Search

Context Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. Objective To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. Evidence acquisition An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. Evidence synthesis The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. Conclusions Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. Patient summary Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist’s experience, are critical to the safety and effectiveness of PCNL.

Introduction Urethro-vesical anastomosis stenosis following radical prostatectomy is a rare complication but represents a challenging situation. While the first-line treatment is endoscopic, recurrences after urethrotomies require a radical approach. We present the updated results of our patient's cohort treated by pure robotic anastomosis refection. Material and methods This is a retrospective, single-center study focusing on one surgeon's experience. Patients presented an urethro-vesical stricture following a radical prostatectomy. Each patient received at least one endoscopic treatment. The procedure consisted of a circumferential resection of the stenosis, followed by a re-anastomosis with well-vascularized tissue. We reviewed the outcomes in terms of symptomatic recurrences and continence after the reconstructive surgery. Results From April 2013 to May 2020, 8 patients underwent this procedure. Half of the patients had previously been treated with salvage radio-hormonotherapy. The median age was 70 years (64-76). The mean operative time was 109minutes (60-180) and blood loss was 120cc (50-250). One patient had an early postoperative complication, with vesico-pubic fistula. The average length of stay was 4.6 days (3-8). Mean follow-up was 24.25 months (1-66). Half of the patients experienced a recurrence at a median time of 8.25 months (6-11) after surgery. Five patients experienced incontinence of which 3 required an artificial urinary sphincter implantation. Conclusion Extra-peritoneal robot-assisted urethro-vesical reconstruction is feasible and safe to manage bladder neck stricture after radical prostatectomy. The risk of postoperative incontinence is high, justifying preoperative information. Level of evidence III.

To compare different extractions routes for robot-assisted living donor nephrectomy in terms of post-operative pain and renal function recovery. Live donor kidney transplantation data from our institution were reviewed from November 2011 to March 2017. Postoperative pain was estimated using cumulative painkillers consumption. Variables were compared between the 3 groups with ANOVA for continuous data, χ2 test for categorial data. A survival analysis with Kaplan–Meier curve assessing time to transplant recipient nadir was performed to compare the renal function recovery. Sixty-three RLDN were performed (23 iliac, 23 vaginal and 17 umbilical extractions). There was no significant difference between the three groups in terms of operative time, blood lost, warm ischemia time, cumulative painkiller consumption and renal function recovery time. Postoperative complications for Umbilical, Vaginal and Iliac were, respectively, of 0, 3 and 1. No major difference was found between the 3 groups beside a slightly longer hospital stay in the iliac group. Iliac incision might impact post-operative pain with a moderate but significant longer hospital stay. Vaginal extraction is an option when cosmetic outcomes present a real demand. The three options appeared to be safe and should be discussed with the patient in regard of the surgeon experience.

Objectives To evaluate the risk of contracting severe COVID‐19, defined as COVID‐19 specific intensive care unit (ICU) admission or death, for patients undergoing urological surgery during the epidemic. To define consequences of receiving surgery for COVID‐19 patients. Patients and Methods This is a multicenter observational cohort study. Every patient receiving a urological procedure in Paris academic urological centers during the 4 initial weeks of surgical restrictions were included. Their status was updated minimum 3 weeks after the procedure. The main outcomes were the COVID‐19 specific ICU admission and death. Statistics were mostly descriptive. The Post‐operative COVID‐19 confirmed group was compared with non‐COVID patients using Chi‐square tests for categorical and Wilcoxon test tests for continuous variables. Results During the 4‐week period, 552 patients received surgery within 8 centers. At follow‐up, 57 (10%) patients were lost. Among the 11 preoperative COVID‐19 cases, one remained in ICU, no new admission, and no death. For the non‐COVID patients, 57 (12%) developed COVID‐related symptoms; only one case (0.2%) required COVID‐19 specific ICU and 3 (0.6%) patients died of COVID‐19 after surgery. Conclusions Performing urological surgery during the COVID‐19 epidemic peak has a limited impact on ICU admissions but presents a real (0.6%) risk of specific mortality. Surgical activities should be maintained according to this risk.

Introduction Kidney transplantation is championed as the gold standard treatment for patients with end-stage kidney disease. According to the biomedical agency, there is an increasing number of patients waiting for kidney transplantation. Faced with organ shortage, the use of marginal grafts may well increase the number of available kidney grafts. Occasionally, during dual kidney graft transplantation, the poor quality of one of the two grafts, or other specific circumstances, may lead to transplantation of only one of the two grafts. We have compared patient outcome concerning single kidney transplantation from an initial dual kidney graft with respect to dual kidney graft transplantation. Material Among 67 patients enrolled for a dual kidney graft, 39 dual kidney grafts (group 1) were compared with 12 grafts performed with only one of the two kidneys of a dual kidney graft (group 2) as well as 15 grafts performed following a classic kidney graft protocol (group 3). Results The survival of grafts was respectively for groups 1, 2 and 3 of 100%, 72,5% and 75,4% (P=0.17). The survival of patients was respectively for groups 1, 2 and 3 of 78.3%, 89.9% and 87.8% (P=0.47). Conclusion Our study suggests that transplantation of a single kidney, initially proposed as dual kidney graft candidate, has satisfying results in terms of graft survival and patient mortality at the expense of poorer renal function in comparison to dual kidney graft. Indeed, there was no significant difference in the survival of patients and grafts. This seems promising taking into consideration that the aim of transplantation in elderly recipients is primarily to avoid dialysis, rather than having optimal post-transplantation kidney function. Level of evidence 4.

Resumen Confrontés à une crise d’une ampleur exceptionnelle liée à la pandémie à coronavirus COVID-19 responsable d’une saturation selon les régions des urgences et des places en réanimation, le Comité Lithiase de l’Association Française d’Urologie (CLAFU) a élaboré pour la première fois les recommandations de prise en charge des calculs urinaires durant cette crise sanitaire.Recommendations of the Urolithiasis Committee of the French Urology Association for the management and the treatment of the stone formers patients during the COVID-19 pandemic crisis.

Classical percutaneous nephrolithotomy consists of several steps executed in a sequence beginning in the lithotomy position followed by a second one in the prone position. For many years, this represented the standard technique. A number of limitations like patient obesity and the necessity of puncturing the upper pole led to several modifications. The lateral position and Bart’s position were recommended for obese patients. Prone flexed position shifts the kidney downward, facilitating access to the upper pole. With the advent of miniaturized flexible instruments, simultaneous antegrade and retrograde access to the kidney became possible. Split leg prone position was proposed for such a dual access. But the main change of paradigm was the arrival of the supine Valdivia position with its variants, especially the Galdakao-modified supine Valdivia position. The latter is a modification of the lithotomy position with the patient slightly tilted toward the site opposite to the stone and the ipsilateral arm crossing the chest.

Resume Objectif La pose d’une nephrostomie est l’un des gestes elementaires en urologie. Souvent realise dans le cadre de l’urgence pour une indication vitale, ce geste doit etre maitrise par tout urologue. Au cours des dernieres annees, cette technique a evolue. L’objectif de cet article didactique est de fournir des details utiles pour sa realisation, a travers l’experience de notre equipe chirurgicale. Materiel et methodes Le patient est installe en position de Valdivia, en decubitus dorsal. La region lombaire est surelevee de 20° du cote a operer a l’aide d’un coussin gonflable (Pelvic Tilt®). La ponction se fait sous double reperage par echographie et amplificateur d’image. Nous utilisons le kit Kolibri®, qui comporte une aiguille de ponction type Chiba de 18 gauge, un guide teflonne de 70 cm et une nephrostomie equipee d’un mandrin metallique creux. La ponction se fait le plus souvent par le calice inferieur posterieur, mais dans certains cas particuliers par le calice moyen ou superieur. Resultats La position en decubitus dorsal simplifie et securise la pose de la nephrostomie. Des precisions techniques et des astuces sont detaillees. Conclusions L’apprentissage de la pose d’une nephrostomie est fondamental pour les futurs urologues. En dehors de son utilite pour prendre en charge les patients dans le cadre de l’urgence, la nephrostomie est une etape incontournable pour ceux qui veulent se former a la chirurgie percutanee.

Percutaneous nephrolithotomy (PCNL) is considered to be the first line of treatment for large renal stones. Though PCNL comes with higher morbidity, its efficacy is unbeaten by other minimally invasive modalities. However, potential complications, such as bleeding, occur. Improved skills and modifications of the procedure may reduce the probability of adverse outcomes. This article discusses the current trends and standards in PCNL technique with special focus on all important steps as positioning, access, instruments, dilation, disintegration, and exit, including outcomes, complication management, and training modalities.

Green tea is widely used as a &lsquo, &rsquo, healthy&rsquo, beverage due to its high level of antioxidant polyphenol compounds. However tea is also known to contain significant amount of oxalate. The objective was to determine, in a cross-sectional observational study among a population of 273 hypercalciuric stone-formers referred to our center for metabolic evaluation, whether daily green tea drinkers (n = 41) experienced increased stone risk factors (especially for oxalate) compared to non-drinkers. Stone risk factors and stone composition were analyzed according to green tea status and sex. In 24-h urine collection, the comparison between green tea drinkers and non-drinkers showed no difference for stone risk factors such as urine oxalate, calcium, urate, citrate, and pH. In females, the prevalence of calcium oxalate dihydrate (COD) and calcium phosphate stones, assessed by infrared analysis (IRS) was similar between green tea drinkers and non-drinkers, whereas prevalence of calcium oxalate monohydrate (COM) stones was strikingly decreased in green tea drinkers (0% vs. 42%, p = 0.04), with data in accordance with a decreased oxalate supersaturation index. In males, stone composition and supersaturation indexes were similar between the two groups. Our data show no evidence for increased stone risk factors or oxalate-dependent stones in daily green tea drinkers.

Objectifs L’alteration de la qualite de vie est la plainte principale des patients presentant une lithiase urinaire. Plusieurs etudes ont compare URSS et NLPC pour le taux de stone free, les complications, les durees operatoires et d’hospitalisaton, etc. Mais aucune ne compare la qualite de vie (QDV) postoperatoire pour des calculs de taille importante. Nous avons donc cherche a evaluer la faisabilite d’une telle etude au niveau national. Methodes Il s’agissait d’une etude prospective, nationale, realisee en partenariat avec le comite lithiase de l’AFU. Les patients devaient presenter un calcul de plus de 15 mm et parler francais. Un questionnaire de QDV multidimensionnel (symptomes urinaires, douleur, etat general, exercice professionnel, sexualite, plus le score etait eleve plus la QDV etait alteree) valide (l’USS-q) etait distribue en preoperatoire, apres recueil du consentement et etait envoye par courrier, ou courriel, ou realise au telephone a j7, m1, m3 et la difference entre le score preoperatoire et chaque temps postoperatoire etait calculee. Etaient aussi analysees la difference d’echelle numerique (en), le taux de reintervention et le nombre de jours d’arret de travail. Resultats Du 01/12/17 au 16/04/18, 19 NLPC et 25 URSS ont ete incluses dans l’etude dans 8 centres differents. La taille moyenne des calculs etait de 25 mm pour les nlpc et 20,5 mm pour les URSS. Les taux de reponses etaient respectivement de 100 %, 88 % et 100 % a j7, m1, m3 (NLPC) versus 70 %, 72 % et 74 % (URSS). Le taux de reintervention etait de 36 versus 44 %. La duree moyenne d’arret de travail etait de 32 jours versus 29,5 jours La difference de score total etait respectivement de −8,06, 1,5 et 6,72 a j7, m1 et m3 (NLPC) versus 1,94, 4,36 et 28,1 (URSS). La difference de score d’en etait de 0,58, 1,29 et 1,38 (NLPC) versus 0,51, 0,57 et 2,9 (URSS) ( Figure 1 , Figure 2 , Figure 3 ). Conclusion Cette evaluation montre que l’etude est donc faisable a une echelle nationale avec un taux de reponse acceptable. La puissance de l’etude avec un nombre faible de patients n’est pas suffisante car les scores sont eleves (total sur 180). A ce stade, les resultats montrent une amelioration de la qualite de vie significativement superieure au 3e mois pour les URSS.

Objective To evaluate the impact of radical prostatectomy on lower urinary tract symptoms by using the International Prostate Symptom Score and International Prostate Symptom Score quality of life. Methods The present prospective study comprised 804 patients having localized prostate cancer who underwent radical prostatectomy. International Prostate Symptom Score and International Prostate Symptom Score quality of life were recorded preoperatively, and at 1, 3, 6, 12 and 24 months. Two study groups were considered: group 1 included patients with International Prostate Symptom Score ≤7 (mild) and group 2 included patients with International Prostate Symptom Score ≥8 (moderate to severe). Student's t-test and logistic regression were carried out to detect a predictive factor of International Prostate Symptom Score ≤7 at 24 months. Results The mean International Prostate Symptom Score was 5.58 ± 6.6, 11.12 ± 7.1 and 7.62 ± 6 at baseline, 1 month and 3 months, respectively (P

Introduction Retrograde ureteroscopy (URS) has become a common procedure for the management of urinary stones. Although its efficacy and safety are well known, the literature about major complications is still poor. This study highlighted some cases of life-threatening complications after semi-rigid ureteroscopy (s-URS) or flexible ureteroscopy (f-URS). Evidence acquisition Experienced endourologists (more than 75 cases/year in the last 3 years) we enrolled, and a survey was performed asking to review their series and report the cases encumbered by major complications (Clavien-Dindo IIIb-IV grade). A literature search was also conducted in the Medline (PubMed) and Cochrane Libraries databases in July, 2016 to identify all studies reporting the presence of major complications in patients underwent URS procedures. A PubMed search was performed using the following key words in combination: "kidney injury," "ureteroscopy," "nephrectomy," "life-threatening," "urinary stones," "complications." Evidence synthesis Eleven urologists reported on 12 major complications (4 after s-URS, 8 after f-URS). Eight patients developed a kidney injury, 1 an arteriovenous fistula, 2 a ureter avulsion and 1 acute sepsis. Six patients underwent open nephrectomy, two surgical repair, one open pyeloplasty, one coil artery embolization and two superselective artery embolization. Conclusions Guidelines and clinical practice give useful recommendations about intraoperative safety and prevention of life-threatening events. The careful postoperative observation and the surgical active treatment of this complications play a key role in reducing morbidity, kidney loss and mortality. This study encourages a strict and active care of patients, supports a routine reporting of complications, and highlights the need for systematic use of standardized classification systems.

Resume Depuis la publication des dernieres recommandations de l’AFU sur la prise en charge des calculs renaux, les pratiques ont beaucoup evolue. Ce texte fait le point sur les mises a jour des traitements des calculs renaux. Ce sont surtout les avancees spectaculaires dans le domaine de l’ureterorenoscopie souple-laser qui ont modifie les pratiques. La nephrolithotomie percutanee s’est enrichie d’artifices techniques et la lithotritie extracorporelle a confirme sa place predominante en premiere intention. Pour les calculs de moins de 20 mm, la lithotritie extracorporelle est le standard avec dans certains cas la possibilite de recommander une ureteroscopie souple en premiere intention (calculs durs, multiples, troubles de la coagulation associes, anomalies anatomiques ou souhait du patient). Pour les calculs de plus de 20 mm, la nephrolithotomie percutanee est le traitement standard seule ou en association, mais en option l’ureteroscopie souple et la lithotritie extracorporelle sont possibles. Les calculs residuels de moins de 5 mm et asymptomatiques justifient d’une simple surveillance radiologique reguliere. La chirurgie ouverte pour calcul devient exceptionnelle, la cœlioscopie conserve un interet en cas d’anomalie associee (syndrome de jonction, diverticule, anomalie anatomique). Le traitement effectue, il faut recueillir les fragments de calculs pour une analyse morpho-constitutionnelle et realiser un bilan metabolique, faire une enquete etiologique et donner des conseils dietetiques afin de prevenir la recidive.

To study the prognostic value of extent, number, and location of positive surgical margins (PSM). A total of 1,504 consecutive adjuvant treatment naive and node-negative radical prostatectomy men were included in a prospective database including extent, number, and location of PSM. Mean follow-up was 33 months. Endpoint was biochemical progression-free (bPFS) survival. The impact of margin status and characteristics was assessed in time-dependent analyses using Cox regression and Kaplan–Meier methods. PSM was reported in 26.7 % of patients. The predominant PSM locations were apex and posterior locations. Median PSM length was 4.0 mm. The 2-year bPFS was 73.7 % in PSM patients as compared to 93.0 % in NSM patients (p

Resume L’objectif de cette mise au point du CLAFU est de servir de guide pratique lors de la prise en charge medicale en premiere intention des patients lithiasiques. L’analyse du calcul renal est un element essentiel pour le diagnostic etiologique de la maladie lithiasique. Il est complete par l’analyse des facteurs de risque de lithiase obtenus a partir d’un recueil des urines de 24 heures. Cet examen permet en effet une evaluation precise des apports quotidiens en eau, sodium et proteines, outils pedagogiques utiles pour expliquer au patient les differentes erreurs dietetiques en insistant tout particulierement sur un volume de diurese superieur a 2000 mL/j, une alimentation equilibree normalisee en calcium (800 mg a 1 g/j), en sel (

Laser fibers are characterized by their ability to fragment even the harder stones and also by their flexibility which allows them to reach each part of the urinary tract. Accordingly, they are presently routinely applied in different endourologic procedures: retrograde intrarenal surgery, percutaneous nephrolithotomy, ureteroscopy and bladder stones.

Objective To demonstrate the feasibility of robot-assisted vesicourethral reconstruction. Vesicourethral anastomotic stricture following radical prostatectomy is a real challenge for reconstructive surgery when facing several endoscopic management failures. Material and Methods This is a case series of robot-assisted vesicourethral reconstruction for anastomotic stricture failing endoscopic management. The procedure was performed with an extraperitoneal approach. The fibrotic anastomotic region was resected and a new vesicourethral running suture was performed with well-vascularized tissue. Bladder catheter was removed after 7 days. Results Six procedures were performed from April 2013 to May 2018 at our department. One patient had a robot-assisted radical prostatectomy at our department; the 5 others were referred from other institutions after receiving open prostatectomies. Three patients had salvage radiation therapy before reconstruction. Mean age was of 73.8 years (68-82). There was no peroperative complication. Mean operative time was of 108 minutes (60-180)], with a mean estimated blood loss of 130 mL (50-300). After surgery, 3 patients presented recurrences managed endoscopically without recurrence after 3, 5, and 11 months. Three patients presented incontinence treated with artificial sphincter implantation. One patient had no residual symptom after 5 years of follow-up. Conclusions Robot-assisted vesicourethral reconstruction is a safe procedure. It is an option to consider when facing recurring anastomotic stricture following radical prostatectomy. It is an alternative to the perineal approach and an option before urinary diversion. Patients should be informed of the risks of incontinence and recurrence before surgery especially if they had radiation therapy.

The Lithiasis Committee of the French Association of Urology (CLAFU) aimed to update the current knowledge about urolithiasis. This update will be divided into four parts: 1) general considerations; 2) the management of ureteral stones; 3) the management of kidney stones; 4) metabolic assessment and medical treatment of urolithiasis. Recent technicals advances helped the urologists to improve stones management: new extracorporeal shockwave lithotripsy (ESWL) devices, new flexible ureterorenoscopes, development of laser fragmentation. ESWL, semi-rigid and flexible ureteroscopy and the percutaneous nephrolithotomy (PCNL) remain currently the main therapeutic options. The first part of this update deals with the description and classification of stones, preoperative assessment, post-operative management and clinical follow-up. Main criteria of therapeutic choices are stone location, stone composition and stone size. Stone composition is assessed with infrared spectrophotometry analysis and its hardness is correlated with U.H. density on CT scan assessment. Preoperative assessment consists in urinary cytobacteriological examine, urinary PH, blood creatininemia, hemostasis. Low-dose CT scan is recommended before urological treatment. The result of the treatment must be done 1 or 3 months later with plain abdominal film and ultrasonography. Medical management of urolithiasis will be based on stone composition, metabolic and nutritional evaluation. Treatment success is definited by absence of residual fragments. Annual follow-up is recommended and based either on plain abdominal film and ultrasonography or low-dose CT scan.

Objectifs Evaluation et mise au point vis-a-vis de l’impact economique des differents procedes d’extraction de sondes double j sous anesthesie locale actuellement disponibles. Methodes Evaluation economique basee sur la collecte des prix catalogue non negocies des dispositifs magnetic blackstar (mbs) (aseptinmed/urotech) et isiris (coloplast), les cotations ccam et se1 ( www.ameli.fr ). Une comparaison a ete effectuee avec les resultats publies (progres en urologie 2017) de la technique classique a l’aide d’un fibroscope resterilisable sous anesthesie locale en externe sans hospitalisation, et renforcee par des donnees retrospectives d’echec d’extraction avec ces nouveaux dispositifs, source potentielle de majoration du cout par le recours complementaire a la technique classique. Resultats L’acte ccam jcge004 (48 €) en externe donnait acces au forfait se1 (73,71 € prive, 75,89 € public). L’extraction en consultation (cs) ne donnait acces qu’au tarif cs (23 €) ou cs + mpc + mcs (30 €) selon l’adhesion a l’optam. Prix catalogue non negocies : isiris 350 €ht, mbs jj + extracteur 92 € ht. Couts : – extraction classique 51,336 € ttc en 2016 ; – mbs : cotation cs induisant une reduction de remuneration des praticiens 18–25 € et des etablissements 22,374 € prive et 24,554 € public. Surcout materiel 77,9 € ttc. Part des consommables 2,25 € ttc. Economie pour l’assurance maladie (am) 91,71–98,71 € ; – isiris : cotations endoscopiques jcge004 et se1. Couts : consommables (3,63 € ttc), materiel (420 € ttc). Deficit de 349,92 € ttc prive et 347,74 € ttc public, sans economie pour l’am ; – cout des dechets majore pour mbs et isiris. Echecs d’extraction : – mbs : uniquement chez les hommes dans 7,7 %, soit 4,65 % tous sexes confondus ; – isiris : 2,98 % d’echecs tous sexes confondus. Conclusion L’utilisation des nouveaux dispositifs induit un surcout pour les etablissements, mais avec cependant : une disparition du risque de transmission virale, une planification plus aisee et une augmentation de la duree de vie des endoscopes resterilisables non quantifiable. Seules les mbs apportent une economie a l’am. Resultats a moduler aux contrats et fonctionnements des differentes structures.

Objectifs La chirurgie mini-invasive s’est imposee pour la nephrectomie pour donneur vivant : elle peut etre effectuee par voie laparoscopique robot-assiste (NRDV). Plusieurs voies d’extraction du greffon ont ete decrites. Si classiquement, elle s’effectue par voie iliaque, pour ameliorer encore les suites, d’autres voies (vaginales, ombilicales) ont ete decrites. Le but de cette etude est de comparer les resultats de l’extraction iliaque, ombilicale et vaginale du rein dans les NRDV. Methodes Entre 2011 et 2017, 63 NRDV ont ete effectuees consecutivement : 23 avec extraction iliaque (EI), 23 avec extraction vaginale (EV) et 17 avec extraction ombilicale (EO). Pour chaque patient, ont ete releves l’âge, le sexe, l’indice de masse corporelle (IMC), le temps d’ischemie chaude (TIC), les pertes sanguine (PS), la duree operatoire (DO), les complications per et postoperatoires, la duree d’hospitalisation (DH) et la douleur postoperatoire evaluee en fonction de la quantite de tramadol et paracetamol donnes selon l’eva de douleur. Les tests statistiques de Student et de Chi2 ont ete effectues a l’aide de Statview®, la difference etant significative, si p Resultats L’âge moyen des donneurs (25 hommes/38 femmes) etait de 47 ans et l’IMC de 25,1. Neuf patients avaient 2 arteres et 2 avaient 2 veines. Respectivement pour l’EI, l’EV et l’EO, la do etait de 133,6, 137,8 et 122 minutes, le saignement de 73,9, 85,9 et 129,5 mL, le tic de 5,2, 6,1 et 4,2 minutes (p > 0,05), le nombre de complications peroperatoires etait de 2, 2 et un, le nombre de doses de tramadol etait 2,6, 2,3 et 1,7, celui de paracetamol de 6, 5,5 et 4,7, la DH etait de 5,65, 4,73 et 4,7 jours (p On note une reprise immediate de la fonction renale chez tous les transplantes. Conclusion Quel que soit la voie d’extraction, la chirurgie mini-invasive robot-assistee permet d’obtenir un greffon de bonne qualite tout en offrant des suites operatoires simplifiees pour le donneur. Les doses d’antalgiques paraissent plus importantes avec la voie iliaque et la duree d’hospitalisation est plus courte avec les extractions vaginales et ombilicales qu’avec la voie iliaque.

Objectives To evaluate the incidence, and clinical and bacterial features of iatrogenic prostatitis within 1 month after transrectal ultrasound-guided biopsy for detection of prostate cancer. Methods From January 2006 to December 2009, 3000 patients underwent a 21-core transrectal ultrasound-guided prostate biopsy at Henri Mondor Hospital (Creteil, France) and were prospectively followed. All patients had a fluoroquinolone antimicrobial prophylaxis for 7 days. The primary study end-point was to evaluate the incidence of iatrogenic acute prostatitis within 1 month after the biopsy. The secondary end-point was to analyze the clinical and the bacterial features of the prostatitis. Results Overall, 20 patients of the entire study population (0.67%) had an acute bacterial prostatitis within 2.90 ± 1.77 days (range 1–7 days) after the transrectal ultrasound-guided biopsy. The groups of patients with (n = 20) and without (n = 2980) infection were similar in terms of age, prostate-specific antigen level and prostate volume. Escherichia coli was the only isolated bacteria. The subsequent tests for antibiotic susceptibility showed a 95% resistance for fluroquinolone and amoxicillin. Resistance to amoxiclav, trimethoprim-sulfamethoxazole, third generation cephalosporin and amikacin was 70%, 70%, 25% and 5% respectively. No resistance to imipenem was reported. They were all admitted for treatment without the need of intensive care unit referral. Complete recovery was achieved after 21.4 ± 7 days of antibiotic treatment. Conclusions A fluroquinolone-based regimen still represents an appropriate prophylaxis protocol to minimize the risk of acute prostatitis secondary to prostate biopsy. Patients should be provided the appropriate care soon after the onset of the symptoms. An intravenous third generation cephalosporin or imipenem-based therapy seem to provide satisfying results.

Objectives To establish the rate of higher risk criteria in various definitions of an active surveillance population. Patients and Methods Over a period of 10 years, 1161 patients were diagnosed with prostate cancer and underwent radical prostatectomy at our institution. Statistical analysis was performed comparing the rates of upgrading, extracapsular extension, seminal vesical involvment and unfavourable disease (Gleason score upgrading >6 and/or T3 disease) for six groups of patients eligible for the University of Toronto, Royal Marsden, John Hopkins, University of California San Francisco, Memorial Sloan Kettering Cancer Center and Prospective Randomized International Active Surveillance. Results Active surveillance protocols including patients with biopsy Gleason score 3+4 (Royal Marsden) had significantly higher rates of extracapsular extension (P = 0.009), upgrading to pathological Gleason >3+4 (P = 0.004) and unfavourable disease (P = 0.001) compared to the most stringent John Hopkins criteria. Unfavourable disease was found in more than 40% of patients in all series with no significant difference between the Gleason 6 protocols. Biochemical recurrence-free survival at 5 and 10 years was 76.7% and 63.3% for the entire cohort. Positive margins (P < 0.001), pT3 tumours (P = 0.006) and unfavourable disease (P < 0.001) were significant predictors of biochemical recurrence. Conclusions Active surveillance in patients with Gleason 3+4 presents a risk of missing unfavourable disease and should be limited to older patients with comorbidities. The differences in inclusion criteria between Gleason 6 protocols did not have a significant impact on the pathological results.

Resume Objectif L’apex est une region particuliere de la prostate dans sa dissection chirurgicale et son analyse anatomopathologique. Nous avons voulu etudier la valeur pronostique de la localisation apicale des tumeurs de prostate. Methode De 1988 a 2010, les donnees pre- (âge, stade clinique, taux de PSA preoperatoires, score de Gleason des biopsies) et postoperatoires (poids de la prostate, stade pathologique TNM 2010, score de Gleason, statut des marges) de 2765 prostatectomies totales ont ete collectees prospectivement. Ces donnees ont ete comparees selon l’existence ou l’absence de tumeur a l’apex. L’impact pronostic des tumeurs a l’apex sur la survie sans recidive biologique (PSA > 0,2 ng/mL) a ete etudie dans des modeles uni- et multivaries. Resultats Mille huit cent dix-sept tumeurs avaient une localisation a l’apex (65,7 %). En analyse univariee, il y avait une difference significative pour le stade clinique, le score de Gleason biopsique et pathologique, le resultat du curage, le stade pathologique et le statut des marges entre les tumeurs de l’apex et les autres. Avec un recul median de 23,9 mois, 502 patients ont eu une recidive biologique (18,1 %). La survie sans recidive a dix ans etait de 60,7 % en cas de tumeur a l’apex versus 65,9 % dans les autres cas. La localisation a l’apex etait significativement associee a la recidive biologique en analyse univariee ( p = 0,01). Apres ajustement sur le stade clinique et pathologique, le taux de PSA, le score de Gleason et les marges chirurgicales, l’apex n’etait plus un facteur predictif pejoratif independant ( p = 0,0087). Conclusion L’existence de tumeur a l’apex prostatique etait associee a des criteres tumoraux plus agressifs et etait un facteur predictif pejoratif independant sur la survie sans recidive biologique a dix ans en analyse univariee. La localisation apicale pourrait etre un argument supplementaire dans la decision de traitement adjuvant apres prostatectomie.

Resume L’ureterorenoscopie souple couplee a la photovaporisation LASER (URSS-L) pour le traitement des calculs du rein est un outil moderne dont la place est en cours d’evaluation. Methodes Sa place en premiere intention a ete etudiee en France en 2010 au sein du Comite lithiase de l’association francaise d’urologie (CLAFU). Une enquete de pratique aupres de 27 experts a concerne les criteres decisionnels suivants : facteurs de comorbidite du patient, nature supposee du calcul, anatomie de l’appareil urinaire du patient. Cette enquete a ete proposee pour un calcul de taille inferieure ou egale a 20 mm, pour un calcul de taille superieure a 20 mm et pour les calculs multiples du rein. Resultats Quatorze experts ont repondu. Les criteres retenus en faveur de l’URSS-L en premiere intention etaient : l’obesite morbide (IMC > 30), un traitement anticoagulant ou antiagregant plaquettaire, les calculs durs (UH > 1000, calculs de cystine), les calculs intradiverticulaires, les calculs caliciels inferieurs, l’echec d’un premier traitement, ou le souhait du patient. Conclusion Selon les experts interroges l’URS-SL etait un traitement de premiere intention valide quelle que soit la taille du calcul et le nombre de calculs du rein, dans les cas ou la LEC et la NLPC etaient contre-indiques ou lorsque leurs resultats previsibles etaient moins bons (calculs durs/obesite morbide/calcul caliciel inferieur), lorsque la localisation du calcul etait difficile d’acces (calcul intradiverticulaire). C’etait aussi le traitement de choix lors de l’echec d’un premier traitement (LEC/NLPC).

Outcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP).We included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥ 0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses.Median age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men60 years. Age60 years, PSA level10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome.Two years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men.

Patients with localized prostate cancer (PCa) who are treated by radical prostatectomy (RP) have a good overall survival rate. Their quality of life, however, can deteriorate because of the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single-knot running suture also known as the Van Velthoven technique (VVT).From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal, or robot-assisted RP for localized PCa. A single-knot running suture according to the VVT was performed for the vesicourethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. BNC was defined by a reduction of the lumen that does not allow the passage of an 18F fibroscope.Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241, and 532 had extraperitoneal, transperitoneal, and robot-assisted prostatectomy, respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% had the diagnosis within the first year of follow-up. Previous transurethral resection of the prostate (TURP) and external beam radiotherapy were independent risk factors of BNC.BNC incidence after MIRP using the single-knot running suture for the vesicourethral anastomosis is low. Previous TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classic laparoscopic or robot-assisted approach.

What's known on the subject? and What does the study add? Several criteria have been described to select patients with prostate cancer in active surveillance (AS) protocols; however, the risk of missing unfavourable disease remains. We report the risk of misclassification using the Prostate Cancer Research International: Active Surveillance (PRIAS) study in an analysis of pathological results after radical prostatectomy. We also define predictors of favourable disease that can be used to better select patients eligible for AS, as well as risk factors associated with disease progression. Objective To identify the risk of failure of active surveillance (AS) in men who had the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria and had undergone radical prostatectomy (RP), by studying as primary endpoints the risk of unfavourable disease in RP specimens (stage >T2 and/or Gleason score >6) and of biochemical progression after RP. Patients and Methods We assessed 626 patients who had the PRIAS criteria for AS defined as T1c/T2, PSA level of ≤10 ng/mL, PSA density (PSAD) of T2) in 129 patients (20.6%), upgrading (Gleason score >6) in 281 (44.9%) and unfavourable disease in 312 patients (50%). There was a statistically non-significant trend for BFS at P = 0.06. Predictors of favourable tumours were age 12 (P = 0.005). Preoperative factors predicting disease progression were a PSAD of >0.15 ng/mL2 (P = 0.008) and biopsy core number of ≤12 (P = 0.017). Conclusions Even with stringent AS criteria, the rate of unfavourable disease remains high. Predictive factors of unfavourable disease and biochemical progression should be considered when including patients in AS protocols.

At the time of castration resistance, it is recommended to realize hormonal manipulations before chemotherapy. We evaluated the impact of a switch from GnRH agonist to antagonist in patients with castration-resistant prostate cancer on PSA and testosterone levels at 3 months.Retrospectively, 17 patients from 5 different centers undergoing androgen deprivation therapy and presenting rising PSA confirmed on 3 blood samples 2 weeks apart and despite a castrate testosterone level (0.5 ng/ml) were reviewed. Antiandrogen withdrawal syndrome had been tested before the switch. Degarelix was administered as followed: 240 mg for the first injection and then 80 mg every month, subcutaneously. We evaluated the PSA and testosterone level variation 3 months after the switch. Patients who experienced a variation in PSA of less than 10% compared to the baseline or who had a more than 10% PSA decrease were defined as responders.Mean PSA level at the switch was 34.3 ± 50.3 ng/ml, with a mean testosterone level of 0.21 ± 0.13 ng/ml. Three months after the switch, mean PSA level was 59.9 ± 81.6 ng/ml (P = 0.061), with a mean testosterone level of 0.19 ± 0.08 ng/ml (P = 0.086). At 3 months, 4 patients (23%) responded to therapy. Thirteen patients (77%) experienced a rise in PSA of more than 10% compared to baseline; 41% of patients decreased their testosterone level. The limitations of this study are its retrospective nature and the limited number of patients.Switch from an agonist to an antagonist of GnRH has a limited impact on PSA at 3 months in castration-resistant prostate cancer patients.

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 1 9 0 ± 8 5 min versus 1 5 4 ± 4 7 ( 𝑃 = 0 . 0 0 1 ) and 9 . 2 ± 6 . 4 days versus 6 . 2 ± 4 . 5 days ( 𝑃 < 0 . 0 5 ), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% ( 𝑃 = 0 . 6 7 ) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% ( 𝑃 = 0 . 9 1 ) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.

Objective To describe a standardized and easily reproducible method for fluoroscopy-guided renal access during supine percutaneous nephrolithotomy (sPCNL). Patients and Methods From January 2009 to January 2010, 35 patients underwent sPCNL. In 10 patients, ultrasound-guided puncture was unsuccessful. In these patients, we completed percutaneous access with a method based on fluoroscopy. We used a simple technique, adapted to sPCNL, consisting of cephalad tilting of the C-arm during puncture of the targeted calyx. We prospectively recorded the time necessary for the puncture, the success, and the complication rate of the puncture. Results Among the 10 study patients, the mean operative time for the puncture was 50 seconds (range 35–180). The puncture was successful after 1 attempt in 7 patients and in the remaining patients after a second or a third attempt. There were no complications related to the puncture technique. Conclusions This technique is easy and reproducible for creating a fluoroscopy-guided renal access adjunctive to ultrasound during sPCNL. It may also be useful for urologists not familiar with ultrasound-guided access.

Resume Objectifs Etudier les caracteristiques anatomopathologiques des pieces de prostatectomie totale (PT) des patients inclus dans l’etude SURACAP. Methodes A partir de 2000 patients ayant eu une PT de 1998 a 2010, ont ete identifies, ceux repondant aux criteres de surveillance active, selon les criteres de SURACAP : âge inferieur a 75 ans, esperance de vie superieure a dix ans, stade clinique T1c ou T2a, PSA inferieur a 10 ng/ml, un adenocarcinome prostatique diagnostique a partir d’une serie de biopsies comprenant au moins dix carottes, avec les caracteristiques suivantes : moins de trois biopsies positives, aucune ne comprenant plus de 3 mm de cancer, un score de Gleason inferieur a 7. Parmi les patients repondant a ces criteres, ont ete retenu ceux ayant eu le diagnostic de cancer sur une deuxieme serie de biopsies (premiere serie negative) afin de se rapprocher au mieux des criteres de SURACAP qui demande une deuxieme serie de biopsie pour valider les resultats de la premiere. Chez ces patients, ont ete evalues le score de Gleason sur la piece, le stade pathologique (TNM), le statut des marges chirurgicales. Resultats Quarante-huit patients repondaient a ces criteres. L’âge moyen etait de 65,4 ans, le stade clinique etait T1c pour 95 % et T2a pour 5 % d’entre eux. Le PSA preoperatoire etait de 6,1 ng/ml. Le score de Gleason de la piece operatoire etait de 6 (3 + 3) chez 57 % des patients, de 7 (3 + 4) chez 38 % et de 8 (4 + 4) chez 5 % des patients. La sous-evaluation du score de Gleason (comparaison biopsies-piece) etait de 43 % (95 % de Gleason 7 et 5 % de Gleason 8). Le stade pathologique etait dans 81 % de pT2a-c, 17 % de pT3a et 2 % de pT3b. Le taux de marges chirurgicales positives etait de 17 %. Conclusion Il existait une sous-correlation du score de Gleason de 43 % et une maladie extraprostatique chez 19 % des patients ayant les criteres de surveillance active sur une deuxieme serie de biopsies (la premiere etant negative).

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE • To assess the mid-term (3 years of follow-up) oncological control of laparoscopic radical cystectomy (LRC) for high-grade muscle-invasive bladder cancer in a well studied male population. PATIENTS AND METHODS • We assessed 40 men with bladder cancer (mean [range] age 66.5 [50–75] years) who underwent LRC and extended pelvic lymphadenectomy at our institution between April 2004 and September 2008. • Of the 40 patients, 13 (32.5%) had a complete laparoscopic procedure (ileal conduit: seven patients; neobladder: five patients; bilateral ureterostomy: one patient) and 27 (67.5%) had an LRC procedure only (ileal conduit: 15 patients; neobladder: 12 patients). RESULTS • No major complications were observed intraoperatively. • The mean operating time was 407 min and the mean blood loss was 720 mL. Four patients (10%) required conversion to open surgery. The mean (range) hospital stay was 10.2 (7–25) days. One patient died of myocardial infarction in the postoperative period. • Pathological analysis showed organ-confined tumours (stage pT0/pT1/pT2/pT3a) in 22 patients (55%) and extravesical disease (pT3/pT4) in 18 (45%). Of the 40 patients, six (15%) had lymph node involvement. The mean (range) number of nodes removed was 19.9 (5–40). • At a mean (range) follow-up period of 36 (0–72) months, 26 patients were alive with no evidence of disease (disease-free survival rate 67%). CONCLUSION • Laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy (ORC). The 3-year oncological efficacy was comparable with that of ORC.

To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center.12 women with symptomatic urogenital prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence.Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred.RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.

We aimed to evaluate the impact of the primary Gleason pattern on biochemical recurrence-free survival (RFS) after radical prostatectomy (RP) in a single-center cohort of patients with Gleason 7 tumors.From 1998 to 2008, 2,239 consecutive patients underwent RP for a localized prostate cancer. A total of 1,248 patients with Gleason score (GS) 7 cancers were included. Follow-up was standardized for all patients and recorded into a prospective database. Median postoperative follow-up was 23.4 months. Biochemical recurrence was defined by prostate-specific antigen level0.2 ng/ml.In all, 721 patients (57.8%) had a final GS of 3 + 4 and 527 (42.2%) of 4 + 3. Patients with GS 4 + 3 had a significantly higher risk of biochemical progression than those with GS 3 + 4 (P0.001). The 3- and 5-year biochemical RFS for Gleason score 3 + 4 cancers was 84.6 and 76.4%, respectively, versus 69.9 and 61.1% in Gleason score 4 + 3 cancers. Multivariate analysis showed that the primary Gleason remained statistically predictive for PSA failure (P = 0.018). When analysis was stratified by both pathologic stage and margin status, predictive value of primary Gleason was significant in pT2R0, pT3-4R0, and pT3-4R1 cancers, whereas survival curves were not statistically different in pT2R1 cancers (P = 0.672).Primary Gleason 4 pattern is an independent predictor for PSA failure. Analysis of Gleason patterns provides clinically relevant prognostic information, which may assist in the management of patients with Gleason score 7 cancers.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE • To investigate the relationship between pretreatment testosterone levels and pathological specimen characteristics, by prospectively examining serum androgen concentrations in a well-studied cohort of patients who underwent radical prostatectomy (RP) for localized prostate cancer. PATIENTS AND METHODS • A total of 107 patients with clinically localized prostate cancer had an assay of total testosterone before laparoscopic RP at our institution. • The results were classified into two groups based on the total serum testosterone: group1, 7 and extraprostatic disease, pathological stage >pT2) in patients who underwent RP for localized prostate cancer.

The first objective of radical prostatectomy is cancer control. However, the success of RP should be also measured by the long-term morbidity outcomes and by the maintenance of quality of life. We performed a review of the literature for combined results of continence, erectile function, and cancer control after radical prostatectomy. Since 2003 and the first report of "trifecta," only 7 series have yet reported such combined results (trifecta rate range: 20%-76%). The preoperative risk (D'Amico) predicted for quality of life outcomes and biochemical recurrence is an aggregate endpoint, the trifecta.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Despite excellent surgical cancer control, up to 40% of patients will have biochemical recurrence following radical prostatectomy (RP) for localized prostate cancer. Positive surgical margins (PSM) have been clearly demonstrated to be one of the main predictive factors for biochemical failure, disease progression and cancer mortality. However, decision of further management (adjuvant or salvage therapy) in patients with PSM remains controversial, and many debatable questions arise concerning the incidence of clinical progression and the impact of systematic adjuvant treatment on the cancer specific and overall survival. Analysis of the pathological and disease recurrence outcomes of our large cohort of patients treated by RP provides evidence that PSMs are associated with a poor prognosis in terms of PSA failure and need for salvage therapy. However, such a distinction between negative or positive margin cancers seems to appear clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score ≥ 8 due to the predominant significance of these two poor prognosis factors for prediction of PSA failure. OBJECTIVE • To study the impact of positive surgical margins (PSMs) as an independent predictor of prostate-specific antigen (PSA) failure after radical prostatectomy in adjuvant treatment-naive patients. PATIENTS AND METHODS • From 2000 to 2008, 1943 men who underwent a radical prostatectomy at Henri Mondor Hospital and who did not receive neoadjuvant or adjuvant therapy were included. Follow-up was recorded into a prospective database. Mean follow-up was 68.8 months. • The biochemical recurrence-free survival (RFS), defined by a PSA > 0.2 ng/mL, and the need for salvage therapy in univariate and multivariate models, were evaluated. RESULTS • PSA failure was reported in 14.7% and PSMs were noted in 25.6%. In the overall cohort, PSM was significantly predictive for PSA failure (P < 0.001; hazard ratio, HR, 2.6), need for salvage therapy (P < 0.001; HR, 2.9) and specific deaths (P= 0.006; HR, 3.7). The 5-year RFS was 84.4% in men with negative margins compared to 57.5% in the case of PSM. • After stratification by pathological stage and Gleason score, margin status was significantly predictive for PSA failure in pT2 (P < 0.001), pT3a (P= 0.001) and/or Gleason score ≤7 cancers (P < 0.001), whereas the impact of PSM did not reach significance in pT3b (P= 0.196), pT4 (P= 0.061) and/or Gleason score ≥8 cancers (P= 0.115). CONCLUSIONS • PSMs are associated with a poor prognosis in terms of RFS and the need for salvage therapy. • Such a distinction between negative or positive margin cancers appears to be clinically less relevant in locally advanced disease with seminal vesicle or high Gleason score (≥8).

The initial management of pyelonephritis needs to look for complicating factors. Ultrasound and X-ray of the abdomen are able to rule out a urinary dilatation or a stone. The treatment is then surgical with renal drainage. Additional investigations such as a CT scan should be performed in patients with complicating factors or recurrence. In uncomplicated pyelonephritis an ambulatory treatment with 2 weeks of fluoroquinolones or cephalosporine Gr3 is sufficient. More severe cases should be admitted to a hospital and treated with initial cephalosporin Gr3 plus aminoside for 3 to 6 weeks. La premiere phase d’evaluation d’une pyelonephrite aigue (PNA) vise a rechercher des signes de gravite ou de complication. Une echographie renale et une radiographie de l’abdomen sans preparation permettent de montrer une dilatation des cavites pyelocalicielles ou un calcul obstructif ; le drainage urgent alors s’impose. En presence de signes de gravite ou de complication, un scanner remplacera l’echographie. En l’absence de signes de gravite, un traitement ambulatoire de deux semaines par fluoroquinolone ou cephalosporine de troisieme generation (C3G) avec relais en fonction des resultats de l’antibiogramme sera suffisant. En revanche, en presence de signes de gravite, une hospitalisation s’impose avec une antibiotherapie initialement double pour un total de trois a six semaines.

Study Type – Prognosis (case series) Level of Evidence 4 OBJECTIVE To study the development of stage migration in prostate cancer after controlling for the number of biopsy cores. PATIENTS AND METHODS In all, 1826 patients had a first set of 21-core biopsies taken between 2001 and 2008. Among the 801 patients with prostate cancer, 443 had a laparoscopic radical prostatectomy (RP). Patients were divided into three subsets according to the date of biopsy, i.e. period 1 (2001–2003), period 2 (2004–2005), and period 3 (2006–2008). Study end points were the development over time of: (i) clinico-biological characteristics; (ii) biopsy variables; (iii) pathological RP features; and (iv) the biochemical recurrence-free (RFS) rate after surgery. RESULTS The mean age decreased significantly over time (P= 0.004). The proportion of men with a prostate-specific antigen (PSA) level of 4–10 ng/mL increased significantly over time at the expense of the proportion of men with a PSA level of ≥10 ng/mL (P= 0.004). A biopsy Gleason score of ≥7 was reported in 53.9% of period 1, compared to 39.6% in period 3 (P= 0.001). RP specimens had a significantly lower proportion of extraprostatic disease (P= 0.013), of high Gleason scores (P= 0.049), and positive margins (P= 0.011) over time. The RFS curves did not vary over time (P= 897). CONCLUSION Current candidates for prostate biopsy are younger and have lower PSA levels than those who had biopsies taken at the beginning of the decade. Cancers are less aggressive in terms of Gleason score, extent of the disease on biopsy cores and rate of extraprostatic disease on RP specimens than those diagnosed at the beginning of the decade.

Resume L’evolution de la resistance du gonocoque aux quinolones ainsi que sa diminution de sensibilite aux cephalosporines imposent d’actualiser la prise en charge des urethrites non compliquees. Nous presentons ici les recommandations de prise en charge de l’urethrite aigue par le comite d’infectiologie de l’Association francaise d’urologie.

Un tableau d’infection urinaire febrile de l’homme doit faire evoquer a priori une prostatite aigue. Les examens complementaires rechercheront des signes de gravite et un residu postmictionnel qui necessitera un drainage. Les valeurs du PSA et de l’echographie endorectale sont rappelees. Un traitement antibiotique probabiliste par C3G ou fluoroquinolone de trois a six semaines est recommande.

Resume Objectif L’incidence du cancer de la prostate est en forte augmentation du fait, d’une part, du vieillissement de la population et, d’autre part, de l’utilisation du taux de PSA. Apres 75 ans, il n’y a pas de regle absolue mais la morbidite competitive augmente et rend le benefice de la chirurgie plus discutable par rapport aux autres alternatives therapeutiques. En realite, la plupart des urologues ne proposent pas la prostatectomie radicale (PR) aux patients de plus de 70 ans. Nous presentons les resultats carcinologiques et fonctionnels de notre serie de patients âges de plus de 75 ans et ayant eu une PR laparoscopique. Methode De 2000 a 2007, 22 patients âges de 75 ans et plus ont ete traites par PR pour un cancer de la prostate localise selon la classification TNM 2002. Les survies, globale, specifique et sans recidive biologique, ont ete analysees selon la methode de Kaplan-Meier. La recidive biologique etait definie par une seule valeur postoperatoire du PSA superieur a 0,2 ng/ml. Une valeur de p Resultats L’âge moyen des patients au moment de la chirurgie etait de 76,5 ans (75–81). Le PSA moyen etait de 10,77 ng/ml (5–30). Le score American Society of Anesthesiologists (ASA) moyen etait de 2 (2–3). Cinq patients (23 %) presentaient une tumeur localement avancee sur l’analyse anatomopathologique. Les marges chirurgicales etaient positives sur trois pieces operatoires (14 %). Avec un suivi moyen de 42 mois, aucun patient n’est decede, cinq ont eu une recidive biologique et sont traites de maniere adjuvante. A 12 mois postoperatoires, 82 % des patients etaient continents (zero protection), 36 % des patients avait une erection permettant un rapport sexuel avec ou sans prise de IPDE-5. Conclusion La PR par voie laparoscopique peut etre proposee chez les patients de plus de 75 ans selectionnes. Les complications postoperatoires semblaient minimes et les resultats fonctionnels et carcinologiques satisfaisants.

The French Association of anesthesiology (SFAR) has published in 1999 the Antibiotic prophylaxis guidelines. Antibiotic resistance has increased and new procedures appeared so new recommendations were needed. We present the antibiotic prophylaxis guidelines from the committee of infectious diseases of the French Association of Urology.

La prise en charge de la cystite aigue recherche des facteurs de gravite, de risque ou de complication. La cystite aigue simple ne necessite aucun examen complementaire, un traitement court est recommande. La cystite aigue compliquee necessite parfois une evaluation clinique, bacteriologique et radiologique, un traitement plus long est recommande. La definition de la cystite recidivante est precisee dans ces recommandations.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To review the biochemical recurrence-free survival (RFS) rates of laparoscopic radical prostatectomy (LRP) in patients with a high risk of disease progression as defined by preoperative criteria of D’Amico et al. PATIENTS AND METHODS Between October 2000 and May 2008, 110 patients had extraperitoneal LRP and bilateral pelvic lymph node sampling for high-risk prostate cancer in our department. High-risk prostate cancer was defined as a prostate-specific antigen (PSA) level of >20 ng/mL, and/or a biopsy Gleason score ≥8, and/or a clinical stage of T2c–T4 stage. The median follow-up was 37.6 months. Risk factors for time to biochemical recurrence were tested using log-rank survivorship analysis and Cox proportional hazards regression. RESULTS Prostate cancer was organ-confined in 36% of patients; the Overall RFS was 79.4% and 69.8% at 1 and 3 years, respectively. The 3-year RFS rates for organ-confined cancer vs extracapsular extension were 100% and 54.3%, respectively (P

Urinary tract infections are frequent. The aim of these guidelines is to improve the management of urionary tract infections. Increasing antibiotic prescriptions may increase bacterial drug resistance. Asymptomatic bacteriuria, bacterial count, pyuria are defined and the clinical value of the bacterial culture and urinary dipstick test are discussed. The good antibiotic use depends on bacteriological, pharmaceutical, patient characteristics and economic findings which are precised in these guidelines.

To prospectively evaluate the diagnostic yield of a 21-sample ultrasound-guided needle biopsy protocol as the initial diagnostic strategy for detection of prostate cancer.Between December 2001 and October 2005, 1000 consecutive patients underwent 21-sample needle biopsies under local anesthesia, comprising sextant biopsies, 3 additional posterolateral biopsies in each peripheral zone, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Each prostate core was numbered and analyzed separately. The patients were divided into subgroups according to the result of digital rectal examination (DRE), serum prostate-specific antigen (PSA), and prostate volume. We evaluated the cancer detection rate overall and in each subgroup. We compared the results of our biopsy protocol to those from 6-, 12-, and 18-core biopsy protocols by analyzing only those cores from our protocol that would correspond to these biopsy schemes.Cancer detection rates using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant, lateral, and TZ biopsies), and 21 samples (sextant, lateral, TZ, plus midline biopsies) were 31.7%, 38.7%, 41.5%, and 42.5%, respectively. The 12-sample procedure improved the cancer detection rate by 22% compared with the 6-sample procedure (p=0.0001). The improvement in the diagnostic yield was most marked in patients with a prostate volumeor =55 ml (36.9%), in patients with normal DRE (26.6%), and in patients with PSA4 (37.5%). The addition of TZ biopsies to a 12-biopsy scheme increased the diagnostic yield by 7.2% overall (p=0.023). Only 10 of 425 (2.3%) patients were diagnosed on the sole basis of midline biopsies.Patients with suspected localized prostate cancer should be offered at least 12 biopsies in the peripheral zone and far lateral peripheral zone (statistically significant). TZ biopsies have to be considered, because these biopsies improve the diagnostic yield. For patients with abnormal DRE and/or PSAor =20 ng/ml, the 6-biopsy scheme seems sufficient (statistically), but 6 far lateral peripheral zone biopsies as well as the TZ biopsies add little incremental value (not significant). Evidence does not support the use of routine midline peripheral zone needle biopsies in the initial biopsy to enhance the detection of prostate cancer.

Resume En dehors des atrophies parenchymateuses segmentaires, l'indication de la nephrectomie partielle est de plus en plus souvent posee pour traiter des tumeurs renales isolees de petite taille. Au cours des dernieres annees, cette technique s'est faite accepter pour l'exerese des tumeurs de moins de 4 cm. Pour diminuer la morbidite de l'intervention, la voie d'abord laparoscopique a ete proposee. Au cours de la derniere decennie, la nephrectomie partielle laparoscopique a atteint sa maturite et cette technique est maintenant devenue bien standardisee. La connaissance et la maitrise des voies trans- et retroperitoneale sont indispensables. La voie extraperitoneale est mieux adaptee pour les lesions posterieures ou au niveau du pole inferieur. La voie transperitoneale est privilegiee en cas de tumeur proche du hile ou anterieure. Differentes methodes de clampage et de refrigeration ont ete elaborees. La section du parenchyme se fait de plus en plus sans utilisation d'energie thermique, ce qui permet de mieux identifier les lesions. Les voies excretrices, les vaisseaux et la tranche de section du parenchyme sont maintenant systematiquement sutures. Bien que complexe, cette technique est devenue reproductible et fiable dans des centres specialises en laparoscopie.