Standardized technique for ejaculation preservation during prostatic endoscopic ablative surgery

PURPOSE

Ejaculatory dysfunction is the most common side effect of benign prostatic hyperplasia surgery. Modified techniques have emerged with the aim of preserving antegrade ejaculation without compromising obstruction relief. None are standardized or validated. The PARTURP study is a randomized study investigating partial versus complete prostate resection. We conducted an investigator consensus meeting to define the ideal surgical technique to achieve both correct obstruction relief with ejaculation preservation.

METHODS

An expert consensus meeting involving all investigators of the PARTURP study took place to define a common technique using the nominal group methodology. The objectives were to define the areas to be resected and the areas to be preserved; to define the criteria for proper obstruction relief; to define the criteria for proper ejaculation preservation.

RESULTS

All investigators (n = 15) attended the consensus meeting, and agreement between all the participants was obtained. The anatomical landmarks to be preserved are located around the verumontanum and along the posterior part of the prostatic urethra. These structures must be preserved up to 2 cm from the verumontanum. The participants agreed on the need to preserve the urethral mucosa in all the areas to be preserved and to reach the enucleation plane in the areas of resection.

CONCLUSIONS

Anatomical landmarks for ejaculation-sparing surgery have been defined by the investigators of the PARTURP randomized study. These landmarks will be used during the study, and the clinical outcomes of this ejaculation-sparing technique will be compared with complete resection with up to 3 years follow-up.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]

OBJECTIVE

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO).

METHODS

All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions.

RESULTS/GUIDELINES

Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm³, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm³. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm³. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm³ without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols.

CONCLUSION

Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Complications following intravesical bacillus Calmette-Guerin treatment for bladder cancer: a case series of 22 patients

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) therapy is an effective and widely used treatment for superficial bladder carcinoma. Local complications are frequent whereas systemic complications are rare but can be serious, and their management is not well known.

METHODS

We describe retrospectively the records of 22 patients treated in 3 infectious disease departments, for complications related to intravesical BCG therapy as treatment of bladder cancer.

RESULTS

All the patients were male, with a median age of 68 years (range 56-88). Complications occurred after a median of 5 instillations (range 1-11) and were observed within 24 h following BCG instillation for 14 patients. Common symptoms were fever (n = 20), impaired general condition (n = 14), and shortness of breath (n = 7). Six patients had a systemic septic reaction leading to transfer into the intensive care unit for five of them. Lung infiltration was the most frequent presentation (n = 11). Mycobacterium bovis was isolated from only two patients, but histology showed the presence of a granuloma in nine patients. Antimycobacterial treatment was initialized in 17 patients; the outcome was favorable in 16 patients, with a median length of symptoms resolution of 22.5 days (range 5-425 days). Eleven patients received corticosteroids in addition to specific treatment and had a more rapid improvement. One patient died with disseminated BCGitis proved by biopsy.

CONCLUSIONS

Complications following intravesical BCG therapy are rare but can be severe and fatal. Histology seems to be the method that contributes most in confirmation of the diagnosis. Antimycobacterial therapy is effective, and probably more efficient when combined with corticosteroids, but the regimen and duration of the treatment are not standardized.

[Evaluation of the impact of CTMH guidelines on the management of benign prostatic hyperplasia]

INTRODUCTION

The French guidelines on the management of benign prostatic hyperplasia (BPH) have been published in 2012 by the LUTS committee of the French Urological Association. The aim of this study was to evaluate the impact of these guidelines on the BPH management by French urologists.

MATERIAL AND METHODS

A questionnaire has been distributed by email to 1141 urologists members of the French Association of Urologists in November 2013.

RESULTS

We collected 222 responses (response rate: 19%). The guidelines have been read by 73% of the urologists. The guidelines were followed most of the time by 76% of them, 11% followed them systematically and 4.5% did not follow them. The new terminology was used by 28 to 52% according to the items. The symptoms were evaluated by the IPSS score (33%), by interrogatory alone (64%) or by neither of them (3%). Prostate volume was not systematically taken for account in the treatment strategy by 57% of the urologists. Sexual function was assessed systematically by 28% of the urologists, 11% used a questionnaire (IIEF: 92%). PSA was tested respectively by 70 and 51% of the urologists at the initial evaluation and the follow-up. After introduction of a monotherapy, 56% of the urologists evaluated the efficacy at 3 months.

CONCLUSION

The French guidelines for the management of benign prostatic hyperplasia (BPH) by the LUTS committee of the French Urological Association were well known and used by French urologists. Some improvements can be expected for the use of the IPSS score, the evaluation of the sexual function, and the use of the new terminology.

LEVEL OF EVIDENCE

4.

Pelvic organ prolapse transvaginal repair by the Prolift system: evaluation of efficacy and complications after a 4.5 years follow up

OBJECTIVES

The Prolift system is a polypropylene device designed for pelvic organ prolapse repair by a transvaginal approach. Numerous studies have reported on short-term outcomes of this procedure, but long-term studies are lacking.

METHODS

A retrospective study of patients who underwent pelvic organ prolapse repair by Prolift between September 2005 and September 2008 was carried out in two tertiary reference centers by two experienced surgeons. Preoperative and postoperative follow up was based on medical records of baseline and follow-up visits with complete clinical examination, including Pelvic Organ Prolapse Quantification stage. At last follow up, the Pelvic Floor Distress Inventory-20 questionnaire was assessed by telephone interview. Cure was defined as an anatomical success at last follow up, being a Pelvic Organ Prolapse Quantification stage ≤ 1 without further surgical intervention in any compartment.

RESULTS

A total of 75 patients were included in this analysis with a mean follow up of 53.7 ± 8.8 months (range 36-72 months). Patients were treated with two-arm Prolift posterior, four-arm Prolift anterior and six-arm Prolift total in three (4%), 51 (69%) and 21 (27%) cases, respectively. At last follow up, 64 (85.3%) patients were cured, with no prolapse recurrence. Mesh exposure occurred in four (5.3%) patients. The Pelvic Floor Distress Inventory-20 symptom score was low at last follow up (median 8, range 3-18), in accordance with objective cure data.

CONCLUSIONS

The Prolift system is safe and efficacious for pelvic organ prolapse repair by transvaginal approach after a 4.5-year follow up.

Evaluating the Prostate Cancer Prevention Trial High Grade Prostate Cancer Risk Calculator in 10 international biopsy cohorts: results from the Prostate Biopsy Collaborative Group

OBJECTIVES

To assess the applicability of the Prostate Cancer Prevention Trial High Grade (Gleason grade ≥ 7) Risk Calculator (PCPTHG) in ten international cohorts, representing a range of populations.

METHODS

A total of 25,512 biopsies from 10 cohorts (6 European, 1 UK and 3 US) were included; 4 implemented 6-core biopsies, and the remaining had 10 or higher schemes; 8 were screening cohorts, and 2 were clinical. PCPTHG risks were calculated using prostate-specific antigen, digital rectal examination, age, African origin and history of prior biopsy and evaluated in terms of calibration plots, areas underneath the receiver operating characteristic curve (AUC) and net benefit curves.

RESULTS

The median AUC of the PCPTHG for high-grade disease detection in the 10- and higher-core cohorts was 73.5% (range, 63.9-76.7%) compared with a median of 78.1% (range, 72.0-87.6%) among the four 6-core cohorts. Only the 10-core Cleveland Clinic cohort showed clear evidence of under-prediction by the PCPTHG, and this was restricted to risk ranges less than 15%. The PCPTHG demonstrated higher clinical net benefit in higher-core compared with 6-core biopsy cohorts, and among the former, there were no notable differences observed between clinical and screening cohorts, nor between European and US cohorts.

CONCLUSIONS

The PCPTHG requires minimal patient information and can be applied across a range of populations. PCPTHG risk thresholds ranging from 5 to 20%, depending on patient risk averseness, are recommended for clinical prostate biopsy decision-making.

Importance of prostate volume in the European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculators: results from the prostate biopsy collaborative group

OBJECTIVES

To compare the predictive performance and potential clinical usefulness of risk calculators of the European Randomized Study of Screening for Prostate Cancer (ERSPC RC) with and without information on prostate volume.

METHODS

We studied 6 cohorts (5 European and 1 US) with a total of 15,300 men, all biopsied and with pre-biopsy TRUS measurements of prostate volume. Volume was categorized into 3 categories (25, 40, and 60 cc), to reflect use of digital rectal examination (DRE) for volume assessment. Risks of prostate cancer were calculated according to a ERSPC DRE-based RC (including PSA, DRE, prior biopsy, and prostate volume) and a PSA + DRE model (including PSA, DRE, and prior biopsy). Missing data on prostate volume were completed by single imputation. Risk predictions were evaluated with respect to calibration (graphically), discrimination (AUC curve), and clinical usefulness (net benefit, graphically assessed in decision curves).

RESULTS

The AUCs of the ERSPC DRE-based RC ranged from 0.61 to 0.77 and were substantially larger than the AUCs of a model based on only PSA + DRE (ranging from 0.56 to 0.72) in each of the 6 cohorts. The ERSPC DRE-based RC provided net benefit over performing a prostate biopsy on the basis of PSA and DRE outcome in five of the six cohorts.

CONCLUSIONS

Identifying men at increased risk for having a biopsy detectable prostate cancer should consider multiple factors, including an estimate of prostate volume.

A panel of kallikrein markers can predict outcome of prostate biopsy following clinical work-up: an independent validation study from the European Randomized Study of Prostate Cancer screening, France

Background

We have previously shown that a panel of kallikrein markers - total prostate-specific antigen (PSA), free PSA, intact PSA and human kallikrein-related peptidase 2 (hK2) - can predict the outcome of prostate biopsy in men with elevated PSA. Here we investigate the properties of our panel in men subject to clinical work-up before biopsy.

Methods

We applied a previously published predictive model based on the kallikrein panel to 262 men undergoing prostate biopsy following an elevated PSA (≥ 3 ng/ml) and further clinical work-up during the European Randomized Study of Prostate Cancer screening, France. The predictive accuracy of the model was compared to a "base" model of PSA, age and digital rectal exam (DRE).

Results

83 (32%) men had prostate cancer on biopsy of whom 45 (54%) had high grade disease (Gleason score 7 or higher). Our model had significantly higher accuracy than the base model in predicting cancer (area-under-the-curve [AUC] improved from 0.63 to 0.78) or high-grade cancer (AUC increased from 0.77 to 0.87). Using a decision rule to biopsy those with a 20% or higher risk of cancer from the model would reduce the number of biopsies by nearly half. For every 1000 men with elevated PSA and clinical indication for biopsy, the model would recommend against biopsy in 61 men with cancer, the majority (≈80%) of whom would have low stage and low grade disease at diagnosis.

Conclusions

In this independent validation study, the model was highly predictive of prostate cancer in men for whom the decision to biopsy is based on both elevated PSA and clinical work-up. Use of this model would reduce a large number of biopsies while missing few cancers.

The relationship between prostate-specific antigen and prostate cancer risk: the Prostate Biopsy Collaborative Group

PURPOSE

The relationship between prostate-specific antigen (PSA) level and prostate cancer risk remains subject to fundamental disagreements. We hypothesized that the risk of prostate cancer on biopsy for a given PSA level is affected by identifiable characteristics of the cohort under study.

EXPERIMENTAL DESIGN

We used data from five European and three U.S. cohorts of men undergoing biopsy for prostate cancer; six were population-based studies and two were clinical cohorts. The association between PSA and prostate cancer was calculated separately for each cohort using locally weighted scatterplot smoothing.

RESULTS

The final data set included 25,772 biopsies and 8,503 cancers. There were gross disparities between cohorts with respect to both the prostate cancer risk at a given PSA level and the shape of the risk curve. These disparities were associated with identifiable differences between cohorts: for a given PSA level, a greater number of biopsy cores increased the risk of cancer (odds ratio for >6- versus 6-core biopsy, 1.35; 95% confidence interval, 1.18-1.54; P < 0.0005); recent screening led to a smaller increase in risk per unit change in PSA (P = 0.001 for interaction term) and U.S. cohorts had higher risk than the European cohorts (2.14; 95% confidence interval, 1.99-2.30; P < 0.0005).

CONCLUSIONS

Our results suggest that the relationship between PSA and risk of a positive prostate biopsy varies, both in terms of the probability of prostate cancer at a given PSA value and the shape of the risk curve. This poses challenges to the use of PSA-driven algorithms to determine whether biopsy is indicated.

[Results of an investigation by questionnaire into interest in neuro-urology of urology residents]

OBJECTIVES

To evaluate the interest borne towards neuro-urology within the community of the urology residents.

MATERIALS AND METHODS

Between January and May 2009, all urology residents received an anonymous questionnaire by e-mail estimating their interest for neuro-urology. The analyzed data were: epidemiologic data; participation in theoretical learning and training courses practices; interest and investment in the speciality; opinion on the current formation. The qualitative variables were compared by the chi-2 test. P values <0,05 were considered significant.

RESULTS

The rate of answer was 45,3 %. The middle age was 28,7+/-2,3 years. Ninety-two (70,7 %) of the 130 urologist residents questioned wished to exert full-time or divided in a hospital structure. They were 40 % to have a multidisciplinary neuro-urology staff, and 80 % were in a service which dealt with suffering patients of neurological bladder. The percentage of urologist residents interested by neuro-urology was 69,2 %, and 61,5 % of them wished to practice this activity in their future exercise. This wish was significantly higher for those resulting from the ENC (p<0,05), for those wishing to exert at the hospital (p<0,01) and for those who practice urology at a level of expertise in neuro-urology (p<0,01). The theoretical and practical teaching of neuro-urology were considered as being insufficient for respectively 73,9 % and 64,2 % of the urologist residents. In contrast, the average note allotted to the neuro-urology module of the ECU was of 7,47 out of 10.

CONCLUSION

Neuro-urology seems to be particularly attractive for the urologist residents, and many wished to integrate it in their future exercise. The motivation was more important for those who wished to carry out a career in hospital. Even if the quality of the teaching was very noted, their modalities were considered to be insufficient by most of them.