The spontaneous elimination rate of ureteral stones decreases with their size, but also in function of their location. The objectives of stone surveillance are to detect the occurrence of a complication (e.g., fever, clinical tolerance) and to verify the potential stone migration/elimination. The use of urological procedures and the choice of technique are based on many different factors. Kidney stone surveillance is proposed mainly to people with low risk of progression or complications (size<4mm and/or lower calyx location and non-infection stone). Surveillance may be extended to patients with larger stones, in function of the clinical context and comorbidities. Conversely, a urological procedure may also be proposed to patients with stones<4mm for professional (e.g., soldier, pilot, expatriate) or social reasons or if travelling is planned. The choice of technique is based on the stone composition (if already known) and density, the advantages and limitations of each technique, and also the clinical context, while trying to choose the least invasive procedure for a stone-free objective. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context. This chapter is based on the references used in the chapters on the different techniques (extracorporeal shock wave therapy, ureteroscopy, percutaneous nephrolithotomy, medical expulsive therapy, postural therapy, chemolysis by alkalinization) as well as the American Urological Association (AUA) and EAU recommendations.
The morphological-compositional analysis of urinary stones allows distinguishing schematically several situations: dietary, digestive, metabolic/hormonal, infectious and genetic problems. Blood and urine testing are recommended in the first instance to identify risk factors of urinary stone disease in order to avoid recurrence or progression. The other objective is to detect a potential underlying pathology associated with high risk of urinary stone disease (e.g. primary hyperparathyroidism, primary or enteric hyperoxaluria, cystinuria, distal renal tubular acidosis) that may require specific management. Lifestyle-diet measures are the basis of the management of all stone types, but pharmacological treatments may be required. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context.
Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and "pop-corning". These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated. METHODOLOGY: These recommendations have been developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.
Postural therapy is a postural procedure to fight against the gravity phenomenon responsible for the non-elimination of lower calyceal stones. It allows improving or accelerating their expulsion and it increases the stone-free rate. This procedure associates forced diuresis, postural inversion, and lumbar percussion. It allows a 50% improvement and an acceleration of fragment elimination. Despite its positive impact, postural therapy remains under-used. These are the first practical recommendations on postural therapy. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.
Background. - Varicocele is the most common correctable cause of male infertility. It was the subject of recent Association francaise d'urologie (AFU) Comite d'andrologie et de medecine sexuelle (CAMS) recommendations. Since then, the literature has provided additional infor-mation. This review will comprehensively reassess current indications for the treatment of varicocele, and revisit contemporary issues in the light of current advances.Methods. - Update of the literature search carried out as part of the CAMS recommendations for the period between 2020 and 2023. Results. - Microsurgical sub-inguinal varicocelectomy remains the surgical treatment of choice for infertile men with clinical varicocele and abnormal sperm parameters. It offers recurrence rates of less than 4%. It significantly improves both natural and in vitro fertilization live birth and pregnancy rates, as well as sperm count, total and progressive motility, morphology and DNA fragmentation rates. All in all, it modifies the MPA strategy in around one in two cases. Varicocele grade and bilaterality are predictive of improved sperm parameters and pregnancy rate. Treatment of subclinical varicocele is not recommended. Complications are rare, notably hydroceles (0.5%), unilateral testicular atrophy due to arterial damage (1/1000), hematomas, delayed healing and postoperative pain. Retrograde embolization is an alternative to surgery. Conclusion. - Whenever possible, the urologist should present and discuss treatment options for varicocele with the MPA team and the patient, taking a personalized approach.(c) 2023 Published by Elsevier Masson SAS.
Les lésions méniscales chirurgicales sont fréquentes et concernent le ménisque médial dans environ 80 % des cas sur un genou stable. Aucun consensus n’existe à propos du protocole de rééducation post-opératoire et une grande variabilité existe entre les protocoles restrictifs et les protocoles de rééducation accélérée. L’objectif principal de notre travail était de rapporter les résultats fonctionnels et le taux d’échec des différents protocoles de rééducation de la série rétrospective de la Société francophone d’arthroscopie (SFA) après suture du ménisque médial sur genou stable en tenant compte du caractère stable ou instable des lésions.Notre hypothèse était que la rééducation accélérée n’était pas associée à une majoration du risque d’échec.Une étude rétrospective, multicentrique, conduite dans 10 centres (6 hôpitaux privés et 4 hôpitaux publiques) a inclus tous les patients opérés d’une suture du ménisque médial sur genou stable entre le premier janvier 2005 et le 31 novembre 2017 pour un recul minimum de 5 ans. Les données démographiques, d’imagerie, de suture, de protocole de rééducation et des scores fonctionnels de TEGNER et du KOOS ont été colligées. L’échec était défini par la réalisation d’une méniscectomie secondaire.Trois cent soixante-sept patients ont été analysés avec un recul moyen de 82 mois. L’appui immédiat était autorisé dans 85 % des cas, le port d’une attelle était présent dans près de 74 % des cas et la flexion était limitée dans 97 % des cas. Les comparaisons inter-groupes retrouvaient un taux d’échec de suture plus élevé dans le groupe avec appui immédiat (35,6 % vs 20 %, p = 0,011) et dans le groupe avec attelle (36,9 % vs 22,4 %, p < 0,001). Il n’existait pas de différence dans le groupe flexion à 90°. Le score de TEGNER était plus élevé dans le groupe sans appui (6,5 vs 5,4, p = 0,028) et le score KOOS QOL était plus élevé dans le groupe sans attelle (82,2 vs 66,8, p = 0,025). En analyse multivariée, l’appui immédiat (OR = 3,6, [1,62 ; 7,98], p = 0,0016) et le port d’une attelle (OR = 2,83, [1,54 ; 5,02], p < 0,001) étaient associés à un taux d’échec plus élevé. Dans le groupe des lésions stables, l’attelle (OR = 3,73, [1,62 ; 8,56], p = 0,0019) était associée à un taux d’échec plus élevé.Aucun consensus concernant le protocole de rééducation n’est établi à ce jour et les résultats de la série rétrospective de la SFA témoignent de la grande variabilité des pratiques à l’échelle nationale. Si les protocoles de rééducation accélérée sont plébiscités à ce jour, la reprise d’un appui complet immédiat doit être considérée avec prudence, étant associée à un risque d’échec plus élevé dans cette série. Un appui différé de 1 mois peut être proposé en cas de lésion de grande taille ou en cas d’atteinte des fibres circonférentielles. Le port d’une attelle ne semble pas avoir d’influence tandis que la limitation de flexion fait toujours consensus.IV, étude rétrospective.
Background. - The role of urogenital infections in male infertility has long been the subject of debate.Methods. - A bibliographic search limited to English-language literature on human subjects published before 5/2023 resulted in the selection of 189 articles.Results. - Male infertility is often of multifactorial aetiology, and to optimise the prognosis it is important to manage all the factors that can be corrected, including infectious causes, which represent one of the most frequent aetiologies. The infectious agents involved in urogenital infections are most often bacterial or viral, and more rarely parasitic. They can infect the seminal tract, male accessory glands and/or testicles, and usually result in inflammation and increased oxidative stress. These infections reduce male fertility, in particular by altering spermogram parameters and increasing sperm DNA fragmentation. For these reasons, the search for a urogenital infection should be systematic, involving a careful history and clinical examination, ultrasound and systematic bacteriological tests guided by clinical findings. Aetiological treatment may be proposed depending on the picture and the germ involved. Conclusion. - This review should help the urologist to establish an accurate diagnosis of the form and extent of the infection, and enable him to define an appropriate therapeutic strategy, tailored to the patient, in order to obtain the best chances of improving male fertility.(c) 2023 Elsevier Masson SAS. All rights reserved.
Background. - Current literature highlights the difficulty in identifying an optimal educational technique for maintaining continence during cough.Objective. - To characterize the effects of an educational intervention focusing on neutral posture during cough in women with cough-induced urinary incontinence (UI).Methods. - This interventional study design included women with cough-induced UI. We recorded PFMs surface electromyographic (sEMG) peak activity, and assessed symptoms and quality of life (QoL) 6 weeks after the intervention. The effect of the experimental situation was estimated using a linear mixed model, sEMG measurements during coughing were indexed to each situation and adjusted to the resting value at, and a moderation analysis was used.Results/Findings. - Eighteen participants were included. The measurement situations (control versus experimental) did not have a statistically significant impact on sEMG peak activity during coughing: mean effect [95% CI] 3.42 [-1.28; 7.66]. Six weeks post-intervention, participants reported statistically significant decrease in urinary symptoms (P = 0.0246) and significant improvement in QoL (P = 0.00776). This was also particularly marked on the dimension related to effort activities (P = 0.00162).Conclusion. - This study suggests that a brief educational intervention focusing on neutral posture during cough, without voluntary pre-contraction of the PFMs, has no clinically significant influence on sEMG peak activity of the PFMs in women with cough-induced UI. However, this intervention can lead to a significant improvement in urinary symptoms and QoL at 6 weeks. These improvements seem to be independent of electromyographic PFMs peak activity recorded during cough. As such, our preliminary results pave the way for future research.
La résection de réévaluation (reRTUV) des tumeurs de vessie (TV) pT1G3 est recommandée mais son impact en termes de survie sans récidive (SSR) et sans progression (SSP) est discuté. L’objectif de cette étude était d’évaluer notre pratique de reRTUV pour ces tumeurs et son impact sur la survie globale (SG), SSR et SSP. Une étude rétrospective était menée entre 2010 et 2020. Le critère d’inclusion était la présence d’une TV pT1G3 nouvellement diagnostiquée. Les critères d’exclusion étaient les résections incomplètes, les suspicions de tumeur infiltrante, une atteinte du haut appareil ou métastatique. Deux groupes étaient constitués : groupe 1 avec une reRTUV et groupe 2 sans reRTUV. Les SSR et SSP étaient évaluées. Au total 78 patients étaient inclus dont 50 (64,1 %) dans le groupe 1. Les deux groupes ne présentaient pas de différences significatives. Le délai de reRTUV médian était de 8 semaines et 60 % de tumeur résiduelle était retrouvée. Une sous stadification initiale était retrouvée dans 12 % des cas. La SSR et SSP étaient significativement meilleures dans le groupe 1 (p = 0,0019 ; p = 0,02). Il n’y avait pas de différence significative en SG et survie spécifique (SS). La reRTUV pour les TV pT1G3 permet la détection de tumeur résiduelle et diminue le risque de sous-évaluation de la RTUVi. Elle est associée à une amélioration significative de la SSR et SSP sans amélioration de la SG et SS. 4. Restaging transurethral resection (re-TUR) of high grade T1 bladder cancer (HGT1-BC) is recommended but the impact in terms of recurrence-free survival (RFS) and progression-free survival (PFS) is discussed. The objective of this study was to evaluate our practice of re-TUR for these tumors and its impact on overall survival (OS), RFS and PFS. A retrospective observational study was conducted between 2010 and 2020. The inclusion criteria was the presence of newly diagnosed HGT1-BC. Patients with incomplete resection, suspicion of infiltrating tumor, upper tract urothelial cancer, or metastatic disease were ineligible. Two groups were defined : Group 1 with re-TUR and Group 2 without re-TUR. RFS and PFS were evaluated. A total of 78 patients were included, including 50 (64,1%) in group 1. There were no significant differences between the two groups. The mean time to re-TUR was 8 weeks and 60% residual tumor was found. Initial under-staging was found in 12% of cases. RFS and PFS were significantly better in Group 1 (P = 0.0019; P = 0,02). No significant were found between the groups in OS and specific survival (SS). Performing a re-TUR for high grade T1 bladder tumors allows detection of residual tumor and decreases the risk of under-evaluation. It is associated with a significant improvement in RFS and PFS with no impact on OS and SS. 4.
Introduction: Intra-lesional injections of collagenase (Xiapex (R) ) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market. Objective: To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet -rich plasma (PRP) under general anesthesia in the treatment of PD. Patients and method: A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature. Result: Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean +/- standard deviation (SD) curvature degree was 57.5 +/- 20.61 degrees (range 20-90 degrees ). After the protocol, the mean curvature degree was 40.86 +/- 25.13 degrees (range 0-90 degrees ). The curvature angle improved significantly ( P = 0.0001), with a mean improvement difference of 16.85 +/- 14.81 degrees (range 0-50 degrees ) and a mean improvement percentage of 47.7 +/- 40.29% (range 0-100%). Conclusion: Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD. Level of evidence: 4: case series study (c) 2023 Elsevier Masson SAS. All rights reserved.
The Post-University Interdisciplinary Association of Sexology (AIUS) has brought together a panel of experts to develop French recommendations for the management of premature ejaculation.Systematic review of the literature between 01/1995 and 02/2022. Use of the clinical practice guidelines (CPR) method.We recommend giving all patients with PE psychosexological counseling, and whenever possible combining pharmacotherapies and sexually-focused cognitive-behavioral therapies, involving the partner in the treatment process. Other sexological approaches could be useful. We recommend the use of dapoxetine as first-line, on-demand oral therapy for primary and acquired PE. We recommend the use of lidocaine 150mg/mL/prilocaine 50mg/mL spray as local treatment for primary PE. We suggest the combination of dapoxetine and lidocaine/prilocaine in patients insufficiently improved by monotherapy. In patients who have not responded to treatments with marketing authorisation, we suggest using an off-label SSRI, preferably paroxetine, in the absence of a contraindication. We recommend treating ED before PE in patients with both symptoms. We do not recommend using α-1 blockers or tramadol in patients with PE. We do not recommend routine posthectomy or penile frenulum surgery for PE.These recommendations should contribute to improving the management of PE.
The subinguinal microsurgical varicocelectomy is considered as the gold standard surgical technique for the treatment of varicocele. The objective of this study is to evaluate the results of this technique on the resolution of pain and the parameters of sperm analysis.Single-center, retrospective study that includes 22 patients who have been operated over a period of six months for a clinically palpable varicocele via the microsurgical subinguinal technique. Nine patients were operated for pain and 13 patients for infertility with an abnormality of their sperm analysis.All the patients operated for pain had a complete resolution of pain at the postoperative follow-up (3 months). Concerning the patients operated for infertility, 76.92% of the patients had a normal sperm analysis, 7.69% of the patients presented a partial improvement, and 15.39% of the patients without any improvement. Analysis of sperm's parameters at 3 months showed a significant improvement in the morphology (4.3% vs 6.69% of typical forms according to Kruger ; P<0.05) and mobility (progressive mobility 15.6% vs 23% postoperatively; P<0.01). A non-significant improvement (low sample) in the concentration was noted (21.58 million/mL preoperative vs 34.9 million/mL postoperative, P=0.08). Pregnancies are noted in 38.5% of patients. A postoperative complication was noted with surgical site infection resolved with antibiotics.This single-center study confirms that the treatment of varicocele by subinguinal microsurgical route is an effective therapeutic strategy on symptomatic varicocele and in infertile men. This technique is associated with few complications.
Introduction. - Surgical resection is the current standard of care for retroperitoneal sarcoma (RPS). Recent data suggests that up to 5% of patient have incomplete (R2) resection. The exact reason why patients scheduled for surgery with a curative intent to treat ended up with an R2 resection is largely unknown.Aim of the study. - To identify intraoperative findings responsible for incomplete (R2) resection in primary RPS.Methods. - All records of consecutive patients scheduled for a non-metastatic primary RPS surgery between 1995 and 2020 in a tertiary care sarcoma centre were retrospective analyzed.Results. - Among the 347 patients scheduled for surgery, 13 (3.7%) had an incomplete (R2) resection. The reasons for incomplete surgery were intraoperative finding of vascular involvement of great vessels in 5 patients, previously undetected peritoneal metastases in 5 patients, invasion of contralateral kidney/ureter in 2 patients and the need to preserve both kidneys in 1 patient because of his past medical history. Among these patients, 3 had a laparotomy without resection and 10 had a partial resection (i.e. debulking surgery). Severe postoperative complications occurred in 5 patients. The median length of stay in hospital was 19 days. After a median follow-up of 12 months, the median survival of patients after incomplete resection was 18 months. The 1-y, 5-y and 8-y overall survival (OS) for these patients were 46%, 14%, and 7%, respectively.Conclusion. - Incomplete (R2) resection for a primary RPS surgery is rare in specialized sarcoma center. The next steps should be to identify the preoperative criteria that lead to this accurate selection and to define the best practice in front of a peroperative discovery of an unresectable RPS. Level of evidence.- III.(c) 2023 Published by Elsevier Masson SAS.
Hypospadias is one of the most common congenital anomalies in men. Outpatient surgery has been proposed but is not widespread. The aim of this study was to evaluate our experience of outpatient surgery for penile hypospadias repair and to specify the constraints for a result similar to a conventional inpatient procedure.Observational, retrospective and single-center study, including all the patients operated on hypospadias for the first time by one of the 3 senior surgeons, between January 2011 and March 2018. Peno-scrotal and perineal hypospadias were excluded because systematically hospitalized.One hundred sixty-six patients were included. 67 patients (40,4%) were treated on an outpatient basis. The mean age at the time of procedure was 15.6 (6-51) months. Forms with curvature were almost exclusively hospitalized (1 vs. 25, P<0.001). There was no significant difference for anterior penile forms (60 vs. 81, P=0.06). Middle and posterior hypospadias were more often hospitalized, although outpatient experience exists. There were no more complications in the outpatient group.Outpatient hypospadias surgery seems to be achievable in most of the cases, provided that medical care is standardized and multidisciplinary, the staff is trained and involved and a specific organization is put in place in the department. Evaluation of the socio-family environment is therefore fundamental.
