported as high as 80% after this surgery. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of postoperative ED. Pharmacological treatment of postoperative ED, using either oral or local approaches, is effective and safe. Thus, most men need adjuvant treatments to be sexually active following RP. These include intracorporeal injections of vasoactive drugs, vacuum constriction devices and transurethral dilators, all of which have reported response rates of 50 to 70%. Unfortunately, long-term compliance is sub-optimal, with a discontinuation rate of nearly 50% at 1year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy (IPDE5) since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections is the gold standard for partients over 60years old and those who underwent non-sparing surgery. In younger patients and/or when preservation of nerve tissue was feasible, oral IPDE5 may be effective in promoting an earlier return of erectile function. Recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in cases of properly selected young patients treated with a bilateral nerve-sparing approach by experienced urologists.

Mini-bandelettes pour le traitement de l’incontinence urinaire d’effort féminine : revue de la littérature

AIM To conduct a review about the use of single incision mini-slings (SIMS) to manage non-neurogenic stress urinary incontinence in women. METHODS Literature search in Pubmed/MEdline database until june 2013. TVT-Secur™ was excluded because this device is not anymore marketed. RESULTS Ajust™ and Mini-Arc™ were the two main SIMS evaluated in the literature. Studies about Mini-Arc™ generated heterogeneous results, with a success rate between 44% and 91% after 1 year. Ajust™ was the most promising device with 80% efficacy after mid-term follow-up. All evaluated SIMS had a low rate of immediate complications. Two randomized controlled trials comparing SIMS and traditional mid-urethral slings were identified, as well as one meta-analysis; they all concluded to non-superiority or inferiority for the mini-sling versus traditional slings. CONCLUSION Due to short follow-up, limited evidence and heterogeneous data, SIMS are not yet standard of care and further research is warranted.

Enseignement et perception de l’urologie à la fin du deuxième cycle des études médicales : état des lieux

OBJECTIVES Our purpose was to determine how the medical students from the second cycle perceived urology and what their learning methods were. MATERIAL AND METHODS An e-questionnaire was sent to 1600 students in 16 teaching faculties during the last year of their second cycle. RESULTS Overall, we obtained 590 answers (36.8%). In our population, 70.2% of the students were women. Of them, 24.1% had been already enrolled in an academic urology unit. Urology was defined as a medical, surgical and medico-surgical discipline by 3.7%, 37.8% and 58% of the students, respectively. Urology was considered as very important, important, not very important and not important at all by 5.1%, 54.4%, 37.5% and 2.4% of the students. The teaching methods used to learn urology were duplicated-notes for ENC preparation (45.3%), conferences for ENC (French national ranking exam) preparation (43.7%), courses of the national urology college (38.6%) and courses of the faculty (32%). The best mastered items were lithiasis disease (86.3%), voiding dysfunction (76.3%) and urological cancers (56.7%). On the contrary, only 34.7% and 28% considered their knowledge sufficient on the erectile dysfunctions and on renal transplantation. Lastly, 7.3% intended to become urologists. Having a work experience in a urology unit was significantly associated to the feeling of being prepared to become an intern (p<0.001) and to the project of becoming a urologist (p<0.001). CONCLUSION Urology was considered like an important discipline by half of the students at the end of the second cycle even though it is under-represented in the national teaching programme for ENC. A third of the students used courses from the faculty to learn urology and a quarter of them had a work experience in a urology unit during their second cycle.

Mise à jour sur les implants péniens gonflables pour le traitement de la dysfonction érectile

Resume L’implantation d’une prothese penienne est une solution a envisager en cas d’echec ou de contre-indication aux traitements medicaux. Le patient doit etre motive et avoir ete informe des risques, notamment infectieux. Une evaluation soigneuse du patient et de ses antecedents permet d’adapter le choix du type de prothese. Ce traitement permet d’obtenir un fort taux de satisfaction lorsque la technique chirurgicale est maitrisee et que le patient est informe du benefice de ce traitement.

Evaluation de la stimulation visuelle combinée aux injections intra-caverneuses pour le traitement de la dysfonction érectile sévère

Resume Objectif Etudier l’interet d’une stimulation visuelle sexuelle combinee aux injections intra-caverneuses (IIC) chez les patients traites pour une dysfonction erectile severe. Materiels et methodes Entre 2005 et 2006, tous les patients ayant une dysfonction erectile severe ont ete inclus prospectivement. Le protocole en consultation consistait a comparer l’efficacite d’une IIC seule d’alprostadil a J0, puis d’une IIC combinee a une stimulation erotique a J8. Les criteres de jugement etaient : le delai d’apparition et la rigidite de l’erection. Une echelle de cotation subjective (1 a 5) a permis de quantifier l’erection. Resultats Quarante patients ont ete inclus. L’âge moyen etait de 64,5 ans (52-70). Tous les patients avaient un score IIEF5 inferieur a 15. Un acte de chirurgie urologique etait a l’origine de la dysfonction erectile dans 35% des cas. A JO et a J8, le delai moyen d’obtention de l’erection a ete respectivement de 10 mn 18 s (2-20) et de 10 mn 50 s (2-20). Concernant la rigidite et la qualite de l’erection, aucune difference significative n’a ete constatee entre J0 et J8 et les erections ont ete evalues respectivement a 5 dans 30 cas (75%), a 4 dans 8 cas (20%) et a 3 dans 2 cas (5%), lors de chaque consultation. Conclusion La stimulation visuelle sexuelle n’a pas fait la preuve de son efficacite reelle en milieu hospitalier en association avec les injections intra-caverneuses. Pour augmenter le taux de satisfaction des patients, l’urologue doit veiller avant tout a eduquer le patient aux injections intra-caverneuses dans un environnement adapte. Objective To assess the value of visual sexual stimulation combined with intracavernous injections (ICI) in patients treated for severe erectile dysfunction. Materials and methods Al1 patients with severe erectile dysfunction were prospectively included in this study between 2005 and 2006. The outpatient protocol consisted of comparing the efficacy of alprostadil ICI alone on DO and ICI combined with erotic stimulation on D8. Endpoints were: time to onset and rigidity of erection. A subjective score (1 to 5) was used to quantify erection. Results Forty patients with a mean age of 64.5 years (range: 52-70 years) were included in the study. Allpatients had an IIEF5 score less than 15. Erectile dysfunction was secondary to uroiogical surgery in 35% of cases. The mean time to onset of erection was I0 min 18 s (range: 2-20 min) on D0 and 10 min 50 s (range: 2-20 min) on D8. No signifcant difference for rigidity and quality of erection was observed between D0 and D8 and erections were scored as 5 in 30 cases (75%), 4 in 8 cases (20%) and 3 in 2 cases (5%) at each visit. Conclusion Visual sexual stimulation has not been demonstrated to be truly effective in the hospital setting in combination with intracavernous injections. In order to increase the patient satisfaction rate, the urologist must above al1 educate the patient in the intracavernous injection technique in an appropriate environment.