[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.

[Holmium laser enucleation of the prostate: Analysis of early complications. Patient selection for day-case surgery]

OBJECTIVES

To evaluate the complications and the risk factors of Holmium LASER Enucleation of the prostate (HoLEP) and to propose selection criteria for day-case surgery.

MATERIAL AND METHODS

We included retrospectively all consecutive single-center HoLEP procedures performed between January 1, 2012 and December 31, 2016. We reported the pre-operative characteristics of the patients (age, BMI, ASA score, estimated prostate volume, presence of a preoperative catheter, operative indication, antiplatelet or anticoagulant intake) and the peri operative data (duration of intervention, catheterization, hospitalization, transfusion, histopathological findings, 30-day postoperative complications given to Clavien-Dindo classification, presence of a catheter at discharge, urologist experience). Uni- and multi-variate analyzes were performed to investigate risk factors for complications.

RESULTS

One thousand two hundred and one patients were included. The overall complication rate was 19.15 %. The transfusion rate was 3.7%. We demonstrated that the age at procedure (P=0.019), an ASA score>2 (P=0.0019), a high prostatic volume (P=0.011), an anticoagulant intake (P=<0.0001), a poor-urologist experience (P=0.048) and a long operative time (P=0.0144) were at risks of complications.

CONCLUSION

The identification of postoperative complication risk factors after HoLEP could help to better select patients who are offered day-case surgery and minimize the risk of failure or early readmission.

LEVEL OF EVIDENCE

4.

[Salvage cryotherapy of prostate cancer after failed external radiotherapy and brachytherapy: Morbidity and mid-term oncological results]

OBJECTIVE

To study the oncologic and functional results of salvage cryotherapy after failure of external radiotherapy and brachytherapy.

MATERIALS AND METHODS

Patients treated by total salvage cryotherapy (3rd generation) in 2 centers (Groupe Hospitalier Saint-Joseph in Paris and Clinique Jule-Verne Nantes) in between January 2008 and April 2016 were included. The biochemical recurrence-free survival (BRFS) was calculated using the Phoenix criteria (PSA>nadir+2ng/mL). The functional results were assessed clinically.

RESULTS

Ninety-seven patients with an average follow up of 39.4months were evaluated retrospectively. The 5-year biochemical recurrence-free survival (5y-BRFS) among all patients was 58.1% (IC à 95% [45.9-68.5]). Low and intermediate risk patients (d'Amico classification) were less prone to biochemical recurrence than high risk (81.05% (IC à 95% [64.1-90.5]) 5y-BRFS as opposed to 35.09% (IC à 95% [20.1-50.4]) respectively) (P<0.0001). As were patients with a Gleason score≤7 75.35% (IC à 95% [59.7-85.6]) compared to 32.31% (IC à 95% [16.5-49.2]) for higher Gleason (>7 scores [P=0.0002]). A Gleason score>7 (OR=6.9; P=0.002), PSA nadir>1ng/mL (OR=25.8; P=0.0026) and peri-urethral invasion (OR=35.8; P<0.001) were major risk factors for local recurrence in univariate analysis. In multivariate analysis, only PSA nadir>1ng/mL (OR=12.9; P=0.042) and peri-urethral invasion (OR=21.6; P=0.0003) remain major risk factors for recurrence. About 13 (16.46%) patients were incontinent of which 3 (3.79%) required placement of an artificial urinary sphincter. Erectile dysfunction was present in 66 (83.5%) patients. Recto-urethral fistula was uncommon in 1 patient (1.27%).

CONCLUSION

Salvage cryotherapy after failure of external radiotherapy and brachytherapy is a reliable and reproducible technique with promising oncological and functional results. Study of prognostic factors will help better select eligible patients in the future.

LEVEL OF EVIDENCE

4.

Phase II study of axitinib for downstaging cT2a to cT1 renal tumors for allowing partial nephrectomy (AXIPAN)

575

Background: Laparoscopic Radical nephrectomy (RN) is the current standard of care for large organ confined renal tumors while partial nephrectomy (PN) is recommended for tumor sizes up to 7 cm. PN preserves long term renal function with possible effect on overall survival. Axitinib, a potent VEGFR TKI can reduce the size of primary tumor in metastatic setting. Our primary objective was to test the ability of axitinib to reduce the size of large tumors for shifting from a RN to a PN indication. Methods: Patients with localized (cT2N0M0) RCCs were enrolled in a prospective phase II trial assessing the effect of neoadjuvant axitinib prior to surgery (PN or RN). Main inclusion criteria were: age ≥ 18, histologically proven clear cell RCC, MDRD creatinine clearance ≥ 60 ml/min, cT2a N0NxM0 tumors ( Ø> 7cm; ≤ 10 cm). Medical treatment consisted in axitinib 5 mg up to 10 mg tw/d during 2 to 6 months prior surgery according to radiological response. Results: A total of 18 patients including 11 men (61%) and 7 women (39%) with a median age of 60 yrs were enrolled. Median baseline tumor size, R.E.N.A.L. score, serum creatinine and MDRD estimated GFR were: 7.5 cm, 11, 0.8 mg/dl and 96.5 ml/min respectively. Duration of treatment was 2, 4 and 6 months in 12 (66%), 3 (17%) and 3 cases (17%), respectively. After neoadjuvant treatment median tumor size and RENAL score decreased to 5.9 cm and 10. 93 % of patients presented a decrease in maximum tumor diameter, with median size reduction of 21.7%. Out of the 17 patients who were operated, 16 (94%) underwent a PN (9 robotic and 7 open), including 84% of the cases which were performed for tumors ≤ 7cm. At 1 month from surgery, median serum creatinine and MDRD estimated GFR were 0.88 mg/dl and 88 ml/min, respectively. Medical and surgical complications rate was 11% including 1 embolization for severe bleeding and 1 Clavien V complication at 1 month after surgery due to massive myocardial infarction. Conclusions: Neoadjuvant axitinib in cT2renal tumors allowed cT1 downstaging and nephron sparing surgery in more than 80% of the cases. However, PN procedures remained high complexity cases requiring adequate surgeon expertise and information of the patients for possible morbidity of these procedures. Clinical trial information: RECF2256.

Holmium laser enucleation versus laparoscopic simple prostatectomy for large adenomas

OBJECTIVE

The aim of this study is to compare Holmium laser enucleation of the prostate with another minimally invasive technique, the laparoscopic simple prostatectomy.

MATERIALS AND METHODS

We compared outcomes of a series of 40 patients who underwent laparoscopic simple prostatectomy (n=20) with laser enucleation of the prostate (n=20) for large adenomas (>100 grams) at our institution. Study variables included operative time and catheterization time, hospital stay, pre- and post-operative International Prostate Symptom Score and maximum urinary flow rate, complications and economic evaluation. Statistical analyses were performed using the Student t test and Fisher test.

RESULTS

There were no significant differences in patient age, preoperative prostatic size, operating time or specimen weight between the 2 groups. Duration of catheterization (P=.0008) and hospital stay (P<.0001) were significantly less in the laser group. Both groups showed a statistically significant improvement in functional variables at 3 months post operatively. The cost utility analysis for Holmium per case was 2589 euros versus 4706 per laparoscopic case. In the laser arm, 4 patients (20%) experienced complications according to the modified Clavien classification system versus 5 (25%) in the laparoscopic group (P>.99).

CONCLUSION

Holmium enucleation of the prostate has similar short term functional results and complication rates compared to laparoscopic simple prostatectomy performed in large glands with the advantage of less catheterization time, lower economic costs and a reduced hospital stay.

Relapses in metastatic germ-cell tumors and relationship to international guidelines compliance: A study from the Institut Gustave Roussy

323

Background: Germ-cell tumors (GCT) are rare but highly curable cancers even in patients with metastatic spread. We aimed at assessing whether relapse after upfront treatment could be explained by low compliance with international guidelines.

Methods: All patients (pts) who were referred to Institut Gustave Roussy from 2000 to 2010 with progression or relapse after treatment for metastatic GCT were included. International guidelines available at the time of diagnosis were used as reference. A list of noncompliant criteria defined as disagreement with the recommendations with a potential impact on outcome was set up.

Results: 78 pts were included. According to the IGCCCG classification, 18 pts (23.1%) had good, 25 pts (32%) had intermediary and 34 pts (43.6%) had poor prognosis. The first-line chemotherapy administered consisted of PEB regimen (70.5%) , PE regimen (15.4%) or other regimen (12.8%). Most patients were treated in cancer centers (52.5%, n=41), whereas 26.9% and 17.9% pts were treated in private or public general hospitals, respectively. Only 50% pts received treatment according to guidelines recommendations. This percentage was significantly higher in cancer centres than in public hospitals (75.6% versus 28.6%, p< 0.001) or also when compared with private hospitals (75.6% versus 14,3%, p<0.001). The most frequent noncompliance criteria were: time to surgery for residual mass (over 6 weeks after the latest chemotherapy cycle)(20.3%) and respected chemotherapy schedule (20.3%). Other noncompliance findings were: inadequate chemotherapy dose (15.6%), number of cycles (12.5%), decision regarding residual disease (12.5%), chemotherapy regimen (6.3%), follow up (4.6%), type of surgery (3.1%), staging(1.6%), IGCCCG classification (1.6%), or decision regarding chemotherapy after residual mass surgery (1.6%).

Conclusions: This study suggests that the majority of relapse for metastatic GCT may be explained by a poor conformity to international guidelines and not only by aggressive tumor biology. These data represent a strong argument for treatment centralization in reference centers in patients with GCT.

[Progress and summary of recent congress: ASCO-GU, EAU, AUA, ASCO about the medical management of locally advanced or metastatic kidney cancer]

During the recent congress of urology and oncology key topics discussed were the evolution of survival data in metastatic kidney cancer which median is now around 40 months, persistent questions about the role of nephrectomy, including access to the systemic treatment of nephrectomized patients and tumor resectability induced by systemic therapies, the emergence of new prognostic models which are adapted to new therapeutic standards, and the emergence of promising new drugs including pazopanib. This article describes these advances.