Chirurgie urologique et ambulatoire (2023)

La photovaporisation prostatique par laser Greenlight^® (GL) s’est fortement développée en France au cours des dernières années représentant désormais près de 30% des chirurgies de l’HBP et faisant de la France le deuxième utilisateur mondial de GL après les États-Unis. L’objectif de cette étude était d’évaluer quelles étaient les pratiques des chirurgiens français utilisant le laser Greenlight^®.

Au cours des 4^esrencontres du groupe des utilisateurs du Greenlight^® en France (GUGL), a été proposé un questionnaire concernant les habitudes de prise en charge des patients. Le questionnaire portait sur les caractéristiques de l’opérateur (âge, expérience avec le GL, etc.), sa stratégie thérapeutique, la prise en charge du patient en préopératoire (anticoagulants…) et postopératoire (ambulatoire, ablation de la sonde vésicale, suivi…) ainsi que sur sa technique chirurgicale (type de fibre, puissance utilisée, etc.).

Parmi les 117participants au congrès, 64ont répondu au questionnaire (55%). Cinquante-six pour cent privilégiaient le GL, quel que soit le volume prostatique, l’adénomectomie voie haute (AVH) était l’alternative la plus utilisée (39%) pour les hauts volumes. Le Kardégic était poursuivi par 89% des praticiens en périopératoire. À l’inverse, le clopidogrel n’était poursuivi que par 19% et les AVK que par 14%. Soixante-treize pour cent des participants pratiquaient systématiquement la vaporisation classique et 3% des techniques plus récentes. En peropératoire, 72% utilisaient une énergie comprise entre 120W et 160W en moyenne. Soixante pour cent utilisaient l’échographie endorectale pendant l’intervention (dont 32% pendant toute l’intervention). Seulement 16% des praticiens réalisaient plus de la moitié de leurs interventions en ambulatoire et près de 33% jamais. Soixante-sept pour cent des chirurgiens ayant une expérience du GL supérieure à 3ans pratiquaient la PVP, quel que soit le volume prostatique versus 23,5% des utilisateurs de moins de 3ans (p=0,002).

Les utilisateurs du Greenlight^® en France ont une approche encore hétérogène dans la prise en charge des patients. Les nouvelles utilisations du Greenlight^® qui se développent actuellement sont encore marginales. La pratique de l’ambulatoire n’est pas encore assez répandue. Les praticiens les plus expérimentés ont tendance à promouvoir la technique dans de plus larges indications.

3.

Photovaporization of the prostate by the Greenlight^® laser (GL) has been strongly developed this past few years in France, representing nearly 30% of surgery for BPH, making France the second GL user worldwide after USA. The objective of this study was to assess the French surgeons practices with the Greenlight^® laser.

During the 4th meeting of French Greenlight^® users group (GUGL), was proposed a questionnaire on the management of patients and the GL technique. The questionnaire covered the operator's characteristics (age, experience with the GL, etc.), the treatment strategy, preoperative management (anticoagulants…) and postoperative management (ambulatory, removal catheter…) as well as the surgical technique (fiber type, energy used, etc.).

Among the 117participants, 64answered to the questionnaire (55%). Fifty-six percent chose GL, whatever was the prostate volume, simple prostatectomy was the most commonly alternative used for high prostate size (39%). The aspirin was pursued by 89% of practitioners perioperatively. Conversely, clopidogrel was continued by only 19% and anticoagulant by only 14%. Seventy-three percent of participants commonly used classic vaporization and only 3% used new techniques (GreenLEP). During procedure, 72% used energy between 120W and 160W. Sixty percent used transrectal ultrasound during surgery (32% throughout the procedure). Only 16% of surgeons made ambulatory procedure and almost 33% never. Surgeons with over 3years of experience (vs.<3years) used the technique regardless of the volume in 67% vs. 23.5% (P=0.002).

In France Greenlight use is still heterogeneous for the patient's management. New techniques which are currently developing (GreenLEP, vapo-enucleation) are still marginal. Ambulatory is still insufficiently used and need to be developed. The experienced surgeon led to wider indication for the technique.

3.

To evaluate the effects of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

This was a randomized, controlled, double-blinded trial. Eligible patients scheduled for retroperitoneoscopic urologic surgeries were randomly assigned to two groups. Group TAP received ultrasound-guided TAP block with 0.5% ropivacaine 20 ml at 30 minutes before surgery, and Group C received TAP sham block with normal saline. All patients received retroperitoneoscopic urologic surgeries under general anesthesia. The primary outcome was the severity of pain after surgery. Secondary outcomes included opioids consumption, analgesics, postoperative nausea and vomiting, time to Foley catheter removal and to passage of flatus, length of post-anesthesia care unit stay and hospital stay.

Eighty patients completed the study, forty cases in each group. Compared to the Group C, the Group TAP had lower visual analogue scale pain scores within two postoperative days (all P<0.05). They also had less consumption of intraoperative fentanyl (2.0±0.5 vs. 3.8±0.7 μg/kg, P<0.05), reduced incidence of postoperative rescue analgesic usage (12.5% vs. 45.0%, P<0.05), and lower incidence of postoperative nausea and vomiting within postoperative 48 hours (12.5% vs. 25.0%, P<0.05) when compared to the Group C. In addition, Group TAP had a shortened post-anesthesia care unit stay (25±8 vs. 49±12 minutes, P<0.05), and a greater proportion of patients discharged within postoperative three days (57.5% vs. 35.0%, P<0.05).

Preoperative ultrasound-guided TAP block is an effective technique to improve postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

La chirurgie ambulatoire est un exercice dont le développement a connu un essor significatif au cours de la dernière décennie. Le but de cette enquête était de faire le point sur les différents aspects de cette pratique, en urologie, en Midi-Pyrénées.

Une étude transversale a été menée auprès des 57urologues exerçant dans la région Midi-Pyrénées en utilisant un questionnaire informatisé rendu disponible sur Internet. Les urologues n’ayant pas répondu étaient relancés à hauteur d’un courrier électronique de rappel par semaine. Le questionnaire comptait 25questions, réparties en quatresous-groupes.

Le taux de réponse était de 57,9% (33/57urologues). Les résultats montraient que la part de la chirurgie ambulatoire était de 26,4%, qu’elle était supérieure dans les structures libérales (33,07±17,16vs 20,42±13,54%, p=0,04), que les actes pratiqués étaient peu en adéquation avec les gestes marqueurs, qu’ils étaient réalisés majoritairement dans des blocs opératoires non dédiés (75,0%) et au sein du programme conventionnel (71,8%). Il existait un protocole de sortie écrit dans 90,6% des cas (29urologues), qui n’était jamais remis au patient dans 7,0% des cas (2urologues) et qui n’était jamais transmis au médecin traitant dans 75,8% des cas (22urologues).

Cette étude a montré qu’un quart des actes chirurgicaux urologiques réalisés en région Midi-Pyrénées, l’étaient dans le cadre de la chirurgie ambulatoire et que l’organisation respectait incomplètement les recommandations de l’International Association for Ambulatory Surgery. Les principaux problèmes étaient l’absence d’information du médecin traitant et le manque de suivi organisé. Les problèmes d’organisation étaient considérés comme les principaux facteurs limitant au développement de ce type d’activité. La quasi-totalité des urologues interrogés exprimaient le souhait d’augmenter la part d’activité ambulatoire dans le futur.

One-day surgery is an exercise whose development has grown significantly over the last decade. This survey aims at reviewing the different aspects of this practice in urology, in the second largest region of France.

A cross-sectional study was conducted among the 57urologists working in the Midi-Pyrénées region. A computerized questionnaire was made available on Internet. The non-responder urologists received a reminder email every week. The questionnaire included 25questions, divided into four subgroups.

The response rate was 57.9% (33/57urologists). Results showed that the 1-day surgery rate was 26.4%. It was higher in the private sector (33.07±17.16vs. 20.42±13.54%, P=0.04). Surgeries were made mainly in non-dedicated operating theaters (75.0%) and in the conventional list (71.8%). There was a written output protocol in 90.6% of cases (29urologists), which was never given to the patient in 7.0% of cases (2urologists) and never sent to the family doctor in 75.8% of cases (22urologists).

This study has shown that outpatient surgery accounted for a quarter of urologic surgery in Midi-Pyrénées region, and that the organization follows the recommendations of the International Association for Ambulatory Surgery. The main problems were the lack of information of the family doctor, and the lack of organized follow. Organizational problems were considered as the limiting factors of this activity development.

Minimally invasive surgery (MIS) is being utilized more frequently as a surgical technique in general surgery and in paediatric urology. It is associated with a steep learning curve. Currently, the centre does not offer a MIS training programme. It is hypothesized that the number of MIS procedures performed in the low-volume specialty of paediatric urology will offer insufficient training potential for surgeons.

To assess the MIS training potential of a highly specialized, tertiary care, paediatric urology training centre that has been accredited by the Joint Committee of Paediatric Urology (JCPU).

The clinical activity of the department was retrospectively reviewed by extracting the annual number of admissions, outpatient consultations and operative procedures. The operations were divided into open procedures and MIS. Major ablative procedures (nephrectomy) and reconstructive procedures (pyeloplasty) were analysed with reference to the patients' ages. The centre policy is not to perform major MIS in children who are under 2 years old or who weigh less than 12kg.

Every year, this institution provides approximately 4300 out-patient consultations, 600 admissions, and 1300 procedures under general anaesthesia for children with urological problems. In 2012, 35 patients underwent major intricate MIS: 16 pyeloplasties, eight nephrectomies and 11 operations for incontinence (seven Burch, and four bladder neck procedures). In children ≥2 years of age, 16/21 of the pyeloplasties and 8/12 of the nephrectomies were performed laparoscopically. The remaining MIS procedures included 25 orchidopexies and one intravesical ureteral reimplantation.

There is no consensus on how to assess laparoscopic training. It would be valuable to reach a consensus on a standardized laparoscopic training programme in paediatric urology.

Often training potential is based on operation numbers only. In paediatric urology no minimum requirement has been specified. The number of procedures quoted for proficiency in MIS remains controversial. The MIS numbers for this centre correspond to, or exceed, numbers mentioned in other literature. To provide high-quality MIS training, exposure to laparoscopic procedures should be expanded. This may be achieved by centralizing patients into a common centre, collaborating with other specialities, modular training and training outside the operating theatre.

Even in a high-volume, paediatric urology educational centre, the number of major MIS procedures performed remains relatively low, leading to limited training potential.