Xavier Biardeau

Robot-assisted Laparoscopic Approach for Artificial Urinary Sphincter Implantation in 11 Women with Urinary Stress Incontinence: Surgical Technique and Initial Experience

BACKGROUND Artificial urinary sphincter (AUS) implantation is recommended for women suffering urinary stress incontinence. Robot-assisted laparoscopy allows improved dexterity and visibility compared to traditional laparoscopy, potentially providing significant advantages for deep pelvic surgery. OBJECTIVE To report our surgical technique and initial experience in transperitoneal robot-assisted laparoscopic AUS implantation in women with urinary stress incontinence. DESIGN, SETTING, AND PARTICIPANTS Eleven eligible patients with AUS implantation or revision using robot-assisted laparoscopy for urinary stress incontinence were included between January 2012 and February 2014 at Department of Urology, Lille University Hospital. SURGICAL TECHNIQUE Procedures were performed with the assistance of a four-arm da Vinci robot. The urethrovaginal space was dissected after transperitoneal access to the Retzius space. An 11-mm port placed in the right iliac fossa allowed introduction of the AUS device. The cuff and balloon tubes were externalised via a 5-mm suprapubic incision. The peritoneum was finally sutured. MEASUREMENTS Clinical data were prospectively collected before, during, and after the procedure. Results were classified as complete continence (no leakage and no pad usage), social continence (leakage and/or pad usage with no impact on social life), or failure (leakage and/or pad usage impacting social life). RESULTS AND LIMITATIONS After mean follow-up of 17.6 mo (interquartile range 10.8-26 mo), eight patients (72.7%) had a successful AUS implantation, of whom seven (87.5%) reported complete continence and one had social continence. Two vaginal injuries and two bladder injuries occurred intraoperatively. Two patients experienced early minor postoperative complications and two had a major postoperative complication. CONCLUSIONS Robot-assisted laparoscopic AUS implantation is a feasible procedure. Further studies will better assess the place of robot-assisted laparoscopy in AUS implantation. PATIENT SUMMARY We investigated the treatment of 11 patients with stress urinary incontinence using robot-assisted implantation of an artificial urinary sphincter (AUS). The results show that the procedure is feasible procedure, and future studies will to help assess the place of robot-assisted laparoscopy in AUS implantation.

Risk of malignancy after augmentation cystoplasty: A systematic review

To systematically evaluate the evidence regarding the risk of malignancy after augmentation cystoplasty.

Intradetrusor Injections of Botulinum Toxin A in Adults with Spinal Dysraphism

Purpose: The aim of the current study was to determine the outcomes of botulinum toxin A intradetrusor injections in adult patients with spina bifida. Materials and methods: All patients with spinal dysraphism who underwent intradetrusor injections of botulinum toxin A from 2002 to 2016 at a total of 14 centers were retrospectively included in analysis. The primary end point was the global success of injections, defined subjectively as the combination of urgency, urinary incontinence and detrusor overactivity/low bladder compliance resolution. Univariate and multivariate analysis was performed to seek predictors of global success. Results: A total of 125 patients were included in study. The global success rate of the first injection was 62.3% with resolution of urinary incontinence in 73.5% of patients. All urodynamic parameters had improved significantly by 6 to 8 weeks compared to baseline, including maximum detrusor pressure (–12 cm H2O, p <0.001), maximum cystometric capacity (86.6 ml, p <0.001) and compliance (8.9 ml/cm H2O, p = 0.002). A total of 20 complications (3.6%) were recorded for the 561 intradetrusor botulinum toxin A injections, including 3 muscular weakness complications. The global success rate of the first injection was significantly lower in patients with poor compliance (34.4% vs 86.9%, OR 0.08, p <0.001). On multivariate analysis poor compliance was associated with a lower global success rate (OR 0.13, p <0.001). Female gender (OR 3.53, p = 0.01) and patient age (OR 39.9, p <0.001) were predictors of global success. Conclusions: Intradetrusor botulinum toxin A injections were effective in adult patients with spina bifida who had detrusor overactivity. In contrast, effectiveness was much lower in adult patients with spina bifida who had poor bladder compliance. The other predictors of global success were female gender and older age.

Early Fesoterodine Fumarate Administration Prevents Neurogenic Detrusor Overactivity in a Spinal Cord Transected Rat Model.

Background In spinal cord injury, onset of detrusor overactivity (DO) is detrimental for quality of life (incontinence) and renal risk. Prevention has only been achieved with complex sophisticated electrical neuromodulation techniques. Purpose To assess the efficacy of early fesoterodine fumarate (FF) administration in preventing bladder overactivity in a spinal cord transected (SCT) rat model. Methods 33 Sprague-Dawley rats were allocated to 6 groups–Group 1: 3 normal controls; Group 2: 6 SCT controls; Group 3: 6 SCT rats + FF 0.18 mg/kg/d; Group 4: 6 SCT rats + FF 0.12 mg/kg/d; Group 5: 6 SCT rats + FF 0.18 mg/kg/d + 72-h wash-out period; Group 6: 6 SCT rats + FF 0.12 mg/kg/d + 72-h wash-out period. SCT was performed at T10. FF was continuously administered. Cystometry was undertaken 6 weeks after SCT in awake rats recording intermicturition pressure (IMP), baseline pressure, threshold pressure (Pthres) and maximum pressure (Pmax). Normal controls and SCT controls were initially compared using the Mann-Whitney U tests in order to confirm the SCT effect on cystometric parameters. The comparisons in cystometric and metabolic cage parameters between SCT controls and treated rats were done using post-hoc Dunn’s tests for Kruskal-Wallis analysis. Statistical testing was conducted at the two-tailed α-level of 0.05. Results Pressure parameters were significantly higher in SCT control group compared to normal controls. Six weeks after SCT, IMP was significantly lower in low dose treated group than in SCT controls. Pmax was significantly lower in 3 treated groups compared to SCT controls. Pthres was significantly lower in full time treated groups than in SCT controls. Conclusion Early administration of FF modulates bladder overactivity in a SCT rat model. Whereas short-term prevention has been demonstrated, the long-term should be further analyzed. Clinical application of these results should confirm this finding through randomized research protocols.

PD64-08 CAN WE AVOID BLADDER AUGMENTATION IN CASE OF FAILURE OF A FIRST INTRADETRUSOR BOTULINUM TOXIN INJECTIONS IN PATIENTS WITH SPINAL DYSRAPHISM?

courses per patient). The urodynamic patterns were detrusor overactivity in 48.6% of patients, isolated poor compliance in 33.6% of patients and combination of poor compliance and detrusor overactivity in 17.8%. The toxin used was in the vast majority onabotulinum toxin A at a dosage of 200 U in 43 patients (34.7%) and 300 U in 62 patients (49.2%). Twenty patients (16.1%) received initially abobotulinum toxin A 750 injections. Global success rate of the first injection was 68.8% with resolution of urinary incontinence in 73.5% of patients. Ninety-six patients (76.8%) underwent a second injection and the mean interval between the first and second injections was 7.5 months. Success rate was significantly lower in case of poor compliance (49% vs. 87%; p<0.0001). In contrast, success rates did not differ significantly between open and closed spinal dysraphism (66.7% vs. 72.3%; p1⁄40.51). The two other predictors of success were female vs. male gender (83.3% vs. 51.7%; p1⁄40.0002) and age (OR1⁄40.1; p1⁄40.005). Out of 561 injections, 20 adverse events were noted (3.6%) including three fatigue/muscular weakness. CONCLUSIONS: IDBTI seems effective in spina bifida patients showing detrusor overactivity regardless of the type of spinal dysraphism (open or closed). In contrast, the effectiveness is much lower in spina bifida patients with poor compliance bladder. The safety of IDBTI in patients with spinal dysraphism is statisfactory

PD64-07 INTRADETRUSOR INJECTIONS OF BOTULINUM TOXIN A IN ADULT PATIENTS WITH SPINAL DYSRAPHISM: RESULTS OF A MULTICENTER STUDY

METHODS: The charts of all patients who underwent a switch to IDI of ATA after failure of an IDI of OTA at six departments of neurourology were retrospectively reviewed. The main outcomes of interest were the bladder diary data and four urodynamic parameters: maximum cystometric capacity (MCC), maximum detrusor pressure (PDET max) and volume at first uninhibited detrusor contraction (UDC). Data were compared before and after treatment with OTA and ATA, using Stuart, Wilcoxon and paired-t tests for paired samples and univariate logistic regression was performed to seek for predictors of switch success. RESULTS: Out of 57 patients included, 38.6% were primary non-responders to Botox, and in secondary non-responder a median number of 5 OTA IDI were performed before failure (range 1-17). Persistent urinary incontinence was observed in 84.2% patients, and 75.4% had persistent detrusor overactivity. Six weeks after the first injection of Dysport, no adverse events were reported. A significant decrease in number of urinary incontinence episodes per day was observed in 52.63% of patients (p <0.001) and all patients experienced a reduction in PDET Max (-8.1 cmH20 on average; p1⁄40.003). MCC significantly increased by a mean of 41.2 ml (p1⁄40.02). The proportion of patients with no UDC increased significantly at after ATA injections (from 15.79% to 43.9%; p1⁄40.0002). Hence, 32 patients draw clinical and/or urodynamic benefits from the botulinum toxin switch from OTA to ATA (56.14%). After a median follow up of 21 months, 87% of responders to BTA switch were still treated successfully with BTA. In univariate analysis, three variables were associated with BTA switch success: low MCC before first ATA IDI (OR1⁄420.4;p1⁄40.01) and dose of ATA (OR1⁄4 10.9; p1⁄40.048) were predictive of increased success rates; poor compliance was predictive of lower success rate (OR1⁄40.2; p1⁄40.04). CONCLUSIONS: Most patients refractory to OTA (Botox) (56.14%) draw benefits from the switch to ATA (Dysport). Low MCC and dose of ATA were predictive of success of BTA switch while poor compliance was predictive of failure.

Can we avoid bladder augmentation in case of failure of a first intradetrusor botulinum toxin injections in patients with spinal dysraphism

Peyronnet B1, Amarenco G2, De Sèze M3, Even Schneider A4, Verrando A5, Hascoet J1, Castel-Lacanal E6, ChartierKastler E7, Denys P4, Schurch B8, Manunta A9, Gamé X6 1. Rennes University Hospital, 2. Tenon University Hospital, 3. Saint-Augustin institute, 4. Raymond Poincaré Hospital, 5. Tenon Hospital, 6. Toulouse university hospital, 7. Pitié-Salpétrière Hospital, 8. Lausanne University Hospital, 9. Rennes university hospital

Reply to Véronique Phé, Morgan Rouprêt, and Emmanuel Chartier-Kastler's Letter to the Editor re: Xavier Biardeau, Jérôme Rizk, François Marcelli, Vincent Flamand. Robot-assisted Laparoscopic Approach for Artificial Urinary Sphincter Implantation in 11 Women with Urinary Stress Incontinence: Surgical Technique and Initial Experience. Eur Urol 2015;67:937–42

We thank Phe et al for their insightful comments regarding our article on robot-assisted laparoscopic artificial urinary sphincter (AUS) implantation in women with stress urinary incontinence [1]. Their knowledge on AUS implantation, derived from leading experience in this field, is of great interest. With the aim of promoting this underdeveloped approach, we would like to address some of the issues they raised. As stated by the commentators, AUS implantation is challenging in women, especially after multiple antiincontinence surgeries, and we agree that careful selection of candidates to undergo this procedure is a necessity. However, we question the validity of a Marshall or submidurethral test in this specific population, especially since data on evaluation of intrinsic sphincter deficiency and/or urethral hypermobility after multiple anti-incontinence surgeries are scarce in the literature. Because of our high intraoperative complication rate, we agree that technical aspects of the procedure should be revised. Step-by-step improvement is inherent to all novel surgical approaches, and in our case will probably lead to a decrease in overall morbidity and description of a more standardized and simplified technique. Now that our own experience with this procedure has grown, we believe that the magnified vision offered by the robotassisted approach initially prompted us to perform a dissection that was too close and medial, and was probably responsible for our initial high rate of intraoperative complications. We now assume that the dissection should be initiated more laterally, distant to the medial anatomic structures. Unpublished results for our most

Techniques de réimplantation urétéro-vésicale sur vessie psoïque, avec ou sans lambeau vésicale, par voie cœlioscopique robot-assistée

The National Library of Australia has a relatively small but important collection of digital materials on physical carriers, including both published materials and unpublished manuscripts in digital form. To date, preservation of the Library’s physical format digital collections has been largely hand-crafted, but this approach is insufficient to deal effectively with the volume of material requiring preservation. The Digital Preservation Workflow Project aims to produce a semi-automated, scalable process for transferring data from physical carriers to preservation digital mass storage, helping to mitigate the major risks associated with the physical carriers: deterioration of the media and obsolescence of the technology required to access them. The workflow system, expected to be available to Library staff from June 2008, also aims to minimise the time required for acquisition staff to process relatively standard physical media, while remaining flexible to accommodate special cases when required. The system incorporates a range of primarily open source tools, to undertake processes including media imaging, file identification and metadata extraction. The tools are deployed as services within a service-oriented architecture, with workflow processes that use these services being coordinated within a customised system architecture utilising Java based web services. This approach provides flexibility to add or substitute tools and services as they become available and to simplify interactions with other Library systems.