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To assess the efficacy and safety of intradetrusor botulinum toxin type A injections (IBTI) for idiopathic overactive bladder (iOAB) in non-neurological adults with an artificial urinary sphincter (AUS). We retrospectively selected, in the 11 French centers, members of a collaborative network (GENULF (Groupe d’etude de neuro-urologie de langue francaise)), the patients who had had an artificial urinary sphincter implantation and who had subsequently developed iOAB requiring IBTI. This study was approved by the French association of urology ethics committee (no 2018012). Between 2006 and 2020, 33 patients were included from 5 French centers. Mean follow-up after the first IBTI was 47 months. The average age of the studied population was 68 years, with 70% of females. A complete resolution of symptoms at optimal IBTI dose was experienced by 21 (64%) patients. Seven (21%) patients had partial improvement. Five non-responder patients (15%) had no improvement at all. Maximum cystometric bladder capacity was 240 ml pre-IBTI and 335 ml post IBTI. Discontinuation free survival at 60 months was 50%. Two erosions occurred during the 6 months following an IBTI both in male patients with a perineal implantation. There were four AUS balloon perforations that occurred during the 6 months following an IBTI, all of them in female patients. IBTI has a good efficacy for the treatment of iOAB in patients with an AUS. However, both patients and practicians must be aware of the risk of rare and usually mild complications.

Resume Introduction Les infections urinaires (IU) sont frequemment rencontrees au cours de la sclerose en plaques en raison de facteurs de risque intrinseques (vessie neurologique) et extrinseques (traitements immunosuppresseurs). Le surrisque de morbi-mortalite doit donc etre pris en compte. Par ailleurs, la mise en jeu du systeme immunitaire, au cours des infections urinaires, pourrait etre un facteur declenchant de poussee ou d’aggravation neurologique. Le depistage et le traitement des IU deviendraient donc determinant dans la prise en charge de la maladie. Pour ces raisons, la Societe francaise de sclerose en plaques (SFSEP) a propose d’etablir des recommandations pratiques sur ce theme. Materiels et methodes Le groupe « recommandations » de la SFSEP a realise une revue de litterature systematique sur le sujet a partir de Pub Med et des bases universitaires de 01/1980 a 12/2019. La methode RAND/UCLA (Haute Autorite de sante, 2007) a ete utilisee pour synthetiser la litterature scientifique et les opinions d’experts afin de formaliser un accord pour chaque proposition. Resultats Les IU ne sont pas associees a un risque accru de poussee ou d’aggravation transitoire de l’incapacite chez les patients atteints de SEP. Seules les IU febriles sont associees a un risque accru d’aggravation transitoire de l’incapacite par l’intermediaire du phenomene d’Uhthoff. Certains traitements immunosuppresseurs augmentent le risque d’IU dans la SEP et necessitent une attention particuliere, surtout en cas d’hypogammaglobulinemie. Les experts recommandent de traiter les IU selon les recommandations de la population generale. La prevention des IU recidivantes passe, avant tout, par une stabilisation de l’etat vesicosphincterien. En cas d’IU recidivantes, les traitements complementaires et l’antibioprophylaxie au long cours ne sont pas recommandes ; seul l’antibiocycle hebdomadaire alterne peut etre propose apres avis d’experts. Les bacteriuries asymptomatiques (BA) ne doivent pas etre depistees ni traitees systematiquement chez les patients atteints de SEP, hormis en cas de grossesse et de geste invasif urologique. Avant un bilan urodynamique, il est recommande de traiter une bacteriurie asymptomatique uniquement en cas de facteurs de risque d’IU connus. En cas de sondages intermittents ou a demeure, il n’est pas recommande de depister ni de traiter les BA chez les patients atteints de SEP. Conclusion Ces recommandations ont pour objectif de mettre a disposition des differents acteurs du systeme de sante une synthese rigoureuse de l’etat de l’art et des donnees de la science, destinee a aider la prise de decision dans le choix des soins ; a harmoniser les pratiques et a reduire les traitements inappropries.

Objective To evaluate the clinical efficacy, urodynamic effect and safety of Botulinum Toxin A (BTXA) injections after failure of augmentation enterocystoplasty (AE) performed for neurogenic detrusor overactivity. Patients and Methods We performed a multicenter retrospective study that included patients who had AE and at least one injection of BTXA after AE in 15 GENULF (French Speaking Neuro-Urology Study Group) centers. Clinical and urodynamic data were collected from medical files according to a standardized questionnaire and colligated in an anonymous database. Results Thirty-three patients with an injection of BTXA after AC in 9 out of 15 centers were included. Mean age at the time of AE was 24 ± 15 years. Overall efficacy (defined by clinical efficacy associated with a request by the patient for reinjection) was observed in 58% of the patients. Mean maximum cystomanometric capacity increased by 28% (333 ± 145 vs 426 ± 131 mL; P = .007) and maximum detrusor pressure (Pdet max) decreased by 43% (44 ± 37 vs 25 ± 18 cm H2O; P = .02) after BTXA. Only one side effect was recorded out of the 152 procedures (transient generalized muscle weakness without respiratory distress). Conclusion In patients with failure after AE performed for neurogenic detrusor overactivity, injection of BTXA in the enlarged bladder was effective in over half of the cases with low morbidity. If this therapeutic approach were confirmed, it could be proposed as an alternative to AE surgical revision.

Aims Purposes of this study were to describe lower urinary tract symptoms (LUTS) and related urodynamic patterns in patients with hereditary spastic paraplegia (HSP), and to characterize LUTS management and associated uronephrological complications. Methods We retrospectively reviewed medical files of HSP patients, consecutively followed in our Physical and Rehabilitation Medicine Department between 1999 and 2016. Clinical, urodynamic, and radiological data were collected and analyzed. Different treatments which have been prescribed and uronephrological complications were also recorded. Patients with other neurological or urological diseases were excluded. Results Thirty-three patients with HSP were included. Mean duration of follow-up was 8.1 ± 5 years, mean age 62 ± 14 years, and 70% were men. The most frequent LUTS was urgency and voiding dysfunction (both 69.7%). Incontinence and retention with a significant postvoid residue above 100 mL accounted for 66.7% and 57.6% of initial symptoms respectively. Neurogenic detrusor overactivity was diagnosed in 80.7% of patients. Two-thirds of our cohort were treated with anticholinergics and 9.1% required intradetrusor botulinum-toxin injections. Only 27.3% of patients performed clean intermittent self-catheterization. Febrile urinary tract infections (21.2%), urolithiasis (15,1%), hydronephrosis (6%), and chronic renal failure (9.1%) were found. Conclusion Given their high prevalence and the risk of uronephrological complications, LUTS should be systematically assessed in HSP patients. The systematic screening of urological dysfunction in this population would improve its management, decrease the incidence of uronephrological complications, and increase the quality of life.

Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population.We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively.Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence.In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

International audience; 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 H 2O, p

Resume Contexte Les infections urinaires sont un probleme majeur de sante publique chez les patients ayant une vessie neurologique. Premiere cause de morbidite et deuxieme de mortalite, leur frequence genere une consommation de soin importante, et entrainent une exposition antibiotique massive conduisant a une prevalence elevee de bacteries multiresistantes. Les strategies preventives non antibiotiques sont essentielles. L’interference bacterienne consiste en l’inoculation intra-vesicale de bacteries non pathogene afin de prevenir les infections urinaires symptomatiques. Objectif Revue systematique de la litterature des donnees cliniques humaines disponibles sur l’interference bacterienne dans la prevention des infections urinaires chez le patient avec vessie neurologique selon la methodologie PRISMA. Resultats Au total 7 etudes ont ete selectionnees. Malgre des effectifs reduits et des populations heterogenes : mode mictionnel variable, antecedents d’infections urinaires differents, protocoles d’inoculation variables, durees de suivis et criteres d’evaluation heterogenes, l’interference bacterienne semble efficace dans la prevention des infections urinaires avec une bonne tolerance et quasi-absence d’effets indesirables. Les limites sont la difficulte a realiser l’inoculation et son faible rendement qui represente un cout medico-economique. Conclusion Les etudes, malgre leur heterogeneite, ont mis en evidence l’efficacite de l’interference bacterienne sur la diminution des infections urinaires symptomatiques. Elles ont egalement montre l’absence d’effet secondaire deletere et la faisabilite de l’inoculation intra-vesicale d’une souche non pathogene d’Escherichia coli 83972 ou HU2117 dans une population avec vessie neurologique. Alternative prometteuse, mais de nombreux developpements sont necessaires pour rendre cette technique plus accessible en pratique quotidienne et assurer son efficacite au long cours.

International audience; We report the natural history and prognosis of tumors after augmentation enterocystoplasty, with a molecular analysis using an oncogene panel to search for potential targeted therapies.Materials and methods: this multicenter, nationwide, retrospective study included 16 patients. A panel of 21 clinically relevant oncogenes was tested on archival tumor specimens using next-generation sequencing. Survival rate was the main clinical outcome and sequences were compared to the reference genome for the genetic outcome.Results: augmentation enterocystoplasties were performed mainly for congenital neurogenic bladder and bladder exstrophy at a median patient age of 17 years (range 4 months to 45 years). Most of the malignancies were diagnosed because of clinical manifestations, with a median latency period of 20 years. Adenocarcinomas were mainly found after gastrocystoplasty, whereas urothelial cell carcinomas were typically found after colocystoplasty. Of the 16 patients 13 were diagnosed at an advanced stage of the disease (positive lymph nodes in 7, distant metastases in 6). The overall 1-year survival rate was 56%. Only 3 patients remained disease-free at a median followup of 70 months. Of the 9 tumors with analyzable DNA 4 were wild-type and 5 harbored missense mutations (KIT-p.Pro573Ser, PDGFRA-p.Glu587Lys, KRAS-p.Gly12Asp, ERBB4p.Arg484Lys, CTNNB1-p.Ser37Phe and p.Ser47Asn).Conclusions: malignancy after augmentation enterocystoplasty is diagnosed late with frequent metastases and a very low 1-year survival rate. More than half the tested samples harbored missense mutations in oncogenes accessible to targeted therapies. An international collaboration to enlarge the genetic panel analysis of these tumors may offer new therapeutic hope to patients.

Background Recurrent urinary tract infections (R-UTIs) are the main cause of morbidity and hospitalizations in subjects with neurogenic bladder (NB) due to spinal cord injury (SCI). We evaluated the efficacy of weekly oral cyclic antibiotic (WOCA) prophylaxis (ie, the alternate weekly administration of 2 antibiotics) in preventing R-UTIs. Methods Randomized (1:1), open-label, superiority-controlled trial compared WOCA prophylaxis to no prophylaxis (control) for 6 months in patients with NB due to SCI, using clean intermittent self-catheterization, and suffering from R-UTIs. Primary outcome was incidence of symptomatic antibiotic-treated UTIs. Secondary outcomes were number of febrile UTIs, number of hospitalizations, WOCA tolerance, antibiotic consumption, number of negative urine cultures, and emergence of bacterial resistance in urinary, intestinal, and nasal microbiota. Results Forty-five patients were either allocated to the WOCA group (n = 23) or the control group (n = 22). Median (IQR) incidence of symptomatic antibiotic-treated UTIs was 1.0 (0.5–2.5) in the WOCA group versus 2.5 (1.2–4.0) (P = .0241) in the control group. No febrile UTIs were recorded in the WOCA group versus 9 (45.0%) (P < .001) in the control group. The median number of additional antibiotic treatment was 0.0 (IQR, 0.0–2.0) versus 3.0 (2.0–5.0) (P = .004) in the WOCA and control groups, respectively. Only few adverse events were reported. No impact on emergence of bacterial resistance was observed. Conclusions WOCA is efficient and well tolerated in preventing R-UTIs in SCI patients. In our study, we did not observe any emergence of antibiotic resistance in digestive and nasal microbiological cultures. Clinical Trials Registration NCT01388413.

IntroductionOur objective was to provide guidelines covering all aspects of intermittent catheterisation (intermittent self-catheterisation and third-party intermittent catheterisation).Materials and methodsA systematic review of the literature based on Pubmed, Embase, Google scholar was initiated in December 2014 and updated in April 2019. Given the lack of robust data and the numerous unresolved controversial issues, guidelines were established based on the formal consensus of experts from steering, scoring and review panels.ResultsThis allowed the formulation of 78 guidelines, extending from guidelines on indications for intermittent catheterisation, modalities for training and implementation, choice of equipment, management of bacteriuria and urinary tract infections, to the implementation of intermittent catheterisation in paediatric, geriatric populations, benign prostatic hyperplasia patients and continent urinary diversion patients with a cutaneous reservoir as well as other complications. These guidelines are pertinent to both intermittent self-catheterisation and third-party intermittent catheterisation.ConclusionThese are the first comprehensive guidelines specifically aimed at intermittent catheterisation and extend to all aspects of intermittent catheterisation. They assist in the clinical decision-making process, specifically in relation to indications and modalities of intermittent catheterisation options. These guidelines are intended for urologists, gynaecologists, geriatricians, paediatricians, neurologists, physical and rehabilitation physicians, general practitioners and other health professionals including nurses, carers…; IntroductionL’objectif était de réaliser des recommandations sur le cathétérisme intermittent dans toutes ses composantes.Matériel et méthodesUne revue systématique de la littérature à partir de Pubmed, Embase, Google scholar a été menée en décembre 2014 avec mise à jour en avril 2019. Devant l’absence de données suffisamment robustes et compte tenu des controverses concernant cette thématique, la méthode de recommandations par consensus formalisé d’experts a été appliquée. Des comités de pilotage, cotation et de lecture ont été constitués.RésultatsAu final, 78 recommandations ont pu être élaborées. Elles portent sur les indications, les modalités d’apprentissage et de réalisation, le choix du matériel, la gestion de la colonisation et de l’infection urinaire, sa réalisation dans les populations pédiatriques, gériatriques, chez les hommes ayant une hyperplasie bénigne de la prostate et chez les patients ayant une dérivation urinaire cutanée continente et la gestion des complications. Elles portent à la fois sur l’autosondage et l’hétérosondage aussi bien en structure de soins qu’en ville.ConclusionIl s’agit des premières recommandations portant spécifiquement sur le cathétérisme intermittent et incluant toutes ses composantes. Elles vont permettre d’aider les utilisateurs dans leur décision clinique relative aux indications et aux modalités du cathétérisme intermittent. Ces recommandations s’adressent aux cliniciens urologues, gynécologues, gériatres, pédiatres, neurologues, médecins de médecine physique et de réadaptation, médecins généralistes ainsi qu’autres professionnels de santé notamment les infirmières, les aidants…

INTRODUCTION AND OBJECTIVES:The aim of this study is to describe the natural history, the prognosis and the molecular analysis of a panel of cancer genes on a large series of patients with malignan...

Resume But Preciser les symptomes du bas appareil urinaire (SBAU) lies a la pathologie diabetique, proposer des modalites de depistage, d’evaluation, de suivi et decrire les specificites de la prise en charge urologique de ces patients. Methodes Etude de la litterature a partir de la base de donnees PubMed en utilisant les mots cles suivants : « diabetes mellitus », « diabetic cystopathy », « overactive bladder », « bladder dysfunction », « urodynamics », « nocturia ». Resultats Les SBAU sont plus frequents dans la population diabetique que dans la population generale avec une prevalence estimee entre 37 et 70 % selon les series. Ils sont polymorphes, associant des troubles de la phase de remplissage et/ou de la phase de vidange, evolutifs et frequemment associes a la duree d’evolution du diabete et des complications de celui-ci. La prevalence de l’incontinence urinaire par urgenturie (IUU) et de l’incontinence urinaire a l’effort (IUE) des populations diabetiques est superieure de 10 points aux populations temoins dans la litterature. Malgre une evaluation importante dans la litterature, aucune recommandation n’encadre l’evaluation et la prise en charge des SBAU dans cette population specifique. Un depistage annuel par l’interrogatoire et l’echographie reno-vesicale avec mesure du residu post-mictionnel (RPM) est requis dans le suivi de tout patient diabetique. Le recours a un specialiste des troubles urinaires et au bilan urodynamique est requis selon les elements cliniques et paracliniques du depistage. Le type de dysfonctionnement, le risque infectieux et la dysautonomie doivent guider la prise en charge specifique de ces patients par l’urologue. Conclusion La pathologie diabetique occasionne un retentissement important sur le bas appareil urinaire. Un depistage des SBAU induits est necessaire au meme titre que les autres complications du diabete. La prise en charge des SBAU doit integrer les risques specifiques du patient diabetique, concernant le defaut de la contractilite vesicale, la dysautonomie et les complications infectieuses.

Objectifs Evaluer la survie statistique a 5 ans apres confection d’une cystostomie continente chez les patients atteints de sclerose en plaques (SEP). Methodes Il s’agit d’une etude retrospective multicentrique. Tous les patients atteints de SEP et ayant eu une cystostomie continente au sein de 9 centres hospitalo-universitaires francais entre janvier 2005 et decembre 2019 etaient eligibles. Le critere de jugement principal etait la frequence des patients realisant toujours des auto-sondages propres intermittents (ASPI) par la cystostomie continente 5 ans apres sa confection. Les criteres de jugement secondaires comprenaient notamment l’analyse en sous-groupe de la survie statistique a 5 ans (EDSS ≤ 7 vs > 7 ; forme de la SEP). Resultats Au total, 52 patients etaient inclus, avec un âge moyen de 51,9 ans, pour un echantillon quasiment exclusivement feminin. Le score EDSS median etait de 7/10 et plus de la moitie des patients etait atteints d’une forme secondairement progressive au moment de la chirurgie. A 5 ans de la chirurgie, 54,8 % des patients realisaient encore les ASPI par la cystostomie continente. Parmi les patients ayant un score EDSS ≤ 7 au moment de la chirurgie, 78,1 % realisaient encore les ASPI par la cystostomie continente apres 5 ans, contre 8,8 % chez les patients ayant un score EDSS > 7 (p Fig. 1 , Fig. 2 ). Conclusion La cystostomie continente peut etre envisagee chez certains patients atteints de SEP, selectionnes selon leurs attentes, leurs capacites fonctionnelles et leur potentiel evolutif apres concertation multidisciplinaire associant medecins urologues, neurologues et reeducateurs.

Electrical stimulation (ES) has been tried for many years in different form of neurogenic lower urinary tract dysfunction, aiming to restore emptying and storage function.

Purpose To describe the epidemiologic characteristics of urethrocutaneous fistulae (UCF) in sacro-perineal pressure ulcer (SPPU) in neurourological patients and to assess outcomes after surgical urinary diversion. Materials and methods Through the French-speaking Neurourology Study Group and Association of Urology network, a retrospective multicenter study in nine major urology and physical medicine and rehabilitation (PMR) units was conducted. All patients with SPPU associated with UCF between 2000 and 2016 were included. Data concerning: sociodemography, clinical, medical and biological comorbidities, neurological and urological history, pressure ulcer characteristics, and finally urinary diversion surgery were collected. Complications and SPPU healing/relapse were assessed. Results In all, 74 patients were included. The median age on diagnosis: 45.9 years (interquartile range [IQR], 38.7-53.4) and median follow-up: 15.1 months (IQR, 5.7-48.8). A psychiatric disorder was the most frequent comorbidity (44.6%). Only 59.5% and 50% had regular PMR and urologic follow-up, respectively. Seventy-one patients (95.9%) underwent urinary diversion surgery. Among those, relapse occurred in 15 (21.1%) at the end of the follow-up. The diversion was noncontinent in 85.9%. The major complications rate was 26.8%. A total of 30 late complications in 21 patients were reported. The most frequent was obstructive pyelonephritis (n = 9). All of the patients who underwent surgical diversion without cystectomy (n = 5) developed a pyocyst. Finally, the pressure ulcer healing rate when patients underwent both urinary diversion and pressure ulcer surgery was 74.4%. Conclusions Our retrospective data suggest that UCF complicating SPPU is a rare and severe pathology. The combination of radical urinary diversion with cystectomy and pressure ulcer surgery should be performed as often as possible.

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

Objectifs L’objectif principal de notre etude etait de rapporter les difficultes rencontrees et les complications au cours de la grossesse et de l’accouchement chez les patientes ayant un antecedent de grossesse et d’accouchement apres reconstruction urologique complexe. Methodes Nous avons realise une etude retrospective multicentrique dans 16 centres. Ont ete incluses les patientes aux antecedents d’enterocystoplastie d’agrandissement (EA), et/ou de derivation cutanee continente (DCC), et/ou de sphincter urinaire artificiel (SUA) et ayant presente une grossesse et accouchement. Resultats Soixante-huit femmes ayant presente 96 accouchements entre 1998 et janvier 2019 ont ete incluses. Cinquante pour cent presentaient un dysraphisme spinal, 30 % une lesion medullaire, 15 % une exstrophie vesicale et 6 % une autre pathologie. Cinquante-deux pour cent avaient une EA, 25 % une DCC et 5 % un SUA. Au cours de la grossesse, 10 % ont presente des difficultes d’auto-sondages et 14,6 % ont necessite un drainage du haut appareil urinaire pour colique nephretique ou pyelonephrite aigue. Concernant l’accouchement, le taux de cesarienne etait de 64 % dont 13 % en urgence. Le taux de prematurite etait de 35 %. Un sur 3 des cesariennes se sont compliquees, principalement par lesion de la reconstruction urologique. La continence urinaire a 6 mois de l’accouchement etait non modifiee pour 93,5 % des femmes, quel que soit le mode d’accouchement (p = 0,293) ( Tableau 1 , Tableau 2 , Tableau 3 ). Conclusion A notre connaissance, il s’agit de la plus grosse cohorte rapportant les complications de la grossesse et de l’accouchement apres reconstruction du bas appareil urinaire. La voie basse, lorsqu’elle est possible, doit etre privilegiee en premiere intention, la cesarienne etant a risque de lesion du montage urologique, et ne semblant pas prevenir une incontinence post-partum.

Resume Introduction A ce jour, il n’existe ni definition de l’echec d’une premiere injection intra-detrusorienne de toxine botulique Botox ® 200 U pour hyperactivite detrusorienne neurogene (HDN), ni recommandation sur sa prise en charge. L’objectif principal de cette enquete etait de determiner la definition en pratique de cet echec et l’objectif secondaire de rapporter les pratiques actuelles dans sa prise en charge. Materiels et methodes Un questionnaire, etabli en s’appuyant sur les donnees de la litterature, a ete envoye par courrier electronique aux experts membres du comite de neuro-urologie de l’Association francaise d’urologie et du Groupe d’etude en neuro-urologie de langue francaise. Il leurs etait demande de completer le questionnaire en ligne. Les experts n’ayant pas repondu au premier courrier ont ete chacun sollicites deux fois, toujours par courrier electronique. Resultats Vingt et un des 42 experts sollicites ont repondu au questionnaire. Pour 19 des experts (90,5 %), la definition de l’echec etait une combinaison de criteres cliniques et urodynamiques. Parmi les criteres urodynamiques proposes, la persistance d’une pression detrusorienne > 40 cm H 2 O etait le plus plebiscite (18/21 ; 85,7 %). Dix-neuf experts (19/21 ; 90,5 %) consideraient que l’effet de la toxine botulique sur l’incontinence urinaire devait etre pris en compte dans la definition de l’echec. Concernant la prise en charge de l’echec, une large majorite des participants (15/20 ; 75 %) consideraient que le traitement de premiere ligne en cas d’echec d’une premiere injection de Botox ® 200 U devrait etre une injection de Botox ® a un dosage plus eleve (300 U) qu’il y ait ou non des facteurs de risque urodynamiques (16/20 ; 80 %). Conclusion Ce travail a permis d’obtenir une premiere vue d’ensemble de la definition de l’echec des injections intra-detrusoriennes de toxine botulique dans l’HDN et de sa prise en charge. Pour 90,5 % des experts repondeurs, la definition de l’echec des injections intra-detrusoriennes de toxine botulique pour HDN devrait etre clinique et urodynamique et 75 % des personnes ayant repondu consideraient qu’en cas d’echec d’une premiere injection de Botox ® 200 U, la reinjection de Botox ® a la dose de 300 U etait l’option therapeutique a preferer. Niveau de preuve 4.

Objective To report the long-term complications of continent cutaneous urinary diversion(CCUD) in spinal cord injured(SCI) patients unable to perform intermittent self-catheterization(ISC) through the urethra. Materials and Methods Between July 2001 and January 2012, adult SCI patients with a neurogenic bladder who underwent CCUD according to Mitrofanoff's/Monti's/Casale's principle were enrolled. A concomitant supratrigonal and augmentation enterocystoplasty were performed because of refractory detrusor overactivity or low bladder compliance. Early postoperative complications were reported according to Clavien-Dindo classification. Long-term complications, stomal and urethral continence, renal function, urodynamic parameters and quality-of-life were assessed. Results Overall, 29 consecutive SCI patients were included, median age 35 years (IQR 26–46). Median follow-up time was 66 months (IQR 50–80). Two post-operative severe complications (grade III–IV) were reported. One patient had a stomal stenosis and another patient a tube stenosis. Both were treated by dilation. Two patients developed fistulae between the tube and the skin and required a surgical treatment. Three patients had bladder stones managed with endoscopy. Two patients had remnant stress urine leakage through the urethra, which was treated surgically: one received periurethral balloons(ACTTM) and one a tension-free vaginal tape. Creatinine clearance remained stable postoperatively. Urodynamic parameters were significantly improved. At last follow-up, 100% of patients had a catheterizable continent stoma and urethral continence was achieved in 96%. An improvement of quality-of-life was reported by 90% of patients. Conclusions CCUD allowed these patients to keep ISC as a voiding pattern and to be continent without any appliance. The main complications were related to the tube and to bladder enlargement; thus, annual monitoring is required. Neurourol. Urodynam. © 2015 Wiley Periodicals, Inc.

Aims To assess the impact of sacral neuromodulation (SNM) on pregnancy and vice-versa, by identifying women who had received SNM for lower-urinary tract symptoms (LUTS) and had become pregnant. Methods A cross-sectional descriptive study was carried out based on responses to an on-line questionnaire sent to practitioners listed on the InterStim enCaptureTM National Registry. Questions were related to pre-pregnancy health and SNM efficacy, deactivation of the device, its impact on LUTS, childbirth, the infant, its reactivation and postpartum effectiveness. Results Twenty-seven pregnancies were recorded among 21 women. Six women had had a pregnancy prior to implantation, two of whom had had a c-section. A total of 18.5% of women had the device disabled prior to conception. The others had their device disabled during the first trimester and did not reactivate it before delivery. Complications were reported in 25.9% of pregnancies: six women had urinary infections, including three of the four treated for chronic retention of urine (CRU), and 1 woman had pain at the stimulation site. There were 24 live births (including one premature birth and four c-sections), one spontaneous miscarriage and two voluntary interruptions of pregnancy. No neonatal disorders have been reported. Effectiveness of sacral neuromodulation decreased in 20% in postpartum. Conclusions In 27 pregnancies established during SNM for LUTS, 18.5% of patients deactivated their case before pregnancy and the others switched it off during the first trimester. Three-quarters of women with CRU had urinary infection. No adverse effects on fetuses were found. SNM effectiveness deteriorated in 20% cases after childbirth.

Aims Aims of this study were to assess the long-term outcomes of Intradetrusor injection of OnabotulinumtoxinA (Botox® injection) associated with clean intermittent-catheterization (CIC) for the treatment of neurogenic detrusor overactivity (NDO) and to identify risk factors for failure. Methods Neurological patients with NDO using CIC who had received Botox® injections between January 2001 and September 2013 were included. Clinical, urodynamic and radiological data were recorded. Primary endpoint was failure and withdrawal rates after 3, 5, and 7 years of management. Survival curves of withdrawals and failures of treatment were calculated with a 95-confidence interval using the Kaplan-Meier method. Risk factors for failure were determined with univariate analysis and multivariate analysis using Cox model. Results Overall, 292 patients, mean age of 40 ± 13, 6 years, were included. Overall, 219 patients (80.6%; IC95% [76.3-85.4%]) were still treated with Botox® injections after 3 years, 128 (71.1%; IC95% [65.7%, 76.9%]) after 5 years, and 58 (60.8%, IC95% [54.0%, 68.4%]) after 7 years. Failure rate was 12.6% (IC95% [8.6-16.5%]) after 3 years, 22.2% (IC95% [16.6-27.3%]) after 5 years, and 28.9% (IC95% [21.9%; 35.3%]) after 7 years of follow-up. Withdrawal rate after 7 years of follow-up was 11.3% (n = 33/292). Severe NDO at baseline appears to be a significant risk factor for failure. Conclusion This study confirms long-term efficacy and tolerance of Botox® injection in patients with NDO using CIC. Long-term failure and withdrawal rates remain low but significant, and need to be managed.

Objectifs L’objectif de cette etude est d’evaluer la survie et de rechercher les facteurs de risque d’interruption a 60 mois des patients atteints de sclerose en plaques (SEP) apres une premiere injection intradetrusorienne de toxine botulinique a (TBA). Methodes Il s’agissait d’une etude retrospective, observationnelle, longitudinale, multicentrique. Tous les patients atteints d’une sclerose en plaques, ayant beneficie d’une premiere injection intradetrusorienne de TBA entre le 1 er janvier 2008 et le 31 decembre 2011, dans un centre de reference francais en neuro-urologie et suivis au moins 60 mois, etaient eligibles. La survie a 60 mois des injections intradetrusoriennes de TBA etait analysee de maniere globale et en fonction du score EDSS et de la forme de la sclerose en plaques lors de l’initiation du traitement, de l’âge au diagnostic ainsi que du sexe a l’aide d’un test du log-rank. Resultats Parmi les 152 patients eligibles, 89 ont finalement ete inclus. A 60 mois, les injections etaient poursuivies chez 69 patients (77,53 %). Vingt patients ont interrompu le traitement, 7 (35 %) pour une perte d’efficacite et 13 (65 %) pour une difficulte a realiser les autosondages. L’arret des injections dans les 60 mois etait significativement plus eleve chez les patients presentant un score EDSS ≥ 6 lors de la premiere injection (66,67 % vs 96,88 % p = 0,0014). En analyse multivariee, le score EDSS etait un facteur de risque independant d’interruption du traitement a 60 mois ( or 1,991 [IC95 % : 1,222–3,244] ; p = 0,0057). Chez les patients presentant une forme progressive, l’arret des injections etait aussi plus frequent, compare aux patients presentant une forme remittente. Cependant, il n’existait pas de difference significative ( Fig. 1 et Tableau 1 ). Conclusion Chez les patients atteints d’une sclerose en plaques, la poursuite a 60 mois des injections intradetrusoriennes de TBA est correlee au score EDSS a l’initiation du traitement.

Objectifs A ce jour, il n’existe pas de definition consensuelle de l’echec d’une injection intradetrusorienne de toxine botulique a (BTX-A) pour hyperactivite detrusorienne neurogene (HDN). L’objectif de cette etude etait d’elaborer une definition consensuelle de l’echec de BTX-A intradetrusorienne pour HDN chez le patient blesse medullaire, spina bifida ou atteint de sclerose en plaques (SEP). Methodes Cette etude suivait la methode de recommandations par consensus formalise de la Haute Autorite de sante. Sur la base d’une revue de la litterature et d’une enquete preliminaire, un comite de pilotage a etabli un questionnaire et selectionne un groupe de cotation constitue de 16 experts du comite de neuro-urologie de l’Association francaise d’urologie (cnuAFU) et du genulf a qui il etait demande de completer le questionnaire en ligne. A l’issue du premier tour, tous les participants ont ete reunis pour discuter des desaccords et un deuxieme tour de questionnaire en ligne a ete effectue permettant de parvenir a un consensus. Resultats Treize des 16 experts sollicites ont repondu aux deux tours du questionnaire. Deux propositions faisaient l’objet d’un accord fort (score median = 9/10) et ont donc ete integrees a la definition des le premier tour : au moins une reinjection de la meme BTX-A a la meme dose doit etre effectuee pour eliminer une cause technique d’echec et une duree d’efficacite Tableau 1 ). Deux propositions additionnelles ont ete retenues lors de ce deuxieme tour sur la necessite d’un calendrier mictionnel (score median = 8/10) et sur la definition du patient refractaire a la BTX-A (score median = 7/10). Conclusion Ce travail a permis de proposer la premiere definition consensuelle d’echec d’une injection de BTX-A intradetrusorienne pour HDN : persistance d’une hyperactivite detrusorienne avec des pressions detrusoriennes maximales > 40 cmH2O et/ou d’un trouble de la compliance et/ou persistance d’une d’incontinence urinaire et/ou d’une urgenturie et/ou d’un nombre d’autosondages quotidien > 8/jour et/ou efficacite

Resume Introduction Les troubles vesicosphincteriens (TVS) sont frequents au cours de la maladie de Parkinson (MP) et des autres syndromes parkinsoniens (SP). Ils sont responsables d’une morbidite et mortalite significative et alterent de maniere notable la qualite de vie des patients. La prise en charge therapeutique de ces TVS exige de savoir distinguer la MP des autres SP et de connaitre leur epidemiologie et physiopathologie. Objectif Proposer une strategie diagnostique et therapeutique des TVS chez les patients presentant un SP. Methode Etude de la litterature a partir de la base de donnee Pubmed en utilisant les mots cles suivants, Parkinson's disease, multiple system atrophy, lower urinary tract disorders, neurogenic bladder , overactive bladder , obstruction, anticholinergics, dopamine, prostate surgery . Resultats Parfois revelateurs de la maladie neurologique, les TVS au cours des SP posent un probleme diagnostique car ils surviennent a un âge ou diverses pathologies urogynecologiques peuvent etre intriquees avec le dysfonctionnement vesical neurogene. Le diagnostic differentiel entre MP et atrophie multisystematisee, important a connaitre par l’urologue, repose sur l’analyse semiologique clinique, la reponse au traitement dopaminergique et l’evolution clinique mais aussi sur les donnees des explorations urodynamiques. La prise en charge therapeutique de ces TVS est rendue complexe par la difficulte d’utilisation de certains traitements pharmacologiques et par les risques d’aggravation apres traitement chirurgical inapproprie. L’arsenal therapeutique comprend l’utilisation prudente des anticholinergiques, la stimulation tibiale posterieure, la stimulation profonde sous-thalamique, les injections intradetrusoriennes de toxine botulique a faibles doses et hors autorisation de mise sur le marche. La decision d’une chirurgie prostatique doit etre prise avec prudence apres avoir prouve l’obstruction sous-vesicale. Conclusion Lors de l’analyse des TVS au cours de SP, l’urologue doit savoir remettre en question le diagnostic initial de MP idiopathique. Les traitements, visant a reduire la morbi-mortalite des TVS et a ameliorer la qualite de vie des patients souffrant de ces maladies degeneratives, ne seront proposes qu’apres concertation pluridisciplinaire neuro-urologique. La decision d’une chirurgie prostatique doit etre prise avec prudence apres avoir prouve l’obstruction sous-vesicale.

A retrospective observational study. To describe specificities of pregnancy in a traumatic spinal cord-injured (SCI) population managed by a coordinated medical care team involving physical medicine and rehabilitation (PMR) physicians, urologists, infectious diseases' physicians, obstetricians and anaesthesiologists. NeuroUrology Department in a University Hospital, France. All consecutive SCI pregnant women managed between 2001 and 2014 were included. A preconceptional consultation was proposed whenever possible. Obstetrical and urological outcomes, delivery mode and complications were reported. Overall, thirty-seven pregnancies in 25 women, of a mean age of 32±4 years, were included. Thirty-five children were born alive (three miscarriages, a twin pregnancy) without complications except for a case of neonatal respiratory distress in premature twins born at 33 weeks. The mean birth weight was 2979±599 g. Twenty-one (57%) pregnancies benefited from preconceptional care. A weekly oral cyclic antibiotic programme was prescribed in 28 (75%) pregnancies. The main complications during pregnancy included pyelonephritis (30%), lower urinary tract infections (UTI) (32%), pressure sores (8.8%) and prematurity (12% deliveries before 37 weeks, with only one delivery before 36 weeks). Two patients suffered from autonomic dysreflexia, one with serious complication (brain haematoma). Caesarean sections were performed for 68% of deliveries (23/34) to prevent syringomyelia deterioration (n=10), stress urinary incontinence aggravation (n=3) or for obstetrical reasons (n=7). Mothers’ and infants’ outcomes were satisfying after pregnancy in SCI women, but required many adjustments. Pregnancy must be prepared by a preconceptional consultation, and managed by a multidisciplinary team involving specialists of neurological disability and pregnancy.

Aims To study clinical and urodynamic data along with immediate and long-term morbidity of surgical management of neurogenic bladder in spinal cord injury (SCI) patients Methods Single-center retrospective study of 61 SCI patients with neurogenic detrusor overactivity (NDO) related urinary incontinence and/or sphincter weakness incontinence who underwent supratrigonal cystectomy with Hautmann pouch ± concomitant stress incontinence procedure (27.9%; n = 17). Results With a mean follow-up of 5.84 years (range 1–20.5) an improved or total continence rate was achieved in 89.7% and 74.1%, respectively. Surgery failed (incontinence persisted) for six (10.3%) patients, three of which had a simultaneous procedure for stress incontinence. On urodynamics, maximum cystometric capacity (MCC) (ml) increased from 305.2 to 509.4 (P

Le syndrome de la queue de cheval est defini par l’existence d’une atteinte urinaire et/ou ano-rectale associee a des troubles sensitifs perineaux ; on retrouve des troubles genito-sexuels dans plus de la moitie des cas. Toutefois on retrouve peu d’etudes dans la litterature traitant specifiquement des troubles genito-sexuels lies a une atteinte de la queue de cheval, et encore moins concernant la population feminine. En ce qui concerne les troubles sexuels masculins, ils sont evalues dans la litterature a plus de 50 % de patients se plaignant de troubles sexuels moderes ou severes (selon le questionnaire IIEF), concernant l’erection, l’orgasme, le desir ou la satisfaction globale. En effet, la lesion de l’arc reflexe parasympathique sacre peut rendre difficile l’obtention d’une erection reflexe par stimulation locale, en revanche les erections psychogenes sont en general conservee, mais rarement suffisantes pour permettre la penetration. Les troubles de l’ejaculation sont moins frequemment rapportes. Des traitements medicamenteux tels que les inhibiteurs de la phosphodiesterase ou les injections intracaverneuses peuvent etre proposes afin d’ameliorer la qualite de l’erection, ainsi qu’une education a l’utilisation du vacuum en cas d’echec de ces therapeutiques. Cette prise en charge doit s’inscrire dans une prise en charge plus globale, tenant compte des troubles vesico-sphincteriens et ano-rectaux frequemment associes, du handicap sensitivomoteur du patient et du vecu du handicap neurologique. Chez la femme, les troubles sexuels dus a un syndrome de la queue de cheval sont encore moins evalues que dans la population masculine. Ils sont majoritairement lies a une perte de la sensibilite locale et a des difficultes a atteindre l’orgasme entrainant une baisse du desir. L’arsenal therapeutique medicamenteux chez la femme est moins riche que chez l’homme et se limite en general aux lubrifiants. Une education est necessaire afin d’informer les patientes sur les zones erogenes preservees a stimuler et sur les possibilites d’utiliser des sex toys afin d’augmenter l’intensite de la stimulation et favoriser l’obtention d’un orgasme. Il est egalement necessaire d’evaluer le retentissement du handicap sur l’estime de soi et rechercher un eventuel syndrome depressif, qui peuvent beneficier d’une prise en charge specifique.

Objectives Patients presenting with neurogenic bladder often require urological procedures (urodynamic testing and botulinum toxin injections) and a preventive antibiotic therapy. We aimed to assess the efficacy of this little known strategy in a cohort of patients. Patients and methods All patients presenting with neurogenic bladder who underwent urological procedure were included in the study. They received an antibiotic therapy in accordance with the urine cytobacteriological examination results. The antibiotic therapy was initiated two days before the procedure and prolonged up until two days after the procedure if the culture was positive. Patients were treated with a single dose of fosfomycin-trometamol in case of a negative culture. The main study outcome was the occurrence of urinary tract infection (UTI), defined by a positive urine culture and symptoms, up until 14 days after the procedure. Results A total of 80 urological procedures were performed. Mean patient age was 47 ± 13.1 years (sex ratio 1.22); 59 (73.8%) presented with asymptomatic bacteriuria before the procedure. Nine (11.1%) UTIs were recorded on Day 14, of which one (1.2%) was febrile. Two patients required an additional curative antibiotic therapy. No patient was hospitalized. Overall, 77.8% of UTIs were cured without antibiotic therapy. Conclusion Screening and treating asymptomatic bacteriuria before urological procedures seems unnecessary and vainly exposes this population at high risk of infectious diseases to antibiotic therapies. This data should be confirmed by a randomized clinical trial.

To report the long-term complications of continent cutaneous urinary diversion(CCUD) in spinal cord injured(SCI) patients unable to perform intermittent self-catheterization(ISC) through the urethra.Between July 2001 and January 2012, adult SCI patients with a neurogenic bladder who underwent CCUD according to Mitrofanoff's/Monti's/Casale's principle were enrolled. A concomitant supratrigonal and augmentation enterocystoplasty were performed because of refractory detrusor overactivity or low bladder compliance. Early postoperative complications were reported according to Clavien-Dindo classification. Long-term complications, stomal and urethral continence, renal function, urodynamic parameters and quality-of-life were assessed.Overall, 29 consecutive SCI patients were included, median age 35 years (IQR 26-46). Median follow-up time was 66 months (IQR 50-80). Two post-operative severe complications (grade III-IV) were reported. One patient had a stomal stenosis and another patient a tube stenosis. Both were treated by dilation. Two patients developed fistulae between the tube and the skin and required a surgical treatment. Three patients had bladder stones managed with endoscopy. Two patients had remnant stress urine leakage through the urethra, which was treated surgically: one received periurethral balloons(ACTCCUD allowed these patients to keep ISC as a voiding pattern and to be continent without any appliance. The main complications were related to the tube and to bladder enlargement; thus, annual monitoring is required. Neurourol. Urodynam. 35:1046-1050, 2016. © 2015 Wiley Periodicals, Inc.

Objectifs Il n’existe a ce jour aucune donnee sur la prise en charge de l’echec d’une premiere injection intra-detrusorienne de toxine botulique chez les patients spina bifida. L’objectif de cette etude etait de rapporter les resultats des reinjections et de comparer l’efficacite des differentes strategies de reinjection chez les patients spina bifida en echec d’une premiere injection de toxine botulique. Methodes Tous les patients spina bifida ayant eu au moins une injection intra-detrusorienne de toxine botulique (IDBTX) entre 2002 et 2016 dans 14 centres francophones ont ete inclus dans une etude retrospective. Seul les patients avec un echec de la premiere injection ont ete inclus dans cette etude. L’echec etait defini comme la persistance soit des urgenturies, soit de l’incontinence urinaire, soit de l’hyperactivite detrusorienne. La strategie de prise en charge variait en fonction des centres : reinjection de la meme toxine a la meme dose, reinjection de la meme toxine a un dosage plus eleve, changement de toxine (« switch ») ou enterocystoplastie d’agrandissement. Resultats Parmi une cohorte de 125 patients, 40 patients en echec d’une premiere injection intra-detrusorienne ont ete inclus (32 %). Les injections sont restees inefficaces chez 63 % des patients malgre une a quatre reinjections, et deux autres patients ont eu une efficacite pendant quelques injections avant d’echapper : 70,4 % ont ainsi finalement eu une enterocystoplastie d’agrandissement. Ainsi 48,1 % des patients ont eu des injections efficaces a un moment de leur prise en charge, 40,7 % avaient des injections toujours efficaces a la fin de la periode d’etude, dont 3 chez qui l’efficacite n’etait que partielle (efficacite clinique mais pas urodynamique), soit seulement 25,9 % des patients avec une efficacite satisfaisante et durable. Aucun patient ayant ete en echec des 3 premieres injections n’a finalement repondu. Conclusion Les strategies de « manipulation toxinique » et de reinjections semblent peu efficaces chez les patients spina bifida en echec d’une premiere injection de toxine botulique ne permettant d’obtenir un resultat satisfaisant que chez 25,9 % d’entre eux ce qui pourrait plaider pour un recours plus rapide a l’enterocystoplastie d’agrandissement chez ces patients.

Objectifs Les escarres associees a des lesions de l’uretre chez le patient blesse medullaire representent un veritable challenge therapeutique pour le chirurgien urologue, plasticien, orthopediste et le medecin reeducateur. Il existe tres peu de donnees sur la prise en charge de ces complications. Le but de ce travail etait de rapporter les resultats de la prise en charge urologique des fistules uretro-perineales avec escarre chez les patients blesses medullaires. Methodes Une etude nationale, descriptive, retrospective et multicentrique dans 9 services de chirurgie urologique ou de medecine physique readaptation (MPR). Nous avons inclus un total de 64 patients blesses medullaires ayant une escarre sacree ou perineale associee a une fistule uretro-perineale entre 2002 et 2016. Les donnees sociodemographiques, le suivi MPR et neuro-urologique et les donnees pre- et postoperatoires des derivations urinaires et des chirurgies d’escarres ont ete recueillis puis analyses. Resultats L’âge median etait de 45,9 ans (IQR = 38,7–53,0), le suivi median de 16,5 mois (IQR = 8,7–51,3). Le sex-ratio H/F etait = 5,7 avec l’absence de suivi neuro-urologique dans 55,7 %. Les auto-sondages intermittents, une sonde a demeure et une cystostomie a demeure etaient retrouves chez 31,3 % (n = 20), 25,0 % (n = 16) et 20,3 % (n = 13) des patients et 51,6 % (n = 33) etaient incontinents. Les complications majeures etaient : l’osteite (46,9 %, n = 30) et la gangrene de Fournier (20,3 %, n = 13). Une chirurgie pour derivation urinaire etait realisee dans 95,3 % (n = 61) des cas. Elle etait non continente (DUNC) dans 79,7 % (n = 51) avec un Bricker le plus souvent (90,2 %). Le taux de complications post-operatoires precoces majeures (Clavien III–V) etait de 21,3 % (n = 13). Une re-intervention a distance etait necessaire dans 29,5 % (n = 18), la plus frequente etait le drainage des voies excretrices (16,3 %) et une DUNC sans cystectomie etait systematiquement associee a un pyocyste (n = 6/6). Enfin 54,7 % (n = 35) des patients beneficiaient d’une chirurgie d’escarre avec une cicatrisation dans 80 % (n = 28). Conclusion En cas d’escarres associees a des lesions de l’uretre chez le blesse medullaire, une prise en charge adaptee avec derivation urinaire et cystectomie si possible, puis chirurgie de recouvrement cutane associee eventuellement a un geste orthopedique permet la cicatrisation dans la majorite des cas. De plus, une prevention par un suivi neuro-urologique et un mode mictionnel adapte sont preponderants pour prevenir ces complications du decubitus.

Objective Review the literature on therapeutic strategies and guidelines for the treatment of neurogenic bladder in multiple sclerosis. Material and method A search on available articles on consensus, recommendations guidelines and algorithm of treatment of urinary tract dysfunction in multiple sclerosis. Results Five national consensus guidelines were recently published and proposed guidelines for the first and second line treatments. Conclusion Multiple sclerosis patients suffering from lower urinary tract disorders must benefit from an early diagnosis and simple first line evaluation and treatment. More complex and invasive evaluation in the neuro-urology unit is appropriate for patients who failed to first line treatment or in case of complications.

Objectifs Realiser un etat des lieux en France sur la neuromodulation des racines sacrees (NMS) dans le cadre des troubles du bas appareil urinaire (TBAU) et la grossesse. Methodes Il s’agit d’une etude transversale realisee a partir d’un questionnaire en ligne envoye aux investigateurs du Registre National InterStim enCaptureTM. Un questionnaire devait etre rempli par patiente enceinte. Une reponse negative etait demandee si aucune patiente n’avait ete enceinte. Les questions portaient sur : – l’indication et l’efficacite avant la grossesse ; – la desactivation et son impact sur les symptomes ; – les modalites d’accouchement ; – l’enfant ; – la reactivation du boitier et son efficacite. L’objectif principal etait de recenser le nombre de grossesses sous NMS pour TBAU. Les objectifs secondaires etaient d’evaluer l’impact de la NMS sur la grossesse et inversement. Resultats Vingt grossesses chez 17 femmes : une a eu 3 grossesses apres implantation, une en a eu deux. Les patientes etaient implantees entre 1999 et 2011, la grossesse survenait avec un delai median de 4 ans [1–8], l’âge median maternel etait de 33 ans [27–39]. Sept patientes ont eteint le boitier avant la grossesse, toutes l’ont desactive et aucune ne l’a rallume. Quatre patientes ont eu des complications pendant la grossesse : –une gene perineale ; –des colonisations ou infections urinaires. Une femme n’a pas accouche a terme, 4 ont eu une cesarienne (22,22 %) et 2 ont realise une IVG. Quinze patientes ont reactive leur boitier en post-partum, trois ont eu une degradation de l’efficacite de la NMS dont deux deplacements d’electrode. Aucun probleme neonatal n’est survenu. Conclusion Nous avons recense 20 grossesses sous NMS pour troubles vesico-sphincteriens, il y a eu 4 cesariennes, 3/5 femmes avec un trouble de la vidange ont eu des complications infectieuses. Il n’y a eu aucun probleme neonatal et l’efficacite de la NMS en post-partum s’est degradee chez 20 % d’entre elles (Tableau 1 ; Tableau 2).

Objective Intradetrusor injection of onabotulinum toxin A (IDIBA) is the third-line therapy for patients with neurogenic detrusor overactivity (NDO). There is few evidence of long-term efficacy but no study assessed reasons for failure or abandonment of IDIBA and CISC (clean intermittent self-catheterization) combined strategy. We aimed to assess its long-term outcome in NDO management, and analyze failure and discontinuation. Materials/patients and methods We retrospectively reviewed medical records of patients admitted in our neurourology department between 2001 and 2013. Inclusion criteria were: age > 18, NDO secondary to spinal cord injury (SCI), multiple sclerosis (MS) or myelomeningocele, NDO management associating IDIBA and CISC, failure of a 3-month combination of two anticholinergics and a 3 year follow-up minimum. Patients with bladder surgery were excluded. Clinical, urodynamic and radiologic data before the first injection, six weeks after the first and last injections were analyzed. Primary endpoints were failure (defined by clinical or urodynamic criteria) and abandonment rates at 3, 5 and 7 years. We secondarily analyzed risk factors for failure and discontinuation. Results During selected period, 292 patients were included, with mean age 40 ± 13.6 years, 58.2% males and mean duration of NDO 10.8 years. Etiologies for NDO were SCI (84.6%), MS (10.6%) and myelomeningocele (3.4%). After 3 years, 219 patients (80.6%) were still treated, 128 (71.1%) and 58 (60.8%) after 5 and 7 years respectively. Failure rates were 12.6%, 22.2% and 28.9% after 3, 5 and 7 years respectively. Discontinuation rate after 7 years was 11.3%. Reasons were: difficulties related to CISC (3.8%), personal convenience (2.7%), pseudobotulism (2.4%), pregnancy (1.03%), pain (1.03%) and prostatic cancer (0.3%). Clinical, urodynamic and radiologic severity criteria of NDO before IDIBA initiation were major risk factors for treatment failure. Discussion/Conclusion This is the first long-term follow-up study of patients with NDO treated by IDIBA and CISC. Less than two third of patients were still treated after 7 years. The main reason for abandonment was difficulties with CISC. Choosing the best time for IDIBA initiation could improve the management of these patients. Further studies are needed to determine the impact of initiation timing, and prior oral anti-muscarinics use on long-term efficiency.

Objective Hereditary spastic paraplegia (HSP) represents a clinically and genetically heterogeneous group of neurodegenerative diseases, with a worldwide estimated prevalence of 1.3/100,000 [1] . The “pure” form of HSP is a characterized by a progressive spastic paraplegia, often associated with lower urinary tract symptoms (LUTS) (72.4% to 77.6%) [2] , [3] . However, urologic complications are rarely reported. The aim of this study was to characterize clinical and urodynamic aspects of LUTS following HSP, and to describe treatment and urological complications of LUTS in a large series of HSP patients. Materials/patients and methods We performed a monocentric retrospective evaluation based on review of medical records of HSP patients admitted in the department of PRM from 1999 to 2016. Inclusion criteria were patients > 18 years. Presenting HSP. Clinical, urodynamic and radiologic data were recorded. Statistical analysis was performed using Microsoft Excel software. Results Thirty-three HSP patients were included. Mean age was 62 ± 14 years with 70% of men. The mean follow-up was 8.10 ± 5 years. Patients presented LUTS: urgency (85%), hesitancy (85%), nocturia (56%) and urinary incontinence (54%). The post-void residual volume (PVR) was over 100 mL in 70%. NDO was diagnosed according to urodynamic testing in 83% of patients, associated in 76% of them with a detrusor-sphinctger-dyssinergia (DSD). HSP patients were exposed to urologic–nephrologic complications: febrile urinary tract infections (25%), urolithiasis (21%), hydronephrosis (8%) and renal failure (17%). HSP patients have been mainly treated with anticholinergics (69%) and 10% were switched to intradetrusor botulinum toxin. Clean intermittent catheterization was performed by 30% of patients. Three patients underwent a non-continent surgical urinary diversion. Discussion/conclusion A significant percentage of HSP patients presenting LUTS mainly resulting of the association of PVR, DO and DSD. However, for the first time, uro-nephrologic complications following LUTS related to HSP are underlined. Thus, HSP patients should be assessed, such as SCI patients, in order to improve management and HSP patients’ quality of life with a decrease of uro-nephrologic complications.

We evaluated the long-term safety and efficacy of an adjustable continence device (ACT® or ProACT™) in male and female patients with neurogenic stress urinary incontinence.Data on patients consecutively treated with implantation of an adjustable continence device due to neurogenic stress urinary incontinence were reviewed from the start of our experience to the current 4-year followup.We reviewed data on 13 male and 24 female patients with neurogenic stress urinary incontinence due to different forms of pelvic nerve or spinal cord lesions. Mean ± SD age at implantation was 46.2 ± 17.4 years. Of the patients 92% performed clean intermittent self-catheterization. The device was implanted bilaterally using general and local anesthesia in 16.2% and 83.8% of cases, respectively. From before implantation to 48-month followup the mean number of urinary incontinence episodes decreased from 6.1 ± 2.4 to 2.8 ± 3.1 and the mean number of pads used per 24 hours decreased from 4.2 ± 2.7 to 2.2 ± 2.2. Of the patients 54.5% indicated more than 50% improvement of stress urinary incontinence symptoms after 48 months, of whom 38.9% indicated complete continence. Adverse events included erosion/migration, device infection or failure, implantation site pain, bladder stone formation and difficult clean intermittent self-catheterization.Implantation of the ProACT/ACT device in patients with neurogenic stress urinary incontinence is minimally invasive and safe. It can significantly improve neurogenic stress urinary incontinence in the long term. Thus, it might be a reasonable option for patients who are not willing, not suitable or not yet ready for more invasive surgery, such as artificial urinary sphincter or fascial suspension sling placement.

To study clinical and urodynamic data along with immediate and long-term morbidity of surgical management of neurogenic bladder in spinal cord injury (SCI) patientsSingle-center retrospective study of 61 SCI patients with neurogenic detrusor overactivity (NDO) related urinary incontinence and/or sphincter weakness incontinence who underwent supratrigonal cystectomy with Hautmann pouch ± concomitant stress incontinence procedure (27.9%; n = 17).With a mean follow-up of 5.84 years (range 1-20.5) an improved or total continence rate was achieved in 89.7% and 74.1%, respectively. Surgery failed (incontinence persisted) for six (10.3%) patients, three of which had a simultaneous procedure for stress incontinence. On urodynamics, maximum cystometric capacity (MCC) (ml) increased from 305.2 to 509.4 (P 0.05), mean compliance (ml/cmH(2) O) increased from 15 to 42.7 (P 0.05) and mean detrusor pressure at MCC (cmH(2) O) fell from 54.1 to 19.1 (P 0.05). Persisent NDO occurred in 20.7% compared to 59% pre-operatively (P 0.05). The overall complication rate was 37.7% but ≤Clavien grade 2 in 82.6%. Notably, the incidence of bowel dysfunction, namely diarrhea and/or fecal incontinence was 27.5%. Concomitant outlet surgery was associated with increased morbidity as three (17.6%) complications led to re-intervention.Supratrigonal cystectomy with Hautmann pouch is an excellent surgical treatment for SCI patients suffering from refractory NDO incontinence. It achieves the main goals of achieving continence (74% complete), reducing rates of infection and preserving upper tract function, which is reflected in the improvement on urodynamics. The incidence of secondary bowel dysfunction and potential risk of a simultaneous procedure for stress incontinence needs to be discussed.

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 multicentric study enrolled 70 MS patients, suffering from OAB for a 3-month study period.Daily sessions of 20 min of TPTNS were provided. No change of associated treatments during the study period. The primary outcome measurement was Urgency and Frequency reported by bladder diary and symptom score performed before the treatment (Day 0, D0) and at D30 and D90. The secondary outcomes measurements were continence, symptom score, quality of life, psychosocial burden at DO, D30, and D90 and cystometry at baseline, with and without TPTNS and at D90.Clinical improvement of OAB was shown in 82.6% and 83.3% of the patients on D30 and D90, respectively, with significant improvement of primary and secondary outcomes compared to baseline. The initial acute cystometric response to TPTNS was positive in 51.2% of the patients (increase of30% of cystometric capacity and/or reflex volume), without correlation with TPTNS clinical efficiency. The procedure was well tolerated.Chronic TPTNS appears to be effective in the management of severe OAB in MS, without compromising bladder emptying or inducing side effect. Treatment may be effective even in the absence of an acute cystometric effect. Additional works are required to demonstrate long-term efficacy of TPTNS.

Urinary symptoms are frequent in case of neurologic diseases, symptoms depends on the pathology as well as the extend and the location of the disease. Initial evaluation includes clinical, biological, urodynamic and radiologic assessment in order to precise symptoms quality of life and risk factors of medical complications. Treatment efficacy, adaptation to incapacities, evolution of the disease and complications require close follow up specially in the spinal cord injury and myelomeningocele population. Multidisciplinary approach is often required to optimise treatment strategy.

Laffont I, Guillon B, Fermanian C, Pouillot S, Even-Schneider A, Boyer F, Ruquet M, Aegerter P, Dizien O, Lofaso F. Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia. Objective To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3). Design A single-center, open-label study. Setting A physical medicine and rehabilitation hospital. Participants Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs. Interventions Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair. Main Outcome Measures Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs. Results All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight ( P =.001), dimension ( P =.006), and effectiveness ( P =.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair—for example, curb clearing and stair climbing—were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively). Conclusions The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.

Bladder compliance is defined by the ratio of the increase of intravesical pressures to the increase of volume (_V/_P). The pathophysiology of disorders of compliance in neurogenic bladder is still poorly elucidated. It can be evaluated in terms of three elements: 1) The natural history of the appearance of these disorders in neurogenic bladders. Clinical experience shows the existence of prognostic factors that determine the development of these disorders, such as the voiding mode adopted (self-catheterization/hetero-catheterization versus indwelling catheter), the level of the spinal cord lesion (suprasacral versus sacral, incomplete versus complete, and cauda equina lesions), and the presence of meningomyelocele. 2). Data derived from conservative management of these disorders in neurogenic bladders: urethral dilatation, various sphincterotomies, bladder disafferentation, alpha-blockers, vanilloids (resiniferatoxin and capsaicin), intra-detrusor botulinum toxin and intrathecal baclofen, have demonstrated a marked improvement of disorders of compliance associated with neurogenic bladder 3). Data derived from experimentations. Morphometric studies on animal or human bladder strips have demonstrated an increased expression of proteolytic enzymes and endogenous tissue inhibitors of metalloproteinases (MMP-1) and type III collagen mRNA in hypocompliant neurogenic bladders. Reduction of bladder wall blood flow, bilateral section of hypogastric nerves in rats, study of the bladders of spinalized rats, and reduction of oestrogenic hormone impregnation, show that these conditions induce loss of the viscoelastic properties of the bladder With the arrival of new treatments, active on afferent and/or efferent pathways or even on the central nervous system, it is very important to further our understanding of the pathophysiology of disorders of compliance in neurogenic bladders. Reversibility of these disorders constitutes a major therapeutic challenge and its functional consequences make it a critical prognostic factor for the outcome of neurogenic bladder

Multiple dramatic consequences follow medullary lesions. Not only are voluntary motor control and sensitivity of the body segment below the lesion lost, but it also becomes impossible to control erection and ejaculation as well as urinary and faecal continency. The first investigations into genito-sexual function in paraplegics have brought about the idea, commonly admitted in the medical world, that this kind of patient is impotent and sterile. Fortunately this idea is disappearing gradually and many data have demonstrated that appropriate treatment is required and some therapies efficient. This is particularly important in the case of the population concerned, namely young men in 70% of the cases, since the usual age bracket at trauma is between 25 and 35 years old. At this time of life, sexual activity is often at its peak, so that the fertility potential becomes erased.