Xavier Gamé

Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: Results of a multicenter prospective study†‡§

Electrostimulation is an established therapeutic option for neurogenic urinary disorders. The aim of this study was to investigate the efficacy of the noninvasive technique of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with multiple sclerosis (MS) and troublesome symptoms of an overactive bladder (OAB).

A MULTICENTER STUDY OF THE MORBIDITY OF RADICAL CYSTECTOMY IN SELECT ELDERLY PATIENTS WITH BLADDER CANCER

PURPOSE We evaluated the morbidity of radical cystectomy for invasive bladder cancer in select patients older than 75 years using recent data from 2 academic hospitals. MATERIALS AND METHODS We analyzed 73 radical cystectomies performed from January 1995 to June 2000 in patients 75 to 89 years old (median age 79.3). Cases were categorized according to the American Society of Anesthesiologists classification with a score of 2 in 41, 3 in 30 and 4 in 2. External urinary diversion was performed in 51 cases and an ileal neobladder was constructed in 22. We evaluated the incidence and type of complications, clinical outcome, and postoperative care unit and hospital stay. Statistical analysis was done using the chi-square and Student t tests. RESULTS Median operative time was 263 minutes (range 95 to 451). The perioperative mortality rate was 2.7%. The intraoperative, early and late postoperative complication rates were 38.4%, 46.5% and 16.4%, respectively. Three reoperations (4.1%) were necessary. The most common early complications were pyelonephritis in 12.3% of cases, disorientation in 10.9%, pneumonia in 8.2% and prolonged ileus in 12.3%. The most common late complications were ureteroileal anastomotic stenosis in 5 cases and hernia in 3. Median postoperative care unit and hospital stays were 12 and 34 days, respectively. At a median followup of 14.4 months (range 6 to 74) the overall mortality rate was 31.5%. Hospital stay was significantly higher in patients with complications. The incidence of complications was similar in the 2 groups. CONCLUSIONS These data support the aggressive surgical management of bladder cancer in select elderly patients. A rigorous multidisciplinary team approach can provide acceptable perioperative morbidity.

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Radical Cystectomy for Bladder Cancer: Morbidity of Laparoscopic Versus Open Surgery

PURPOSE We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. MATERIALS AND METHODS This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. RESULTS Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. CONCLUSIONS Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

Evaluation of male sexual function after pelvic trauma by the International Index of Erectile Function.

OBJECTIVES To assess the multifaceted male sexual function after pelvic ring fracture. METHODS A cross-sectional study of male sexual function after pelvic ring fractures was conducted, using the International Index of Erectile Function (IIEF). The department of traumatology database was scanned (June 1996 to April 1999) for 30 to 70-year-old male patients with pelvic fracture. Seventy-six consecutive, literate patients were then contacted by mail. IIEF domain scores were calculated for all responders. Cappelleris method for identification and grading of erectile dysfunction was applied for patients sexually active within the past 4 weeks. Students t test was used to compare the domain scorings of patients with those of the control population used for the IIEF psychometric validation. Relationships between IIEF results and patient characteristics were sought by Spearmans rank correlation coefficient for quantitative variables and Students t test for classes. RESULTS Forty-six patients answered (60.1% response rate). Thirty-seven patients had experienced sexual intercourse in the past 4 weeks during which 11 patients (29.7%) had exhibited various degrees of impaired erection. As a whole, compared with the published controls a significant decrease in overall satisfaction (P <0.05) was demonstrated. Pubic diastasis was further related to impaired erectile function and overall satisfaction; we suggest that cavernosal nerves might be damaged at the time of diastasis. CONCLUSIONS This study evidenced the impairment of sexual overall satisfaction after pelvic trauma and the specific decrease in erectile function and erection firmness and confidence associated with pubic diastasis. The IIEF questionnaire might be considered at the time of rehabilitation to identify those patients that could benefit from supportive treatments.

Sacral neuromodulation for treating neurogenic bladder dysfunction: clinical and urodynamic study.

The efficacy of sacral neuromodulation for treating refractory idiopathic lower urinary tract dysfunction is now well established. Nevertheless, results of this technique in neurological patients are still controversial. The aim of this retrospective study was to assess the results of sacral neuromodulation in neurogenic bladder dysfunction.

Three-dimensional conformal radiotherapy for localized prostate cancer in kidney transplant recipients.

Background. This is the first report of graft function and prostate cancer control in renal transplant recipients subjected to modern conformal radiotherapy. Methods. Eight kidney transplant recipients were treated with three-dimensional conformal radiotherapy. All patients but one were subjected to transitory hormonal deprivation. A three-dimensional radiotherapy-planning system (Pinnacle, Philips Medical System, Bothell, WA) was used to delineate anatomic contours on pretreatment computed tomography and for dose computation. The clinical target volume encompassed the prostate and was expanded with a 10-mm wide margin in all directions to obtain the planning target volume. The irradiation technique consisted of a nine-field arrangement delivering 70 Gy in 2-Gy fractions, with 18-MV photon beams. Biochemical recurrence was defined as two consecutive increases in prostate-specific antigen (>1.5 ng/mL). Graft function was monitored by creatinine clearance. Excretory profiles were assessed by furosemide-stimulated diethylenetriaminepentaacetic acid renography. All patients were subjected to hip magnetic resonance imaging to assess for avascular hip necrosis. Results. After a mean follow-up of 28 months, two patients showed isolated biochemical recurrence and six patients remained free of recurrence. In seven patients with functional allografts, the creatinine clearance was unimpaired by treatment. However, significant obstruction of the terminal ureter was revealed in two patients by furosemide-stimulated diethylenetriaminepentaacetic acid renograms. The doses delivered to the uretero-neocystostomy were calculated to range from less than 20 Gy to more than 45 Gy depending on bladder repletion. Conclusions. Adequate cancer control was achieved at the expense of infraclinical ureteral obstruction. The doses delivered to the uretero-neocystostomy may be reduced by having a full bladder at the time of irradiation. No avascular hip necrosis was observed.

Congenital pelvic arteriovenous malformation in male patients: a rare cause of urological symptoms and role of embolization.

OBJECTIVES Congenital pelvic arteriovenous malformations (pAVM) are rare in male patients. The purpose of our study was to obtain information about the presenting symptoms, differential diagnosis, radiological diagnosis and therapy. PATIENTS AND METHODS The record of two men with congenital pAVM were reviewed to evaluate the initial symptomatology, diagnostic examinations and findings, therapeutic procedures and clinical outcome. Furthermore, our data are compared to the findings of all men reported in the literature. RESULTS Including the two cases reported by us, the data on 17 men with congenital pAVM could be analyzed. Most men presented with unspecific symptoms like pelvic discomfort, pain, impotence or dysuria. The radiological diagnosis was established by magnetic resonance imaging (MRI) or by computed tomography (CT) and was confirmed by angiography in all cases. Therapy consisted of surgical excision in nine cases, embolization in four cases, embolization and surgery in three cases and medical supervision in one case. CONCLUSION Pelvic arteriovenous malformations in male patients are rare. Because of the lack of specific symptoms, they are difficult to diagnose. CT or MRI and arteriography make the diagnosis. Intra-arterial embolization can be considered as the first line treatment.

Incidence of donor‐specific antibodies in kidney transplant patients following conversion to an everolimus‐based calcineurin inhibitor‐free regimen

Scarce data exist regarding the incidence of donor‐specific antibodies (DSAs) in kidney transplant patients receiving everolimus‐based immunosuppression without calcineurin inhibitors (CNIs). The aim of this retrospective case–control study was to compare the incidence of de novo DSAs in patients converted to an everolimus‐based regimen without CNIs with that seen in patients maintained on CNIs. Sixty‐one DSA‐free kidney transplant patients who had been converted to an everolimus‐based regimen (everolimus group) were compared to 61 other patients maintained on CNIs‐based regimen (control group). Patients were matched according to age, gender, induction therapy, date of transplantation, and being DSA‐free at baseline. At last follow‐up, the incidence of DSAs was 9.8% in the everolimus group and 5% in the control group (p = ns). In the everolimus group, the increased incidence of DSAs between baseline and last follow‐up was statistically significant. Antibody‐mediated rejection occurred in 6.5% in the everolimus group and 0% in the CNIs group. The incidence of DSAs is numerically increased in kidney transplant patients treated with an everolimus‐based without CNIs. A study including a larger number of patients is required to determine whether a CNI‐free everolimus‐based immunosuppression significantly increases DSAs formation.

Treatment of neurogenic male urinary incontinence related to intrinsic sphincter insufficiency with an artificial urinary sphincter: a French retrospective multicentre study

Study Type – Therapy (retrospective cohort)
Level of Evidence 2b