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Purpose: Iatrogenic recto-urinary fistulas are a disastrous complication of therapeutic interventions on the prostate. Many surgical approaches have been described to repair recto-urinary fistulas and no consensus has been reached regarding the better approach. The objective of this study is to present the results of our updated 20-year experience in the surgical management of recto-urinary fistula using a modified York Mason procedure.Methods: We proceed to a retrospective single-institution review of surgically treated patients for iatrogenic recto-urinary fistulas between 1998 and 2017 by the modified York Mason technique. Descriptive analysis of our population was performed. Continuous and categorical variables were compared using Mann-Whitney and Fischer tests, respectively. All tests were two-sided with a significance level set at p value < 0.05.Results: We included 30 consecutive patients treated for iatrogenic recto-urinary fistula. The median follow-up was 76 months (2-195). The median size of the fistula was 5 mm (2-20). Successful healing of the recto-urinary fistula was observed in 80, 97, and 100% of patients after 1, 2, or 3 York Mason procedure. During the study period, no one single case of acquired urinary incontinence or durable fecal incontinence has been observed.Conclusions: Our modified York Mason technique is a reliable and effective procedure with a 100% success rate for the repair of small iatrogenic recto-urinary fistulas in non-irradiated patients. It has a very low morbidity rate, and no case of postoperative urine or fecal incontinence has been observed. [ABSTRACT FROM AUTHOR]

Background: Guidelines on the clinical management of non-metastatic castrate-resistant prostate cancer (nmCRPC) generally focus on the need to continue androgen deprivation therapy and enrol patients into clinical trials of investigational agents. This guidance reflects the lack of clinical trial data with established agents in the nmCRPC patient population and the need for trials of new agents. Aim: To review the evidence base and consider ways of improving the management of nmCRPC. Conclusion: Upon the development of castrate resistance, it is essential to rule out the presence of metastases or micrometastases by optimising the use of bone scans and possibly newer procedures and techniques. When nmCRPC is established, management decisions should be individualised according to risk, but risk stratification in this diverse population is poorly defined. Currently, prostate-specific antigen (PSA) levels and PSA doubling time remain the best method of assessing the risk of progression and response to treatment in nmCRPC. However, optimising imaging protocols can also help assess the changing metastatic burden in patients with CRPC. Clinical trials of novel agents in nmCRPC are limited and have problems with enrolment, and therefore, improved risk stratification and imaging may be crucial to the improved management. The statements presented in this paper, reflecting the views of the authors, provide a discussion of the most recent evidence in nmCRPC and provide some advice on how to ensure these patients receive the best management available. However, there is an urgent need for more data on the management of nmCRPC. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility of prostate histoscanning true targeting (PHS-TT) guided transrectal ultrasound (TRUS) biopsy. Methods: This is a prospective, single center, pilot study performed during February 2013-September 2013. All consecutive patients planned for prostate biopsy were included in the study, and all the procedure was performed by a single surgeon aided by the specialized true targeting software. Initially, the patients underwent PHS to map the abnormal areas within the prostate that were ≥0.2 cm. TRUS guided biopsies were performed targeting the abnormal areas with a specialized software. Additionally, routine bisextant biopsies were also taken. The final histopathology of the target cores was compared with the bisextant cores. Results: A total of 43 patients underwent combined 'targeted PHS guided' and 'standard 12 core systematic' biopsies. The mean volume of abnormal area detected by PHS is 4.3 cm. The overall cancer detection rate was 46.5 % (20/43) with systemic cores and target cores detecting cancer in 44 % (19/43) and 26 % (11/43), respectively. The mean % cancer/core length of the PHS-TT cores were significantly higher than the systematic cores (55.4 vs. 37.5 %. p < 0.05). In biopsy naïve patients, the cancer detection rate (43.7 % vs. 14.8 %. p = 0.06) and the cancer positivity of the cores (30.1 vs. 6.8 %. p < 0.01) of target cores were higher than those patients with prior biopsies. Conclusion: PHS-TT is feasible and can be an effective tool for real-time guidance of prostate biopsies. [ABSTRACT FROM AUTHOR]

Background: A growing number of treatment options exist to treat metastatic castrate-resistant prostate cancer (mCRPC), and with these newer options, many questions about optimising treatment remain unanswered. One recommendation that may potentially be overlooked by practitioners is that androgen deprivation therapy (ADT) should be maintained when CRPC develops and when treatment with any of the newer agents is initiated. Aim: However, to emphasise this recommendation, it is valuable to interrogate the evidence for maintaining ADT in different clinical situations. Outcome: This statement, reflecting the views of the authors, provides a discussion of this evidence and the rationale behind the recommendation that ADT should be continued in CRPC. [ABSTRACT FROM AUTHOR]

Purpose : To assess the impact of micropapillary histological variant on oncological outcome after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinomas (UTUCs). Methods: A French multicenter retrospective study was performed on patients who underwent RNU between 1995 and 2010. Pathological reports were reviewed to identify patients with pure urothelial carcinomas (PUC) and those with micropapillary histological variant (MPC). Uni- and multivariate Cox regression analyses were performed to identify factors predictive of survival. Results: Overall, 519 patients were included and divided into two groups: 480 PUC and 39 MPC. Median follow-up were 28 and 19 months, respectively ( p = 0.63). There was no difference between the two groups for gender, age and tumor location (pelvicalyceal or ureteral). MPC was associated with high-stage and high-grade UTUC ( p < 0.001 and 0.04). No difference was observed between the two groups for 5-year cancer-specific survival (76.1 vs. 88.2 %; p = 0.54). The 5-year metastasis-free survival was significantly lower in the MPC group (48.9 vs. 73.8 %; p = 0.037). In multivariate analysis, pT stage, lymphovascular invasion, margin status and adjuvant chemotherapy administration were independent predictors of specific survival ( p = 0.002; 0.001; 0.02; 0.01), contrary to histological variant ( p = 0.94). Conclusions: Micropapillary histological variant was associated with advanced UTUC and reduced metastasis-free survival after RNU. It should be considered as an aggressive tumor and thus be stated in any pathological report after radical surgery. [ABSTRACT FROM AUTHOR]

Purpose: Cancer is the leading cause of death among patients aged 65 years and older. In this population, the cancer diagnosis is often made at a more advanced stage and worse prognosis than in younger patients. Specific mortality in older patients is superior to that reported in their younger counterparts. Moreover, the impact of curative treatment that has proven benefit in overall population may be not well studied in the sub-group of older patients. Thus, the management of cancer in the elderly is a major public health concern in most Western countries. Methods/results: In this review, we summarize this challenging treatment decision-making in older urologic patients with prostate, kidney or bladder cancer. The estimation of life expectancy remains a difficult task. Chronological age should not be considered as the main decisive factor anymore when considering aggressive cancer treatment. Comorbidities increase the complexity of cancer management and affect survival. Multidisciplinary evaluation and comprehensive geriatrics assessment using specific scales are critical to improve the treatment decision-making and to minimize both overtreatment of low-risk disease and undertreatment of high-risk disease. When an aggressive and potential quality-of-life-threatening treatment is scheduled after this comprehensive geriatrics assessment, personalized patient care must be early predefined by the geriatric team. Conclusions: In the elderly, an enhanced support including specific geriatric assessment and management optimizes the treatment course, including preoperative optimization, prevents treatment-related complications and loss of autonomy using or not geriatrics clinic or rehabilitation units, and limits the length of hospital stay and costs. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the long-term outcomes of patients with prostate cancer who have pathological pT3b N0-Nx, with postoperative PSA < 0.1 ng/ml and no systematic adjuvant treatment. Materials and methods: Using a monocentric prospectively maintained database, we identified among 2,142 men who underwent minimally invasive radical prostatectomy, 104 pT3b N0-Nx patients, with postoperative PSA < 0.1 ng/ml and at least 5 years of follow-up. Patients were considered for salvage treatment at biochemical recurrence (PSA ≥ 0.2 ng/ml). Results: The median time of follow-up was 83.5 months (interquartile range [IQR]: 69-99). Overall, 102 patients (98 %) had T2 clinical stage or less. Specimen Gleason score was 7 in 71 patients (68 %) and <7 in 15 (14 %). Thirty-eight patients (37 %) were upgraded for Gleason score after radical prostatectomy. The overall 5-year probability of freedom from biochemical recurrence for the entire cohort was 55.8 % (95 % CI 45.8-65.8) and 73.3 % for patients who had specimen Gleason score <7 ( p = 0.005). In univariate analysis, specimen Gleason score and surgical margin status were significant predictors for biochemical failure after radical prostatectomy ( p = 0.05 and 0.007, respectively). In multivariate analysis, only specimen Gleason score >7 was significantly associated with biochemical failure ( p = 0.009). Conclusion: SVI is an adverse prognostic factor, but it is not associated with a uniformly poor prognosis. Specimen Gleason score and surgical margin status are significant predictors of recurrence after radical prostatectomy in patients with prostate cancer and SVI. [ABSTRACT FROM AUTHOR]

Objectives: To identify predictive factors and assess the impact on oncological outcomes of intravesical recurrence after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC). Methods: Using a national multicentric retrospective dataset, we identified all patients with UTUC who underwent a RNU between 1995 and 2010 ( n = 482). Intravesical recurrence was tested as a prognostic factor for survival through univariable and multivariable Cox regression analysis. Results: Overall, intravesical recurrence occurred in 169 patients (35 %) with a median age of 69.2 years (IQR: 60-76) and after a median follow-up of 39.5 months (IQR: 25-60). Actuarial intravesical recurrence-free survival estimates at 2 and 5 years after RNU were 72 and 45 %, respectively. On univariable analyses, previous history of bladder tumor, tumor multifocality, laparoscopic approach, pathological T-stage, presence of concomitant CIS and lymphovascular invasion were all associated with intravesical recurrence. On multivariable analysis, previous history of bladder cancer, tumor multifocality and laparoscopic approach remained independent predictors of intravesical recurrence. Existence of intravesical recurrence was not correlated with worst oncological outcomes in terms of disease recurrence ( p = 0.075) and cancer-specific mortality ( p = 0.06). Conclusions: In the current study, intravesical recurrence occurred in 35 % of patients with UTUC after RNU. Previous history of bladder cancer, tumor multifocality, concomitant CIS and laparoscopic approach were independent predictors of intravesical recurrence. These findings are in line with recent published data and should be considered carefully to provide a definitive surveillance protocol regarding management of urothelial carcinomas regardless of the location of urothelial carcinomas in the whole urinary tract. [ABSTRACT FROM AUTHOR]

Objectives: Recent publications have assessed the prognostic significance of hydronephrosis in the outcome of upper tract urothelial carcinoma (UUT-UC). Our study sought to determine the prognostic impact of hydronephrosis on UUT-UC survival and its relationship to the clinicopathological features. Materials and methods: A retrospective, multi-institutional French study was conducted on 401 patients who underwent radical nephroureterectomy for non-metastatic UUT-UC. Hydronephrotic status was determined using preoperative imaging reports. Univariate and multivariate analyses were conducted to identify factors associated with survival. Results: Preoperative hydronephrosis was present in 74 patients. Median follow-up was 26 months. Hydronephrosis was associated only with ureteral localisation ( p < 0.001). No difference was observed in 5-year cancer-specific survival (CSS) between the hydronephrosis group (80.1 %) and the no hydronephrosis group (83.6 %) ( p > 0.05). Only age ( p = 0.02) and pT stage ( p = 0.01) were independent predictors of CSS. Hydronephrosis was not a significant predictor of CSS in the univariate and multivariate analyses ( p = 0.87 and p = 0.66). No significant difference was observed for 5-year metastasis-free survival (MFS) between the hydronephrosis group (69.8 % ± 6.6 %) and the no hydronephrosis group (80.5 % ± 3 %) ( p = 0.052). Hydronephrosis was not a significant predictor of MFS in the univariate and multivariate analyses ( p = 0.16 and p = 0.36). Multifocality ( p = 0.02), pT stage ( p < 0.001) and positive surgical margins ( p = 0.02) were independent predictors of MFS. For the pelvic tumours subgroup, hydronephrosis was an independent predictor of MFS ( p = 0.01) but not CSS ( p = 0.86). Conclusion: Preoperative hydronephrosis was not associated with survival. However, among tumours presenting with hydronephrosis, pelvicalyceal tumours appear to have a worse prognosis than ureteral tumours. [ABSTRACT FROM AUTHOR]

To present oncological results with intermittent androgen deprivation (IAD) in a single center. Between 1992 and 2008, 566 patients with prostate cancer (PC) were selected for a non-randomized study of IAD. Two hundred and eighteen patients had biochemical recurrence (BCR) after local treatment for PC and 348 patients had micro- or macro-metastatic disease. On-treatment period (ONTP) consisted of three-monthly injections of gonadatropin-releasing hormone (GnRH) agonist combined with daily oral androgen receptor antagonist. Off-treatment period (OFTP) was indicated when prostate-specific antigen (PSA) was <4 ng/ml. Criteria for resumption of hormonal therapy were PSA >20 ng/ml or clinical symptoms. Cancer specific survival curves were computed according to the Kaplan–Meier method. Median follow-up was 81 months (12–230). Median age was 74.7 years (52–92). Median Gleason score at diagnosis was 7 (3–9). Median initial PSA was 17 ng/ml (0.4–433). Cycle duration decreased progressively from 23 months for the 1st cycle to 10 months at 12th cycle. The number of patients who became hormone resistant was 182 (32%). Median cancer specific survival probability for the series is 12 (10.8–infinity) years. No previous treatment group showed a higher cancer specific survival probability (log rank test, CI 95%, P = 0.003) versus BCR group. Multivariate analysis of cancer specific survival demonstrates age, initial Gleason score and initial PSA level as significant factors affecting mortality ( P < 0.05). Intermittent androgen deprivation is an acceptable treatment in different stages of PC. Duration of cycle decreased progressively during therapy. Age, Gleason score and PSA are factors predicting mortality. [ABSTRACT FROM AUTHOR]

To assess the oncological safety of laparoscopic procedures for the management of urothelial carcinomas of the urinary tract. Data on laparoscopic management of urothelial carcinomas in the literature were analysed using MEDLINE and by matching the following keywords: urological malignancies, upper tract tumours, bladder carcinomas, laparoscopic approach, recurrence, follow-up and metastasis site. Minimally invasive techniques are being used increasingly in the management of these tumours and successfully achieving the benefits of lower blood loss and more rapid patient recovery. To date, no evidence level 1 information is available and published series of these technically challenging cases are small and follow-up limited. Short to medium term follow-up appears encouraging in terms of recurrence and survival rates, but long-term data are immature compared to the established open techniques these procedures seek to duplicate. Specific concerns in terms of the oncologic safety of laparoscopy, especially with regard to the pneumoperitoneum, tumour manipulation and specimen extraction are addressed. Port-site metastases and tumour seeding are rare events and appear to be mainly related to the grade and stage of the tumour. Specific precautions are required to minimise these risks. Oncological results of the laparoscopic approach are difficult to compare with those of open surgery. However, recent series have not reported unusual tumour dissemination or a higher rate of recurrence with this approach. Laparoscopic techniques are not yet standard of care in invasive urothelial carcinomas. Long-term assessment is ongoing and awaited. [ABSTRACT FROM AUTHOR]

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151–453) versus 182 min (141–250) for RALP. Estimated blood loss for the LRP averages 482 ml (185–850) versus 234 ml (75–500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes. [ABSTRACT FROM AUTHOR]

Objectives: According to the current upper urinary tract urothelial carcinomas (UTUC) guidelines, ureteroscopic evaluation (URS) is recommended to improve diagnostic accuracy and obtain a grade (by biopsy or cytology). However, URS may delay radical surgery [e.g., nephroureterectomy (RNU)]. The objective of this study was to evaluate the influence of URS implementation before RNU on patient survival., Methods: A French multicentre retrospective study including 512 patients with nonmetastatic UTUC was conducted between 1995 and 2011. Achievement of ureteroscopy (URS), treatment time (time between imaging diagnosis and RNU), tumour location, pT-pN stage, grade, lymphovascular invasion (LVI) and the presence of invaded surgical margins (R+) were evaluated as prognostic factors for survival using univariate and multivariate Cox regression analyses. Cancer-specific survival (CSS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were calculated using the Kaplan-Meier method., Results: A total of 170 patients underwent ureteroscopy prior to RNU (URS+ group), and 342 did not undergo URS (URS-). The median treatment time was significantly longer in the URS+ group (79.5 vs. 44.5 days, p = 0.04). Ureteroscopic evaluation was correlated with ureteral location and lower stage and tumour grade (p = 0.022, 0.005, 0.03, respectively). Tumour stage, LVI+ and R+ status were independently associated with CSS (p = 0.024, 0.049 and 0.006, respectively). The 5-year CSS, RFS and MFS did not differ between the two groups (p = 0.23, 0.89 and 0.35, respectively). These results were confirmed for muscle-invasive (MI) UTUC (p = 0.21, 0.44 and 0.67 for CSS, RFS and MFS, respectively)., Conclusions: Despite the increased time to radical surgery, diagnostic ureteroscopy can be systematically performed for the appraisal of UTUC to refine the therapeutic strategy without significantly affecting oncological outcomes, even for MI lesions.