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We explored the characteristics of a sample of men who had undergone a biopsy in clinical practice in France and evaluated initial treatment choice in men with a positive biopsy.This was a multi-centre, retrospective chart review including men who had undergone a biopsy in France. Clinical variables were collected using an electronic data capture system.Eight hundred and eight men were included; 632 men (78%) had an initial biopsy and 176 men (22%) had one or more repeat biopsy. The mean age was 64 years and 9% of men were 75 years or more. The mean (median) PSA was 11.6 (7.0) ng/mL; 25% of men had a PSA greater than 10 ng/mL. Twenty-eight percent of men had a suspicious DRE. A total of 52% of men had a positive initial and 26% a positive repeat biopsy. One hundred and eleven patients (34%) had low-risk PCa (stage T1c-2a, PSA10 ng/mL, Gleason sum7) and 195 (59%) were at intermediate/high risk of disease progression. The most common treatment was radical therapy (54% of patients), even in men with low-risk PCa (40% of patients). A total of 38% of low-risk patients chose active surveillance.The French biopsy sample appeared to be at a relatively high risk of having PCa at initial biopsy. Radical therapy was the most common treatment choice in men with a positive biopsy. In patients with low-risk PCa, radical therapy and active surveillance were used most often and to the same extent.

Lymph node invasion is the first step of metastatic evolution of prostate cancer. In this case, today, no local treatment should be proposed. Detection of lymph node invasion is performed by CT-scan and RMI, which show hypertrophied nodes. No difference in term of sensibility and specificity is observed between CT-scan and RMI. Invaded nodes are defined by modifications of size, form, and aspect of the architecture of nodes. Sentinel node belongs to expert centers. Surgical lymphadenectomy remains the best way to evaluate lymph node status. Limited to ilio-obturator land, it underestimates the risk of lymph node invasion: Extended lymph node excision defined by the association of bilateral ilio-obturator, internal iliaca and external iliaca lymphadenectomy should be systematically proposed to intermediate and high risk prostate cancer. A "well done" lymphadenectomy is represented by more than 10 nodes removed. Lymph node invasion represents bad prognosis. However, therapeutic value and influence of prognosis of lymphadenectomy in prostate cancer is still not established. Therefore, one or two invade lymph nodes represented a population of patients with better prognosis, specially if no capsular effraction is observed. After radical prostatectomy, in case of lymph node invasion, immediate hormonotherapy is the standard; however, this treatment is discussed in case of low number of invaded nodes (one or two) and if postoperative PSA is equal to zero. In this case, radiotherapy is still in evaluation and chemotherapy has no indication.

Two randomised trials and negative conclusion of the FDA about inhibitors of 5 alpha-reductase in prevention of prostate cancer need a revision of the indications of these drugs.After description of fundamentals data, review of the literature in PubMed library was performed to analyse the indications of these drugs according to the different stages of prostate cancer.Even if PCPT and REDUCE studies showed a decrease of cancers with the use of 5 alpha-reductase (5ARI) but with side effects, there is no indication for prostate cancer prevention by these drugs. In the same way, despite the results of REEDEM study, there is no indication of these drugs in active surveillance.Despite the large interest of these drugs, no recommendation can be given for indications of 5ARI in prevention or treatment of prostate cancer.

Localized prostate tumors have various clinical, biological and histopathological characteristics that lead to different progression profiles. High-risk prostate cancer has been classically defined by clinical examination, PSA levels and histopathological data. High-risk prostate cancer has usually a worse outcome, but classic stratification predictive of outcome for prostate cancer is a matter of debate concerning its accuracy.A systematic review of the literature on high-risk prostate cancer over the 15 last years was carried out on Medline database. The literature selection was based on evidence and practical considerations.A great deal of scientific work have been deployed to prove that high-risk prostate cancer should be approached by teamwork including radio-hormone therapy, systemic treatment with long term use of LH-RH and a radical prostatectomy with adequate lymph node dissection. Selection of patients is essential to define individualized therapeutic strategy and timing for every modality should come as a consensus of medical supported evidence.Accurate patient selection and multimodal treatment offer the best therapeutic option in high-risk prostate cancer.

The objective of this manuscript is to provide an evidence-based analysis of the current status and future perspectives of robotic laparoendoscopic single-site surgery (R-LESS). A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). All clinical and investigative reports for robotic LESS and NOTES procedures in the urological literature have been considered. A significant number of clinical urological procedures have been successfully completed utilizing R-LESS procedures. The available experience is limited to referral centers, where the case volume is sufficient to help overcome the challenges and learning curve of LESS surgery. The robotic interface remains the best fit for LESS procedures but its mode of use continues to evolve in attempts to improve surgical technique. We stand today at the dawn of R-LESS surgery, but this approach may well become the standard of care in the near future. Further technological development is needed to allow widespread adoption of the technique.

Localized prostate tumors have various clinical, biological and histopathologic characteristics that lead to different progression profiles. High-risk, clinically localised disease has been classically defined by clinical examination, PSA levels and histopathologic data. High-risk localized prostate tumors have usually a worse outcome, but classic stratification predictive of outcome for prostate cancer is a matter of debate concerning its accuracy. Diagnosis of high-risk prostate cancer has been improved by the use of MRI for local extension and risk of metastases. Pet-scan shows promising results for lymph node metastasis detection. Bone scan is widely used, as recommended. Optimal treatment for these men is the combination of androgen deprivation therapy and radiation therapy, although surgery can be used in some cases. Recent and major advances in the field of molecular biology are expected to provide new tools to better stratify men with prostate cancer at diagnosis. Indeed, numerous biomarkers are in development, as a consequence of a better comprehension of molecular basis of prostate cancer. New biomarkers (including circulating tumor cells) and genetic variations associated with prostate cancer aggressiveness should help us to define more precisely high-risk disease. Endly, these data should help to determine predictive factors for individual treatment response and indications, leading to an individualized management by targeted therapies.

Among the different options recommended for high-risk prostate cancer, radical prostatectomy is admitted as radiotherapy, but its role is still controversial in monotherapy and difficult to evaluate in combined treatments. The results of clinical trials combining an external radiotherapy to a long-term androgen deprivation in locally advanced tumours sustain the principle of a multidisciplinary management in high-risk prostate cancer. The impact of surgery on the risk of progression and local recurrence is important in selected patients with low grade and small tumoral volume. Clinical and histological data associated to the MRI assessment remain essential and enhance the preoperative multidisciplinary decision, especially regarding nodal and distant metastases. Radical prostatectomy with an extended pelvic lymphadenectomy can be considered as a viable alternative to radiotherapy and hormonal therapy in these patients with a long life expectancy but presenting a high risk of local progression and a low risk of metastatic disease. Morbidity of the procedure is similar to radical prostatectomy for organ-confined tumours despite more erectile dysfunction due to non-sparing radical prostatectomy in most of cases. Oncological results from recent compiled series show 10- and 15-year specific survival rates around 85 and 75%, respectively, including adjuvant or salvage treatments with radiotherapy, androgen deprivation or chemotherapy.

During the EAU and AUA congress in 2009, major work about the urothelial carcinoma was interested in the classification T1a / b and its therapeutic consequences, the last results of BCG therapy and photodynamic diagnosis. At ASCO congress, the main studies presented focused on the systemic treatment, in adjuvant situation, in first line treatment of metastatic bladder cancer, particularly with the addition of anti-angiogenic to chemotherapy, and in conservative treatment in association with radiotherapy.

Surgical approach for radical prostatectomy is even today a subject of debate in the urologic community. Many comparative studies between retropubic and laparoscopic approach (robotic assisted or not) were reported since 10 years without being able to decide between the supporters of retropubic or laparoscopic approach. The committee of cancer research of the French urological association took hold this question after a recent meta-analysis publication on this subject. Although imperfect, this meta-analysis exists and permits to conclude partially on the advantages and the inconveniences supposed for each surgical approach. Regarding morbidity after radical prostatectomy, the only significant difference reported concerns the hemorrhagic risk in favour of the laparoscopic approach. Regarding oncologic results, the only exploitable data concern positive surgical margins rate, which is identical whatever surgical approach. Concerning the functional results, no difference was reported in the literature between different surgical approaches.

The aging of the population has resulted in an increase in the number of elderly patients with prostate cancer. Among the curative treatment options in the elderly subject, external radiotherapy is the most frequently chosen option. Combined treatment including radiotherapy and hormone therapy should be preferred to hormonal therapy alone, including in elderly patients, whenever life expectancy surpasses 4-5 years. The indications for this radiotherapy should be defined in an attempt to prevent excessive or insufficient treatment, to adapt the treatment modalities to the patient's age by assessing its potential toxicity, and to discuss the possible alternatives. In cases of localized prostate cancer in men who are aging well, a standard treatment should be proposed, preferring radiotherapy possibly associated with hormone therapy in cases with negative prognostic factors. Patients with a reversible health problems can also receive standard treatment, notably in cases with aggressive prognostic factors.

Prostate cancer (PaC) is a significant health problem. Elderly have the highest incidence of the disease as age is its strongest risk factor. Despite its complications, the use of androgen suppression in aging patients with prostate cancer has become extremely frequent with probable excess. However, some of these complications carry specific mortality and all of them have a negative impact on quality of life. It is critical to perform a geriatric assessment, concerning physical, mental and social items, before to consider androgen suppression in this population. Indications of androgen suppression for the treatment of prostate cancer follow the guidelines of CCAFU. Delayed treatment deserves a special attention when possible. Treatment modalities are no specific to the elderly, but complications have to be anticipated with preventive measures. Intermittent androgen suppression should be considered with caution. Close follow up will focus on the diagnosis of adverse effects of androgen suppression.

Only few studies have been published regarding the results of radical Prostatectomy (RP) in elderly patients. The available data suggest that advanced age does not increase the postoperative mortality and morbidity rates, as far as reasonable selection is performed. Similarly, oncological results of RP are similar in patients aged70 years and in younger patients. Only the risk of incontinence may be increased, with a potential impact on quality of life. There are no studies comparing the various curative treatments of Prostate cancer (RP, radiation therapy, brachytherapy, active surveillance) in the elderly population.

Evaluation of the efficiency of wound infiltration of ropivacaine in postoperative pain after extraperitoneal laparoscopic radical prostatectomy.Prospective single institution study included 130 patients treated by extraperitoneal laparoscopic radical prostatectomy from January to March 2007. One hundred and two patients were included and randomised in two groups according to the year of birth (pair or impair). Only patients from the first group (year pair) had wound infiltration at the end of the procedure. The second group (year impair) was the control group. An analogic visual scale (EVA) permitted evaluation of pain at 30 minutes, 1, 6 and 12 hours after the procedure. Use of analgesics after procedure were noted for each patient.In the first group, the median of EVA was 1.44, 1.34, 1.72 and 1.51 respectively at 30 minutes, 1, 6 and 12 hours. In the second group, the median of EVA was 1.28, 1.36, 1.46 and 1.44. We found no statistically significant difference for pain and use of analgesic between the two groups (p=0.71, 0.96, 0.47 and 0.86 respectively at 30 minutes, 1, 6 and 12 hours).Ropivacaine in wound infiltration did not decrease significantly the postoperative pain and must not be used systematically.

The aim of this multicenter study was to determine the prognostic value of the depth of invasion of lamina propria and more specifically the influence of the invasion of the muscularis mucosae on survival parameters in T1 bladder carcinoma.Six urological centers included patients between 1994 and 2004 who had an initial T1 bladder tumor. All T1 tumors were substaged according to the muscularis mucosae (MM) invasion into T1a (no invasion beyond the MM) and T1b (invasion beyond MM but preserving the muscle). Among the 387 patients included, 269 (69.5%) were found T1a and 118 (30.5%) T1b. Mean follow-up was 45.4 months. T1a and T1b groups were comparable except for tumor grade that was higher in T1b (p0.001).Survival without recurrence was not significantly different between T1a and T1b groups (p0.3) but T1a stage was found as an independent factor for survival without progression (RR=0.49; IC 95%=[0.71-0.90]), specific survival (RR=0.33; IC 95%=[0.16-0.67]) and global survival (RR=0.52; IC 95%=[0.32-0.85]).This study, the largest on the subject to our knowledge, have shown that muscularis mucosae invasion was a prognostic factor for survival without progression, specific survival, and global survival. We support that routine pathological assessment of the level of MM invasion in patients with stage T1 bladder cancer should be included in the histopathological report.

The primary goal of robotic-assisted radical prostatectomy (RALP) is to completely remove the cancer and cure the patient of their carcinoma. Secondary goals of definitive therapy for prostate cancer include both the preservation of preoperative continence and potency. The apical dissection is one of the most crucial steps in the RALP. The dissection of the apex is the one part of this procedure in which the oncological outcome as well as the functional outcomes are in jeopardy if done inaccurately or incorrectly. The surgeon must clearly identify the apex of the prostate to avoid inadvertently entering the prostate and creating a positive surgical margin. The nerves are located in close proximity to the urethra and may be injured if not identified. Post-operative continence is also dependent on an accurate apical dissection. The rhabdosphincter should be clearly identified and a maximum functional urethral length should be maintained to prevent damage to these structures and to avoid postoperative incontinence. If the surgeon does not perform a meticulous dissection the “trifecta” of longterm cancer control, along with recovery of continence and sexual function will not be achieved [1].

Vesico-urethral anastomosis is the last step of radical prostatectomy. Whatever the approach, radical prostatectomy remains a difficult surgical intervention. The dissection steps are similar whatever the selected access, open or laparostopic. Laparoscopic anastomosis requires specific skills that must be adequately mastered by the surgeon before starting any laparoscopic radical prostatectomy program. Pelvi-trainers allow training on the anastomosis technique, with reproducible results. This chapter presents the key points for laparoscopic vesico-urethral anastomosis.

Evaluation of the results of lumboscopic repair of ureteropelvic junction syndromes.Retrospective study of 25 consecutive lumboscopic retroperitoneal pyeloplasties performed over 3 years in 14 women and 11 men with symptomatic ureteropelvic junction syndrome.The mean operating time was 200 minutes (range: 120-360 minutes) and mean blood loss was 60 ml. Surgical conversion was necessary in three cases due to the difficulty of dissection and in one case because of rupture of the ureter. Analgesic prescription was generally only necessary for the first 2 postoperative days. The mean hospital stay was six days (range: 2-16 days). Patients were able to return to work an average of 10 days after the operation. With a mean follow-up of 9 months (range: 6 to 18 months), all patients were asymptomatic except for one patient who reported pain at a trocar site. Follow-up urography at 3 months showed marked improvement in 18 patients (85.7%), moderate pyelocaliceal dilatation in 2 cases and one failure.Lumboscopic pyeloplasty is an alternative to endopyelotomy. It provides a comparable success rate to that of conventional surgery, while reducing the morbidity, length of hospital stay and convalescence. However, it requires mastery of intracorporeal suture techniques.

Evaluate the technical feasibility of laparoscopic radical prostatectomy, its carcinological efficacy and per- and post-operative morbidity.We performed radical prostatectomy using a new laparoscopic technique in 28 patients between February 1 and August 31, 1998.Radical prostatectomy was achieved totally by a laparoscopic approach in 24 patients (86%). No conversion was required in the last 14 patients. In 9 patients (32%) ilio-obturator node resection was also performed as indicated by preoperative extension work-up. Mean operative time was 270 minutes. The only major complication was one rectal wound (patient n degree 8) which had a benign course after suturing under laparoscopy. The bladder catheter was removed a mean 7.7 days after the procedure. Five patients (18%) required transfusions (mean 2.7 units, range 2-3). Rapid discharge on day 3 was possible due to rapid pain relief postoperatively. Tumor classes were pT2 in 26 patients, NO in 9, NX in 17. The surgical border was doubtful at the apex in one case. The last prostate specific antigen assay was below detectable levels (0.1 ng/ml) in 16 patients (89%) among the 18 with levels know prior to the procedure. Continence was assessable in 20 patients after a 1 to 6 month follow-up. Continence was perfect in 18 patients and becoming so in 12. Sexual activity was not assessed in this series due to the short follow-up.Radical prostatectomy can be reasonably performed as a routine laparoscopic procedure by a well-trained team. The cancerological results in this series were equivalent to those with conventional retropubic surgery and morbidity was very low. Improved operative vision was considerable, allowing much more precise dissection. The laparoscopic technique appears to be an important improvement for radical prostatectomy and should help improve functional outcome.

Ureteric polyp is a benign lesion, and an uncommon cause of hydronephrosis in children. It is associated with intermittent lumbar pain and haematuria. The diagnosis is usually based on intravenous urography or retrograde urography. Treatment must be conservative and consists of simple resection of the polyp, associated with varying degrees of ureteric resection depending on the size of the lesion. No case of recurrence after treatment has been reported to date. The authors report a case in a 7-year-old boy and present a review of the literature.

To define the diagnostic and therapeutic approach to intradiverticular bladder tumour.Five cases are reported in which initial diverticulectomy was followed by cystectomy in one case, systemic MVAC chemotherapy in 2 cases and concomitant radiotherapy-chemotherapy (CRC) in 2 cases.One patient has died (MVAC), one patient is in partial remission (MVAC) and three patients are in complete remission (1 cystectomy and 2 CRC).Intradiverticular bladder tumour is a disease with a poor prognosis, whose histological features require aggressive treatment. Concomitant radiotherapy-chemotherapy appears to be a useful alternative.

This work studies the morphology of distal roots of the first mandibular with the support of X rays and transversal sections. The frequency of the different types of roots (according to the Weine classification) and the shape of their section is studied statistically. The results enable a better approach of the endodontic shaping.