Background and objectiveOur aim was to report the first clinical trial of TENSI+, a new device for transcutaneous posterior tibial nerve stimulation (TNS) for treatment of overactive bladder (OAB).MethodsA prospective, multicentre clinical trial was conducted in adults with OAB in seven French centres. The main exclusion criteria were prior percutaneous or transcutaneous TNS or invasive OAB treatment, current antimuscarinic use, 24-h polyuria, known bladder disease, postvoid residual volume >150 ml, and pelvic organ prolapse stage >2. Patients self-administered daily TTNS sessions of 20 min with TENSI+ at home after education by a specialized nurse. A bladder diary, Urinary Symptom Profile and OAB-q questionnaires, and Patient Global Impression of Improvement (PGI-I) scores were evaluated at baseline and 3 and 6 mo. The primary endpoint was efficacy, based on PGI-I and variations in bladder diary parameters. Success was defined as a PGI-I score ≤3 and any improvement ≥30% in bladder diary parameters.Key findings and limitationsThe study included 78 patients (13 males). Nine patients had neurological disease, 21 had previously tried antimuscarinics, and 41 had wet OAB at baseline. At 3 mo, 65/78 patients had a full analysis set. Treatment was successful in 44/65 patients (67%), with 25/65 (38%) reporting both an objective improvement and high satisfaction. All OAB-related endpoints were significantly improved, except bladder capacity and total voided volume per 24 h. At 6 mo, only five of 44 patients had interrupted their treatment. No factor predictive of success was identified. Two adverse events (pain at stimulation site and/or pelvic pain) were reported and spontaneously resolved without treatment interruption.Conclusions and clinical implicationsTENSI+ is a safe and effective TTNS treatment option for OAB management.Patient summaryTENSI+ is a new device for nerve stimulation in patients with overactive bladder. Patients use the device at home every day. In our short-term trial, TENSI+ use improved symptoms in 67% of patients. Further evaluation over a longer period of time is needed.

INTRODUCTION:Inflammatory and sensory chronic bladder diseases have a significant impact on quality of life. These pathologies share alteration of the layer between urine and urothelium, making the use of topical agents appropriate. OBJECTIVES:Review the efficacy and tolerance of intravesical treatments for these pathologies. Give practical guidelines for the use of agents currently available in France. METHOD:A narrative review was performed in March 2021 using PubMed/MEDLINE, Google Scholar and the international guidelines. Pharmaceutical companies and pharmacies were interviewed. RESULTS:Although numerous molecules were tested over the last 5 decades, only dimethylsulfoxyde and glycosaminoglycans are available in France today. Results are promising: response rates are up to 95% and 84% respectively in bladder pain syndrome. In urinary tract infections, glycosaminoglycans could decrease annual number of cystitis by 2.56 (95% confidence interval (CI) -3.86, -1.26; P<0.001) and increase the time to first cystitis recurrence by 130 days (95% CI: 5.84 - 254.26; P=0.04). In radiation cystitis, results could be comparable to hyperbaric oxygen regarding pain and frequency of voiding (-1.31±1.3 visual analogic scale et -1.5±1.4 voiding per day, respectively, at 12 months, P<0.01). However, literature has a low level of evidence. CONCLUSION:Chronic bladder diseases have limited treatment options. Intravesical agents are a good alternative, although their cost is significant and their outcome uncertain.

IntroductionLes cystopathies chroniques inflammatoires et douloureuses sont des pathologies impactant lourdement la qualité de vie des patients qui en sont atteints. Bien qu’avec des physiopathologies différentes, les cystopathies chroniques ont en commun une altération de la couche, faisant interface entre l’urine et l’urothélium, rendant appropriée l’utilisation d’agents topiques.ObjectifsFaire une revue de l’efficacité et de la tolérance des traitements endovésicaux pour ces pathologies, ainsi qu’un guide pratique pour l’utilisation des molécules actuellement disponibles sur le marché français.MéthodeUne revue narrative de la littérature a été effectuée en mars 2021 sur PubMed/MEDLINE et Google Scholar, ainsi qu’une revue des recommandations françaises et internationales. Les laboratoires et pharmacies ont été interrogés.RésultatsDe nombreuses molécules ont été essayées au cours des 50 dernières années, mais ne sont disponibles, actuellement, que le diméthylsulfoxyde et les glycosaminoglycanes. Les résultats en sont prometteurs : leurs taux d’amélioration des douleurs vont jusqu’à 95 % et 84 % de réponse, respectivement dans le syndrome douloureux vésical. Dans les cystites bactériennes, les glycosaminoglycanes permettent de réduire le nombre moyen annuel de cystites de 2,56 (intervalle de confiance (IC) à 95 % −3,86 – −1,26 ; p<0,001), avec une augmentation du délai avant récidive de 130 jours (IC à 95 % : 5,84–254,26 ; p=0,04). Dans la cystite radique, ils ont montré des résultats comparables à l’oxygénothérapie hyperbare sur l’amélioration de la douleur et de la pollakiurie (−1,31±1,3 points sur l’échelle EVA et −1,5±1,4 mictions par jour respectivement, à 12 mois, p<0,01). La littérature reste cependant à faible niveau de preuve.ConclusionLes cystopathies chroniques ont des options de traitement limitées. Les instillations endovésicales sont une option de traitement à ne pas négliger avec, pour limite, un coût non négligeable pour un résultat incertain.

La stimulation du nerf tibial postérieur (PTNS) est une option thérapeutique validée pour le traitement des symptômes du bas appareil urinaire SBAU, avec une efficacité d'environ 60 % à court terme et peu d'effets secondaires. L'objectif de cette étude était d'évaluer les résultats du nouveau dispositif de PTNS transcutané TENSI+ dans le cadre du soin courant. Une étude multicentrique rétrospective a été réalisée dans 7 centres français. Les patients traités par le dispositif TENSI+ (Stimuli Technology, Boulogne-Billancourt, France) entre septembre 2021 et février 2022 ont été inclus. Les patients avaient reçu une éducation thérapeutique à domicile par un prestataire, avec prescription d'une séance quotidienne de 20 minutes. Les données recueillies comprenaient les données démographiques, les antécédents, les symptômes cliniques initiaux et les traitements antérieurs (anticholinergiques). Le succès était défini par la persistance du traitement après la première visite à 3 mois. L'efficacité était évaluée par le score Patient Global Impression of Improvement (PGI-I). Les effets secondaires ont été recueillis. Cent trois patients ont été inclus. Les caractéristiques cliniques sont résumées dans le Tableau 1. L'indication principale était l'hyperactivité vésicale. Après un suivi médian de 12 [10–21] semaines, le taux de succès était de 68 %. Cinquante-deux pour cent des patients avaient un score PGI-I égal à 1 ou 2, et 18 % un score PGI-I à 3 (Tableau 2). Aucun des paramètres initiaux testés (âge, sexe, indice de masse corporelle, maladie neurologique, fuites par urgenturies, antécédents de traitement anticholinergique) n'était significativement associé au taux de succès. Quatre patients ont rapporté des effets secondaires réversibles à l'arrêt du traitement (deux cas de douleur pelvienne et deux cas de douleur de jambe au site de la stimulation). Le traitement par stimulation du nerf tibial postérieur par le dispositif TENSI+ était associé à un taux de succès d'environ 68 % à court terme, avec un taux très faible d'effets secondaires réversibles. De plus amples études, notamment comparatives, sont nécessaires pour confirmer le rôle de TENSI+ dans l'arsenal thérapeutique.

INTRODUCTION: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. OBJECTIVES: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. RESULTS: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. CONCLUSION: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.

Introduction. - Vaginal LASER therapy is increasingly used in the field of urogynecology, but several points remain unclear. Our goal was to produce a systematic review of available evidence and provide a critical appraisal of available data. Methods. - A systematic review until march 2020 was conducted using PubMed/MEDLINE. Cochrane and Embase databases. All studies about vaginal LASER use in the field of urogynecology were included. Results. - Forty studies have been included (8 for genitourinary syndrome of menopause, 19 for stress urinary incontinence, 3 for overactive bladder, 7 for urogenital prolapse, 3 for other indications). Data were heterogeneous, and level of evidence was weak or very weak. Few studies were comparative, and only 3 were randomized). Mild improvement of symptoms and quality of life and limited satisfaction were seen for genitourinary syndrome, stress urinary incontinence, overactive bladder and prolapse. Few adverse events were reported. However, major methodological biases were noted regarding efficacy and safety evaluation. No long-term results were available. Conclusions. - While Vaginal LASER therapy seem to provide encouraging results, the level of evidence supporting its use was weak, especially regarding long-term outcomes. Studies of better quality are warranted before any recommendation can be made. Current use should be limited to clinical research. (C) 2020 Elsevier Masson SAS. All rights reserved.

OBJECTIVE:To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m2), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

Introduction: The issue addressed in this chapter of recommendations is: What is the clinical and para-clinical assessment to achieve in women with genital prolapse and for whom surgical treatment has been decided. What are the clinical elements of the examination that must be taken into account as a risk factor of failure or relapse after surgery, in order to anticipate and evaluate possible surgical difficulties, and to move towards a preferred surgical technique?Material and methods: This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane Database of Systemactic Reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement [AP]).Results: It suits first of all to describe prolapse, by clinical examination, helped, if needed, by a supplement of imagery if clinical examination data are insufficient or in case of discrepancy between the functional signs and clinical anomalies found, or in case of doubt in associated pathology. It suits to look relapse risk factors (high grade prolapse) and postoperative complications risk factors (risk factors for prothetic exposure, surgical approach difficulties, pelvic pain syndrome with hypersensitivity) to inform the patient and guide the therapeutic choice. Urinary functional disorders associated with prolapse (urinary incontinence, overactive bladder, dysuria, urinary tract infection, upper urinary tract impact) will be search and evaluated by interview and clinical examination and by a flowmeter with measurement of the post voiding residue, a urinalysis, and renal-bladder ultrasound. In the presence of voiding disorders, it is appropriate to do their clinical and urodynamic evaluation. In the absence of any spontaneous or hidden urinary sign, there is so far no reason to recommend systematically urodynamic assessment. Anorectal symptoms associated with prolapse (irritable bowel syndrome, obstruction of defecation, fecal incontinence) should be search and evaluated. Before prolapse surgery, it is essential not to ignore gynecologic pathology.Conclusion: Before proposing a surgical cure of genital prolapse of women, it suits to achieve a clinical and paraclinical assessment to describe prolapse (anatomical structures involved, grade), to look for recurrence, difficulties approach and postoperative complications risk factors, and to appreciate the impact or the symptoms associated with prolapse (urinary, anorectal, gynecological, pelvic-perineal pain) to guide their evaluation and their treatment. (C) 2016 Published by Elsevier Masson SAS.

Objective: To provide clinical practice guidelines (CPGs) based on the best evidence available (level of evidence (LE)), concerning colpocleisis as a surgical treatment of pelvic organ prolapse.Methods: This article concern a systematically review of the literature concerning colpocleisis (obliterative surgery).Results: At short term follow-up, colpocleisis is associated with an anatomical success rate of 98 % (LE3) and a subjective success rate of 93% (LE3). A decrease in genital, urinary and anorectal symptoms and an enhancement of quality of life are observed in most women following colpocleisis (LE4). At mid-term (1 to 3 years) follow-up, patients' satisfaction ("satisfied" or "very satisfied" ranges from 85 to 100% (LE3)). At long-term follow-up, regret rate (women who regret having had the surgery) is 5% (LE4). In women over 80 years old, colpocleisis is associated with a decrease in per- and post-operative complication rates when compare to other surgical techniques used for pelvic organ prolapse surgery (LE2).Conclusion: Colpocleisis is a valid surgical option for elderly patients with pelvic organ prolapse surgery, and who are definitely permanently sexually inactive (Grade C). (C) 2016 Published by Elsevier Masson SAS.

INTRODUCTION:The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh. METHOD:This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)). RESULTS:The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions. CONCLUSION:If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS.

Introduction: Prolapse and urinary incontinence are frequently associated. Patente (or proven) stress urinary incontinence (SUI) is defined by a leakage of urine that occurs with coughing or Valsalva, in the absence of any prolapse reduction manipulation. Masked urinary incontinence results in leakage of urine occurring during reduction of prolapse during the clinical examination in a patient who does not describe incontinence symptoms at baseline. The purpose of this chapter is to consider on the issue of systematic support or not of urinary incontinence, patent or hidden, during the cure of pelvic organs prolapse by abdominal or vaginal approach.Material and methods: This work is based on an systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systematic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement).Results: In case of patent IUE, concomitant treatment of prolapse and SUI reduces the risk of postoperative SUI. However, the isolated treatment of prolapse can treat up to 30% of preoperative SUI. Concomitant treatment of SUI exposed to a specific overactive bladder and dysuria morbidity.The presence of a hidden IUE represents a risk of postoperative SUI, but there is no clinical or urodynamic test to predict individually the risk of postoperative SUI. Moreover, the isolated treatment of prolapse can treat up to 60% of the masked SUI. Concomitant treatment of the hidden IUE therefore exposes again to overtreatment and a specific overactive bladder and dysuria morbidity.Conclusion: In case of overt or hidden urinary incontinence, concomitant treatment of SUI and prolapse reduces the risk of postoperative SUI but exposes to a specific overactive bladder and dysuria morbidity (NP3). The isolated treatment of prolapse often allows itself to treat preoperative SUI. We can suggest not to treat SUI (whether patent or hidden) at the same time, providing that women are informed of the possibility of 2 stages surgery (Grade C). (C) 2016 Published by Elsevier Masson SAS.

Objective. Develop guidelines for surgery for primary pelvic organ prolapse (POP).Methods. Literature review, establishment of levels of evidence, external review, and grading of recommendations by 5 French academic societies: Association Francaise d'Urologie, College National des Gynecologues et Obstetriciens Francais, Societe Interdisciplinaire d'Urodynamique et de Pelvi-Perineologie, Societe Nationale Francaise de Colo-proctologie, and Societe de Chirurgie Gynecologique et Pelvienne.Results. It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B). A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C). (C) 2016 Published by Elsevier Masson SAS.

OBJECTIVE:Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article. MATERIAL AND METHODS:This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association. RESULTS:Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary. CONCLUSION:Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

87 Background: It is reported that a Fcholine Positron Emission Tomography (PET/CT) scan can change the management of the patients with prostate cancer up to 20% of the cases. The aim of this study was to evaluate the impact of 18FCholine PET/CT when its indication was taken by a multi-disciplinary staff in case of initial diagnosis or in case of recurrence. Methods: This retrospective study involved 84 patients between May 2013 and July 2014. After a selective approach 86 18F-PET/CT were performed consecutively: 37 (43%) for the initial staging and 49 (57%) in biochemical failure. The acquisition protocol included a pelvic dynamic scan after injection of 4 MBq/kg of 18FCholine followed by a whole-body scan. Mean age, PSA level and Gleason score were respectively in relapse and initial staging: 71 years (59-82), 4.9 (0.12-32.8), 7 (6-9) and 63 years (48-76), 16 (2.42-55) and 8 (6-10). Results: In initial diagnosis, prostate cancer was identified in all the patients on PET/CT. Local disease was seen in 23/37 scans (62.2%); loco-regional node involvement in 8 (21.6%) and metastatic disease in 6 (16.2%). PET/CT confirmed the therapeutic decision in 48.6% of cases and led to a therapeutic modification in 43.2% of cases,avoiding radical prostatectomy and lymphadenectomy in 25% of cases or modifying the extend of radiotherapy (25%) . In biochemical recurrence, PET/CT showed relapse in the prostatic area in 14 patients (28.6%); abnormal pelvic lymph nodes in 10 cases (20.4%) and distant metastases in 18 patients (36.7%). It failed to identify the cause of relapse in 7 cases (14.3%). PET/CT confirmed the therapeutic approach in 24.5% and led to a therapeutic change in 61.2% of cases The diagnostic performance of the FCholine PET/CT scan on nodes, according to the pathological results were: sensitivity 80 %, specificity 84.6%, positive predictive value 66.7% and negative predictive value 91.7 % Conclusions: A rigorous selection of the patients before the realization of a FCholine PET/CT scan in the management of a prostate cancer can increase the diagnostic performance and provide a better impact. In this study the treatment modification affected 54.8% of the patients.

Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article.This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association.Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH20) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT(®)) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary.Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.

Les tumeurs en situation hilaire représentent une difficulté technique surajoutée pouvant engendrer lors de la réalisation d’une chirurgie conservatrice des durées d’ischémie rallongées. L’objectif de cette vidéo était d’illustrer un cas de néphrectomie partielle robotisée (NPR) d’une tumeur hilaire sous clampage suprasélectif. Les étapes clés de l’intervention, réalisée avec le robot chirurgical Da-Vinci (Intuitive Surgical) par voie transpéritonéale, à l’aide de 3 bras opérateurs, 2 optiques de 0 et 30° et 2 trocarts de 5 mm et 10 mm pour l’aide opératoire, sont présentées. Le clampage artériel a été réalisé à l’aide de clamps bulldog à usage robotique de 25 mm (SCANLAN). Les données cliniques associées au cas présenté sont issues de la base de données UroCCR et y ont été collectées après consentement. La patiente, âgée de 66 ans, présentait un cancer bilatéral avec, une tumeur polaire supérieure gauche de 3,5 cm et une tumeur hilaire droite de 5,3 cm. La lésion gauche, de prise en charge la plus simple, fut traitée en premier par NPR. La tumeur droite, de complexité élevée (RENAL-10ph PADUA-11p), a été prise en charge 2 mois plus tard. Une dissection du pédicule vasculaire a alors été réalisée jusqu’en intra-hilaire et 2 artères à destinée tumorale directe ont été individualisées, clippées puis sectionnées. L’exérèse tumorale a été conduite sous clampage sélectif de 2 branches artérielles de 2e et de 3e ordre respectant ainsi la vascularisation du tiers inférieur du rein. La durée de clampage était de 22 minutes. Les 2 lésions étaient des CCRc de grades 2 et 3 de Führman. Une tumeur en situation hilaire nécessite, du fait de ses rapports avec les vaisseaux, une dissection pédiculaire poussée, elle-même propice à la réalisation d’un clampage suprasélectif.

La diminution de l’ischémie globale du rein au cours de la néphrectomie partielle (NP) est un des challenges techniques de cette intervention. Le clampage suprasélectif est une des méthodes pour y parvenir. L’objectif de cette vidéo était d’illustrer une démarche d’évaluation de notre pratique par l’analyse de l’imagerie préopératoire, au bénéfice d’une amélioration de la technique de clampage. Nous avons analysé, a posteriori, un cas de double NP laparoscopique robot-assistée gauche. Les étapes clés de l’intervention, réalisée avec le robot chirurgical Da-Vinci (Intuitive Surgical) à l’aide de 3 bras opérateurs et 2 trocarts de 5 mm et 10 mm pour l’aide opératoire, sont présentées. Des reconstructions 3D de la phase artérielle du scanner préopératoire ont été obtenues à l’aide du logiciel en accès libre et gratuit OsiriX v5.8.5 32-bit (plateforme MacOSX). La possibilité d’amélioration de la technique de clampage a alors secondairement été discutée. Les données cliniques associées au cas présenté sont issues de la base de données UroCCR et y ont été collectées après consentement. Le patient, âgé de 48 ans, présentait 2 lésions rénales gauches. La première, médiorénale, endophytique et hilaire, de 4,2 cm était de complexité élevée (RENAL-11ah, PADUA-13a). La deuxième, polaire supérieure et postérieure, partiellement exophytique et mesurant 1,2 cm était de complexité faible (RENAL-5p, PADUA-7p). La vascularisation artérielle du rein était assurée par 2 artères : principale et polaire inférieure. La dissection des pédicules vasculaires a été réalisée jusqu’en intra-hilaire. Le rein a été complètement mobilisé pour accéder à la lésion postérieure. Les tumorectomies des lésions hilaire puis postérieure ont respectivement été réalisées sous clampage de 24 minutes du tronc de l’artère principale puis sans clampage. Les reconstructions 3D-TDM, comparées aux images opératoires, permettaient d’envisager un clampage plus sélectif de branches artérielles de 4e ordre lors de la tumorectomie de la lésion hilaire. L’analyse du scanner préopératoire par le chirurgien lui-même, à l’aide d’un logiciel gratuit et en libre accès, pourrait permettre d’améliorer la sélectivité du clampage artériel lors de la NP.

Sacral nerve stimulation (NMS) is a therapeutic alternative for the treatment of urinary functional disorders as diverse as overactive bladder (OAB), urinary retention or pelvic pain syndromes. With the increasing use of NMS, we must deal with the postoperative management of this therapy.We report the results, postoperative adverse events and their management in our center.This is a retrospective single-center single-operator study of 93 patients who were tested for NMS between January 2005 and December 2013.Of the 93 patients, 78 had a definitive implantation of the device for OAB (n=44), urinary retention (n=11), pain, interstitial cystitis (n=12), bladder hyperactivity and pain (n=8) or dysuria (n=3). The average follow-up was 38.86 months (2.06 to 88.3±28.9). Among patients with OAB, 75% had a clinical improvement greater than or equal to 50%, 11.3% were considered as cured. Among patients with urinary retention, 63.5% were improved. Painful patients were improved for 58.3% of them, 2 were considered as cured. We reported 3 early postoperative complications (2 local infections, 1 hematoma), and adverse events in 49 patients (multiple visits for parameter settings, revision of the device [n=38], explantation [n=14]).Our results confirm the long-term effectiveness of NMS for the treatment of refractory overactive bladder, urinary retention, chronic pelvic pain, vesico-uretral dyssynergies. Studies are still needed to improve the selection of ideal candidates, identify prognostic factors and reduce the rate of complications and revisions.4.