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INTRODUCTION The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery. METHOD We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison. RESULTS Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=

Resume Introduction La mise en place d’une bandelette sous-uretrale est le gold standard dans la prise en charge chirurgicale de l’incontinence urinaire d’effort de la femme en France. L’efficacite de ce materiel n’est plus a demontrer mais les complications per- et postoperatoires font l’objet a l’heure actuelle d’une controverse importante en Europe mais egalement outre-Manche et outre-Atlantique ayant conduit a la modification des indications operatoires. En France, la reglementation evolue egalement avec un encadrement plus strict des indications operatoires par RCP et une obligation de suivi postoperatoire a court, moyen et long terme. Objectifs Dans ce contexte, le CUROPF a entrepris de realiser une revue de la litterature rassemblant les preuves scientifiques disponibles concernant la survenue de complications per- et postoperatoires relatives a la pose de BSU. Materiel et methode La recherche bibliographique a ete realisee a partir de la base de donnees Medline et 123 articles ont ete retenus. Resultats L’analyse des donnees met en evidence des complications variees, dependantes du materiel implante, du terrain initial et de l’indication operatoire. La bandelette sous-uretrale retro-pubienne est pourvoyeuse de plus d’effraction vesicale peroperatoire (jusqu’a 14 %), plus de douleurs sus pubiennes (4 %) et plus de retention aigue d’urine et dysurie en postoperatoire (jusqu’a respectivement 19,7 % et 26 %). La bandelette sous-uretrale trans obturatrice est responsable de plus d’effraction vaginale peroperatoire (10,9 %), plus de douleur de membre inferieur d’origine neurologique (jusqu’a 26,7 %). Le risque de survenue d’un syndrome d’HAV est similaire dans les 2 voies d’abord (33 %). Mais ces risques de complications sont a ponderer par un fort impact de la chirurgie de l’incontinence urinaire sur l’amelioration de la qualite de vie globale de ces femmes. Conclusion Ainsi la connaissance de ces risques ne doit pas limiter l’indication de la prise en charge de l’incontinence urinaire d’effort par la pose de la BSU mais doit permettre de ponderer les indications operatoires en fonction du terrain, d’informer les patientes de maniere eclairee et les surveiller etroitement sur long terme.

To compare transcorporal vs bulbar artificial urinary sphincter (AUS) implantation in men with fragile urethra and to investigate the risk factors of AUS explantation in this population. The charts of all male patients who had an AUS implantation between 2004 and 2020 in 16 centers were reviewed retrospectively. The primary endpoint was device explantation-free survival. Only patients with a fragile urethra were included in the present analysis. Fragile urethra was defined as a urethra carrying a high risk of cuff erosion because of prior radiotherapy and/or history of AUS explantation and/or history of urethral stricture surgery. The patients were divided in two groups according to the implantation site: bulbar vs transcorporal. 464 patients were included for analysis. 88 patients underwent a transcorporal AUS implantation and 376 underwent a bulbar AUS implantation. Explantation-free survival was similar in both groups (estimated 5-year explantation free survival rates 55.3% vs. 58.4%; p=0.98). In the subgroup of patients with a history of previous AUS explantation, transcorporal approach tended to bring longer explantation-free survival (2-year explantation-free survival: 61.9% vs. 58.2%; p=0.096). In multivariate analysis, the only risk factor of shorter explantation-free survival was the history of previous AUS explantation (HR=2.65; p=0.01). Transcorporal AUS implantation was not associated with longer explantation-free survival. History of previous AUS explantation was the only risk factor associated with shorter explantation-free survival and this subgroup of patients may be the only one to draw benefits of transcorporal AUS implantation.

International audience; Purpose of review The aim of the present manuscript is to provide an overview on the current state of artificial intelligence (AI) tools in either decision making, diagnosis, treatment options, or outcome prediction in functional urology. Recent findings Several recent studies have shed light on the promising potential of AI in functional urology to investigate lower urinary tract dysfunction pathophysiology but also as a diagnostic tool by enhancing the existing evaluations such as dynamic magnetic resonance imaging or urodynamics. AI may also improve surgical education and training because of its automated performance metrics recording. By bringing prediction models, AI may also have strong therapeutic implications in the field of functional urology in the near future. AI may also be implemented in innovative devices such as e-bladder diary and electromechanical artificial urinary sphincter and could facilitate the development of remote medicine. Over the past decade, the enthusiasm for AI has been rising exponentially. Machine learning was well known, but the increasing power of processors and the amount of data available has provided the platform for deep learning tools to expand. Although the literature on the applications of AI technology in the field of functional urology is relatively sparse, its possible uses are countless especially in surgical training, imaging, urodynamics, and innovative devices.

International audience

Very popular in many parts of the world, autologous fascial pubovaginal sling (AFPVS) remains marginally used in France. However, it may be of particular interest in patients carrying a high risk of mesh-related or device-related related complications. The aim of the present series was to report the outcomes of AFPVS in this high-risk population.The charts of all female patients who underwent a fascial sling for SUI at a single academic center between April 2019 and May 2021 were reviewed retrospectively. Only patients deemed at high-risk of device/mesh related complications were included in the present analysis: female with a neurological condition who were doing clean intermittent catheterization (CIC), female with SUI after radical cystectomy and ileal neobladder, female with urethral/bladder extrusion of any synthetic material placed for SUI. Success was defined as complete resolution of SUI at 3 months.Sixteen patients were included in this study: 13 rectus fascia slings and 3 fascia lata slings. The success rate was 56.3% (9/16 patients). Four patients were improved but not completely dry (25%). Two patients had major postoperative complications (i.e. Clavien grade 3 or higher, 11.2%). Two patients had a persisting significant post-void residual (PVR) postoperatively, managed by self-catheterization (transition to self-catheterization at 3 months: 2/8, 25%).The use of autologous fascia pubovaginal sling is an interesting option in female SUI patients with high risk of device/mesh related complications with satisfactory functional outcomes.4.

Purpose:The main objective of this study was to assess the prevalence and risk factors of male artificial urinary sphincter (AUS) mechanical failures and nonmechanical failures.Materials and Method...

Background Artificial urinary sphincter (AUS) is the gold standard for the management of moderate to severe stress urinary incontinence (SUI) in the male population. While outcomes of this device in postprostatectomy incontinence (PPI) are widely described, those obtained for incontinence after benign prostatic obstruction (BPO) surgery remains poorly explored. Objective To compare continence outcomes after AUS implantation in a PPI population with those obtained in men incontinent after BPO surgery. Design, setting, and participants A retrospective review of all cases of AUS implantation between 2005 and 2020 in 16 different French centers was conducted. Only patients with primary implantation whose indication was moderate to severe SUI after prostatectomy or BPO surgery were included (excluding those with a history of radiation therapy, brachytherapy, cystectomy, high-intensity focused ultrasound therapy, or neurogenic disease). Outcome measurements and statistical analysis The primary endpoint was the rate of social continence (zero or one pad per day) at 3 mo. Complications were also noted within 90 d of implantation. Results and limitations A total of 417 patients were included in the PPI group and 50 in the BPO surgery group. Social continence rates at 3 mo were similar between the groups (79% vs 72%, p = 0.701). Complication rate was significantly higher in the BPO group (8% vs 18%, p = 0.044). The same was found for the Clavien-Dindo type 2 complication rate (20.6% vs 44.4%, p = 0.026). The retrospective nature and lack of precise definition of incontinence are the main limitations of this study. Conclusions This multicentric study strengthens the position of AUS as gold standard for SUI after radical prostatectomy. Comparable efficacy results were found for incontinence after BPO surgery, with nevertheless a higher rate of complications. Patient summary Artificial urinary sphincter represents the gold standard for the treatment of moderate to severe stress urinary incontinence. Efficacy results are comparable between postprostatectomy incontinence and incontinence after benign prostatic obstruction surgery.

Urinary incontinence after High Intensity Focused ultrasound (HIFU) is a poorly documented issue. To our knowledge, no study has evaluated the outcomes of artificial urinary sphincter (AUS) after HIFU. The aim of this study was to evaluate the functional outcomes of AUS for post-HIFU urinary incontinence.The charts of all male patients who underwent an AUS implantation between 2004 and 2020 in 13 centers were reviewed retrospectively. Only men with a history of HIFU were included. The primary endpoint was social continence at 3 months defined as wearing 0 to 1 pad per day.Out of 1318 procedures, nine men were implanted with an AUS after HIFU including four men with an history of pelvic irradiation: 3 pelvic radiation therapy and 1 prostatic brachytherapy. The patients were divided into two groups, 5 in the HIFU group without a history of pelvic irradiation, 4 patients in the HIRX group with a history of pelvic irradiation. The median age was 74 years (IQR 71-76). There was no perioperative complication. The median follow-up was 47.5 (IQR 25-85.5) months. Social continence at 3 months was 75% in the total cohort: 80% in the HIFU group and 67% in the HIRX group.AUS implantation may provide satisfactory long-term functional outcomes in the treatment of stress urinary incontinence resulting from HIFU. Larger series are needed to confirm these findings.4.

Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term.In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected.Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women.Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Objectifs Les patients en insuffisance renale terminale avec un CaP represente un dilemme de priorisation de traitement. Le traitement immunosuppresseur d’induction par Thymoglobulines expose les patients a un sur-risque d’infections et de tumeurs malignes. L’objectif de notre etude etait de comparer les Resultats oncologiques de patients avec CaP localise selon qu’ils aient ete greffes avant ou apres le traitement de leur CaP et de definir l’impact des Thymoglobulines sur la survenue ou la recidive d’un CaP en post greffe Methodes Il s’agit d’une etude retrospective monocentrique analysant les patients ayant une GR et un CaP de 1995 a 2020. Deux groupes ont ete constitues en fonction de leur sequence therapeutique : GR puis CaP (groupe 1) et inversement (groupe 2) ( Tableau 1 ). Pour la premiere question et deux groupes etaient definis suivant leur immunotherapie a l’induction pour la deuxieme question : Basiliximab (groupe 1) ou Thymoglobulines (groupe 2) ( Tableau 2 ). Le critere de jugement principal etait la recidive biologique (RB) du CaP pour les deux questions. Les criteres secondaires pour la premiere question concernaient la creatininemie, le taux de retour en dialyse, la survie du greffon et la survie globale et pour la deuxieme question le delai d’apparition du CaP par rapport a l’induction, la creatininemie apres GR, la survie du greffon et la survie du patient. Resultats Pour la premiere question 30 patients ont ete inclus, avec une egale repartition entre les groupes. Le suivi median etait de 9,83 ans [7,19–14,69]. La duree de dialyse est plus longue (3,96 vs 2,24 ans [p = 0,057]) et la survie du greffon plus courte (8,92 vs 5,06 ans (p = 0,005)) dans le groupe 2 par rapport au groupe 1. On ne rapportait pas de difference significative de RB du CaP avec n = 2/15 (13,3 %) et n = 3/15 (20 %) cas dans les groupes 1 & 2 respectivement (p = ns) ( Tableau 1 ). Pour la deuxieme question 24 patients ont ete inclus, 14 dans le groupe 1 et 10 dans le groupe 2. Le taux de RB etait similaire avec 2 (14,3 %) cas et 1 (10 %) cas dans les groupes 1 et 2 respectivement (p = 1) ( Tableau 2 ). Le delai de survenu du CaP apres GR tendait a etre plus precoce dans le groupe Thymoglobulines que dans le groupe Basiliximab (2,4 ans vs 6,2 ans respectivement [p = 0,089]). Conclusion Le delai necessaire entre la guerison du CaP et la possibilite de greffe majore le temps passe en dialyse avec ses repercussions sur la survie du greffon. Sans modifier les resultats oncologiques, priorite pourrait etre donnee a la GR en cas de CaP chez un patient en attente de GR sous reserve d’etude a plus grande echelle. Le type d’induction ne modifierait pas l’incidence du CaP chez les GR, mais les Thymoglobulines pourraient favoriser sa survenue plus precoce.

Objectifs Evaluer les caracteristiques cliniques et les resultats chirurgicaux, oncologiques et fonctionnels des patients âges de plus de 75 ans ayant beneficie d’une prostatectomie radicale robot assistee en comparant les donnees a une population standard Methodes Nous presentons une cohorte (janvier 2017–novembre 2020) d’un centre tertiaire de patients ≥ 75 ans traites par prostatectomie radicale robot-assistee avec ou sans curage lymphatique pelvien. L’option chirurgicale a ete validee par un geriatre oncologue via une evaluation geriatrique complete, considerant leur esperance de vie et leur etat de sante. Les donnees ont ete collectees prospectivement et extraites de notre base donnee. Nous comparons a un groupe controle forme de tous les patients Resultats Deux cent soixante neuf patients ont beneficie d’une prostatectomie radicale robot assiste dont 56 sont dans le groupe d’etude et 213 dans le groupe controle. Les groupes etaient similaires sur le plan demographique et des categories de risque de cancer prostatique. L’analyse des donnees peri-operatoires entre les groupes n’a pas montre de difference statistiquement significative : extension extra-prostatique (49,8 % vs 50,1 %, p = 0,33), marges chirurgicales positive (35,2 % vs 36,5 %, p = 0,86), la valeur post-operatoire du PSA (p = 0,37), respectivement dans le groupe d’etude et le groupe controle. Les pertes sanguines moyennes (± SD) etait de 215 cc ± 175cc dans le groupe d’etude vs 297 cc ± 293 cc dans le groupe controle (p Tableau 1 ). Conclusion Apres une evaluation geriatrique complete, une prostatectomie radicale robot-assistee chez les sujets âges peut etre realisee de maniere sure et semble mener aux memes Resultats oncologiques et fonctionnels chez les patients âges compare a une population plus jeune.

International audience; Objectives: The aim of the present study was to compare the perioperative outcomes of extracorporeal (EXTRA) vs intracorporeal (INTRA) urinary diversion in patients undergoing robotic cystectomy and ileal conduit for neurogenic bladder. Methods: All consecutive patients who underwent robot-assisted cystectomy and ileal conduit for neurogenic bladder in six centers between 2011 and 2020 were included in a retrospective study. Four centers performed exclusively INTRA urinary diversion all over the study period, one center performed exclusively EXTRA urinary diversion, and the last center performed EXTRA urinary diversion during a first period and INTRA during the subsequent period. Results: Ninety-seven patients were included: 66 in the EXTRA group and 31 in the INTRA group. There were 11 major (Clavien grade >= 3) postoperative complications in the overall population (11.3%) with no statistically significant difference between both groups (EXTRA = 12.1% vs INTRA = 9.7%; p = 0.99). The mean length of stay did not differ significantly between INTRA and EXTRA (13.1 vs 14.1 days; p = 0.44). The mean times to oral feeding and to return of bowel function were similar in the two groups (3.9 vs 3.5 days; p = 0.28 and 4.1 vs 4.1 days; p = 0.51, respectively). There was no incisional hernia in the INTRA group vs five in the EXTRA group (0% vs 7.6%; p = 0.17). Conclusion: The perioperative morbidity of robotic cystectomy and ileal conduit for neurogenic bladder appears to be relatively limited compared with the historical open series. Possibly due to the relatively small sample size, no difference was found between INTRA and EXTRA urinary diversion in terms of perioperative outcomes.

Resume Introduction Les urgences urologiques representent 7 % des motifs d’admission aux urgences (SU). Nous avons souhaite analyser l’effet de la mise en place d’un circuit court vers une consultation post-urgence (CPU) apres regulation medicale urologique differee. Methodes Tous les patients admis au sein du SU dans un centre universitaire, sur la periode de decembre 2017 a juillet 2018 et pour lesquels etait programmee une CPU etaient inclus. La regulation concernait la date de CPU et des complements d’examens. Le critere de jugement principal etait le niveau de performance du circuit. Ce dernier etait evalue par la capacite a apporter une reponse efficace selon une grille predefinie de solutions specifiques aux motifs de consultation. Resultats Cent vingt-huit patients ont ete inclus. L’âge median etait de 57 ans (18–97). L’efficacite etait de 76 %. Ce taux etait plus faible chez les patients consultant pour des motifs rares, complexes ou ne se presentant pas a la CPU « no-show ». Ces derniers (47 %, n = 60) n’etaient pas joignables au premier appel dans 51,6 % des cas, avec une distribution d’âges et de motifs similaire aux autres. Sur l’ensemble des consultants (n = 1863) seulement 6,9 % (n = 128) avaient ete adresses en CPU par les urgentistes. La decision etait une seconde consultation dans 70 % (48), un nouvel examen dans 10 % (7), une chirurgie en urgence differee dans 12 % (8) et enfin 18 % (12) d’abstention de suivi. Conclusion La CPU suivant une regulation precoce par un urologue permet d’apporter une reponse efficace dans 76 % des situations. L’analyse des « no-show » permettrait d’identifier des groupes a risque. Niveau de preuve III.

Resume Introduction Lors de la premiere vague epidemique Covid-19, des mesures de triage, sans PCR systematique, etaient mises en place pour selectionner les patients a operer. Notre etude a compare leurs resultats chirurgicaux apres triage a ceux d’un groupe controle. Materiel L’analyse portait sur l’ensemble des patients initialement programmes dans un centre Covid de reference et inclus consecutivement, du 15 mars au 1er mai 2020 ( NCT04352699 ). Leurs donnees etaient recueillies prospectivement et ulterieurement comparees a celles des patients operes 1 an auparavant sur la meme periode dans ce centre. Le critere d’evaluation principal etait l’admission post-operatoire en unite de soins intensifs (USI). La morbidite, la mortalite postoperatoire, le report d’interventions, les tests PCR etaient evalues. Des analyses de sous-groupes etaient realises pour les patients operes de cancer. Resultats Apres triage, 96 des 142 interventions programmees ont du etre reportees. Sur les operes, 48 (68 %) l’etaient pour cancer. Au total, aucun cas de pneumonie Covid-19 post-operatoire n’a ete identifie. Trois patients (4 %) ont ete admis en USI, dont un finalement decede pour sepsis urinaire. Chez ces patients, les RT-PCR etaient negatives. Globalement, comparativement au groupe controle, aucune difference d’admission en USI, ni de taux de mortalite post-operatoire n’ont ete rapportees. Conclusions Le triage de la premiere vague n’a pas surexpose les patients selectionnes a un risque de complication ou de deces post-operatoire, particulierement pas pour ceux operes pour cancer. En revanche, 67 % des patients ont ete reportes, avec un risque associe a des retard de soins pouvant conduire au deces. Niveau de preuve 3.

The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery.We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison.Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=0.001) as did the overall proportion of robotic by 45% to 85% (P=0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=0.001) and €27 vs €24/min (P=0.029), tending towards a break-even point (=zero deficit) at 430 operations per year.Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term.3.

Urodynamic (UD) is an exam intended to explore the mechanisms underlying lower urinary tract symptoms (LUTS) or urinary incontinence (UI). It involves the measurement of bladder and sphincter pressures using uretrovesical and rectal catheters with pressure transducers, but also the measurement of urinary flow and bladder sensation during filling. UD is far from being systematic in the assessment of LUTS or UI and must seek to tackle a specific clinical or therapeutic question. Thus, history taking, physical examination, voiding diary and questionnaires are essential prerequisites to UD per se. UD steps include a free (unintubated) uroflowmetry, a cystometry, post-void residual measurement±an urethral profilometry, a pressure-flow study or sensitization tests. The pressures are set to zero before to start the study and the validity of the equipment is tested. This control is continued throughout the procedure to ensure the quality of the recording. Any event (e.g., urine leakage, change of position, urgency) is noted during the study. A final report is made by the doctor. The competence of the nurse ensures the reliability, reproducibility and interpretability of the UD study and the nurse's humanity guarantee f an atmosphere as favourable as possible for this uncomfortable and invasive test.

Urological emergencies represent 7 % of the outpatients at the emergency department (ED). We assessed the effect of setting up a post-emergency consultation (CPU) after deferred urological medical regulation.All patients admitted to the ED in a university center over the period December 2017 to July 2018 and for whom a CPU was scheduled were included. The regulation concerned the date of CPU and supplementary exams. The main outcome was the ability to provide an efficient response according to a predefined grid of specific solutions.One hundred and twenty-eight patients were included. The median age was 57 years (18-97). Efficacy of the CPU was 76 %. This rate was lower in no-show patients or consulting for rare and complex motives (47 %, n=60). The no-show were not reachable on the first call in 51.6 % of cases, with a similar age and motives distribution to the others. Only 6,9 % (n=128) of all consultants (n=1863) had been referred to the CPU by emergency physicians. The decision was a second consultation in 70 % (48), a new exam in 10 % (7), deferred emergency surgery in 12 % (8) and finally 18 % (12) of no follow-up.CPU following early regulation by a urologist provides an effective response in 76 % of situations. Assessment of "no-shows" helped to identify groups at risk.III.