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OBJECTIVE: To assist urologists in the management of andrological and sexual medicine pathologies during the COVID-19 crisis. MATERIAL AND METHOD: Use of the formalized consensus method. RESULTS: The medical and surgical management of patients in andrology and sexual medicine must be adapted. Consultations should, as far as possible, be carried out by tele-consultation. For operative procedures, the delay between the operative decision and the date of (re)scheduling of the procedure will depend on: (1) the level of criticality of the clinical situation; (2) the type of intervention; (3) the functional and psychological repercussions, including quality of life while waiting for the procedure; (4) the notion of losing the chance of having an optimal outcome; (5) the risk of potential complications from delaying a procedure for too long; and (6) taking into account the patient's risk factors for severe forms of COVID-19. The protection of urologists from COVID-19 should be considered. Each urologist must make the best decision for the patient, taking into account the acceptable time frame and quality of life impact before surgical management, the COVID risk parameters, the technical and anesthetic feasibility and the structural possibility of the health care institution to ensure a specific dedicated pathway during the COVID-19 health crisis. CONCLUSION: The management of andrological and sexual medicine pathologies must be adapted to the COVID-19 crisis context. Some patients may require surgery, including in emergency. These recommendations are transitional and will end with the COVID-19 crisis.

Objectifs L’IRM est l’examen d’imagerie de reference actuelle pour la recherche des cancers de prostate cliniquement significatifs (CPcs). La micro-echographie (MUS) est une nouvelle technologie qui a la capacite d’identifier des lesions suspectes. L’objectif principal de notre etude est de comparer les performances de l’IRM et de la MUS pour la detection des CPcs. Methodes De novembre 2017 a decembre 2020, 314 hommes ont beneficie des biopsies de prostate a l’aide du micro-echographe ExactVu 29 MHz pour suspicion de cancer de prostate localise dans un seul centre. La suspicion de cancer etait basee sur une elevation du PSA et/ou un toucher rectal anormal et/ou une IRM suspecte. Tous les patients ont eu une MUS pre-biopsie. Le Prostate Risk Identification using MUS (PRI-MUS) a ete utilise pour classer les cibles. Des biopsies ciblees (basees sur la MUS et l’IRM) et des biopsies systematiques ont ete effectuees. Les cibles etaient definies par des images PIRADS ≥ 3 or PRI-MUS ≥ 3. Resultats Les performances de la MUS et l’IRMmp pour la detection des CPcs etaient respectivement pour la sensibilite 90,7 % contre 80,7 %, pour la valeur predictive negative 87 % contre 76,7 %, pour la specificite de 29,3 % contre 27,9 %, et pour la valeur predictive positive de 37,7 % contre 32,9 %. Concernant les discordances 14 patients (4,1 %) avec une IRM negative et une MUS positive qui avaient du CPcs. Six patients (1,7 %) avec MUS normale et IRMmp suspectes avaient du CPcs. Seulement 3 patients avaient une IRM negative et une MUS negative avaient du CPcs. Conclusion La micro-echographie 29 MHz possede une meilleure sensibilite et specificite compare a l’IRM pour la detection des cancers de prostate cliniquement significatifs. La MUS donne des informations supplementaires et ameliore la detection des CPcs.

Objectifs La micro-echographie haute resolution est une nouvelle technique ultrasonore 29 MHz pour les biopsies de prostate ciblees en temps reel. La resolution micro-echographique de 70 microns permet de visualiser les caracteristiques tissulaires. Il a ete demontre que la micro-echographie avait une sensibilite superieure a l’echographie conventionnelle pour la detection du cancer de la prostate. Methodes Les images de 16 patients ayant subi une prostatectomie radicale apres une biopsie de prostate guidee par micro-echographie (ExactVu, Exact Imaging Markham, Canada) ont ete utilisees. Les images micro-echographiques de tous les sujets ont ete evaluees pour predire l’extension extra-prostatique a l’aide de l’image caracteristique en halo anterieur/apical et/ou de retrecissement ou interruptions de la capsule posterieure. Les comptes rendus anatomopathologiques des prostatectomies radicales ont ete utilises comme references. Resultats Les comptes rendus anatomopathologiques des pieces de prostatectomies radicales rapportaient une extension extra-prostatique dans 15/32 lobes de prostate chez 11/16 patients. La sensibilite globale pour la detection de l’extension extra-prostatique etait de 91 % (10/11 patients) avec des valeurs predictives positive et negative de 91 % (10/11) et 80 % (4/5 patients) respectivement. En analysant chaque lobe prostatique de facon independante, la sensibilite etait de 87 % (13/15 lobes) et les valeurs predictives positive et negative de 87 % (13/15) et 88 % (15/17). Conclusion La micro-echographie 29 MHz apparait comme un bon outil predictif de l’extension extra-prostatique en anterieur comme en posterieur. L’extension extra-prostatique est caracterisee en micro-echographie par un halo epais ou irregulier le long de la capsule apicale et/ou anterieure, caracteristique n’ayant pas ete decrite auparavant en echographie conventionnelle. L’analyse d’une base de donnees plus importante permettra de corroborer ces resultats.

Resume Introduction La reeducation erectile apres prostatectomie totale est definie comme l’utilisation de tout traitement pharmacologique ou mecanique permettant d’ameliorer le retour d’erections spontanees apres prostatectomie totale. Les donnees experimentales suggerent l’interet des phosphodiesterases 5 (IPDE5) dans cette indication pour maintenir l’oxygenation tissulaire. Proposee par 54 a 87 % des urologues en postoperatoire, l’interet clinique de la reeducation erectile est cependant discute. Methodes Une revue critique de la litterature entre janvier 2000 et mars 2014 concernant les principales etudes publiees sur l’utilisation des IPDE5, des injections intracaverneuses de prostaglandine E1 (IIC) et de l’erecteur a depression dans cette indication est proposee. Resultats Les resultats cliniques issus de 3 etudes prospectives randomisees sont contradictoires pour les IPDE5. Elles n’ont pas montre d’effet a long terme de la prise quotidienne ou a la demande en comparaison du placebo a l’issue de la periode de traitement. Des criteres de selection de patients pouvant beneficier de cette approche apparaissent mais restent a confirmer. L’utilisation des injections intracaverneuses et de l’erecteur a depression est discutable en l’absence d’etudes solides. La reeducation erectile semble efficace dans la prevention du raccourcissement de verge frequent apres prostatectomie totale. Conclusions Les patients doivent etre informes de ces incertitudes avant de s’engager dans cette prise en charge necessairement longue pour esperer une efficacite. Lorsqu’elle est utilisee, il est conseille de la combiner a d’autres modalites therapeutiques pour l’obtention d’erections permettant les rapports pour entretenir la motivation du couple et reduire la frequence des abandons therapeutiques.

Objectifs La surveillance active (SA) est une recommandation de premiere intention chez les patients ayant un cancer de prostate a faible risque evolutif. Il est demontre qu’il n’y a pas de risque a court terme de resultats anatomopathologiques degrades du fait du delai d’intervention par rapport au diagnostic. Cependant, ce risque n’est pas connu a moyen terme. Methodes Au total, 102 patients (pts) avec un recul theorique d’au moins 5 ans (inclusion jusqu’en 12/2012), issus d’une base observationnelle de 189 pts en sa inclus depuis 2007 pour un cancer de prostate a faible risque initial (criteres prias) font l’objet de cette etude. L’âge median etait de 65,2 ans [48,3–79,7]. Au total, 89,2 % etaient classes t1c et 10,8 % t2a. Un total de 85,76 % ont un recul de suivi > 1 an. Durant celui-ci,27 pts ont eu une prostatectomie totale de 2e intention. Le motif etait: choix personnel (6 pts), recommandation du protocole (12 pts), choix du chirurgien (9 pts). Resultats Les resultats anatomopathologies des pieces de prostatectomie sont classes en favorable (pt2 et score de Gleason 3 + 3) 12 pts (44 %) dont 11 r0, intermediaire (pt2 et score de Gleason 3 + 4) 4 pts (15 %) dont 2 r0, defavorable (≥ pt3 ou score de Gleason ≥ 4 + 3) 11 pts (41 %) dont 3 r0. Concernant le groupe de resultats favorables pouvant potentiellement poursuivre la sa, il s’agissait d’un choix personnel (83 %), du chirurgien (67 %) ou du protocole (25 %). Pour le groupe defavorable, 6 etaient ≥ pt3 (aucun pt3b), 2 avaient un score de Gleason 4 + 3 et 3 un score de Gleason ≥ 4 + 4. Conclusion Parmi les pts ayant eu une prostatectomie de 2e intention, 44 % avaient un resultat favorable permettant theoriquement la poursuite la sa. Il s’agissait souvent d’un choix personnel du patient ou du chirurgien. L’amelioration de l’information au patient et des outils de surveillance (notamment l’IRM) devrait permettre de reduire la part des traitements curatifs sans risque carcinologique supplementaire.

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX(®) ("Fracture Risk Assessment Tool") algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

In case of biochemical recurrence after radical prostatectomy, hormonal treatments are equally efficient. Early hormonal treatment after biochemical recurrence reduces specific mortality, local and metastatic progression. In locally advanced prostate cancer, adjuvant radiation therapy after biochemical recurrence reduces local and metastatic recurrence. Withdrawal of the steroid hormone should be the first maneuver after primary hormonal therapy failure. Second generation anti-androgens (abiraterone and MDV 3100) should be released soon. These new hormonal agents are in clinical trials and show promising activity in patients with CRPC.

The aging of the population has resulted in an increase in the number of elderly patients with prostate cancer. Among the curative treatment options in the elderly subject, external radiotherapy is the most frequently chosen option. Combined treatment including radiotherapy and hormone therapy should be preferred to hormonal therapy alone, including in elderly patients, whenever life expectancy surpasses 4-5 years. The indications for this radiotherapy should be defined in an attempt to prevent excessive or insufficient treatment, to adapt the treatment modalities to the patient's age by assessing its potential toxicity, and to discuss the possible alternatives. In cases of localized prostate cancer in men who are aging well, a standard treatment should be proposed, preferring radiotherapy possibly associated with hormone therapy in cases with negative prognostic factors. Patients with a reversible health problems can also receive standard treatment, notably in cases with aggressive prognostic factors.

Male infertility is present in 50% of couple infertility. Diagnosis of infertility requires methodical and rigorous approach based upon knowledge of the pathophysiology and the causes of infertility.

Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.

Aunque el objetivo del urologo sigue siendo corregir los factores masculinos de infertilidad y dar prioridad a una reproduccion natural, el tratamiento debe inscribirse en el enfoque terapeutico de la pareja y tener en cuenta la fertilidad femenina. Algunas infertilidades masculinas tienen un tratamiento especifico. En los demas casos, sobre todo en los mas graves, los progresos recientes de la reproduccion asistida han modificado el pronostico de las infertilidades masculinas e incluso de las mixtas. La micromanipulacion de gametos permite sustraer los espermatozoides a las condiciones naturales de seleccion y de fecundacion, asi como obtener gestaciones clinicas en las situaciones mas complejas. No obstante, estas tecnicas exponen a la descendencia a una transmision de enfermedades geneticas. Este riesgo destaca la necesidad de una valoracion genetica de las infertilidades masculinas mas graves. Dicho estudio debe guiar al urologo para realizar un tratamiento rapido de la pareja, evitando las exploraciones inutiles y los tratamientos medicos o quirurgicos ineficaces.

La infertilidad masculina se encuentra presente en mas del 50% de los casos de infertilidad de la pareja, de forma aislada o no. Su diagnostico requiere un enfoque metodico y riguroso, basado en el conocimiento de los mecanismos anatomofisiologicos y de las causas potenciales de infertilidad.

El diagnostico de la infertilidad masculina requiere un enfoque metodico, y en primer lugar clinico, con la finalidad de identificar todos los factores potenciales de infertilidad. Las pruebas de laboratorio y radiologicas permiten confirmar uno o mas diagnosticos, asi como evaluar el pronostico y las posibilidades terapeuticas del trastorno.

The diagnosis of male infertility requires methodical approach which is primarily clinical, aimed at identifying all potential factors. Biological and radiological assessments allow diagnosis confirmation, and evaluation of both prognosis and therapeutic strategy.

Resume Le traitement des dysfonctions erectiles a evolue au cours des dernieres annees. Si la prise en charge etiologique reste d'actualite lorsqu'elle est identifiee, le symptome demeure la cible privilegiee. Les traitements oraux (inhibiteurs des phosphodiesterases V) facilitateurs de l'erection, dont les caracteristiques pharmacologiques permettent pour certains d'eviter une programmation de l'acte avec peu d'effets secondaires, sont devenus en quelques annees la principale option therapeutique. Cependant, les injections intracaverneuses de prostaglandine E1 gardent une place importante en premiere intention ou en rattrapage apres echec des traitements oraux. De meme, les erecteurs a depression peuvent egalement etre une alternative pour les patients ne pouvant pas realiser les injections. Malgre les progres pharmacologiques, les implants peniens restent indiques en cas d'echecs des traitements moins invasifs. Chez des patient bien informes, et poses par des urologues ayant une bonne pratique de cette chirurgie, le taux de satisfaction est important. En quelques annees, l'arsenal therapeutique s'est donc considerablement enrichi et permet de traiter pratiquement tous les patients impuissants qui en font la demande.

Resume Objectif. – Evaluer l’echographie endovaginale pour expliquer les troubles mictionnels observes dans les suites du TVT® (Tension-free Vaginal Tape). Patientes et methodes. – Cinquante-quatre patientes ont beneficie d’une echographie endovaginale trois mois apres TVT avec mesure de la taille de la bandelette et de sa distance par rapport au col vesical. Parallelement, la guerison (groupe 1), l’existence de troubles mictionnels a type de dysurie (groupe 2), l’existence d’imperiosites (groupe 3) ou la persistance de fuites urinaires sont evaluees par un autoquestionnaire et un examen clinique. Les analyses statistiques utilisent le test de comparaison de variance (Anova). Resultats. – L’analyse des mesures de la distance bandelette–col vesical montre une difference significative entre les groupes 1 et 2 : 13,2 vs 7,6 mm et entre les groupes 1 et 3 : 13,2 vs 17,7 mm. De meme, il apparait une difference significative dans l’analyse des tailles de bandelettes entre les groupe 1 et 2 : 8,8 vs 6,6 mm et entre les groupes 1 et 3 : 8,8 vs 6,5 mm. L’analyse des distances bandelette–col vesical dans les groupes 2 et 3 montre une difference significative : 7,6 vs 17,7 mm. En revanche, la taille de la bandelette n’est pas significativement differente entre ces deux groupes (6,6 vs 6,5 mm). Discussion et conclusion. – Ces resultats montrent une correlation entre les differents troubles mictionnels observes a distance du TVT et la mesure echographique par voie endovaginale de la distance entre la bandelette et le col vesical.

Purpose: Endothelial P2y purinoceptor stimulation is known to induce vasodilatation mediated by NO release from endothelial cells. We examined the effect of a potent P2y agonist, adenosine-5′-O-(2-thiodiphosphate) (ADP beta S), on human corporal cavernosal strips and its dependence on a functional endothelial lining.Materials and Methods: The preparations mounted in isometric conditions were precontracted by noradrenaline (NA) at a concentration of 0.1 micro M. Increasing concentrations of ADP beta S from 1 micro M to 100 micro M were added in the presence and absence of a functional endothelium or in the presence and absence of an NO synthase inhibitor and a selective P2y antagonist. Acetylcholine (Ach)-induced relaxation was used in each experiment for control.Results: In human precontracted corporal cavernosal strips with a functional endothelium (relaxed by acetylcholine) ADP beta S induces a dose-dependent relaxation with maximal relaxation of 45.5 +/− 5.0% and an EC50 of 11.7 micro M. The re...

To analyze patients' views with regards to local consultations given by specialists in urology and to an offer of pre- and postoperative visits in the local general hospital with surgical interventions taking place at the university hospital.An opinion survey by mail questionnaire was carried out in all 473 patients who had had a consultation with a specialist in two local general hospitals between November 2009 and April 2010.Response rate was 74%. Mean patient age was 65.5 ± 12 years [range, 20-90]. The reason for the consultation was cancer-related in 31.2% of patients. The majority (89%) made the journey to hospital under their own steam and would have had to travel a 4 times greater distance if the consultation with the specialist had taken place at the university hospital. Overall, 54.6% of patients were willing to travel 20 km further to see a specialist and 76.5% were willing to travel 20 km further for a surgical intervention. Virtually all of the patients (99%) saw benefits to local consultations given by specialists. The offer of a consultation at the general hospital and intervention at the university hospital met with the approval of 60.8% patients and 56.3% had already experimented this offer.Local consultations by specialists might be an answer to demographic issues in France, that is, to the small number of urologists practicing in general hospitals.

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX(®) ("Fracture Risk Assessment Tool") algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

Androgen deficiency of the aging male is a pathological syndrome and should not be viewed simply as a stage in physiological aging. It is often overlooked despite evidence for a deleterious impact on many physiological processes and on quality of life. Its identification should be part of the routine practice of physicians in charge of this population, in particular general practitioners and specialists treating associated comorbidities (e.g. metabolic syndrome, diabetes, cardiovascular disorders) or sexual dysfunction. The consultant urologist has a key role to play in prostate surveillance before and during treatment. Treatment is often simple with few side-effects. However, long-term benefits and side effects need to be investigated in prospective studies.

Intravesical instillations of BCG remains the gold standard for intermediate and high risk NMIBC management. Maintenance treatment is recommended, however, the frequency of side effects responsible for the discontinuation of maintenance therapy over four out of five patients before the third year suggest a reduction or even spacing instillations. The objective of the study URO-BCG-4 was the evaluation of a new maintenance schedule by intravesical instillations of BCG combined reduced dose (third dose) and a decrease number of instillations per cycle (two or three).Multicenter study of the French Association Oncologic Committee (12 university hospital centers), randomized, prospective, comparing reference diagram of BCG maintenance therapy one third of usual dose (group I) to a regimen combining third dose and decrease the number of instillations per cycle (two instead of three) (group II). We present the preliminary results at 1year of this Program of Clinical Research (CHU Rouen Promoter 2003-081).The rate of recurrence was respectively 9 and 7% (P=0.678) in groups I and II. The rate of tumor progression are 3 and 2.8% in groups I and II (P=1). Tolerance of intravesical instillations of BCG scored according to the WHO classification (Geneva 1979) was similar in the two groups.The decrease in the BCG dose (third dose) and the changes in the number and rate of instillations did not alter free tumor recurrence survival. The toxicity of intravesical instillations of BCG was identical in both groups. The use of the WHO classification has shown its limitations in the study of side effects of BCG as too complex and often not exhaustive. The rate of increase muscle was comparable in the two groups; however, a larger clinical experience is required.

Pathological endothelin axis is known to be involved in prostate cancer progression. Our study evaluates immunohistochemical expression of ET-1 and ET-AR on prostate biopsy specimen and the predictive value for biochemical relapse on patients with advanced and metastatic cancer. We also evaluated the impact of ET-1 and ET-AR expression on local progression and metastatic bone progression for these patients.From 1992 to June 2009, 44 patients with clinical T3 stage and metastatic lymph nodes were included. PSA levels, Gleason score in biopsy cores, number of invaded lymph nodes, the existence of nodular capsule transgression and hormonal treatment given to the patient, were analyzed. Biopsy cores were submitted to immunohistochemical study of the expression of ET-1 and ET-AR. Semi-quantitative ET-1 and ET-AR staining assessment was always realised by the same pathologist.The average age of the cohort was 65.6 (standard deviation 6.3), median PSA level was 52.8 ng /ml (3-227), median time of follow-up was 70 months (6-144). Biochemical relapse was observed in 62.8%. Statistically significant stronger ET-1 expression was observed in biopsies of patients with a biochemical relapse (p=0.014). Eighty percent of patients with a biochemical relapse had a high level of ET-AR expression, but no statistical significance has been shown (p=0.109). The relative risk for progression under hormonal therapy was 1.9 in case of high level of ET-1 expression and biochemical relapse was confirmed 8 months earlier in average. High level of ET-AR expression on biopsy cores may indicate earlier local progression and metastatic bone progression but there were no statistical proof.In our study, the strength of ET-1 expression in prostate cancer biopsy cores is a prognostic factor of biochemical relapse for cT3 stage patients with metastatic lymph nodes. We have not been able to prove that ET-1 is an independent prognostic factor. A high level of ET-AR expression on prostate biopsy cores is not, in our study, a prognosis factor for predicting the biochemical relapse.

Objectifs La surveillance active (SA) est une option de prise en charge avec traitement differe a un stade potentiellement curable si necessaire. L’objectif est d’evaluer les resultats anatomo-pathologiques apres biopsie prostatique a 1 an, dans une cohorte issue d’un protocole prospectif de surveillance active (SA) (criteres d’inclusion PRIAS) pour les adenocarcinomes de prostate a faible risque evolutif. Methodes Etude observationnelle prospective (2008–2014) de 116 patients en SA (inclus dans l’etude internationale PRIAS) pour un adenocarcinome de prostate T1c/T2 a faible risque. Les criteres d’inclusion etaient : PSA initial ≤10 ng/mL, densite du PSA Resultats A l’inclusion 61,21 % des patients avaient 1 biopsie positive, et 38,79 %, 2 biopsies positives avec un PSA median a 5,5 ng/mL et un âge median de 64,7 ans. Au TR, 88,8 % etaient T1c et 11,2 % T2a. A 1 an, 83 patients ont ete biopsies (33 manquants : 6 inclusions Tableau 1 , Tableau 2 ). Conclusion Les biopsies a 1 an etaient negatives dans 1/3 des cas et montrent une progression dans 36,14 % soit par le nombre de carottes ou le score de Gleason ou les deux. Les patients choisissant la SA doivent etre informes initialement de la necessite d’un controle biopsique a court terme et des resultats a en attendre.

Active surveillance as an alternative approach to immediate curative treatment is demonstrated for an increasing number of patients with low risk prostate cancer. Optimization of selection and surveillance criteria to guarantee a low risk issue to patients are discussed in this review. They lead to consider active surveillance as an option rather than a standard of care for patients ideally included in clinical research protocols.

In case of biochemical recurrence after radical prostatectomy, hormonal treatments are equally efficient. Early hormonal treatment after biochemical recurrence reduces specific mortality, local and metastatic progression. In locally advanced prostate cancer, adjuvant radiation therapy after biochemical recurrence reduces local and metastatic recurrence. Withdrawal of the steroid hormone should be the first maneuver after primary hormonal therapy failure. Second generation anti-androgens (abiraterone and MDV 3100) should be released soon. These new hormonal agents are in clinical trials and show promising activity in patients with CRPC.

The aging of the population has resulted in an increase in the number of elderly patients with prostate cancer. Among the curative treatment options in the elderly subject, external radiotherapy is the most frequently chosen option. Combined treatment including radiotherapy and hormone therapy should be preferred to hormonal therapy alone, including in elderly patients, whenever life expectancy surpasses 4-5 years. The indications for this radiotherapy should be defined in an attempt to prevent excessive or insufficient treatment, to adapt the treatment modalities to the patient's age by assessing its potential toxicity, and to discuss the possible alternatives. In cases of localized prostate cancer in men who are aging well, a standard treatment should be proposed, preferring radiotherapy possibly associated with hormone therapy in cases with negative prognostic factors. Patients with a reversible health problems can also receive standard treatment, notably in cases with aggressive prognostic factors.

Prostate cancer (PaC) is a significant health problem. Elderly have the highest incidence of the disease as age is its strongest risk factor. Despite its complications, the use of androgen suppression in aging patients with prostate cancer has become extremely frequent with probable excess. However, some of these complications carry specific mortality and all of them have a negative impact on quality of life. It is critical to perform a geriatric assessment, concerning physical, mental and social items, before to consider androgen suppression in this population. Indications of androgen suppression for the treatment of prostate cancer follow the guidelines of CCAFU. Delayed treatment deserves a special attention when possible. Treatment modalities are no specific to the elderly, but complications have to be anticipated with preventive measures. Intermittent androgen suppression should be considered with caution. Close follow up will focus on the diagnosis of adverse effects of androgen suppression.

Only few studies have been published regarding the results of radical Prostatectomy (RP) in elderly patients. The available data suggest that advanced age does not increase the postoperative mortality and morbidity rates, as far as reasonable selection is performed. Similarly, oncological results of RP are similar in patients aged70 years and in younger patients. Only the risk of incontinence may be increased, with a potential impact on quality of life. There are no studies comparing the various curative treatments of Prostate cancer (RP, radiation therapy, brachytherapy, active surveillance) in the elderly population.

Background Renal allograft vascular thrombosis is a complication that often results in graft loss. Since there are no guidelines on immediate postoperative thromboprophylaxis, we performed a telephone survey of clinical practice in all renal transplantation centers in France. Methods Each center considered 4 cases relating to renal transplant candidates on dialysis with an increasing risk of thrombosis: Case 1: patient with no identified risk factors; Case 2: patient with an earlier incidence of deep vein thrombosis; Case 3: patient with ischemic heart disease on antiplatelet therapy; Case 4: patient with atrial fibrillation taking a vitamin K antagonist (VKA) with lupus nephritis syndrome. Results The treatments proposed by the centers (%) were: Case 1: No anticoagulation therapy (57.1%), calcium heparin at prophylactic doses (P-dose) (40%), or unfractionated heparin (UFH); (P-dose; 2.9%). Case 2: No anticoagulation therapy (34.3%), calcium heparin (P-dose; 51.4%), or UFH (P-dose; 5.7%). Case 3: (A) Interruption of aspirin (65.7%), and either no anticoagulation therapy (21.7%) or substitution of aspirin by calcium heparin (P-dose; 56.6%) or by UFH (P-dose; 8.7%). (B) No interruption of aspirin (34.3%), and either no additional prophylaxis (58.3%) or calcium heparin (P-dose; 33.3%). Case 4: Interruption of VKA (100%), and UFH at a curative dose (68.6%), UFH (P-dose; 14.3%), or calcium heparin (P-dose; 11.4%). Conclusions Practices varied widely in the absence of studies of sufficiently high power. There is a need for a preoperative classification of thrombotic and hemorrhagic risk among renal transplant candidates and for consensus guidelines.

The identification of fusion genes provides new insights into the initial mechanisms of molecular events implicated in the prostate cancer tumorigenesis. The presence of TEMPRSS2-ETS fusion in up to half of all human prostate cancer makes it perhaps the most common genetic rearrangement in human epithelial tumors. Some data suggest that TMPRSS2-ERG fusion prostate cancers have a more aggressive phenotype, which may affect cancer progression and outcome in localized tumors treated with prostatectomy. This discovery should pave the way towards future targeted therapies.

To assess the impact of RP on patients' sexual desire and orgasm.Prospective, cross-sectional survey using a 16-item self-administered questionnaire. We assessed relevant domains of male sexual function (erectile function, sexual desire, and orgasm), psychological impact and treatment of ED.A total of 63 consecutive patients after RP were included (mean age: 63.9). Median time between questionnaire and RP was 26.8 months (range 6-67). After RP, 74.6 % of patients used ED treatments. Lower sexual desire and intercourse frequency were reported in respectively 52.4 and 79.4 %. Orgasm was modified in most patients: 39.7 % described loss of orgasm and 38.1 % reported decreased intensity. Involuntary loss of urine at orgasm (climacturia) was reported in 25.4 %. Negative psychological impact was reported in 68.3 % (loss of self-esteem, loss of masculinity, anxiety).RP adversely affected erectile and orgasmic functions but also sexual desire, self-esteem and masculinity despite treatments. Candidates for RP should be aware of ED but also of other postoperative sexual dysfunctions.

To evaluate the recommended erectile dysfunction treatment algorithm for men over age 65.Between 2004 and 2006, 334 men were treated for ED at our institution, of whom 64 were greater than 65 years old (19.2%). Medical history, ED treatments and patients' satisfaction were reported. The first line therapy was PDE 5 inhibitors except after radical prostatectomy, followed by intracavernous injections (ICI). When conservative treatments failed, penile prosthesis was proposed. Mean follow up was 23.7 months.Mean age was 69.2 years (65-81). Aetiology of ED was organic in 85.9% (39.1% after radical pelvic surgery) and partially drug induced in 45.8%. With PDE 5 inhibitors, the mean success rate was 26.5 and 7.1% after radical pelvic surgery. Because of cost, 30.8 % of satisfied patients stopped PDE 5 inhibitors. Mean ICI success rate was 60.4% but 34.5% of satisfied men interrupted them. Finally, 14% of patients were successfully treated by PDE 5 inhibitors and 29.7% by ICI. Penile prosthesis was implanted in 12 patients (18.7%) with a mean success rate of 83.3%. No successful ED treatment was found in a third of patients.PDE 5 inhibitors after 65 were found to be less successful as envisaged. This study points out the probable inadequacy between the patients' expectations and the therapeutic options, including socioeconomic terms.

Graft thrombosis is a major complication of transplantation. However, there are no recommendation on immediate postoperative thromboprophylaxis after kidney transplantation. We recorded clinical practices in France.In 29 transplantation centres, four case studies were submitted to the medical kidney transplantation referent (compatible graft from cadaveric donor, without perioperative complication). N(o) 1: Man, 27-years-old, IgA glomerulonephritis, without history of hypercoagulability or cardiovascular risk factor. Hemodialysis since 12months. N(o) 2: Man, 53-years-old, with history of deep venous thrombosis after cholecystectomy 15years before. Membranous nephropathy. Hemodialysis since 10months. N(o) 3: Man, 58-years-old, with history of myocardial infarction. On aspirin therapy. Nephroangiosclerosis and diabetic nephropathy. Peritoneal dialysis since 6months. N(o) 4: Woman, 63-years-old. Atrial fibrillation on vitamin K antagonists therapy. Lupus nephritis without antiphospholipid syndrome. Hemodialysis since 12months.N(o) 1: No anticoagulation therapy (62%), calcium heparin at prophylactic doses (34.5%). N(o) 2: No anticoagulation therapy (38%), calcium heparin at prophylactic doses (44.8%). N(o) 3: 62% interrupted aspirin of whom 22% without any immediate anticoagulation and 55% replaced aspirin with calcium heparin at prophylactic doses. Thirty-eight percent carried on with aspirin of whom 63.6% without other prophylaxis and 27.3% in association with calcium heparin at prophylactic doses. N(o) 4: Unfractionned heparin at curative dose (62%), unfractionned heparin at prophylactic doses (17.2%), calcium heparin at prophylactic doses (13.8%).Postoperative anticoagulation after renal transplantation is established as a local dogma rather than evidence-based medicine. Guideline recommendations and standardized protocols for the use of anticoagulation after kidney transplantation should be developed.

Male infertility is present in 50% of couple infertility. Diagnosis of infertility requires methodical and rigorous approach based upon knowledge of the pathophysiology and the causes of infertility.

Although the objective of the urologist is to correct the factors of male infertility and to favour natural procreation, the strategy must consider also the couple and the female aspects of infertility. Some types of male infertility require specific treatment. In severe cases, recent advances in medical assistance to procreation have changed the prognosis of male infertility. Pregnancy can be obtained by the means of gamet manipulation and spermatozoid selection. Nevertheless, such techniques expose to genetic disorders transmission. Subsequently, genetic assessment is required during male infertility management, especially for difficult cases.

The diagnosis of male infertility requires methodical approach which is primarily clinical, aimed at identifying all potential factors. Biological and radiological assessments allow diagnosis confirmation, and evaluation of both prognosis and therapeutic strategy.

This study was carried out to evaluate the ultrasonographic findings on patients with voiding disorders after the tension-free vaginal tape procedure (TVT).Fifty-four women had ultrasonographic evaluation 3 months after TVT procedure. The prolene tape position was evaluated with a complete sagittal view and the width of the tape and the distance between the bladder neck and the tape were measured. In the same time, patients completely cured by TVT (group 1), postoperative dysuria (group 2), de novo urge incontinence (group 3) and ineffective treatment were evaluated with a self-questionnaire and physical examination. Statistical analysis was performed using ANOVA test.The distance between the tape and the bladder neck shows a significant difference between group 1 and 2 (13.2 mm compared to 7.6 mm) and between group 1 and 3 (13.2 mm compared to 17.7 mm). The width of the tape is significantly different between group 1 and 2 (8.8 mm compared to 6.6 mm) and between group 1 and 3 (8.8 mm compared to 6.5 mm). The distance between the tape and the bladder neck in group 2, compared with group 3, is significantly shorter (7.6 mm compared to 17.7 mm). There is no difference between the width of the tape between groups 2 and 3 (6.6 mm compared to 6.5 mm).These results show a correlation between voiding disorders after TVT procedure and transvaginal ultrasonographic measurement of the distance between the prolene tape and the bladder neck.

Midodrine hydrochloride (Gutron) is proposed to induce ejaculation in spinal injury patients desiring paternity as an alternative to vibromassage, electrostimulated ejaculation and surgical collection of spermatozoa. The authors report their experience in 10 spinal injury patients.14 trials of pharmacologically-induced ejaculation were performed in a context of medically assisted reproduction (MAR) in 10 spinal injury patients (7 with paraplegiaT11; 1 with paraplegiaor = T11; 2 with quadriplegia) an average of 4.5 years after the injury. Patients had a mean age of 28.5 years (range: 18 to 36 years). Nine had persistent reflex erections. After IC injection of prostglandin E, 10 to 30 mg of Gutron was administered by slow i.v. infusion. Spermatozoa were collected during antegrade ejaculation and/or in previously alkalinised urine.Ejaculation was obtained in 10 cases (71.4%), either antegrade (7 cases), or retrograde (3 cases). The 4 failures corresponded to ejaculation failure in 3 cases and adverse effects of Gutron (hypertension) in 1 case. However, storage of spermatozoa could be performed in only 4 cases (40%), as pyospermia or severe necrospermia were observed in 6 cases.Midodrine hydrochloride gives good results in terms of ejaculation in spinal injury patients. However, the quality of semen collected is often poor due to the long interval since the initial trauma. Midodrine hydrochloride, ideally used after antibiotic treatment, can nevertheless constitute an alternative to other techniques.