X. Gamé

Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality.

Objective: We have reviewed our surgical experience to assess intra– and postoperative morbidity and mortality in 25 patients 75 years old or older with invasive bladder cancer who underwent radical cystectomy and urinary diversion or bladder substitution. Methods: Between January 1993 and February 1999, of 190 patients who underwent radical cystectomy, 23 men and 2 women were aged from 75 to 87 (median 79) years. Urinary diversion was performed in 23 cases and bladder substitution in 2. All patients had significant comorbidity and 15 patients were ASA II and 10 ASA III. Results: Median operating time was 4 h. Perioperative mortality rate was 4%. Intraoperative, early and late postoperative complications occurred in 15, 16 and 6 patients, respectively. The most common early complications were pyelonephritis (32%), disorientation (20%), additional pulmonary infection (20%) and prolonged ileus (32%). No secondary procedures were necessary. The most common late complication was ureteroileal anastomotic stricture (16%). The median hospital stay and intensive care unit stay were 24 and 14 days, respectively. With a median follow–up of 14 (5–50) months the overall mortality rate was 32%. Conclusions: Radical cystectomy can be performed in elderly patients with acceptable perioperative mortality and morbidity. However, because of the high incidence of minor medical complications, hospital stay is often prolonged.

Chapitre B - Troubles vésico-sphinctériens et sexuels des spina bidida et myélomeningocèles

Resume Les vessies neurologiques secondaires au spina bifida peuvent revetir un masque proteiforme. En revanche, elles ont une caracteristique commune qui est le risque eleve de degradation a la fois de la qualite de vie des patients, mais aussi de leur esperance de vie par lesion du haut appareil urinaire. Dans cet article, nous presentons les caracteristiques epidemio-logiques de cette pathologie, ses principaux tableaux cliniques et urodynamiques, puis nous exposons les risques evolutifs de la pathologie, en insistant sur l’interet potentiel de la surveillance de ces patients a haut risque.Neurogenic bladder secondary to spina bifida can have a very variable clinical presentation, but all forms share a common feature: a high risk of deterioration of the patients quality of life and their life expectancy due to damage to the upper urinary tract. In this article, the authors present the epidemiological characteristics of this disease, its main clinical and urodynamic signs and discuss the prognosis of the disease, with particular emphasis on the value of close surveillance of these high-risk patients.

Suivi des patients après injection de toxine botulique intradétrusorienne: Recommandations de bonne pratique clinique chez le patient neurologique

Injections of botulinum toxin into the detrusor is a major evolution for treatment of neurogenic bladder. They are now considered as a treatment of choice, safe and efficient, in refractory neurogenic overactivity in catheterized patient. To date, there are no consensual practical guidelines for the follow-up of patients having been treated by intradetrusor botulinum toxin, whatever the indication of the treatment, functional, that is, for improving continence and overactive bladder syndrome or organic, that is, for treatment of high-detrusor pressure and their deleterious impact of urinary tract. This lack of guidelines leads to heterogeneity of treatment management and limit the definition of optimal modalities of intradetrusor botulinum toxin treatment in neurogenic patients. The aim of your work, prepared jointly with the International Francophone Neuro-Urological expert study group (GENULF), aimed at putting forward well-informed specific recommendations for the follow-up of patients having been treated by intradetrusor botulinum toxin for functional or organic indication of neurogenic detrusor overactivity.

Chapitre B - L’incontinence anale et les troubles digestifs et leurs traitements en neuro-urologie

Resume L’incontinence anale et les troubles digestifs representent une des causes majeures d’alteration de la qualite de vie des patients ayant une pathologie neurologique. De plus, les patients ont tres souvent honte d’en parler et evoquent rarement spontanement leur probleme. Enfin, les problemes de constipation chronique amenent a une maceration microbienne qui est un facteur de risque reconnu d’infection de l’arbre urinaire. Dans cet article, nous reprenons les elements principaux de la physiologie permettant une exoneration normale, puis nous en decrivons les principales atteintes dans les differentes pathologies neurologiques. Enfin, nous decrivons leur prise en charge.

Chapitre B-5 B - Dérivation cutanée non continente en neuro-urologie

Resume Les derivations urinaires non continentes peuvent etre proposees chez les patients neurologiques de facon transitoire ou en fin d’ evolution. Elles sont notamment proposees chez les patients en retention chronique pour lesquels un catheterisme intermittent n’est pas envisageable pour des raisons anatomiques ou pratiques (en raison du handicap neurologique). Dans ce travail, nous presentons les differentes derivations urinaires non continentes qui ont ete rapportes dans la litterature. Nous presentons pour chacune d’ entre elles les modalites techniques de realisation, puis leurs principales complications et les resultats a court, moyen et long terme.

Chapitre C-2 C - Traitement de l’hyperactivité détrusorienne neurologique : entérocystoplasties

Resume L’importance d’un reservoir vesical de bonne capacite capable de se remplir a basse pression est aujourd’hui etablie. Ces qualites ont un double avantage. Elles permettent aux patients d’avoir une continence urinaire et, previennent les alterations du haut appareil urinaire. En cas d’echec des differents traitements medicaux, incluant les injections de toxine, un agrandissement chirurgical de la vessie peut etre discute. Il s’impose notammentt en cas de defaut de compliance du reservoir vesical. Nous presentons ici les details techniques de l’agrandissement vesical par un segment digestif ou par des techniques alternatives, puis nous presentons leurs resultats a moyen et long terme, afin de connaitre la surveillance a mettre en place dans les suites de ces chirurgies.

Les traitements de recours dans la cystite interstitielle

Interstitial cystitis is the first cause of bladder pain. In case of failure of the usual treatments, several other modalities have been proposed. These therapeutic modalities are posterior sacral root neuromodulation, posterior tibial nerve stimulation, vanilloid agent intravesical instillation, intradetrusor botulinum toxin injections and surgery. A certain efficiency of each of these treatments in the interstitial cystitis has been reported. However, the evaluation of these treatments is limited and the level of evidence is too low to propose these treatments in routine.

Œstrogénothérapie locale en urologie et pelvi-périnéologie. Revue de littérature

OBJECTIVE To conduct a literature review of the efficiency of vaginal local estrogenotherapy (LE) on genitourinary disorders related to menopause and those side effects. MATERIALS A literature review was conducted using Pubmed database using the keywords vaginal estrogen, urinary incontinence, urgency, urinary tract infection, vulvar and vaginal atrophy, dyspareunia, breast cancer, endometrial cancer, thrombosis. The most relevant articles were selected and analyzed. RESULTS The LE demonstrates its efficiency on preventing urinary tract infections, treatment of overactive bladder and vaginal disorders of postmenopausal women in controlled studies or meta-analysis level of evidence 1. Local side effects (discharge, erythema, vaginal bleeding, etc.) are rare. The systemic diffusion of low dose LE is limited and allowed to prescribe it to postmenopausal women without special supervision. However, using LE might be avoided in women with a history of oncological breast due to the lack of controlled studies evaluating the risk of developing breast cancer under LE. Except for high-risk women, LE does not increase the risk of thrombosis. CONCLUSION Vaginal administration of low dose of estrogen is an effective and safe treatment in the management of postmenopausal genitourinary disorders. However, using LE for women with history of breast cancer or high risk of thrombisis should be avoided.

Le parcours de l’opéré en neuro-urologie : de la programmation opératoire à la convalescence. L’avis d’expert du Comité de neuro-urologie de l’AFU

The surgical care pathway of neurologic patients has two aims: preventing urinary morbidity and mortality and improving their quality of life. It requires taking into account the specificities of disabilities in domains of body functions: circulatory, ventilation and digestive physiology, motor functions, sensory functions, mental functions, and skin fragility which are responsible of dependencies in this heterogeneous group of patients. This management is necessarily multidisciplinary to be optimal and through specific clinical care pathway, providing guidance to the surgical procedure: preparation of the surgery, its realization, and post-operative rehabilitation. The indication for surgery must be coordinated and validated in neuro-urology multidisciplinary staff. Preoperative stay in a physical and rehabilitation medicine center may be useful to ensure a complete assessment and anticipate problems related to surgery. The patient will be hospitalized in the urology department in a single room suited to their disabilities and handicaps. The chronic treatments should be not modified if possible. The lack of sensitivity does not dispense anesthesia to prevent autonomic hyperreflexia, the most severe complication after high complete spinal cord injury. The laparoscopy and sub-peritoneal surgery, the early removal nasogastric tube and early refeeding make it possible to early resumption of intestinal transit. In many cases, the patients should be transferred to a physical and rehabilitation medicine during post-operative period where the nursing care will be most suitable. A quickly adapted rehabilitation must be able to reduce loss of function and physical dependence.

Estetrol, a Fetal Selective Estrogen Receptor Modulator, Acts on the Vagina of Mice through Nuclear Estrogen Receptor α Activation

The genitourinary syndrome of menopause has a negative impact on quality of life of postmenopausal women. The treatment of vulvovaginal atrophy includes administration of estrogens. However, oral estrogen treatment is controversial because of its potential risks on venous thrombosis and breast cancer. Estetrol (E4) is a natural estrogen synthesized exclusively during pregnancy by the human fetal liver and initially considered as a weak estrogen. However, E4 was recently evaluated in phase 1 to 2 clinical studies and found to act as an oral contraceptive in combination with a progestin, without increasing the level of coagulation factors. We recently showed that E4 stimulates uterine epithelial proliferation through nuclear estrogen receptor (ER) α, but failed to elicit endothelial responses. Herein, we first evaluated the morphological and functional impacts of E4 on the vagina of ovariectomized mice, and we determined the molecular mechanism mediating these effects. Vaginal epithelial proliferation and lubrication after stimulation were found to increase after E4 chronic treatment. Using a combination of pharmacological and genetic approaches, we demonstrated that these E4 effects on the vagina are mediated by nuclear ERα activation. Altogether, we demonstrate that the selective activation of nuclear ERα is both necessary and sufficient to elicit functional and structural effects on the vagina, and therefore E4 appears promising as a therapeutic option to improve vulvovaginal atrophy.