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The aim of this study was to assess the impact of the acquisition of a Da VinciIt was a single center retrospective study including 280 patients who underwent PN from January 2006 to May 2013. The number of PN, tumors and patients' characteristics and perioperative outcomes have been assessed over 3 periods defined according to the main surgical approach: 2006-2008 (open PN), 2008-2010 (laparoscopic PN) and 2010-2013 (robotic PN).Over the study period, the surgical approach has changed significantly in favor of minimally-invasive surgery and especially robotic approach. The PN/nephrectomy rate has also evolved to a higher proportion of PN over radical nephrectomy (P=0.002). No significant difference was noted between the three periods in terms of tumor size but there was a higher rate of highly complex tumors (RENAL score≥10) during the last period (10.7%; 18.6% and 33.2%; P=0.04). Warm ischemia time increased from 2006-2008 to 2008-2010 (26 vs. 23minutes) but decreased thereafter during the robotic era (14.5minutes; P0.001). Regarding postoperative outcomes, the only change was a decreased length of stay over time (P=0.003).In this single center series, the robotic approach was associated with a spread of PN and with an improvement of nephron-sparing surgery outcomes.4.

Targeted molecules are used in the treatment of metastatic kidney cancer. Their use before surgery could reduce tumor volume, facilitate surgical resection and treat micrometastases. In this literature review, we present the main results of studies that evaluated the benefit of targeted therapies in kidney cancer.This article is based on a systematic literature search by using Pubmed database.In prospective studies, a decrease in the size of the primary tumor has been reported to be 9.6 to 28.3%. In case of metastatic kidney cancer, cytoreductive nephrectomy could be possible after targeted therapies in tumors that initially were not available for surgery. In localized kidney cancer, a reduction of tumor volume of more than 30% is obtained in 5 to 45% of cases after neoadjuvant targeted therapies. Their use is associated with the occurrence of the usual side effects of targeted therapies plus a specific risk of delayed healing and metastatic progression during the perioperative period. The study of tumors after surgery shows a lower efficiency of the production of tumor necrosis in non-clear cell carcinomas.Data from the literature are not currently in favor of neoadjuvant use of targeted therapies in the treatment of kidney cancer. Prospective studies will be required to determine their interest in the prevention of metastatic recurrence after surgery.

The diagnosis of angiomyolipoma with tumor thrombus from the renal vein into the inferior vena cava is rare, especially during pregnancy. We report the case of a 31-year-old pregnant woman who was diagnosed with a 9 cm angiomyolipoma of the right kidney with inferior vena cava thrombosis, managed by active surveillance during pregnancy and delayed surgery after childbirth.

To assess the influence of vascular clamping and ischemia time on long-term post-operative renal function following partial nephrectomy (PN) for cancer in a solitary kidney.This is a retrospective study including 259 patients managed by PN between 1979 and 2010 in 13 centers. Clamping use, technique choice (pedicular or parenchymal clamping), ischemia time, and peri-operative data were collected. Pre-operative and last follow-up glomerular filtration rates were compared. A multivariate analysis using a Cox model was performed to assess the impact of ischemia on post-operative chronic renal failure risk.Mean tumor size was 4.0±2.3cm and mean pre-operative glomerular filtration rate was 60.8±18.9mL/min. One hundred and six patients were managed with warm ischemia (40.9%) and 53 patients with cold ischemia (20.5%). Thirty patients (11.6%) have had a chronic kidney disease. In multivariate analysis, neither vascular clamping (P=0.44) nor warm ischemia time (P=0.1) were associated with a pejorative evolution of renal function. Pre-operative glomerular filtration rate (P0.0001) and blood loss volume (P=0.02) were significant independent predictive factors of long-term renal failure.Renal function following PN in a solitary kidney seems to depend on non-reversible factors such as pre-operative glomerular filtration rate. Our findings minimize the role of vascular clamping and ischemia time, which were not significantly associated with chronic renal failure risk in our study.5.

Present national estimations of the incidence and mortality trends in urological cancers in France between 1980 and 2012.Francim database and French Register of Cancers.Analysis of the current data shows a regular increase of the incidence of renal cancer in men and women (7,781 cases in men and 3,792 in women in 2012). For bladder cancer, trends are divergent. There is a small reduction in incidence for men and an increase for women (9,549 cases in men and 2,416 in women in 2012). Testicular cancer is still increasing slightly (2,317 incidental cases in 2012). The incidence of prostate cancer experienced a huge increase up until 2005, and thereafter it decreased sharply, though it is difficult to discern whether this drop (which was observed up until 2008) continued at the same rate after that point (56,841 incidences in 2012 based on the rates calculated for 2009).The analyses by organ database show that there are significant variations in the incidence of urological cancers, particularly for prostate cancer, which shows that both the natural history of urological tumours and the methods of detection have an impact on incidence.

The objective of the 2013 recommendations performed by the different committees of CCAFU is to improve the management of urological cancers regarding diagnosis, clinical assessment and treatments in men and women.2010 clinical guidelines were updated based on international AUA and EAU guidelines and on systematic literature search performed by each sub-Committee in Medline and PubMed databases to evaluate references, levels of evidence and grade of recommendation.CCAFU clinical guidelines reply to the main clinical questions on management of urological cancers.French clinical guidelines are updated every three years by CCAFU in accordance with the main international guidelines in onco-urology.

Quantify the rate of residual bladder tumor following systematic second look resection of pTa high-grade versus pT1 high-grade patients.From January 2010 to July 2013, 53 patients with a non-muscle-invasive bladder cancer with high-risk of recurrence and progression underwent a second systematic resection in accordance with the current guidelines of the French Association of Urology (AFU).Among the 53 patients with a high-risk non-muscle-invasive bladder cancer, histological examination of the initial resection identified: 17 pTa high-grade (32.1%) and 36 pT1 high-grade (67.9%). There was a significant difference between the 2 groups of patients (Ta high-grade versus T1 high-grade) concerning the rate of residual tumor on second look resection (11.8% versus 66.7%, P=0.0002). The predictive factors of residual tumor after second resection were the pT1 stage (P=0.0002), tumor multifocality (P=0.02) and presence of associated Cis (P=0.0005).The high rate of residual tumor in our series confirmed the importance of a systematic second look resection for high-risk non-muscle-invasive bladder cancers. However, for the pTa tumors without associated Cis, the interest of this second look seemed of less concern.5.

Upper tract urinary carcinoma (UTUC) pT3 tumors are a heterogeneous entity including tumors invading the renal parenchyma, tumors with peripelvic fat invasion or peri-ureteral fat invasion. The aim of this study was to evaluate the prognostic significance of these three different groups of pT3 tumors.Between 1998 and 2012, 205 patients with UTUC were operated in two centers, including 52 patients with pT3 tumor stage. pT3 tumors were divided into three groups: peri-ureteral fat invasion (pT3U, n = 16), peripelvic fat invasion (pT3G, n = 21), and renal parenchyma invasion (pT3P, n = 15). The prognostic significance of the type of tumor infiltration was evaluated on specific and disease-free survival.Median follow-up was 18.9 months [6-133.4]. In univariate analysis, renal parenchyma invasion was associated with a better prognostic in both specific (P = 0.026) and disease-free survival (P = 0.031) compared with peripelvic or peri-ureteral fat invasion. Mutivariate analysis retained the pT3 subgroup as an independant prognostic factor in both specific and disease-free survival (P = 0.02).pT3 tumors with renal parenchyma invasion had a better prognosis than those with peripelvic or peri-ureteral fat invasion. The heterogeneity of the pT3 group should be taken into account to improve the care of patients.

The aim of this study was to clarify the current role of adjuvant and neo-adjuvant in the treatment of kidney cancer.The data were explored in Medline (http://www.ncbi.nlm.nih.gov) using the following MeSH terms or combinations of these keywords: "cancer", "rein", "kidney", "adjuvant", "neoadjuvant", "antiangiogenique", "antiangiogenic" and selecting the items produced in their methodology, their relevance to the theme explored and their date of publication.Thirty-two English and French items published between 2001 and 2011 were selected: five studies of evidence level 1, nine level 2 studies, nine level 4 studies, five studies at level 5 and four literature reviews. The cytoreductive nephrectomy as first-line treatment of locally advanced or metastatic kidney cancer is now controversial with the advent of new targeted anti-angiogenic therapies. In neoadjuvant setting, these treatments showed a moderate decrease in tumor volume and rarely improved resectability. In adjuvant setting, their place has yet to be specified and several trials are currently underway.Recent years have seen the anti-angiogenic therapeutic strategies upset in locally advanced and metastatic renal cancer. The development of clinical trials and research protocols will allow us to determine in the near future the optimal therapeutic sequences.

Melanoma is a slowly growing malignancy, with potential distant metastasis at various sites. In this article, we reported three original cases of melanoma metastases in the upper urinary tract, and we achieved a literature review. Symptoms are inconstant and non-specific (pain or haematuria). Nephroureterectomy is performed in the majority of cases. Even if this metastatic location remains uncommon, it should be timely detected in order to allow an appropriate management and to improve the prognostic of melanoma.

Pyelonephritis is a bacterial infection of the upper urinary tract and renal parenchyma. Infection occurs primarily by urinary contamination upward and backward from the intestinal flora, and genital skin, explaining that the seeds are most commonly encountered Gram-Negative bacilli (GNB), Escherichia coli in mind. The peak incidence is among women aged 15 to 65, but pyelonephritis may include subjects of all ages and both sexes. The diagnosis is usually straightforward and based on a combination of fever, unilateral flank pain and a positive urine culture. Biology and imaging aim to seek any form of pyelonephritis complicated, especially due to the obstructive form a barrier (usually a calculation) of the urinary tract and is a surgical emergency. Support depends on the existence of signs of severity or complications. Treatment consists of antibiotics, to begin immediately, initially probabilistic and secondarily adapted to the antibiogram. Patients hospitalized in the urology will be those with complicated pyelonephritis (urinary obstruction, abscess, sepsis, renal insufficiency, solitary kidney, comorbidity).

Nowadays, most of renal cancers are incidental tumors less than 4 cm. Prevalence of lymph node involvement is low and does not require a systematic lymphadenectomy as described by Robson in the 1960s. Radiologic progress and particularly CT scan describe with high precision lymph node involvement in the initial work-up. In renal cancer with a high risk of recurrence, lymphadenectomy has a pronostic interest and therapeutic role in rare situations where lymph node involvement is isolated. In metastatic patients, the role of cytoreductive nephrectomy has to be assessed.

To evaluate the feasibility and morbidity of laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPK).This is a retrospective multi-centre study (University Hospitals of Lyons, Toulouse, Nantes and Rennes). Sixty-eight patients who had undergone laparoscopic nephrectomy for polycystic kidney disease between November 1999 and May 2009 were included. This involved unilateral nephrectomy 64 cases, one-stage bilateral in one case and two-stage bilateral in three cases.The mean operating time was 218±74min (100-420) Conversion was necessary in 7 cases. The mean weight of the removed kidney was 1291±646g (240-3400). We regret to report 20 postoperative complications, including one death on postoperative day 50, following an abscess in the renal pelvis, 6 retroperitoneal haemoatomas and 5 arteriovenous fistula thromboses. Postoperative analgesia involved PCA treatment with morphine for a mean period of 1.59±0.8 days (0.5-4). The mean length of hospital stay was 8.3±6.1 days (3-50).This study shows the feasibility of the laparoscopic approach for nephrectomy in ADPK. This procedure should be performed by experienced laparoscopic surgeons. Indeed, the complication rate is moderate but there is still a risk of severe complications.5.

The main news in kidney oncourology are PET CaIX as potential new diagnostic and monitoring tool, the lack of progress in terms of drug combination therapy, the sequential approach remains the standard, lack of progress also in selecting good candidates for immunotherapy, the possible benefit of nephrectomy, that only the CARMENA study will determine, and the emergence of determining the risk of recurrence after nephrectomy using genomic study. Concerning non muscle invasive bladder cancer, endoscopic diagnosis seems improved by the NBI and immunofluorescence. The staging of pT1 tumors may evolve. The poor prognosis of Cis was stressed. The indication of cystectomy for BCG failure has been clarified. For muscle invasive bladder cancer, the prognostic impact of lympho-vascular invasion was reported. The importance of an extended lymphadenectomy has been demonstrated. In cases of symptomatic bone metastases, zoledronic acid increased overall survival. An analysis of performance and drawbacks of radio-hormonotherapy was performed. The denosumab and zoledronic acid were compared in prevention of bone loss during androgen deprivation. The antagonists of LH-RH, the cabazitaxel and immunotherapies could be part of the therapies for advanced prostate cancer. For penile cancer treatment, in case of suspicious nodes, ultrasound guided cytopuncture is useful. For testis cancer, the recurrence rate for stage I seminoma has been estimated, at 15%. The PET-scan is also helpful to assess the nodal tumoral spread during the staging and the follow-up of patients treated by chemotherapy.

To determine the prognostic significance of the neutrophil gelatinase-associated lipocalin (NGAL) and the matrix metalloproteinase 9 (MMP-9) in clear cell renal cell carcinoma (CCRCC).NGAL and MMP-9 expression were quantified by immunohistochemistry in clear renal cell carcinoma tissues and in sera by Enzyme Linked Immunosorbent Assay (Elisa). Results were associated with clinicopathologic data.Seventy-four patients operated for CCRCC in Rennes between 2003 and 2009 were included. High concentrations of NGAL-MMP-9 complex in serum were associated with short progression free survival (PFS) (33.3 months versus 47.3 months, P=0.016) and poor overall survival (42.5 months versus 51.9 months, P0.047). High NGAL concentrations in serum were also associated with shorter PFS (13.6 months versus 41.6 months, P=0.04). However, no NGAL expression was observed in renal tumor cells. Interestingly, NGAL was expressed by neutrophils infiltrating CCRCC and we showed that the density of NGAL expressing neutrophils was associated with pejorative PFS and survival (36.9months versus 56.1 months, P0.006).In this study, we showed the pejorative significance of NGAL-MMP-9 complex and NGAL rates in serum of CCRCC. We also confirmed that density of NGAL expressing neutrophils in CCRCC was associated with poor outcome.

The objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm.The data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant.Seven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004).The renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

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.

The medical treatment of renal-cell carcinoma, and of its most frequent subtype, clear cell renal-cell carcinoma, has recently been drastically changed by the emergence of targeted therapies. The development of these drugs has been made possible by more precise knowledge of molecular mechanisms involved in the carcinogenesis of these tumors. We present in this article the molecular pathways linked to targeted therapies for clear cell renal-cell carcinoma: VHL/HIF/VEHF and PI3K/AkT/mTOR pathways. We also describe succinctly the EGFR pathways, and the molecular mechanisms involved in other histological subtypes. Then, we briefly describe how these targeted therapies work. We finally discuss how biology could improve the use of these therapies, by developing new prognostic factors, and predictive factors of response to treatment.

Advanced or metastatic renal carcinoma represents a frequent disease in oncologic practice. Few years ago, in immunotherapy era, treatments had quickly reached deadlock. New therapies targeting vascular endothelial growth factors and their receptors (VEGF-R), sorafenib, sunitinib and bevacizumab, and the mammalian target of rapamycin (mTOR), temsirolimus and everolimus, have modified these patients prognosis and their quality of life in a few years. Nevertheless, patients included in randomized trials presented severe inclusion criteria. Then in the daily practice, patients have distinctive characteristics which were not evaluated in large pivotal studies: poor performance status, older patients, renal dysfunction, cerebral metastases or non clear cell renal cancer. In published trials, a few data concerning these situations are reported, and these studies have often included small samples, were retrospective or not randomised. However compared to global population, tolerance have not been very different in geriatric patients, or patients with poor performance status, or with central neurological metastases, or with papillary and chromophobe sub-types. On the contrary progression free or overall survivals increases are more difficult to confirm. Also before starting treatment, ratio between potential benefit and possible toxicities have to be evaluated. In patients with renal insufficiency, VEGF receptor inhibitors seem to be cautiously initiated at reduced doses, and to be increased according to tolerance. Due to these poor proof levels, clinical trials are needed for these specific populations.

to present our initial experience of laparoendoscopic single site (LESS) renal surgery.between May 2009 and March 2010, nine nephrectomies and one cyst decortication were performed in nine patients. Eight of the procedures were done with three 5mm trocars inserted through a unique peri-umbilical incision. In two cases, a specific single-port device was used. All operations were achieved with a 5-mm 30° lens and conventional laparoscopic instruments. The specimens were entrapped in a 10mm endoscopic bag and extracted through the umbilical incision.mean age was 56 years old. Mean BMI was 23.5 [19-34]. Mean operative time was 149min [80-240], and estimated blood loss was 90ml [20-250]. None of the patients required blood transfusion. Mean length of stay was 4.1 days [3-5]. Only one major complication occurred (functional occlusion). One conversion to conventional laparoscopy was necessary in a case of inflammatory kidney. Histologic exam showed benign lesions (cyst and non functional kidney) in seven cases, and papillary carcinoma in three cases.LESS surgery is feasible. Its advantages over conventional laparoscopy are not clear. LESS is a new procedure that should benefit from the improvement of technical instrumentation.

The concomitant increase in life expectancy and the incidence of kidney cancers will result in an increase in kidney cancers in subjects over 75 years of age in the coming years. A wait-and-see attitude in cases of voluminous tumors, particularly symptomatic tumors, may well alter the quality of life of these patients through chronic abdominal pain, macroscopic hematuria, or alteration of the general condition due to metastatic progression. Curative or palliative surgical management can be envisioned and should be discussed in the multidisciplinary consensus meeting. Before validating the indication for nephrectomy in the elderly patient, a preoperative geriatric assessment should be made. Moreover, preoperative renal function should be carefully evaluated to measure the risk of terminal renal failure. The reduction in the mean duration of the hospital stay provided by laparoscopic surgery allows patients to return home or to their institution more quickly, an important consideration in the rehabilitation of these patients, who are very sensitive to such changes. Laparoscopic nephrectomy, with evidence in the literature of reduced morbidity and satisfactory oncological results, could therefore be superior to open surgery when indicated and technically feasible.

The development of ablative techniques in renal oncology has profoundly changed treatment of small renal tumors. The objective of this review of the literature was to assess the arguments for treating localized kidney tumors with these techniques in the elderly patient. The two techniques retained because of their recognized use, for all approaches, are radiofrequency and cryotherapy. The data in the literature report more frequent local recurrence with these techniques than with surgical excision and an advantage to cryotherapy over radiofrequency. There seems to be no difference in terms of metastatic progression. Morbidity is not insignificant, with major complications in slightly less than 10% of cases. Given the need to consider small tumors (4 cm), the advantage in terms of life expectancy is challenged by series studying active monitoring of the oldest patients who present co-morbidities. At present, the indications should therefore be measured and based on a general assessment of the patient, with particular consideration of the existing co-morbidities so as not to treat a patient while imposing undue complications.

Treatment of metastatic kidney cancer in elderly subjects is identical to treatment of younger subjects. Whereas cytokines were classically contraindicated in patients over 70 or 75 years (notably IL2), new targeted therapies have been evaluated and found to be usable with no age limit, and all of the phase III studies have included patients 80 years old and older. Overall, there seems to be no difference in efficacy based on age (except perhaps for temsirolimus). As for tolerance, it is satisfactory for all therapies. Dose reduction is slightly more frequent, which calls for caution, notably with sunitinib, for which a direct correlation between the dose administered and efficacy has been reported. Given the data available today, no dose adaptation in relation to age is recommended in metastatic renal cancer.

Surgery is a major arm in cancer management. Elderly patients have more co-morbidities than younger patients. These coexisting conditions can result in contraindicating the necessary act. However, other than terminating a cystectomy (cutaneous derivation or replacement), in exceptional cases they have an impact on the surgical technique. The objective of this study was to review the different possible situations in urinary oncology, with the most important aspect of this surgery being patient management by a medical and surgical team in which the geriatrician and the paramedical team are at least as important as the surgeon and the anesthesiologist.

The Aurora kinase family plays a crucial role in the regulation of mitosis. Over-expression of Aurora A and B has been reported in many malignant tumors. The objective of this study was to analyze the expression of Aurora A and B in renal cell carcinoma (RCC) and its correlation with usual clinical and pathological parameters.In a retrospective study, have been studied the tumoral samples of 40 consecutive patients who had been operated between 2003 and 2006 for a renal tumor. RNA was extracted from frozen corresponding tumoral samples. Thirty-one samples were retained based on RNA quality. RT-PCR was done on each of these samples to assess the expression of Aurora A and B genes. Statistical analysis was performed using Chi-square test to compare Aurora A and B levels.Median age was 65 years (35-82). Seven (22%) patients had nodal invasion and eight (26%) had distant metastases. Most of the tumors (74%) were grade 3 or 4. Eighteen patients (58%) had clear cell cancer histology, 12 (39%) had papillary histology, and one a Bellini type tumor. Aurora A overexpression was associated with lymph node invasion (p=0.001). Aurora B over-expression was associated with both nodal involvement (p=0.02) and histologic subtype (significantly over-expressed in clear cell tumors; p=0.001).Aurora A and B were differentially over-expressed in clear cell RCC and primary tumors of patients with lymph node involvement.

Optical spectroscopy refers to a group of novel technologies that uses interaction of light with tissues to analyze their structure and chemical composition. The objective of this article is to describe these technologies and detail their potential for assessing urological tumors.It has been shown that optical spectroscopy can accurately analyse multiple solid tumors. Several publications specifically aimed at assessing prostate cancers, renal carcinomas and urothelial tumors.There are three types of spectroscopy that all use light focussed on a tissue and thereafter collect a specific reflected optical signal. Optical spectroscopy can differentiate benign (adenoma or inflammation) and malignant (adenocarcinoma) prostatic tissues. It can also distinguish normal bladder tissue from inflammatory or cancerous cells. Regarding renal tumors, spectroscopy can identify normal and tumoral tissue and differentiate benign and malignant tumors. Its diagnostic accuracy is about 85%. However, reported studies only concentrate on in vitro or ex vivo specimen and the numbers of patients are quite small.Optical spectroscopy can be envisioned as an "optical biopsy" tool. Potential applications in the clinical field are promising. Larger studies on in vivo specimen need to be undertaken to confirm phase I preliminary reports.

To evaluate the diagnostic performance and the benefit in terms of management of low-dose CT for the imaging assessment of renal colic (CN) emergencies.Two hundred and ninety-one patients admitted to emergency for CN were included in this study. Eighty-seven had a low-dose CT and 40 an ASP and an ultrasound (ASPE). Different parameters evaluating the diagnostic performance and efficiency of care were compared between the two groups. The quantitative and qualitative variables were compared by Student t test and χ(2) test, respectively.CT and ASPE confirmed the diagnosis of CN in 76% and 54% of patients, respectively (p=0.013). The average lengths of stay were 408 minutes versus 520 (p=0.013) in group scanner and ASPE, respectively. The scan was obtained more rapidly (139 min versus 224, p=0.002). There were more requests for expert advice (30% versus 20%, p=0.18) and gestures endo-urology (9.5% versus 5%, p=0.31) in the CT group compared to the group ASPE. Finally, the patients in the scanner have less painful recurrences (6% versus 12.5%, p=0.18) and fewer imaging examinations of second-line (0% versus 30%, p0.001).The low dose CT has been more efficient than the couple ASPE for a CN diagnosis. It optimizes the management of emergency patients by reducing their length of stay, waiting time and the rate of second consultation.

The most innovating studies presented at the 2008 international conferences in the field of kidney cancer were selected. In localized kidney cancer, contrast-enhanced ultrasonography could be a new diagnostic tool. Many communications dealed with positive surgical margins and their consequences, and predictive factors of chronic kidney disease after nephrectomy. Robot-assisted laparoscopic nephrectomy seems to be a safe and effective technique. Mini-invasive treatments are promising. In metastatic kidney cancer, sunitinib was compared to IFN-alpha in first line treatment and survival data are now available. Everolimus could become the new standard after tyrosine kinase inhibitor failure.

Identification of prognostic factors in renal cell carcinoma is very important today for three goals: providing patient information, giving appropriate treatments and selecting patients for adapted treatment schedules as well as new clinical trials. Prognostic factors in RCC include: anatomical (TNM classification), histological (Fuhrmann grade and histological subtype), clinical (symptoms and performance status) and molecular factors. For improving predicative accuracy of prognostic systems such as the TNM classification, new prognostic algorithms or nomograms have been designed combining independent prognostic variables. UISS and SSIGN are the 2 most effective prognostic systems within localized RCC. In metastatic disease, the two main systems that have been used for predicting response to immunotherapy are the model of the French Group of Immunotherapy and the Motzer model. With the arrivals of new molecular factors, these systems will perhaps have to evaluate: these new systems will require further validation as part of large prospective clinical trials.

Partial nephrectomy requires control of renal blood flow by using renal vessels clamping. Multiple clamping techniques are available. The clamping procedure can be parenchymal or vascular, involving enbloc arterial and veinous clamping or arterial onlone, being continuous or intermittent, associated or not with renal cooling. The purpose of this present review was to analyze technical aspects of clamping methods during partial nephrectomy and their functional consequences in terms of blood loss, surgical margins status and changes in renal function.

The most innovating studies presented at the 2007 international conferences in the field of kidney cancer were selected. The notable topics presented covered diagnostic biopsies and the growing place of conservative surgery and laparoscopy in kidney cancer management. For cases with poor prognosis, the new anti-angiogenic therapies were thoroughly evaluated.

Since 2004, the treatment of metastatic renal cell carcinoma is in deep mutation. Before, the Management was mostly relying on the use of cytokines in association with radical nephrectomy. From 2004, studies of new antiangiogenic molecules, acting on the pVHL-HIF way, VEGF, PDGF or tyrosine-kinase receptors have modified the management of metastatic patients. Antiangiogenic agents improve progression-free survival as shown with sunitinib, in first line treatment, or sorafenib, as second line treatment. The m-TOR inhibitors (Temsirolimus), can be used with a benefit on overall survival in case of poor prognosis renal cell carcinoma or non clear cell carcinoma. Lastly, bevacizumab, an antibody re-combining humanized monoclonal, is able to target VEGF. Side effects are different for each molecule and are not negligible. Nevertheless, the place of these molecules have to be defined in the sequence of the treatment.

Anti-angiogenic agents have modified therapeutic strategies in the management of metastatic renal cell carcinoma. Regarding molecules that already available such as sunitinib, sorafenib, temsirolimus and bevacizumab, clinical trials are now focused on the improvement of their effectiveness, overall survival, response's criteria and toxicity. In the light of recent data, these treatments will be tested in adjuvant situation to radical nephrectomy, but also as an alternative option to radical surgery. The place of radical nephrectomy in metastatic renal cell carcinoma has been recently strongly discussed. I n the future, the systematic radical surgery will not be a rule any more. From now on, renal cell carcinoma patients have to be included in numerous ongoing therapeutic trials to manage anti-angiogenic agents in the best manner.

In case of a single renal cell carcinoma strictly located in the kidney, the radical nephrectomy remains the treatment of choice. However, it has been estimated that nearly 30 to 40 % of renal cell carcinoma are about to recur after primitive surgery. In certain cases, conservative surgery can be discussed as an alternative to radical treatment, especially in case of exophytic renal tumour or less than 4 cm in diameter. New ablative techniques (radiofrequency and cryoablation) have shown promising results but the follow-up is still very limited. French national recommendation regarding kidney cancer have been updated in 2007 and following the development of clinical trials using antiangiogenic agents. Regarding the use of antiangiogenic agents, several points have to be taken into account: existence of renal cell carcinoma, presence of metastasis, number of metastasis, location and risk factor prognosis determination.

Malignant tumours may have a cystic appearance. They are dominated by multilocular cystic renal cell carcinoma, usually low-grade, which rarely metastasize. The Bosniak classification distinguishes non suspicious lesions (type I and II) from suspicious lesions (type III and IV) requiring resection and lesions requiring follow-up (type IIF). The main feature suggestive of malignancy is the enhancement of the septa and the walls of the cyst. Renal cysts classified as IIF require surveillance by contrast-enhanced imaging (CT, MRI or ultrasound). The treatment of cystic tumours is based on surgery. Partial nephrectomy is recommended in this type of tumour regardless of the size. Laparoscopy is a validated technique in experienced hands. Aspiration is not very effective for the treatment of benign cysts, but may be useful for diagnosis. Surgical resection of the roof of the cyst is the most effective technique.

The indications for partial or radical nephrectomy of a kidney tumour are based on tumour diameter with a cut-off of 4cm. Tumour diameter has been demonstrated to be a continuous prognostic parameter which, ideally, should be integrated into multivariate prognostic models. The 4cm cut-off is reasonable, but was established pragmatically on the basis of series comprising selection biases. At least six series now question the validity of this cut-off, and some of them have demonstrated that partial nephrectomy and radical nephrectomy are equivalent in terms of cancer control for pT1b tumours. Furthermore, the excess mortality induced by broader indications for partial nephrectomy appears to be acceptable. These data appear to suggest that the feasibility of partial nephrectomy should be considered regardless of tumour diameter before proposing the indication for radical nephrectomy.

When announcing the diagnosis of renal cell carcinoma, the urologist and the patient can wonder about the waiting time for surgically treating the cancer. This review aimed to investigate the scientific facts to determine the time between the diagnosis of kidney cancer and the achievement of surgically. The natural history of kidney cancer has been the fundamental of the therapeutic management. The time between diagnosis and surgical treatment depends on the conditions under which the diagnosis was established. Patients with symptomatic cancer or discovered at metastatic stage had to be treated quickly. In case of incidental diagnosis, evaluation of tumors has resulted in the selection of patients who can wait several months between diagnosis and surgical treatment of kidney cancer on the condition watchful waiting. The modalities of this assessment, radiological and anatomopathological, must be validated by further studies.

To describe the practice of partial nephrectomy (PN) in France and assess its results in terms of morbidity and cancer control.Seven French University Hospitals in which nephron sparing surgery represents at least 30% of the total number of nephrectomies for renal tumour, participated in this study. All centres included, as exhaustively as possible, all their PN cases. For each patient, 70 variables were harvested in order to characterize the patient population, the indications, the operative technique, the per- and postoperative course and complications, the tumor specificities, the carcinologic control and renal function follow-up.Seven hundred and forty-one PN, of which 579 for malignant tumours were analysed. The mean tumour size was 3.4+/-2.1 cm (0.1-18) and 20.8% of the tumours were larger than 4 cm. In 30.1% of cases, the indication was imperative. Among the PN, 12.2% were performed laparoscopically. The mean operating time was 151+/-54.2 min (55-420). The medical and surgical complications rates were respectively 15.2 and 14.7%. At a mean 38 months follow-up, the local recurrence rate was 3.5% and the specific death rate was 4.5%.PN is nowadays getting a more and more widely used technique in France. This expansion is completely justified by its results and urologists must consider nephron sparing surgery as the gold standard treatment for renal tumours measuring less than 4 cm.

The purpose of this article is to report our experience concerning the indications and results for combined liver-kidney transplantation in our centre.From July 1991 to October 2006, 26 patients underwent combined liver-kidney transplantation in our establishment. This group comprised 16 men and 10 women with a mean age of 50.1 years (range: 19 to 68 years). The main indications were as follows: hepatorenal polycystic disease, type I hyperoxaluria, cirrhosis associated with end-stage renal failure.The median follow-up was 62.73 (+/-50.9) months. Only two patients of this series died, one at 70 months from gastric cancer, and the other at 89 months from cerebral metastases. Nine patients developed surgical complications (29%). Liver function was normal in the 24 surviving patients. Only one case of loss of renal graft was observed at 12 years and this patient is currently on dialysis. The mean creatinine level in these patients (apart from the dialysed patient) at the last follow-up visit was 120.3 (+/-30.43)micromol/l.Combined liver-kidney transplantation can be performed with acceptable morbidity and mortality and excellent long-term results.

To evaluate the morbidity of partial nephrectomy (PN) according to tumour size and the type of indication based on a multicentre retrospective study.Seven French teaching hospitals participated in this study. Data concerning tumour size, indication for PN (elective or necessity), age, gender, TNM stage, histological type, Fuhrman grade, ASA score and performance status (ECOG) were analysed. Medical and surgical complications, intraoperative blood loss, blood transfusion rate and length of hospital stay were also studied. Statistical analysis of qualitative and quantitative variables was performed with Chi-square test (Fisher's test) and Student t-test.Six hundred and ninety one patients were included. The median tumour diameter was 3cm (0.4-18). Tumours measuring less or equal to 4cm and incidental tumours represented 77.7 and 80.7% of cases, respectively. Clear cell carcinomas represented 75.1% of malignant tumours. Some 89.1% of tumours were T1, 1.6% were N+ and 2.3% were M+. In the 486 elective indications: the operating time (p = 0.03), mean blood loss (p = 0.04), and urinary fistula rate (p = 0.01) were significantly higher in tumours greater than 4cm. These differences were not associated with an increase in the medical (p = 0.7) or surgical complication rate (p = 0.2), or the length of hospital stay (p = 0.4).Broader indications for elective PN is associated with an increased morbidity but which remains acceptable. This is an important point for patient information and to guide the choice of surgical strategy, particularly in elderly, frail patients or patients with major comorbidities.

Rupture of posterior urethra is usually seen in major traumas with associated pelvic fractures. Clinical presentation classically associates blood at the uretral meatus and urinary retention. Urinary diversion should be achieved by suprapubic puncture and major associated traumatic injuries (abdominal, orthopaedic, and neurological lesions) must be treated prior to urological management. Retrograde uretrocystography is performed a few days later in order to localize and classify the urethral lesion. Treatment of posterior urethral ruptures has evolved over the years. Immediate open repair is no longer recommended. The supra-pubic catheter can be left in place until resorption of the pelvic hematoma. Obliteration occurs in 100% of the cases and is treated by open surgery at 3 months. More and more patients are treated by early endoscopic realignment which has diminished by half the incidence of urethral strictures. Impotence and incontinence secondary to trauma or surgery occur in 20% and 10% of the patients respectively. Long term follow-up should be achieved in every patient.

T1G3 tumours are the most aggressive superficial tumours of the bladder, with a high risk of recurrence and progression. Complete endoscopic resection of the tumour is the first diagnostic and therapeutic step in T1G3 management. A second resection should be done at 1 month to avoid residual tumour and misdiagnosis of a muscle infiltrative cancer. As a result of treatment by instillations of Calmette and Guérin bacillus following endoscopic resection, a 5-year survival rate of 80% has been reported, with 50 to 60% of bladder preservation. BCG is the only conservative treatment that has proven effectiveness on both tumour recurrence and progression. Long term protocols seem to give the best results. Endovesical chemotherapy is not commonly used as its impact on progression has not been demonstrated. Radical cystectomy can be chosen as first line treatment in patients with particularly aggressive tumours. Long term and close surveillance should be achieved in every patient.

Traumatic injuries of the urethra are uncommon. Most Lesions of the anterior (bulbar urethra) are straddle injuries and are initially dealt with by a suprapubic catheter with delayed treatment when urethral stenosis does ensue. Traumatic disruption of the posterior urethra is in most cases related to a pelvic fracture and is often associated with multiple life-threatening injuries, which receive priority treatment. Management of posterior urethral disruption remains a highly controversial issue: alternative treatments include early endoscopic realignment, early open surgical repair and suprapubic catheter and delayed open surgical repair. Management of urethral injuries is described and the different operative techniques are detailed.

Hospital acquired infections represent a medical priority for surgeons as well as anesthetists and nursing staff. ANAES charged with national hospital accreditation program establishes protocols and objectives to be attained in terms of quality of care and patient satisfaction. According to available pilot studies, prevention of hospital acquired infections relies on surgical environment, preoperative patient preparation, sterilisation techniques, antibiotic prophylaxis and catheter care. Great improvements are under way in this domain and in management of multiresistant bacterial infections with a decrease in multiresistant kelbsiella infections. Our optimism is however tempered by the increase in methicillino-resistant Staphylococcus aureus (MRSA) infections. Many questions on nosocomial infections are still unanswered due to insufficient scientific evidence and difficulty in organising rigorous studies. Further progress will require a full involvement of hospital administrations and funding health organisations to provide the financial support required to implement preventive procedures and related architectural modifications.

To study the incidence, clinical presentation, pathological prognostic factors and disease outcome of RCC in young adults less than 40-years-old.The notes of 400 patients treated by radical nephrectomy for RCC suspicion, between January 1984 and december 1999 were reviewed. Twenty-nine patients (7.25%) were under 40.The most common histological cell type was clear cell carcinoma, found in 20 patients (69%). At a median follow-up of 80 months, 20 patients (69%) were disease free and 9 (31%) died of the disease. When comparing patients less than 40 years vs older than 40 years, we found significant differences in histology type (clear cell carcinoma 69% vs 91%; P = 0.0001), and tumor stage at presentation (pT2 = 34.5% vs 17.3%; P = 0.04) (pT3 = 20.7% vs. 42%; P = 0.03). Disease free survival was not significantly different between the 2 groups (69% vs 65.7%; Log rank test P = 0.4).Although rare, RCC in young adults seems to follow a course similar to the disease seen in older patients. Stage at presentation was different between the 2 populations however survival was not affected by age.