251 research outputs found
Editorial Comment from Dr Peyronnet and Dr Bensalah to Early unclamping might reduce the risk of renal artery pseudoaneurysm after robot-assisted laparoscopic partial nephrectomy
No full textInternational audienceIn this issue of International Journal of Urology, Kondo et al. report a series of 96 robotic partial nephrectomies (PN) carried out with either conventional unclamping or early unclamping (EU) of the renal pedicle.[1] Their main finding is that EU is associated with a decreased rate of pseudoaneurysm (PA). Their study raises several interesting issues that we would like to comment on
Contribution of central nervous system MRI to lower urinary tract control
No full textLa neuro-imagerie est un outil puissant pour étudier le contrôle cérébral sur le bas appareil urinaire. L'imagerie par résonance magnétique fonctionnelle (IRMf) nous permet aujourd'hui de comprendre quelles zones du cerveau jouent un rôle dans les phases de stockage et de miction du cycle mictionnel. Celui-ci implique de multiples zones clés de organisées en un réseau cérébral complexe que l'imagerie par résonance magnétique fonctionnelle (IRMf) tend à décrire depuis une vingtaine d'années. Nous avons étudié plusieurs dimensions inexplorées du réseau cerveau-vessie en IRMf.Une revue exhaustive de la littérature était notre point de départ pour mettre à jour les progrès de l'IRMf dans la description du réseau cerveau-vessie et nous avons présenté les lacunes de connaissances. Parmi les résultats, nous avons montré que le rôle du cervelet devait être clarifié et que le contrôle de la vessie par la moelle épinière et la tractographie des symptômes urinaires dans la sclérose en plaque (SEP) n'avaient jamais été étudiés.Nous avons donc réalisé une étude IRMf sur le remplissage de la vessie à l'état de repos afin de déterminer de nouvelles régions d'intérêt dans le cervelet.Ensuite, nous avons travaillé sur l'imagerie du tenseur de diffusion (TD) de la SEP pour évaluer les associations entre les symptômes du bas appareil urinaire et la charge lésionnelle des faisceaux de fibres blanche (FFB) associée à la progression de la maladie.Enfin, nous avons conçu un protocole d'étude pour évaluer l'activité IRMf liée à la tâche dans la miction de la moelle épinière à l'aide d'un nouvel outil dédié pour déclencher le réflexe bulbocaverneux.Nous avons examiné la littérature des 12 dernières années en utilisant des mots-clés appliqués à la base de données Medline.Les activations du cervelet ont été analysées sur une séquence IRMf à l'état de repos. Vingt volontaires sains ont été étudiés avant et après le remplissage de la vessie. Trois régions ont été identifié avec une analyse région d’intérêt vers voxel.Les FFB de dix femmes atteintes de sclérose en plaques et présentant des symptômes mictionnels a été analysée. Le % de résidu post-mictionnel/capacité vésicale montrait une forte association avec la progression de la maladie et la dégradation des FFB.Nous avons construit un marteau réflexe compatible IRM pour déclencher facilement le réflexe bulbocaverneux et explorer la moelle épinière lombosacrée en IRMf. Pendant le remplissage de la vessie, des activations significatives ont été retrouvées.L'IRM et ses dérivés sont essentiels pour comprendre le fonctionnement de l'appareil urinaire. Nous avons identifié des zones du cervelet à intégrer dans le modèle, défini des symptômes urologiques en corrélation avec la progression de la SEP et la dégradation des FFB associée, et mis au point un outil permettant d'étudier pour la première fois les centres sacrés de la miction.Ces résultats font non seulement progresser notre compréhension du réseau cerveau-vessie, mais ouvrent également la voie à de futures recherches et applications cliniques dans ces trois domaines interconnectés.Neuroimaging is a powerful tool for investigating the neural control of the lower urinary tract. Functional magnetic resonance imaging (fMRI) now allows us to understand which brain areas contribute to the proper function of the storage and voiding of the lower urinary tract. The micturition cycle involves multiple control key zones organized in a complex brain network that functional MRI (fMRI) imaging has tended to describe for the past twenty years. We studied several unexplored aspects of the brain-bladder network on fMRI.We reviewed the fMRI advances in the brain bladder network description and presenting the gaps in knowledge. Among the findings, we showed that the cerebellum's role needed to be clarified and that spinal cord bladder control and tractography of urinary symptoms in multiple sclerosis (MS) had never been studied.Thus, we performed an fMRI resting-state bladder filling study to determine new regions of interest in the cerebellum.Then, we worked on multiple sclerosis (MS) diffusion tensor imaging (DTI) to assess associations between lower urinary tract symptoms and the white matter tract (WMT) burden associated with the disease progression.Finally, we designed a protocol study to assess task-related fMRI activity within the spinal cord micturition with a new dedicated tool to elicit the bulbocavernosus reflex.We reviewed the literature for the past 12 years using a keyword formula applied to the Medline database.Cerebellum activations were analyzed on a resting-state fMRI sequence. Twenty healthy volunteers were studied before and after bladder filling. Three regions were identified with a seed-to-voxel analysis.The WMT of ten MS women with voiding symptoms was analyzed. The % post-void residual/bladder capacity showed the strongest association between disease progression and WMT degradation.We built an MRI-compatible reflex hammer that successfully conveniently triggered the bulbocavernosus reflex, allowing for exploring the lumbosacral spinal cord in fMRI. During bladder filling, significant activations were elicited.MRI and its derivatives are vital in understanding the functioning of the urinary tract. We have identified areas of the cerebellum for integration into the model, defined urological symptoms correlated with MS progression and degradation of associated WMT and developed a tool to study the sacral centers of micturition for the first time.These significant findings not only advance our understanding of the brain-bladder network but also pave the way for future research and clinical applications in these three interconnected fields
Reply to Bernhard Liedl, Klaus Goeschen, and Florian Wagenlehner’s Letter to the Editor re: Benoit Peyronnet, Emma Mironska, Christopher Chapple, et al. A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment. Eur Urol 2019, 75:988–1000
No full textInternational audienc
A Comprehensive Review of Overactive Bladder Pathophysiology: On the Way to Tailored Treatment
No full textCONTEXT: Current literature suggests that several pathophysiological factors and mechanisms might be responsible for the nonspecific symptom complex of overactive bladder (OAB). OBJECTIVE: To provide a comprehensive analysis of the potential pathophysiology underlying detrusor overactivity (DO) and OAB. EVIDENCE ACQUISITION: A PubMed-based literature search was conducted in April 2018, to identify randomised controlled trials, prospective and retrospective series, animal model studies, and reviews. EVIDENCE SYNTHESIS: OAB is a nonspecific storage symptom complex with poorly defined pathophysiology. OAB was historically thought to be caused by DO, which was either "myogenic" (urgency initiated from autonomous contraction of the detrusor muscle) or "neurogenic" (urgency signalled from the central nervous system, which initiates a detrusor contraction). Patients with OAB are often found to not have objective evidence of DO on urodynamic studies; therefore, alternative mechanisms for the development of OAB have been postulated. Increasing evidence on the role of urothelium/suburothelium and bladder afferent signalling arose in the early 2000s, emphasising an afferent "urotheliogenic" hypothesis, namely, that urgency is initiated from the urothelium/suburothelium. The urethra has also recently been regarded as a possible afferent origin of OAB-the "urethrogenic" hypothesis. Several other pathophysiological factors have been implicated, including metabolic syndrome, affective disorders, sex hormone deficiency, urinary microbiota, gastrointestinal functional disorders, and subclinical autonomic nervous system dysfunctions. These various possible mechanisms should be considered as contributing to diagnostic and treatment algorithms. CONCLUSIONS: There is a temptation to label OAB as "idiopathic" without obvious causation, given the poorly understood nature of its pathophysiology. OAB should be seen as a complex, multifactorial symptom syndrome, resulting from multiple potential pathophysiological mechanisms. Identification of the underlying causes on an individual basis may lead to the definition of OAB phenotypes, paving the way for personalised medical care. PATIENT SUMMARY: Overactive bladder (OAB) is a storage symptom syndrome with multiple possible causes. Identification of the mechanisms causing a patient to experience OAB symptoms may help tailor treatment to individual patients and improve outcomes.sponsorship: Benoit Peyronnet certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Benoit Peyronnet is a consultant for Astellas, Allergan, Medtronic, and Boston Scientific. Christopher Chapple is a consultant, researcher, and speaker for Astellas, Allergan, Pfizer, and Medtronic; has received personal fees and nonfinancial support from Allergan and Pfizer; and has received grants, personal fees, and nonfinancial support from Astellas. Linda Cardozo has received funding for research or lecturing from Astellas and Pfizer, and for research consultancy and/or advisory work from Allergan, Astellas, BMR, Ferring, Pfizer, and Syner-Med. Matthias Oelke reports personal fees from Allergan, Bayer Healthcare, Biocompatibles, Ferring, and Mundipharma; personal fees and other from Apogepha; grants, personal fees, and nonfinancial support from Astellas and Pfizer; personal fees, nonfinancial support, and other from GlaxoSmithKline; personal fees and nonfinancial support from Lilly and Recordati, all outside the submitted work. Roger Dmochowski is a consultant/advisor for Medtronic and Allergan. Gerard Amarenco is a consultant and speaker for Astellas, Pfizer, Allergan, Laborie, and Wellspect. Xavier Game is a consultant for Astellas, Pierre Fabre, Allergan, Medtronic, and Ipsen. Frank Van Der Aa has spoken on behalf of and received honorarium from Astellas, Pfizer, and GlaxoSmithKline; and is a consultant for Medtronic, Allergan, and Astellas. Roger Kirby has been reimbursed by Astellas, GSK, Pfizer, and MSD for attending conferences, lecturing, and expenses of research studies. Jean-Nicolas Cornu is a consultant/speaker for Astellas, Pfizer, Boston Scientific, Medtronic, and Bouchara Recordati. Emma Mironska has nothing to disclose. (Astellas, Pfizer, GlaxoSmithKline)status: Publishe
AMS‐800 Artificial urinary sphincter in female patients with stress urinary incontinence: A systematic review
No full textAims To perform a systematic review of studies reporting the outcomes of AMS‐800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD). Methods A systematic literature search of the Medline and Embase databases was performed in June 2018 in accordance with the PRISMA statement. No time limit was used. The protocol was registered in PROSPERO (CRD42018099612). Study selection and data extraction were performed by two independent reviewers. Results Of 886 records screened, 17 were included. All were retrospective or prospective non‐comparative case series. One study reported on vaginal AUS implantation, 11 on open AUS implantation, two on laparoscopic AUS implantation, two on robot‐assisted AUS implantation and one compared open and robot‐assisted implantations. The vast majority of patients had undergone at least one anti‐incontinence surgical procedure prior to AUS implantation (69.1‐100%). The intraoperative bladder neck injury rates ranged from 0% to 43.8% and the intraoperative vaginal injury rates ranged from 0 to 25%. After mean follow‐up periods ranging from 5 to 204 months, the complete continence rates ranged from 61.1% to 100%. The rates of explantation, erosion and mechanical failure varied from 0% to 45.3%, 0% to 22.2% and 0% to 44.1%, respectively. Conclusions AMS‐800 AUS can provide excellent functional outcomes in female patients with SUI resulting from ISD but at the cost of a relatively high morbidity. High level of evidence studies are needed to help better define the role of AUS in the female SUI armamentarium
Multimodal assessement of neurogenic lower urinary tract dysfunction in spina bifida patients
No full textObjectifs : Décrire les spécificités des troubles vésico-sphinctériens des patients spina bifida, leur impact sur la mortalité et l’intérêt d’outils diagnostiques alternatifs à l’urodynamique pour l’évaluation du régime de pression vésicale dans cette population. Méthodes : une cohorte prospective a été utilisée pour décrire les troubles vésico-sphinctériens des patients spina bifida et une étude épidémiologique nationale sur la base PMSI a été effectuée pour évaluer l’implication des causes urologiques sur la mortalité de cette population. Une étude prospective a été menée pour évaluer le rôle des marqueurs urinaires et de la radiomique dans l’évaluation du régime de pression vésicale chez les patients spina bifida. Résultats: Les troubles vésico-sphinctériens se caractérisent par la forte prévalence de troubles de la compliance et haut régime de pression vésicale. Les pathologies urologiques sont ainsi la première cause de mortalité des patients spina bifida en France. Le TIMP 2 et le MMP-2 urinaire ont associés à l’hypocompliance vésicale et le TIMP 2 urinaire a des performances diagnostiques légèrement supérieure aux paramètres urodynamiques pour l’atteinte du haut appareil urinaire. Le profil des marqueurs urinaires em cas d’hyperactivité détrusorienne diffèrent entre les spina bifida et les autres pathologies neurologiques en particulier pour les marqueurs de remodelage de la matrice extracellulaire tel le TGFβ-1. La radiomique, en particulier l’analyse de texture scanner est associé à certains paramètres urodynamiques et pourrait permettre l’évaluation du régime de pression vésicale chez les patients spina bifida. Conclusion: Les patients spina bifida présentent des troubles vésico-sphinctériens singuliers et sévères dont le remodelage de la matrice extracellulaire semble être un déterminant physiopathologique important. Un évaluation multimodale du régime de pression vésicale incluant les biomarqueurs urinaires et la radiomique pourrait permettre d’optimiser la prise en charge.Aims : To describe neurognenic lower urinary tract dysfunctions (NLUTD) in spina bifida patients, their impact on mortality and the role of alternatives to urodynamics in evaluating NLUTD in this patients’ population. Methods: A prospective cohort was used to describe NLUTD in spina bifida patients and a nationwide epidemiological study was performed to assess the proportion of urological causes in the overall mortality of this population. A prospective study was conducted to evaluate the role of urinary biomarkers and radiomics in the assessement of bladder pressure in spina bifida patients. Results: There is a high prevalence of low bladder compliance and high bladder pressure in spina bifida patients. Urological disorders are the leading cause of death in spina bifida patients in France nowadays. Urinary levels of TIMP-2 and MMP-2 are associated with low compliance bladder and urinary TIMP-2 has diagnostic performances slightly superior to urodynamics for upper urinary tract damage. Markers of extracellular matrix remodeling such as TGFβ-1 differ between spina bifida and other neurological conditions in case of NDO. Radiomics, especially CT texture parameters is associated with several urodynamic parameters and might help to evaluate bladder pressures in spina bifida patients. Conclusion: Spina bifida NLUTD are singular and severe, with strong implication of extracellular matrix remodeling. Multimodal evaluation of spina bifida NLUTD including urinary biomarkers and radiomics might help to optimize the management of these patients
Efficacy and Safety of Mirabegron versus Placebo Add-On Therapy in Men with Overactive Bladder Symptoms Receiving Tamsulosin for Underlying Benign Prostatic Hyperplasia: A Randomized, Phase 4 Study (PLUS)
No full textInternational audienc
The learning curve for robot-assisted partial nephrectomy: impact of surgical experience on perioperative outcomes
No full textRobot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo >= 2 postoperative complication (CD >= 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patient's operation. Median WIT was 14 min and the rate of CD >= 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p = 2-free postoperative course (p = 0.001), but not with PSMs (p = 0.7). The relationship between EXP and WIT emerged as nonlinear, with a steep slope reduction within the first 100 cases and a plateau observed after 150 cases. Conversely, the relationship between EXP and CD >= 2-free course resulted linear, without reaching a plateau, even after 300 cases.Patient summary: Perioperative outcomes after robot-assisted partial nephrectomy (RAPN) are importantly and individually affected by surgeon's experience. After 150 RAPNs, no further improvement is observed with respect to ischemia time, but the learning curve appears endless with respect to complications. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.</p
Failures and long-term discontinuations of intradetrusor botulinum toxin injections for neurogenic detrusor overactivity: A new challenge in neurourology
No full textUréthroplastie dorsale par greffon de muqueuse orale dans les sténoses de l’urètre féminin
No full textBackground - Female urethral stricture (FUS) is a rare, but also largely underdiagnosed condition. Urethral dilation and vaginal flap urethroplasty have been the most commonly described treatments for FUS. Objective - The aim of this study was to assess the outcomes of dorsal onlay oral mucosa graft urethroplasty for FUS. Design settings and participants - We retrospectively reviewed the charts of all female patients who underwent dorsal onlay oral (buccal or lingual) mucosa urethroplasty for urethral stricture between 2011 and 2020 at two academic institutions. The exclusion criteria were patients under 18-year-old, or urethroplasty performed for other indications than urethral stricture (e.g. sling erosion). Surgical procedure: Four surgeons performed the urethroplasties using a standardized technique: suprameatal incision, dissection and longitudinal opening of the dorsal aspect of the urethra, harvest of the oral mucosa graft, graft onlay sutured into the urethral opening. Outcomes measurements and statistical analysis. The primary endpoint was clinical success defined as any subjective improvement in LUTS self-assessed by the patients 1 to 3 months after catheter removal. Results and limitations - Nineteen patients were included over the study period. The mean operative time was 126.6 minutes and the median length of hospital stay was one day (range:0-3). There were two postoperative complications both of which were minor (1 UTI and 1 sinusitis, Clavien grade 2). The clinical success rate was 94.7% at 1 to 3 months and 90.9 % at 1 year. After a median follow-up of 12 months (range 1-49) there was one recurrence (5.3%), clinical success was achieved in 17 patients (89.5%) and both the maximum urinary flow rate and post void residual were significantly improved (15.2 vs. 7.4 ml/s preoperatively; p=0.008 and 71.5 vs. 161.1 ml preoperatively; p=0.001 respectively). The de novo stress urinary incontinence rate was 15.7 % at 1 to 3 months and 9.1% at 1 year. Conclusion - Dorsal onlay oral mucosa graft urethroplasty for FUS appears feasible across multiple surgeons and is associated with a low perioperative morbidity, satisfactory functional outcomes and a low recurrence rate. Other series with larger sample size and longer follow-up are needed to confirm these findings.Introduction – L’objectif de cette étude était d’évaluer les résultats de l’uréthroplastie dorsale par greffon de muqueuse orale pour les sténoses de l’urètre féminin. Méthodes – Toutes les femmes ayant été opérées d’une uréthroplastie dorsale par greffon de muqueuse orale (buccale ou linguale) pour une sténose de l’urètre entre 2011 et 2020 dans deux centres universitaires ont été inclues. Les critères d’exclusion étaient les patientes âgées de moins de 18 ans, les patients de sexe masculin ou la réalisation d’une uréthroplastie pour d’autres indications que la sténose de l’urètre (ex : érosion prothétique). Quatre chirurgiens ont réalisé les uréthroplasties suivant une technique standardisée. Le critère de jugement principal était le succès clinique définit comme toute amélioration subjective des symptômes du bas appareil urinaire d’après l’auto-évaluation des patientes 1 à 3 mois après l’ablation de la sonde vésicale. Résultats – Dix-neuf patientes ont été inclues durant la période de l’étude. Le temps opératoire moyen était de 126.6 minutes et la durée de séjour moyenne d’un jour (0-3). Il y a eu deux complications post opératoires mineurs (une infection urinaire et une sinusite, Clavien 2). Le taux de succès clinique était de 94.7% entre 1 à 3 mois et 90.9 % à un an. Après une durée moyenne de suivi de 12 mois (1-49), il y a eu une récidive (5.3%), le succès clinique était atteint pour 17 patientes (89.5%) et le débit urinaire maximal ainsi que le résidu post mictionnel étaient significativement améliorés (15.2 vs. 7.4 ml/s en pré opératoire; p=0.008 et 71.5 vs. 161.1 ml en pré opératoire ; p=0.001 respectivement). Le taux d’incontinence d’effort de novo était de 15.7% entre 1 à 3 mois et 9.1% à un an. Conclusion – L’uréthroplastie dorsale par greffon de muqueuse orale pour les sténoses de l’urètre féminin semble être une technique faisable par différents chirurgiens et est associée à une morbidité post opératoire faible et des résultats fonctionnels satisfaisants avec un taux de récidive faible. D’autres séries avec de plus larges échantillons et des durées de suivi plus longues sont nécessaires pour confirmer ces résultats
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