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Resume Introduction L’incidence du cancer du rein est en augmentation ces dernieres decennies du fait d’une plus grande frequence des decouvertes fortuites de petites tumeurs par imagerie. Le but de cet article est de decrire les resultats actuels des traitements ablatifs (TA) et les comparer aux autres modalites de traitement des petites tumeurs du rein en termes d’efficacite oncologique, preservation nephronique, morbidite et cout. Materiel et methode Une recherche bibliographique a partir de Medline ( http://www.ncbi.nlm.nih.gov/ ) et Embase ( http://www.embase.com/ ) a ete realisee en utilisant les mots cles (MeSH) entre janvier 2005 et mai 2017. Les articles ont ete selectionnes sur leur methodologie, leur langue de publication et leur pertinence. Resultats Quatre-vingt-onze articles ont ete analyses. Nous avons decrit les resultats du TA par energie utilisee et par voie d’abord, compare les resultats oncologiques, fonctionnels et perioperatoires des TA par rapport aux autres modalites therapeutiques. Nous avons recherche les facteurs predictifs pouvant jouer un role dans les resultats des TA et realise une revue des analyses medico-economiques des traitements des petites tumeurs renales. Conclusion Malgre les limitations des etudes et leur niveau de preuve bas, les differentes etudes ont montre que dans la population âgee traitee par TA pour des tumeurs cT1a, la survie specifique est comparable a la nephrectomie partielle alors que la survie globale est moindre du fait des risques competitifs de deces dans cette population fragile. Le taux de recidive locale parait plus important pour le TA. Concernant les resultats fonctionnels, la preservation nephronique est identique entre le TA et la nephrectomie partielle (NP), neanmoins les complications postoperatoires sont plus importantes pour la NP par rapport au TA. Les exigences actuelles de la medecine par la preuve ne permettent pas de valider les TA avec un niveau de preuve suffisant pour etendre les indications actuelles.

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.

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.

The intravesical instillation of dimethyl sulfoxide (iDMSO), performed without anesthestic, is a therapeutic option for the painful bladder syndrome/interstial cystitis (PBS/IC). Some patients are against those iDMSO because of bad tolerance. Our study evaluates the tolerance and the outcome of the iDMSO under general anesthetic (GA) after the failure of the iDMSO without anesthetic.From May 2013 to April 2016, 11 patients with a PBS, 9 women (81.8 %), have been treated by iDMSO without anesthetic, without improvement because of bad tolerance and no possibility to have a one hour contact between the bladder and the DMSO. The 11 patients were evaluated by mictional calendar and Sant O'Leary score. All the patients had a hydrodistension and a per os treatment without improvement.Six new iDMSO were performed under general anesthetic in ambulatory surgery with good tolerance for the 11 patients. The frequency and the nocturia before iDMSO without anesthetic and after iDMSO under general anesthetic were 32.2minutes [15; 60] and 6.3 per night [3; 10] and 126.9minutes [25; 240] and 3 per night [2; 6], so a variation respectively of 96.4minutes [0; 180] and of 3.75 per night [2; 6]. The symptom score and the problem index were 17.5 [13; 20] and 15.5 [13; 16] before and 13.5 [4; 20] and 12 [1; 16] after iDMSO under general anesthetic; a variation of 3.2 [0; 9] and 4 [0; 12].The iDMSO under general anesthetic seems to improve objectively and subjectively the patients who are not improved by the instillations without anesthetic because of bad tolerance.4.

The incidence of kidney cancer has increased significantly over the past few decades presumably due to the increased use of imaging. The aim of this article is to describe contemporary outcomes of ablative therapy and to compare them to other therapeutic options in terms of oncological, functional, perioperative outcomes and cost.We searched MEDLINENinety-one articles were analyzed. We described the outcomes of ablative therapy in relation to the energy used and the approach, and compared these outcomes to the other therapeutic options in terms of oncological, functional and perioperative outcomes. We analyzed these studies in order to search for predictive factors influencing the results of ablative therapy. We also analyzed the economic burden of small renal tumor management.The strength of evidence is based almost entirely on retrospective studies and is susceptible to the inherent limitations of this study design. Although, the evidence was low among studies, our revue showed that, in elderly patients treated with ablative therapy for cT1a tumors, the cancer-specific survival was comparable to partial nephrectomy with differences in overall survival that are explained by competing risks of death in the old population. Considering the functional results, the renal function preservation seems to be comparable between the 2 groups while the perioperative morbidity is higher in the partial nephrectomy group. The evidence base medicine at this time cannot support the extension of the indications of ablative therapy beyond the actual implementations.

Resume But Rapporter notre experience de l’utilisation de l’ureteroscopie souple-laser (URSS-L) dans le traitement des calculs renaux et ureteraux. Patients et methodes Nous avons effectue une etude retrospective portant sur 191 calculs renaux et/ou ureteraux traites au service d’urologie du nouvel hopital civil (Strasbourg) sur une periode de 2 ans. En tout, 219 URSS-L ont ete faites. Nous nous sommes interesses aux indications de l’URSS-L, a ses complications, aux resultats du traitement et aux facteurs predictifs de l’obtention d’un sans-fragment residuel. Les complications postoperatoires ont ete rapportees selon la classification de Clavien-Dindo. Resultats Les indications etaient de premiere intention dans 62,3 % des cas, des echecs de LEC dans 26,2 % des cas et des echecs d’alcalinisation dans 5,2 % des cas. Comme complications peroperatoires, nous avons eu un cas de desinsertion pyelo-ureterale et un cas de spasme bronchique a l’origine d’un arret de l’ureteroscopie. Des complications postoperatoires sont survenues apres 38 ureteroscopies (17,3 %). Tous grades confondus, elles etaient infectieuses dans 50 % des cas. Elles etaient de grade I, II, III, IV et V dans respectivement 5,9 ; 7,3 ; 2,7 ; 1,3 et 0 % des cas. Leur survenue n’etait correlee significativement ni a la taille des calculs ni au caractere uni- ou bilateral de l’URSS-L. Le taux global de sans-fragment a trois mois etait de 71,7 %. Les facteurs determinant significativement l’obtention d’un sans-fragment residuel etaient la taille du calcul renal et l’experience de l’operateur. Conclusion Dans notre centre, l’URSS-L est de plus en plus utilisee en premiere intention du fait de sa faible morbidite et de ses excellents resultats surtout pour le traitement des calculs renaux de moins de 20 mm et des calculs ureteraux. Elle constitue une alternative de qualite a la NLPC dans les calculs renaux de plus de 20 mm. Niveau de preuve 4.

Resume Objectifs Evaluer les resultats et le taux de satisfaction des patients implantes d’une prothese penienne. Patients et methode Entre janvier 2000 et 2009, 50 patients ayant une dysfonction erectile (DE) d’origine organique ont ete traites par la pose d’un implant penien d’erection (IPE) hydraulique par le meme operateur. Seules les primo implantations ont ete etudiees. Les dossiers ont ete recuperes de maniere retrospective. Les informations que nous avons recueillies etaient les caracteristiques demographiques, celles de la prothese, les complications per- et postoperatoires, et la satisfaction etait mesuree par un questionnaire. La collecte des informations a eu lieu par analyse des dossiers et par enquete telephonique personnalisee. En plus de l’analyse des donnees de notre centre, nous avons voulu connaitre quel etait le devenir reel des patients implantes, la facon dont ils utilisaient leurs protheses au quotidien, et au final le vecu de cette transformation de leurs vie sexuelle. Resultats L’âge moyen des patients etait de 60,2 ± 8,46 ans (35–75 ans). Trente patients (60 %) implantes etaient diabetiques. La voie d’abord etait penoscrotale dans 100 % des cas. Trois types de prothese ont ete utilises : AMS Ambicor, AMS 700, Titan OTR. Chez 24 patients, l’IPE etait a deux compartiments et chez 26 un IPE a trois compartiments. Deux des patients ont eu leur prothese retiree pour des raisons de dysfonctionnement du materiel, trois patients pour une erosion prothetique et deux patients pour une infection de prothese. Sur ces sept explantations, quatre patients ont eu une repose de l’IPE. Le recueil des donnees du questionnaire etait realise apres un suivi median de 45 mois (5–114 mois) chez 47 patients (trois explantes). Le taux de satisfaction etait de 81 %. Quatre-vingt-quatre pour cent ( n = 42) d’entre eux ont eu au moins un rapport par semaine. Vingt-deux pour cent ( n = 11) etaient decus par le manque de longueur de leur verge en erection, cela concernait surtout (72 %) les patients implantes avec une prothese bi-compartiment. Quatre-vingt quatre pour cent ( n = 42) recommanderaient l’intervention a leurs proches, 86 % n = 43 pensaient que leur partenaire en est satisfaite. Dix-huit pour cent ( n = 9) ont eprouves des difficultes lors de l’apprentissage de la technique. L’erection etait jugee naturelle par plus de 80 % des patients, plus de 80 % des partenaires etaient satisfaites par le dispositif selon les patients, et 75 % des implantes ont repris confiance en leur fonction sexuelle. Conclusion Dans cette serie, le taux de satisfaction etait plus important avec des protheses trois compartiments ; plus proches de la physiologie avec une sensation de verge plus longue par le patient, 94 % (47/50) des patients interroges avaient une prothese parfaitement fonctionnelle apres un recul moyen de 45 mois. Les motifs d’insatisfaction les plus frequemment releves etaient la survenue de complications telles que des sepsis, une defaillance mecanique ou une erosion prothetique, mais qui au final ont ete pour 60 % ( n = 4) corrigees de maniere chirurgicale.

Resume La radiofrequence est une technique mini-invasive permettant par l’application de moyens physiques au centre de la lesion, la destruction de la tumeur. Il existe une indication pour les techniques de destruction in situ dans le cadre du carcinome renal hereditaire deja opere comme le cas de la maladie de Von Hippel-Lindau (VHL). Nous rapportons un cas clinique de fistule reno-pleurale survenue apres destruction par radiofrequence (RF) percutanee d’une tumeur du pole superieur du rein gauche chez un patient avec un VHL. Il s’agit d’une patiente suivie depuis l’âge de 20 ans pour des kystes renaux dans le cadre d’une maladie de VHL familial. A l’âge de 30 ans, devant l’apparition d’une composante solide au sein d’un kyste renal gauche, la patiente a eu une nephrectomie partielle (tumorectomie). La surveillance radiologique etait marquee par l’apparition de trois lesions renales gauches. Un traitement par RF percutanee (en deux seances) a ete realise sur ces lesions renales. L’imagerie de controle apres RF percutanee avait mis en evidence une persistance tumorale sur une des trois lesions. Un traitement complementaire par RF a ete realise, complique par l’apparition d’une fistule reno-pleurale. Cette fistule a ete traitee de facon conservative, par restriction hydrique et drainage ureteral. Trois semaines de drainage etaient necessaires pour permettre une disparition complete de la fistule.

El sindrome de dolor vesical/cistitis intersticial (SDV/CI) es un diagnostico clinico que asocia manifestaciones dolorosas de la vejiga o la pelvis y sintomas urinarios tales como miccion urgente y polaquiuria. La fisiopatologia aun es imprecisa, pero una hipotesis actualmente aceptada es que el SDV/CI estaria relacionado con otros sindromes dolorosos como el colon irritable, la fibromialgia y el sindrome de fatiga cronica. En este articulo se hara hincapie en las modificaciones terminologicas recientes, los sintomas de sospecha de la enfermedad, las pruebas complementarias y los posibles tratamientos, ademas de un algoritmo terapeutico a modo de ejemplo.

Objectifs Depuis nos debuts en cryotherapie totale de cancer de prostate (CP), nous modifions notre technique pour augmenter precision et reproductibilite, en conservant la puissance de l’IRM du depistage jusqu’au traitement, pour evoluer ensuite vers la cryotherapie focale IRM-guidee. L’objectif de notre video est d’expliquer les etapes qui permettrait de proposer a des patients selectionnes le « tout IRM » du diagnostic au traitement focal. Methodes Nous participons a la realisation des CT et des biopsies par voie transperineale (BTP) en relation avec l’equipe de radiologie interventionnelle qui dispose d’une IRM (AERA XW, 1.5 T, Siemens®). Lors des differentes etapes nous avons pu ameliorer successivement (i) l’installation avec des jambieres integrant une grille perineale IRM compatible (evitant des implantations a main levee comme nous le faisions initialement), (ii) la mise en place d’un thermocouple pour monitoring de la temperature a proximite du sphincter, (iii) la dissection de l’espace inter-prostato-rectal par du sang du patient pour eloigner la paroi anterieure du rectum. Resultats Nous avons debute notre experience par des traitements complets a main levee dont les resultats ont ete publies [1] . Nous avons stoppe notre programme pour developper le materiel IRM compatible afin d’ameliorer la reproductibilite. Dans une demarche coherente nous debutons un essai clinique prospectif randomise evaluant les biopsies perineales sous controles IRM aux biopsies transrectales echoguidees. Ceci nous parait etre une etape indispensable pour l’apprentissage des radiologues, des radiologues interventionnelles, des anatomopathologistes et des urologues pour pouvoir s’orienter vers le traitement focal « vrai » avec le maximum de securite carcinologique. Conclusion L’IRM est l’imagerie la plus precise et pertinente en matiere de CP, il parait legitime de l’utiliser tout au long de la prise en charge du CP. Ne pouvant realiser un essai multicentrique francais sur cette thematique du fait de l’absence de diffusion d’IRM interventionnelle, il nous parait important d’exposer notre demarche a notre communaute afin de recueillir ses reflexions.

Resume Objectif Definir par une etude multicentrique des facteurs predictifs d’echec de bandelettes sous-uretrale a encrage osseux type InVance™ (American Medical System, Etats-Unis) pour la cure d’incontinence urinaire d’effort (IUE) masculine. Methode Les cas d’IUE masculine traites par bandelette type InVance™ entre janvier 2005 et decembre 2007 ont ete recueillis dans quatre centres hospitaliers francais. Resultats Quatre-vingt-quatre patients ont ete evalues. Leur âge moyen etait de 68 ans. Avec un recul moyen de 20 mois, 38 patients (45 %) etaient secs, 22 (26 %) etaient ameliores et 24 (29 %) en echec. En analyse univariee, trois parametres etaient significativement lies a un resultat pejoratif : une IUE severe (p = 0,005), une instabilite detrusorienne au bilan urodynamique (p = 0,043) et une IUE dont la cause etait un double traitement comprenant une radiotherapie externe (p = 0,031). Si zero ou un de ces facteurs de risque etait present en preoperatoire, le risque d’echec etait de 25 %, contre un risque de 67 % si deux ou trois facteurs de risque etaient presents (p = 0,013). En analyse multivariee incluant ces trois parametres, seul un double traitement comprenant une radiotherapie etait un facteur independant significativement associe au resultat de l’intervention (p = 0,017). Conclusion Deux groupes de patients ont ete definis, permettant de differencier des bons et des mauvais candidats a la cure d’IUE par bandelette InVance™.

La incontinencia urinaria es una complicacion frecuente de la prostatectomia total que puede aparecer secundariamente a una afectacion esfinteriana, una disfuncion vesical o a la asociacion de ambos. En la literatura se observan incidencias variables, pero las ultimas publicaciones presentan un indice de menos del 10% de incontinencias definitivas tras una prostatectomia total. Se intenta disminuir este porcentaje mediante los constantes progresos de la tecnica quirurgica. No existe una definicion tipo de la incontinencia urinaria, pero en lugar de hacer apreciaciones subjetivas habra que evaluarla mediante cuestionarios validados y pruebas objetivas. Puesto que la incontinencia urinaria repercute sobre la actividad, las relaciones afectivas y la autoestima de los pacientes, es necesario evaluar la calidad de vida. Sobre todo durante los meses inmediatamente posteriores a la prostatectomia total, el tratamiento puede ser conservador, basado en la expectativa, el uso de productos absorbentes o no absorbentes, modificaciones de los habitos de vida, prescripcion de medicamentos y reeducacion funcional perineal. Si al cabo de un plazo aproximado de un ano no se obtiene una recuperacion suficiente, se debe pasar al tratamiento quirurgico: inyecciones peri o intrauretrales (entre ellas las de terapia celular, que se anuncian prometedoras), bandas suburetrales, balones periuretrales o esfinter urinario artificial. La indicacion terapeutica dependera de la clinica, el estudio complementario y la demanda y las expectativas del paciente.

Interstitial cystitis (IC) is a chronic, debilitating condition that is often associated with late diagnosis and a delay in initiation of appropriate IC-specific therapy. The typical patient with interstitial cystitis (IC) is symptomatic for many years and consults multiple physicians before IC is diagnosed. These observations suggest that the clinical presentation of IC is not widely recognized. The resultant underdiagnosis may be explained in part by the nonspecific nature of IC symptoms, such as urinary urgency, frequency, nocturia and pain, as well as by the lack of an objective diagnostic test. Pelvic pain of bladder origin may refer to pain in any location in the pelvis, is affected by the menstrual cycle and flares with sexual intercourse. As a result of variations in disease definition and diagnostic criteria for interstitial cystitis (IC), the performance of epidemiologic studies has been challenging. The true prevalence of IC is much greater than the early studies suggested. Over the last decade, the recognized prevalence of IC has increased and it is consistently greater among women as compared to men.

There is currently no guideline regarding the management of neurogenic detrusor overactivity (NDO) refractory to intra-detrusor botulinum toxin injections. The primary objective of the present study was to find a consensus definition of failure of botulinum toxin intra-detrusor injections for NDO. The secondary objective was to report current trends in the managment of NDO refractory to botulinum toxin.A survey was created, based on data drawn from current literature, and sent via e-mail to all the experts form the Group for research in neurourology in french language (GENULF) and from the comittee of neurourology of the French urological association (AFU). The experts who did not answer to the first e-mail were contacted again twice. Main results from the survey are presented and expressed as numbers and proportions.Out of the 42 experts contacted, 21 responded to the survey. Nineteen participants considered that the definition of failure should be a combination of clinical and urodynamics criteria. Among the urodynamics criteria, the persistence of a maximum detrusor pressure40 cm H2O was the most supported by the experts (18/21, 85%). According to the vast majority of participants (19/21, 90.5%), the impact of injections on urinary incontinence should be included in the definition of failure. Regarding the management, most experts considered that the first line treatment in case of failure of a first intra-detrusor injection of Botox(®) 200 U should be a repeat injection of Botox(®) at a higher dosage (300 U) (15/20, 75%), regardless of the presence or not of urodynamics risk factors of upper tract damage (16/20, 80%).This work has provided a first overview of the definition of failure of intra-detrusor injections of botulinum toxin in the management of NDO. For 90.5% of the experts involved, the definition of failure should be clinical and urodynamic and most participants (75%) considered that, in case of failure of a first injection of Botox(®) 200 U, repeat injection of Botox(®) 300 U should be the first line treatment.

Specify urinary functional impairment associated with diabetic pathology. Propose guidance for screening, monitoring of clinical signs of lower urinary tract (LUTS) and describe the specifics of the urological treatment of patients.A review of literature using PubMed library was performed using the following keywords alone or in combination: "diabetes mellitus", "diabetic cystopathy", "overactive bladder", "bladder dysfunction", "urodynamics", "nocturia".LUTS are more common in the diabetic population with an estimated prevalence between 37 and 70 %, and are probably underevaluated in routine practice. They are heterogeneous and are frequently associated with other diabetic complications. Both storage and voiding symptoms can coexist. Despite a major evaluation in the literature, no recommendation supervises the assessment and management of LUTS in this specific population. An annual screening including medical history, bladder and kidney ultrasound and post-void residual measurement is required in the follow-up of diabetic patients. Specific urologial referral and urodynamic investigations will be performed according to the findings of first-line investigations. The type of bladder dysfunction, the risk of urinary tract infections and dysautonomia should be considered in the specific urological management of these patients.Diabetes mellitus significantly impacts on the lower urinary tract function. A screening of LUTS is required as well as other complications of diabetes. The management of LUTS must take into consideration the specific risks of the diabetic patient regarding the loss of bladder contractility, the possibility of dysautonomia and infectious complications.

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.

Urethral stenosis has a recurrent character. The urethroplasty is often proposed for repeat stenosis. This study seeks to explore the interest of clean intermittent self-catheterization in the evolution of urethral stenosis after urethrotomy.Single-center retrospective study from 2008 to 2013, concerning patients who received urethrotomy to treat urethral stenosis which was confirmed by endoscopy and a flow chart. Some accomplished self-catheterization in addition to urethrotomy to prevent recurrence. The monitoring was provided during consultation by a subjective assessment (patient and surgeon) and a flow chart. The restenosis were confirmed by endoscopy and flow chart.Ninety-three patients treated with urethrotomy alone (50 patients) or associated with self-catheterization (43) was included. Urethral stenosis were mostly iatrogenic (75%), short10mm (84%), single (74%) and primary (50.5%). Mean follow-up was 99.3±72.8 weeks. Eighteen patients (19%) had symptomatic recurrence suspected by flow chart with a mean Qmax at recurrence was 6.25±2.8mL/s (P0.001), 8 in urethrotomy group and 10 in the urethrotomy+self-catheterization group. Recurrence rates were comparable in the 2 groups, urethrotomy (16%) urethrotomy+self-catheterization (23%) (P=0.46). The mean time to recurrence was 81.1±87 weeks and was different in the 2 groups: 76.8±76.3 weeks in urethrotomy group, 83.3±93.9 in urethrotomy+self-catheterization group (P=0.014). An analysis recurrence for the primitive urethral stenosis showed that the recurrence rate was not statistically different: 18% for urethrotomy+self-catheterization group vs 14% for urethrotomy group. An analysis of recurrent relapses for urethral stenosis showed a rate of 26%, comparable in the 2 groups (P=1).After urethrotomy, urethral stenosis recurs in 1 patient over 5, after 18 months especially if they were complicated (multiple, recurrent, extended). Self-catheterization do not provide benefit in terms of recurrence (for the general population and for primitive urethral stenosis) compared to only urethrotomy but seem to extend the time without recurrence (76.8 weeks vs 83.3 weeks).5.

The objective of this study was to assess the oncological results of a population of patients which undergo surveillance after diagnosis of stage I testicular seminoma (2, 5 and 8 years overall, specific and recurrence free survival). We also research recurrence risk factors.We have looked at the data of all patients treated in our center since 1993 for a grade I testicular seminoma. We focused on age at diagnosis, biological (tumoral markers) and pathological (tumor size, rete testis, lymphovascular, tunica albuginea or spermatic cord invasion) data. During surveillance, we noted the number, the localization and the interval until recurrence and death. We calculated 2, 5 and 8 years overall, specific and recurrence-free survival and searched recurrence risk factors.Sixty-nine patients (mean age: 37) were followed during a mean time of 97 months. Sixty-three per cent of the tumours were less than 4 cm (50 lesions). Lymphovascular, rete testis, spermatic cord and tunica albuginea invasion were present in respectively 21%, 33%, 4% and 29% of the cases. LDH and HCG were above normal rate in respectively 44 and 27% of the cases. Eighteen patients (23%) relapsed at a mean time of 12 months. Recurrence-free survival was respectively 81%, 77% and 77% at 2, 5 and 8 years. Tumor size4 cm (P = 0.002), rete testis invasion (P = 0.03) and stage ≥ pT2 (P = 0.012) were associated with recurrence in univariate analysis. Using multivariate analysis, only tumor size4 cm was a recurrence risk factor (risk multiplied by 3). At the end of the study, 77 patients are alive (97.5%). Overall and specific survival was 97.5% at 2, 5 and 8 years.We show here the interest of surveillance in case of stage 1 testicular seminoma. The overall and specific survivals are the same as after chemotherapy or radiotherapy. Furthermore, we confirm the role of tumor size to stratify recurrence risk.

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).

To evaluate the outcome of postoperative male stress urinary incontinence surgery using the I-STOP TOMS(®) sub-urethral sling.Between April 2007 and August 2012, 29 patients had been treated by sub-urethral sling. Stress urinary incontinence was classified as mild, moderate or severe according to the number of pads per day. Patients were also assessed thanks to IQOL, MHU and Ditrovie self-administered questionnaires.Before surgery, 16 patients (55.2%) had mild incontinence, 12 (41.4%) had moderate incontinence and one (3.4%) had severe incontinence. Preoperative median MHU was 9 (5-12); median IQOL was 73 (58-88); and median Ditrovie was 2.7 (2.1-3.3). Three months after surgery, median MHU was 7 (4-9); median IQOL was 85 (75-99); and median Ditrovie was 2.1 (1.6-2.4). Pre- and postoperative questionnaires scores show a significant improvement for IQOL (P=0.014) and Ditrovie (P0.001). After 3 months, six patients were dry (20.7%), 19 patients had mild incontinence (65.5%) and four had moderate incontinence (13.8%); in résumé 17 patients (58.6%) showed a significant improvement in the number of pads (20.7% dry, 37.9% improved). After a mean follow-up of 24 ± 19.9 months, five patients were dry (17.2%), 20 patients (69%) had mild incontinence and four had moderate incontinence (13.8%).I-STOP TOMS(®) sub-urethral sling improved the level of postoperative stress urinary incontinence. However, the continence rate was weak.

To evaluate satisfaction rates and results in patients with penile prosthesis (5 PP).From January 2000 till 2009, 50 patients with organic erectile dysfunction (ED) were implanted with hydraulics penile prosthesis by the same surgeon. Medical records were collected retrospectively. We analysed demographic characteristics, type of prosthesis used, per- and postoperative complications, prosthesis explantations and satisfaction rate measured by EDITS modified.Mean age of patients was 60.2 ± 8.46 years (35-75). Thirty implanted patients (60%) were diabetics. We used a peno-scrotal incision in all patients. Three types of prosthesis were used; AMS Ambicor, AMS 700, Titan OTR. A bi-compartment and three-compartment prosthesis were implanted respectively in 24 and 26 patients. The prosthesis was retrieved in two patients secondary to a mechanical failure, in three patients for prosthesis erosion, in two patients for prosthesis infection. In four out of the seven explanted patients, a second prosthesis was implanted. The EDITS questionnary was realized by telephonic interview in 47 patients after a mean follow-up of 45 months (5-114). The response rate was of 83%. The satisfaction rate was of 81%.In our series, the satisfaction rate was better for the three-compartment prosthesis. After 45 months of follow-up, 73% (31/42) of patients had a functional prosthesis. The non-satisfaction most frequently found were patients who have complications as sepsis; mechanical failure, and prosthesis erosion, and subjective feeling of penile length reduction.

The effects of intracavernous alprostadil injection (IAI), a primary treatment for post-radical prostatectomy (RP) erectile dysfunction (ED) (pRPED), on the sex life of women partnered with men who have undergone RP have received little attention.The aim of this study is to investigate the sexual quality of life in female partners of men receiving IAIs for pRPED.We retrospectively studied the sex lives of 152 women partnered with men who were being treated for pRPED with IAI and previously had normal erectile function. Women completed the Index of Sexual Life (ISL) questionnaire 1 year after their partner's RP. Male patients completed the International Index of Erectile Function (IIEF-15), the Erection Hardness Score (EHS) questionnaire, the International Consultation on Incontinence Questionnaire (ICIQ), and the UCLA Prostate Cancer Index (UCLA-PCI) urinary function questionnaire. Penile pain was assessed using the visual analog scale (VAS). Statistical analysis was performed using t-tests, Spearman correlation, and multiple linear regression.Female sexual life satisfaction (SLS), sexual drive (SD), and general life satisfaction (GLS) were assessed using the ISL questionnaire.Mean ages for the 104 couples included were 62.3 and 59.8 years for the men and women, respectively. Mean ISL, SD, SLS, and GLS scores at 12 months were 25.4, 3.8, 14.1, and 7.5, respectively. ISL scores were strongly correlated with IIEF-15 domains, mainly erectile function (r 0.41, P 0.00002) and intercourse satisfaction (r 0.27, P 0.005). Age and VAS, ICIQ, and UCLA-PCI scores were negatively correlated with some ISL domains. IIEF-15 erectile function and intercourse satisfaction were the most significant domains predicting female SLS. An IIEF-15 erectile function of 25 corresponded to a 75% chance of an SLS score ≥18.Indexes of female sexual quality of life were low overall but were highly correlated with the partner's response level to IAI treatment. IAI-related pain, increased age, and poor urinary function of the male partner appear to negatively impact female sex life.

Radiofrequency is a minimally invasive therapy allowing tumor destruction by applying physical means to the core of the lesion. There is a particular indication for the hereditary already surgically treated renal carcinomas like Von Hippel-Lindau's disease. We present a case of renal-pleural fistula developed after a percutaneous radiofrequency ablation under computed tomography (CT) guidance of a renal tumor in a VHL female patient with a renal cell carcinoma of the upper pole of the left kidney. The kidney manifestations begin at 20-year-old with the appearance of cystic lesion at the lower pole of the left kidney. At 30-year-old, a computed tomography study revealed a solid lesion arising from a cyst. The patient underwent a partial nephrectomy by flank incision. Follow-up studies discovered three solid lesions of the upper pole of the left kidney. The patient undertook a radiofrequency ablation of these lesions. Follow-up control showed a contrast enhancement of one of the three lesions treated. Under this condition another course of RF was performed, complicated by a renal-pleural fistula. A conservative management of this iatrogenic fistula was attempted combining a water restriction and the insertion of a ureteral catheter. Three weeks were necessary until the fistula completely regress.

We wanted to study the role of dynamic pelvic MRI (D-MRI) in the surgical management of patients with genito-urinary prolapse.A routine D-MRI examination before and after laparoscopic double promontofixation was performed in 15 cases with symptomatic vaginal prolapse in need of surgical treatment. The review included also three self-administered questionnaires of symptoms and quality of life. We compared the preoperative clinical evaluation of the studied cases with D-MRI data. Changes after the surgical treatment were also studied.The D-MRI provides an accurate diagnostic evaluation of the pelvis, which is both objective and reproducible. The correlation between clinical scores and radiological magnetic resonance was 53.3% only. In cases with absence of previous pelvic surgery, there was a radio-clinical discrepancy of 40% of cases, while in cases with history of a previous pelvic surgery we found a discrepancy of 60% of cases. This was due to clinical difficulty in differentiating between peritoneocele and rectocele, or due to under-diagnosis of complex prolapse. The sensitivity of MRI in the diagnosis of cystocele, hysterocele and rectocele were respectively 100, 100 and 83%. The gain in sensitivity provided by the MRI was significant for the diagnosis of peritoneocele: 100% against 33%. The specificity was 100%. Static images allowed a detailed study of damaged connective tissues and pelvic muscles.The D-MRI seems an appropriate tool in pre-operative assessment of cases with vaginal prolapse. It will help in focusing our surgical strategy, especially in cases that present post-hysterectomy and in cases with residual or recurrent prolapse.

Despite considerable research on the etiology and treatment of interstitial cystitis, diagnosis still depends on the suspicion of this condition by the physician.

To define predictive factors of treatment failure in a multicentric study for the treatment of stress male urinary incontinence by InVance (American Medical System, USA) bone anchored sub-urethral sling.Cases treated by InVance between January 2005 and December 2007 in four French academic centers were collected.Eighty-four patients were evaluated. Mean age was 68 years old. With a mean follow-up of 20 months, 38 patients (45%) were dry, 22 (26%) were improved, and 24 (29%) suffered treatment failure. In univariate analysis, three parameters were significantly associated with treatment failure, including severe urinary incontinence (P=0.005), urodynamic instability (P=0.043), and incontinence due to a bitherapy including external radiotherapy (P=0.031). If zero or one versus two or three risk factors were present, treatment failure rate was 25 and 67%, respectively (P=0.013). In multivariate analysis, bitherapy including radiotherapy was the sole independent treatment failure risk factor (P=0.017).Two patient groups were defined, allowing to determine preoperatively good candidates and bad candidates for stress urinary incontinence treatment by InVance sling.

To assess the ability of the University of Los Angeles Integrated Staging System (UISS) to stratify patients with a renal cell carcinoma (RCC) in one single French centre.Four hundred and forty-three patients operated for a RCC in the Urological Department of Strasbourg University Hospital between January 1989 and December 2000 were classified according to the UISS, which combines TNM stage, Fuhrman grade and Eastern cooperative oncology group performance status. Two groups were created: 362 patients with localized and 81 patients with metastatic RCC.The UISS stratified the localized RCC into three different risk groups (p0.0001). The 5-year survival rates were 75, 61 and 29% for low-, intermediate- and high-risk groups, respectively. For the metastatic RCC, the UISS couldn't well discriminate (p=0.092), with the 5-year survival rates of 18, 9 and 12% for low-, intermediate- and high-risk groups, respectively.This study validates the UISS for predicting survival in patients with localised RCC in our centre and, therefore, qualifies us to participate in clinical trials using this model. In metastatic RCC, the UISS was less accurate due to the small number of patients and the heterogeneity of treatments.

To assess the role of the introital ultrasound in the evaluation of patients with low urinary tract symptoms after sling placement.From 2000 till 2007, a total of 31 patients underwent sub-urethral tape placement for a stress urinary incontinence and developed thereafter a low urinary tract symptoms. The urological evaluation consisted of a detailed medical history, a urogynecologic examination, a complete urodynamic exam, a measurement of the postvoiding residue and a introital ultrasound. All patients filled the mesure du handicap urinaire (MHU) questionnaire. These patients had a transvaginal tape lysis under local anesthesia. We correlated the ultrasound findings with postoperative clinical success and failure.Thirty-one patients with low urinary tract symptoms secondary to sling placement underwent a tape lysis. Median age was 63.1+/-10.9 years, the median time between the anti-incontinence surgery and the tape lysis was 21.5+/-16.2 months. Seven patients had only obstructive symptoms, 15 patients had obstructive and bladder overactivity symptoms and nine patients had bladder overactivity symptoms. Introital ultrasound revealed an abnormality of the tape in 26 patients. Ten patients had a position abnormality of the tape, five patients had urethral angulation abnormality and 11 patients had the previous two abnormalities. After tape lysis, the obstructive symptoms disappeared in 19 out of 22 patients (86%), the bladder overactivity symptoms disappeared in 16 out of 24 patients (66%). In case of introital ultrasound abnormalities, the tape lysis was efficient in 23 out of 26 patients (89%), while in the absence of ultrasound abnormalities (five patients), the tape lysis was not useful in treating LUTS in all patients.Ultrasonography is a useful tool in investigating postoperative low urinary tract symptoms and in the selection of patients who will benefit from tape lysis.