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Resume Introduction L’objectif de ce travail etait d’analyser l’evolution des pratiques et des resultats de la nephrectomie partielle (NP) avec l’acquisition du robot Da Vinci ® . Materiels et methodes Il s’agit d’une etude monocentrique retrospective portant sur 280 patients traites par NP pour une tumeur renale de janvier 2006 a mai 2013. Le nombre de NP, les caracteristiques tumorales, et les resultats perioperatoires ont ete etudies sur 3 periodes en fonction de la voie d’abord majoritairement utilisee : 2006–2008 (NP ouverte), 2008–2010 (NP laparoscopique) puis 2010-2013 (NP robot-assistee). Resultats Le ratio NP/nephrectomies a evolue avec une augmentation significative du nombre de NP par rapport au nombre de nephrectomies elargies ( p = 0,002). Aucun changement significatif de la taille tumorale moyenne n’a ete observe ( p = 0,42) au cours de l’etude mais la proportion de tumeurs complexes (RENAL score ≥ 10) a augmente de facon significative au cours des trois dernieres annees (10,7 % ; 18,6 % et 33,2 % ; p = 0,04). Le temps de clampage a augmente passant de 23 minutes en 2006–2008 a 26 minutes en 2008–2010, puis diminue durant l’ere robotique passant a 14,5 minutes ( p p = 0,003). Conclusion Dans cette serie monocentrique, la chirurgie robotique a contribue au developpement et a l’amelioration des resultats de la chirurgie renale conservatrice. Niveau de preuve 4.

Introduction and objectives: To evaluate the prognostic role of modified Glasgow prognostic score (mGPS) for the prediction of oncological outcomes in a retrospective large multicenter cohort of upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy (RNU). Materials and methods: We retrospectively analyzed a multicenter cohort of patients treated with RNU for clinically nonmetastatic UTUC. Multivariable logistic regression analyses were performed to evaluate the ability of mGPS to predict nonorgan confined (NOC) disease and lymph-node involvement (LNI) at RNU. Multivariable Cox-regression models were performed to evaluate the preoperative and postoperative prognostic effect of mGPS on survival outcomes. Results: Overall, 2,492 patients were included in the study. Of these, 1,929 (77%), 530 (21%), and 33 (1%) had a mGPS of 0, 1, and 2, respectively. mGPS was associated with characteristics of tumor aggressiveness and independently predicted LNI and NOC at RNU (both P < 0.05). On univariable and multivariable Cox-regression analyses, higher mGPS was independently associated with recurrence-free, cancer-specific, and overall survival, both in a preoperative and in a postoperative setting. The inclusion of mGPS significantly improved the discrimination of a preoperative model for the prediction of oncologic outcomes compared to standard prognosticators. Conclusions: We found that mGPS is independently associated with clinicopathologic features and survival outcomes after RNU. Future studies should investigate the role of mGPS in a panel of preoperative markers for the prediction of NOC and LNI in UTUC patients, thus possibly improving the selection for perioperative systemic therapy.

The efficacy of partial nephrectomy (PN) in setting of pT3a pathologic-upstaged renal cell carcinoma (RCC) is controversial. We compared oncologic and functional outcomes of radical nephrectomy (RN) and PN in patients with upstaged pT3a RCC.This was a multicenter retrospective analysis of patients with cT1-2N0M0 RCC upstaged to pT3a postoperatively. The primary outcome was recurrence-free survival, with secondary outcomes of overall survival and de novo estimated glomular filtration rate (eGFR) 60. Multivariable analysis was performed to identify predictive factors for oncologic outcomes. Kaplan-Meier analyses (KMA) were obtained to elucidate survival outcomes.A total of 929 patients had pT3a upstaging (686 [72.6%] RN; 243 [25.7%] PN; mean follow-up, 48 months). Tumor size was similar (RN 7.7 cm vs. PN 7.3 cm; P = .083). PN had decreased ΔeGFR (6.1 vs. RN 19.4 mL/min/1.73mIn pathologically upstaged pT3a RCC, PN did not adversely affect risk of recurrence and provided functional benefit. Surgical decision-making in patients at risk for T3a upstaging should be individualized and driven by tumor as well as functional risks.

To evaluate the impact of Greenlight 180W photoselective vaporization of the prostate (PVP) and endoscopic enucleation of the prostate (GreenLEP) on ejaculatory and erectile functions.Between January 2014 and September 2016, 440 men with low urinary tract symptoms or complications related to benign prostate obstruction with prostate80 g and sexually active, underwent a PVP or GreenLEP performed by experienced surgeons at a single institution. Patients were matched in a 1:1 fashion according to preoperative transrectal ultrasonography prostatic volume and cardiovascular risk factors (smoking, diabetes, and hypertension).One hundred patients in each group were included. Mean prostatic volume were 110 g (95%CI: 101-118) and 107 g (95%CI: 99-115) in the GreenLEP and PVP groups, respectively (P = .68). Mean total energy delivered in the PVP group was 4.42 kJ/g (4.2-4.6). Surgical retreatment was required in 9 patients (10.1%) in the PVP group and none in the GreenLEP group (log rank test: P = .002). Mean prostate specific antigen level and International Prostate Symptom Score score were significantly lower in the GreenLEP group than in the PVP group at 3, 12, and 24 months (P.001). Preserved antegrade ejaculation was reported in 24 patients (26.9%) in the PVP group vs 1 patient (1.2%) in the GreenLEP group at 12 months (P.001). In multivariate analysis, age, history of coronary artery disease, and surgical treatment with PVP were independent factors of IIEF-5 decline.Despite a poor rate of preserved antegrade ejaculation, GreenLEP was associated with better erectile function outcomes possibly due to greater improvement of low urinary tract symptoms.

Background: Optimal follow-up (FU) strategy to detect potentially curable (PC) recurrences after treatment of localised clear cell renal cell carcinoma (ccRCC) is unclear. This study retrospectively analysed a large international database to determine recurrence patterns and overall survival (OS), as part of a wider project to issue recommendations on FU protocols. Objective: To analyse associations between RCC recurrences in patients with ccRCC, their risk group stratifications, treatments, and subsequent outcomes. Design, setting, and participants: Nonmetastatic ccRCC patients treated with curative intent between 1 January 2006 and 31 December 2011, with at least 4 yr of FU, were included. Patient, tumour and recurrence characteristics, Leibovich score, and management and survival data were recorded. Isolated local, solitary, and oligometastatic (three or fewer lesions at a single site) recurrences were considered PC, while all others were probably incurable (PI). Intervention: Primarily curative surgical treatment of ccRCC while at recurrence detection metastasectomy, systemic therapy, best supportive care, or observation. Outcome measurements and statistical analysis: Incidence, time to recurrence (TTR), and OS were measured. Competing risk analysis, Kaplan-Meier, and Cox regression models were used. Results and limitation: Of 1265 patients with ccRCC, 286 had a recurrence, with 131 being PC and 155 PI. Five-year cumulative risks of recurrence for low- (n = 53), intermediate- (n = 105), and high-risk (n = 128) patients were, respectively, 7.2%, 23.2%, and 61.6%, of whom 52.8%, 37.1%, and 30.5% were PC, respectively. Median TTR was 25.0 for PC patients versus 17.3 mo for PI patients (p = 0.004). Median OS was longer in PC compared with that in PI patients (p< 0.001). Competing risk analysis showed highest risk of ccRCC-related death in younger and high-risk patients. Limitations were no data on comorbidities, retrospective cohort, and insufficient data excluding 12% of cohort. Conclusions: Low-risk group recurrences are rare and develop later. Treatment of recurrences with curative intent is disappointing, especially in high-risk patients. An age- and risk score-dependent FU approach is suggested. Patient summary: We analysed data from eight European countries, and found that the incidence of the kidney cancer recurrence and patient survival correlated with clinical factors known to predict cancer recurrence reliably and age. We conclude that these factors should be used to design follow-up strategies. Renal cell carcinoma recurrences are rare in low-risk patients. Potentially curable recurrences are more frequent in high-risk patients, but local treatment is unlikely to be curative. Competing risk analyses suggest age and risk score as important factors in developing follow-up strategies.

International audience; BACKGROUND: Long-term responders (LTRs) are defined by at least 18 months of response to sunitinib in metastatic clear-cell renal cell carcinoma (ccRCC). Well-described by clinical studies, the phenotype of these tumors has never been explored.PATIENTS AND METHODS: In a retrospective and multicenter study, 90 ccRCCs of patients with metastatic disease were analyzed. Immunohistochemistry (carbonic anhydrase IX, vascular endothelial growth factor, c-MET, programmed death-ligand 1 [PD-L1], and PD-1) and VHL status were performed. Progression-free survival and overall survival were calculated from sunitinib introduction and from progression. LTRs and their corresponding tumors were compared with others using univariate and multivariate analysis.RESULTS: Twenty-eight patients were LTRs. They had a median progression-free survival of 28 months versus 4 months for other patients (P < .001). Similarly, LTRs had a median overall survival of 49 months versus 14 months (P < .001), even from progression (median, 21 vs. 7 months; P = .029). They were associated with a favorable or intermediate risk (International Metastatic Renal Cell Carcinoma Database Consortium model) (P = .007) and less liver metastasis (P = .036). They experienced more frequent complete or partial responses at the first radiologic evaluation (P = .035). The corresponding ccRCCs were associated with less nucleolar International Society for Urological Pathology grade 4 (P = .037) and hilar fat infiltration (P = .006). They were also associated with low PD-L1 expression (P = .02). Only the International Metastatic Renal Cell Carcinoma Database Consortium model and PD-L1 expression remained significant after multivariate analysis (P = .014 and P = .029, respectively).CONCLUSION: Primary tumor characteristics of LTRs were studied for the first time and demonstrated a different phenotype. Interestingly, they were characterized by low expression of PD-L1, suggesting a potentially lower impact of targeted immunotherapy in these patients.

Recent randomised trials have demonstrated a survival benefit for a front-line ipilimumab and nivolumab combination therapy, and pembrolizumab and axitinib combination therapy in metastatic clear-cell renal cell carcinoma. The European Association of Urology Guidelines Panel has updated its recommendations based on these studies. PATIENT SUMMARY: Pembrolizumab plus axitinib is a new standard of care for patients diagnosed with kidney cancer spread outside the kidney and who did not receive any prior treatment for their cancer (treatment naive). This applies to all risk groups as determined by the International Metastatic Renal Cell Carcinoma Database Consortium criteria.

INTRODUCTION AND OBJECTIVES:Radical Nephrectomy (RN) has been the standard of care for complex and locally advanced renal cell carcinoma (RCC). Partial Nephrectomy (PN) utilization has increased in...

The benefit of surgical metastasectomy (SM) for patients with metastatic renal cell carcinoma (mRCC) remains controversial because of the lack of high-level evidence on the role of SM in terms of survival benefit in the era of systemic therapy.To perform a systematic review of the literature on the role of SM in the treatment of mRCC and discuss key issues in the SM decision-making process.A systematic search of the Embase and Medline databases was carried out and a systematic review of the role of SM in mRCC was performed. A total of 56 studies were finally included in the evidence synthesis.All the studies included were retrospective and mostly noncomparative. Median overall survival (OS) ranged from 36 to 142mo for those undergoing SM, compared to 8-27mo for no SM. SM was associated with a lower risk of all-cause mortality compared to no SM (pooled adjusted hazard ratio 2.37, 95% confidence interval 2.03-2.87; p0.001). Morbidity and mortality were similar for SM and primary tumor surgery. The most important prognostic factor for OS was complete resection of metastases. Other prognostic factors included disease free-survival from nephrectomy, primary tumor features (T stage ≥3, high grade, sarcomatoid features, and pathological nodal status), the number of metastases, and performance status. Lung metastasectomy seemed to show the best survival benefit.Although no randomized clinical data are available, published studies support the role of SM in selected patients in the modern era. Complete SM allows sustained survival free of systemic treatment. Integration of SM and systemic therapy in a multimodal approach remains a valid option for some patients.Surgical resection of metastases originating from renal cell carcinoma may play a role in prolonging survival and avoiding systemic therapy when complete resection is achievable. This strategy is an option for selected patients with a limited number of metastases who still have good general health status.

Objective: To evaluate the incidence and survival outcomes of histological variants of upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU). Materials and Methods: We retrospectively analysed data from 1610 patients treated with RNU for clinically non-metastatic UTUC between 1990 and 2016 in several centres participating in the UTUC Collaboration. Histological variants were classified as micropapillary, squamous, sarcomatoid and other, including other rare variants (

Objective: Modality and frequency of image-based renal cell carcinoma (R.C.C.) follow-up strategies are based on risk of recurrence. Using the R.E.C.U.R.-database, frequency of imaging was studied in regard to prognostic risk groups. Furthermore, it was investigated whether imaging modality utilized in contemporary follow-up were associated with outcome after detection of recurrence. Moreover, outcome was compared based on whether the assessment of potential curability was a pre-defined set of criteria’s (per-protocol) or stated by the investigator. Materials and methods: Consecutive non-metastatic R.C.C. patients (n = 1,612) treated with curative intent at 12 institutes across eight European countries between 2006 and 2011 were included. Leibovich or U.I.S.S. risk group, recurrence characteristics, imaging modality, frequency and survival were recorded. Primary endpoints were overall survival (O.S.) after detection of recurrence and frequency of features associated with favourable outcome (non-symptomatic recurrences and detection within the follow-up-programme). Results: Recurrence occurred in 336 patients. Within low, intermediate and high risk for recurrence groups, the frequency of follow-up imaging was highest in the early phase of follow-up and decreased significantly over time (p < 0.001). However, neither the image modality for detection nor ≥ 50% cross-sectional imaging during follow-up were associated with improved O.S. after recurrence. Differences between per protocol and investigator based assessment of curability did not translate into differences in O.S. Conclusions: As expected, the frequency of imaging was highest during early follow-up. Cross-sectional imaging use for detection of recurrences following surgery for localized R.C.C. did not improve O.S. post-recurrence. Prospective studies are needed to determine the value of imaging in follow-up.

International audience; Objective - Modalities of surveillance to detect recurrence after nephrectomy for localized or locally advanced renal tumor are not standardized. The aim was to assess the impact of surveillance scheme on oncological outcomes. Methods - Patients treated for localized or locally advanced renal tumor with total or partial nephrectomy between 2006 and 2010 in an academic institution were included retrospectively. According to the University of California Los Angeles Integrated Staging System (UISS) protocol, follow-up was considered adequate or not. Symptoms, location and number of lesions at recurrence diagnosis were collected. Recurrence-free, cancer-specific and overall survivals were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were calculated to identify prognostic factors. Results - A total of 267 patients were included. Median follow-up was 72 months. Recurrence rate was 23.2% (62/267 patients). Recurrences were local (16%), single metastatic (23%), oligo-metastatic (15%) or multi-metastatic (46%). 72.6% of the recurrences occurred within the 3 years after surgery. No recurrence was diagnosed by chest X-ray or abdominal ultrasound. One hundred and twenty-one patients had inadequate follow-up. They had similar recurrence-free survival, cancer-specific survival and overall survival as patients with adequate follow-up. In multivariable analysis, the presence of multi-metastatic lesions was an independent prognostic factor of worse cancer-specific mortality after recurrence diagnosis (HR = 10.15, 95% CI: 2.29-44.82, p = 0.002). Conclusion - Role of chest X-ray and abdominal ultrasound for the detection of recurrences is limited. Rigorous follow-up according to the UISS protocol does not improve oncological outcomes. Follow-up schedules with less frequent imaging should be discussed.

To evaluate the prognostic value of BRCA1-associated protein-1 (BAP1) expression in upper tract urothelial carcinoma (UTUC), as BAP1 mutations have been associated with prognostic implications in urologic and non-urologic malignancies. We reviewed a multi-institutional cohort of patients who underwent radical nephroureterectomy (RNU) for high-grade UTUC from 1990–2008. Immunohistochemistry (IHC) for BAP1 was performed on tissue microarrays. Staining intensity was graded from 0–3, with BAP1 loss defined as an average intensity of

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.

Little is known about the natural history of sporadic angiomyolipomas (AMLs); there is uncertainty regarding the indications of treatment and treatment options.To evaluate the indications, effectiveness, harms, and follow-up of different management modalities for sporadic AML to provide guidance for clinical practice.A systematic review of the literature was undertaken, incorporating Medline, Embase, and the Cochrane Library (from 1 January 1990 to 30 June 2017), in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No restriction on study design was imposed. Patients with sporadic AML were included. The main interventions included active surveillance, surgery (nephron-sparing surgery and radical nephrectomy), selective arterial embolisation, and percutaneous or laparoscopic thermal ablations (radiofrequency, microwaves, or cryoablation). The outcomes included indications for active treatment, AML growth rate, AML recurrence rate, risk of bleeding, post-treatment renal function, adverse events of treatments, and modalities of follow-up. Risk of bias assessment was performed using standard Cochrane methods.Among 2704 articles identified, 43 were eligible for inclusion (zero randomised controlled trials, nine nonrandomised comparative retrospective studies, and 34 single-arm case series). Most studies were retrospective and uncontrolled, and had a moderate to high risk of bias.In active surveillance series, spontaneous bleeding was reported in 2% of patients and active treatment was undertaken in 5%. Active surveillance is the most chosen option in 48% of the cases, followed by surgery in 31% and selective arterial embolisation in 17% of the cases. Selective arterial embolisation appeared to reduce AML volume but required secondary treatment in 30% of the cases. Surgery (particularly nephron-sparing surgery) was the most effective treatment in terms of recurrence and need for secondary procedures. Thermal ablation was an infrequent option. The association between AML size and the risk of bleeding remained unclear; as such the traditional 4-cm cut-off should not per se trigger active treatment. In spite of the limitations and uncertainties relating to the evidence base, the findings may be used to guide and inform clinical practice, until more robust data emerge.Sporadic angiomyolipoma (AML) is a benign tumour of the kidney consisting of a mixture of blood vessels, fat, and muscle. Large tumours may have a risk of spontaneous bleeding. However, the size beyond which these tumours need to be treated remains unclear. Most small AMLs can be monitored without any active treatment. For those who need treatment, options include surgical removal of the tumour or stopping its blood supply (selective embolisation). Surgery has a lower recurrence rate and lower need for a repeat surgical procedure.

Renal cell carcinomas (RCC) are divided in several subtypes, characterized by morphological and histological features, protein expression patterns and genetics criteria. The main subtypes include Clear cell renal cell carcinoma (CCRCC), Papillary RCC (PRCC), Chromophobe RCC (ChRCC), oncocytoma, TFE3 and TFEB Translocation renal cell carcinoma (TRCC). In most cases, RCC can be easily classified according to histological criteria and immunohistochemistry. Nevertheless, the subtyping process can be more complex in some cases: differential diagnosis (CCRCC or TFE3 TRCC, PRCC or TFE3 TRCC, oncocytic tumors corresponding to ChRCC or oncocytoma), molecular confirmation (TFEB TRCC) and unclassified RCC. Complementary analyses are required such as fluorescence in situ hybridization (FISH) for the detection of chromosomal abnormalities associated to each subtype. In this aim, this study assessed the performance of FISH analysis in the histological classification of 359 RCC exhibiting unusual histological characteristics and/or occurring in young people. FISH probes were selected according to the histological features of each tumor. FISH analysis contributed to the histological classification in 73% of the RCC (261/359). Conversely, FISH did not contribute to the diagnosis in 19% of the cases (69/359) and a hybridization failure was observed for the remaining tumors (8%; 29/359). Considering the different RCC subtypes, FISH analysis was highly efficient to confirm the histological diagnosis of CCRCC, PRCC, and TFE3 TRCC and to identify abnormalities of the TFEB gene. However, this strategy showed some limitations for the diagnosis of oncocytic tumors and unclassified RCC, suggesting that additional molecular assays should be evaluated in these cases.

To evaluate the impact of accidental surgical incision into the tumour (ASIT) on oncological outcomes in patients undergoing RPN for a malignant tumour. A retrospective review of our prospectively maintained database was performed to identify all patients who underwent RPN for a localized RCC between June 2010 and July 2016. We stratified our cohort into two groups according to the presence of an ASIT. Perioperative data were compared between the two groups. Logistic regression analyses were used to assess the variables associated with ASIT. Recurrence-free survival was estimated using the Kaplan–Meier method and compared between groups with the log-rank test. A total of 234 patients were identified. 32 (14%) ASIT were observed. Patients’ characteristics were similar in the two groups. Most of intraoperative outcomes were comparable between the two groups, but patients in the ASIT group had greater EBL (475 vs. 300 mL; p = 0.01). In multivariate analysis, tumour size (p = 0.02), RENAL score (p = 0.02), EBL (p = 0.05) and low surgeon experience (p = 0.03) were all predictive factors of ASIT. 15 (6%) of recurrences were observed over a median follow-up of 36 months. There was no difference in recurrence-free survival between the two groups (p = 0.57). In our experience, accidental surgical incision into the tumour during RPN was a common event that did not appear to compromise oncological outcome.

e16557 Background: In the current era of Immune checkpoint inhibitors (ICI), the role and timing of nephrectomy is still unknown. We aimed to evaluate the oncological outcomes of patients with metastatic renal cell carcinoma (mRCC) managed with nephrectomy for residual disease after complete response (CR) or major partial response (mPR defined as > 80%) on metastatic sites following ICI. Methods: Patients who underwent nephrectomy after prior ICI between 2015 and 2020 were retrospectively included and clinicopathological data were reviewed. Perioperative data, postoperative complications, toxicities related to ICI, continuation or discontinuation of systemic treatment following surgery, and 1-year oncological outcomes were recorded. Results: Twenty-five patients without initial cytoreductive nephrectomy at diagnosis underwent delayed nephrectomy after long ICI administration because of CR (or mPR) on metastatic sites. Median age was 62 years [38-79]. 88% of patients had clear cell RCC on the initial biopsy. IMDC prognostic group was intermediate (80%) or poor (20%). ICI was administered as first-line therapy in 56.0% of cases and as second-line option after TKI in 44.0% of cases. Treatments regimens were: nivolumab + ipilimumab (n = 12), nivolumab + tivozanib (n = 2) or nivolumab alone (n = 11). The mean duration of ICI treatment was 11.8 months (range: 3-38 months) and the mean number of cycles was 19 (range: 6-75). Twelve patients had a CR on metastatic sites while 13 patients had a mPR ( > 80%). Overall, 64% of patients experienced toxicities related to ICI treatment. Median operative time was 210 minutes [90-345] and mean blood loss was 558 cc [40-4000]. In 80.0% of cases, surgeons experienced difficulties in finding dissection plans due to adhesions and/or inflammatory infiltration. The 30-day Clavien-Dindo postoperative complication rate was 36.0%, including 1 surgery-related death. Pathological report showed lymphocyte and/or macrophage infiltration in 60% of cases and complete pathological response (pT0) in 3 cases (12%). After a mean follow-up of 19.4 months, 79.2% of the patients were free from progression and 70.8% free from systemic treatment. The recurrence-free survival (RFS) and overall survival (OS) at 1 year were 79.5% and 89.8% respectively. CR on metastatic sites was significantly associated with good RFS compared to mPR (1-year RFS = 100% vs. 56.8%, median RFS = 21.6 vs. 4.25 months, p = 0.006) while the duration of IO treatment exposure was not. Conclusions: Nephrectomy following ICI for mRCC can be a difficult procedure. However, it may provide good long-term RFS, with systemic treatment discontinuation following surgery in most cases. This strategy may be offered in well-selected patients, especially in case of CR on metastatic sites before surgery.

Cystic renal masses are a specific renal entity with a different management from solid lesions. Renal cysts are present in over 50% of patients after 50 years. Radiological diagnostic enables to rank their suspect nature of malignancy through the Bosniak classification. Type III and IV lesions are at high risk of malignancy, and are usually treated by partial nephrectomy.

International audience; Risk stratification for kidney sparing procedures (KSP) to treat upper tract urothelial carcinoma (UTUC) is a major issue. A non-systematic Medline/PubMed literature search was performed using the terms "upper tract urothelial carcinoma" with different combinations of keywords to review the current knowledge on this topic. Original articles, reviews and editorials in English language were selected based on their clinical relevance. Available techniques for KSP include segmental ureterectomy and endoscopic resection through a percutaneous or flexible ureteroscopic access. These approaches were traditionally restricted to patients with imperative indications. Current recommendations suggest that selected patients with normal contralateral kidney should also be candidates for such treatments. Modern imaging and endoscopy have improved to accurately stage and grade the tumor while various prognostic clinical factors and biomarkers have been proposed to identify tumor with aggressive features and worse outcomes. Several predictive models using different combinations of such baseline characteristics may help clinicians in clinical decision making. However, risk-adapted based approach that has been proposed in recent guidelines to identify patients who are more likely to benefit from KSP only relies on few clinical and pathological factors. Despite growing understanding of the disease, treatment of UTUC remains challenging. Further efforts and collaborative multicenter studies are mandatory to improve risk stratification to decide and promote optimal KSP in UTUC. These efforts should focus on the integration of promising biomarkers and predictive tools in clinical decision making.

Resume Introduction L’objectif etait de rapporter les resultats perioperatoires et oncologiques de la cystectomie radicale robot assistee dans une serie monocentrique prospective francaise, et d’evaluer l’impact de l’experience sur les donnees perioperatoires. Materiels et methodes Entre mars 2012 et janvier 2016, 41 patients operes d’une cystectomie robot-assistee pour une TVIM dans un centre par un meme operateur ont ete inclus prospectivement. Les donnees perioperatoires et oncologiques ont ete recueillies. Les survies sans recidive, specifique et globale ont ete estimees selon la methode de Kaplan-Meier. L’impact de l’experience sur les resultats perioperatoires a ete evalue en utilisant le test de correlation de Spearman. Resultats L’âge moyen etait de 67,7 ans (± 10,6). Une chimiotherapie neoadjuvante avait ete realisee dans 73,2 % des cas. La duree d’intervention et les pertes sanguines moyennes etaient respectivement de 319,5 minutes (± 85,3) et 662,5 mL (± 360,9). Huit patients (19,5 %) ont necessite une transfusion durant l’intervention, et une conversion a ete necessaire dans 3 cas (7,3 %). Une enterocystoplastie a ete realisee dans 26,8 % des cas (intracorporelle dans 54,5 % des cas), et un conduit ileal dans 73,2 %. Le nombre de ganglions preleves par curage etait en moyenne de 17,7 (± 9,3). Un patient avait des marges positives (2,3 %). La duree moyenne d’hospitalisation etait de 13,2 jours (± 9,8). Le taux de complications postoperatoires etait de 46,3 %. Apres un suivi median de 16 mois, les survies globale et specifique estimees etaient respectivement de 62 et 76,1 % a 2 ans. La survie sans recidive estimee a 2 ans etait de 67,6 %. Les resultats perioperatoires s’amelioraient avec l’experience, avec une diminution significative de la duree operatoire ( p = 0,04) et une augmentation significative du nombre de ganglions par curage ( p = 0,05). Conclusion Dans cette serie monocentrique, la cystectomie robot-assistee etait associee a des resultats perioperatoires et oncologiques satisfaisants malgre la courbe d’apprentissage. Les resultats perioperatoires s’amelioraient avec l’experiences. Des resultats a long terme sont necessaires pour confirmer ces donnees. Niveau de preuve 4.

Surgical removal of the primary tumor in metastatic prostate cancer (mPCa) is becoming a hotly debated issue. The purpose of this review was to summarize the current knowledge on cytoreductive radical prostatectomy (cRP) in this setting. We performed a non-systematic Medline/PubMed literature search of articles published in the field between January 2000 and April 2015. Cytoreductive surgery has demonstrated its benefit in various malignancies with a solid biological rationale to justify its assessment in mPCa. cRP appears as a safe and feasible procedure in expert hands and well-selected patients. A growing body of evidence suggests a survival benefit for patients undergoing cRP as a part of a multimodal approach compared to those treated with systemic treatment alone. Nevertheless, little is known about the best clinical and tumor characteristics for the selection of patients most likely to benefit from cRP. The current literature is based on retrospective studies with small cohorts and limited follow-up or large uncontrolled population-based studies. Data from various other malignancies together with the biological rationale and preliminary results in PCa suggest that cytoreductive surgery may be an option in some mPCa patients. The lack of randomized controlled trials and the low level of evidence in the current literature preclude any firms conclusion on the benefit of cRP in mPCa. Ongoing phase II and future phase III studies are mandatory to define the exact role of cRP in mPCa and to identify the patients who are most likely to benefit from cRP.

International audience; OBJECTIVE: To assess the association of smoking status with standard clinicopathological features and overall survival (OS) in a large multi-institutional cohort of patients with metastatic renal cell carcinoma (mRCC) treated with cytoreductive nephrectomy (CNT). METHODS: A total of 613 patients with mRCC treated with CNT in US and Europe institutions between 1990 and 2013 were included. Smoking history comprised smoking status, smoking duration in years, number of cigarettes per day and years since smoking cessation. Cumulative smoking exposure was categorized as light short term, heavy long term and moderate. Association between smoking history and OS was assessed by Cox regression logistic analysis. RESULTS: One hundred and seventy-one patients (27.9 %) never smoked, 193 (31.5 %) were former smokers and 249 (40.6 %) were current smokers. Smoking status was associated with a higher number of metastases (p \textless 0.001) and an abnormal preoperative corrected calcium level (p = 0.01). Median follow-up was 16 (IQR 7-24) months. Current smokers had a shorter OS than never and former smokers (log rank, p = 0.004). Smoking status was significantly associated with OS in univariable analysis (HR 1.45; 95 % CI 1.16-1.82; p \textless 0.001), and in multivariable analysis that adjusted for established prognostic factors (HR 1.46; 95 % CI 1.16-1.84; p = 0.002). Daily consumption of more than 20 cigarettes, more than 20 years of smoking exposure and heavy long exposure were all independent prognosticators of worse OS. CONCLUSIONS: Current smoking and a higher cumulative smoking exposure are associated with a higher risk of death in patients with mRCC treated with CNT. Even at this stage, smoking negatively affects kidney cancer outcomes

Objectifs Les stenoses de l’anastomose vesico-uretrale (SAVU) sont rares mais complexes a traiter. La premiere ligne de traitement est souvent base sur l’uretrotomie endoscopique (UE) mais qui a un taux important d’echec, surtout chez les patients ayant eu une radiotherapie. Le but de cette video etait de decrire une technique de plastie YV et de lambeau peritoneal robot assistee pour stenose d’anastomose vesico-uretrale apres prostatectomie radicale et radiotherapie. Methodes La technique est decrite dans la video. Nous presentons le cas d’un patient de 77 ans avec un antecedent de prostatectomie radicale et de radiotherapie en 2009. Il a developpe une SAVU traitee par UE en 2018 suivie d’une incontinence urinaire totale associe a une recidive de stenose. Il a ensuite eu un sphincter urinaire artificiel (SUA) et une nouvelle UE. Dix jours apres l’activation du SUA, il a fait une retention aigue d’urine traitee par cystostomie. Le but de la plastie YV etait d’amener du « tissu sain » pour elargir la zone fibreuse. Le patient etait consentent a une cystectomie Bricker. Resultats Une approche transperitoneale a ete utilisee et 5 trocarts ont ete places incluant 3 trocarts pour les bras robotiques et un trocart de 12 mm pour l’aide operatoire. Le col vesical est disseque et ouvert utilisant comme repere la lumiere du fibroscope qui a ete passe dans le trajet de cystostomie. La stenose est incisee jusqu’a que le fibroscope CH17 passe completement la stenose. Le lambeau en V est ensuite cree et suture a l’ouverture du col vesical en utilisant un surjet. En constatant une fuite associee pendant le test de remplissage, il est decide d’utiliser un lambeau de peritoine pour renforcer la suture. Le patient est sorti a J7. Il a fait une infection urinaire traitee par antibiotique. La sonde uretro-vesicale a ete otee a 3 semaines et la cystostomie a 4 semaines. Le SUA a ete reactive a 8 semaines. A 9 mois, le patient a une legere stenose non symptomatique sans aucun residu et il est parfaitement continent avec son SUA. Conclusion La plastie YV avec Lambeau peritoneal robotique est faisable et peut apporter des resultats satisfaisants comme procedure de sauvetage chez des patient ayant une SUVA recidivante apres prostatectomie radicale et radiotherapie.

Objectifs Le lymphangiome kystique est une entite rare de tumeur benigne developpee au depens du systeme lymphatique, presente essentiellement chez les enfants. Les formes retroperitoneales representent seulement 1 % des lymphangiomes. Le traitement de reference reste la chirurgie. Dans cette video didactique, nous presenterons la technique mini-invasive de resection de cette masse kystique par chirurgie robotique en retracant pas a pas les differentes etapes. Methodes Il s’agit d’un patient de 21 ans, presentant un lymphangiome kystique de 12 cm de la veine cave inferieure (VCI) decouvert dans un bilan de douleurs abdominales. Le patient est installe en decubitus lateral gauche et 4 trocars robotiques sont utilises ainsi que 2 trocars pour l’aide. Dans un 1er temps, la dissection consistera a liberer le colon droit, puis le duodenum de la masse et de la VCI. La liberation se fera jusqu’a apercevoir le battement de l’aorte. La masse kystique sera liberee et dissequee progressivement de la VCI ou on retrouve un plan, en prenant garde a ne pas realiser de plaie vasculaire et a ne pas leser sur la partie externe la veine genitale et l’uretere droit. La piece est extraite en fin d’intervention par l’orifice du trocar optique apres l’avoir videe de son liquide dans le sac. Resultats La duree de l’intervention etait de 70 min. Les pertes sanguines etaient quasiment nulles. Les suites operatoires ont ete simples avec une reprise du transit a J1, autorisant un retour a domicile des le lendemain de l’intervention. L’analyse histologique a montre un lymphangiome kystique typique sans critere de malignite, avec des marges negatives. Conclusion La resection de lymphangiome kystique par chirurgie robotique est une technique sure, presentant les avantages d’une chirurgie mini-invasive. La resection doit imperativement eviter toute marge positive. La difficulte et le danger restent le risque de plaie vasculaire et de saignement majeur.

Objectifs Les fistules vesico-vaginales (FVV) sont un probleme de sante publique. Elles sont principalement liees a des sequelles de chirurgie pelvienne et radiotherapie dans les pays occidentaux. Il n’existe a ce jour pas de consensus sur la technique de reparation de ces FVV. L’objectif de cette video etait de presenter une technique de cure de FVV du col vesical par voie vaginale en position du jockey (procubitus). Methodes Nous presentons le cas d’une patiente de 67 ans, suivie pour une vessie neurologique avec trouble de la compliance et insuffisance sphincterienne apres hematome du cone medullaire. Suite a la pose d’une bandelette aponevrotique pubovaginale (BAPV) occasionnant des auto-sondages traumatiques, une fistule vesico-vaginale est apparue avec un orifice fistuleux de 2 cm de diametre au niveau du col vesical. Une cure de la fistule vesico-vaginale avec interposition d’un lambeau de Martius a ete realise par voie vaginale en position du Jockey en raison de la position tres distale de la fistule (qui a fait preferer la voie vaginale) et d’un col vesical plaque a la paroi vaginale anterieur en raison de la BAPV (qui a fait preferer la position du Jockey pour permettre une meilleure vision). Resultats La duree operatoire etait de 130 minutes. L’intervention commence par la realisation d’une incision vaginale en U inverse. La dissection inter-vesico-vaginale permet de visualiser la bandelette autologue modifiant la position du col et de la sectionner. Les berges vesicales et vaginales de la fistule sont excisees largement avant de refermer la vessie dans un axe vertical. Le lambeau de Martius est preleve sur la grande levre droite et pediculise sur sa vascularisation inferieure, pour etre interpose entre la vessie et le vagin. La paroi vaginale anterieure est refermee dans un axe horizontal. Les urines sont derivees par une cystostomie sus pubienne et par une sonde vesicale. La patiente a quitte le service au 3e jour postoperatoire. La patiente n’a pas presente de recidive de la fistule apres 2 mois de suivi. Conclusion La cure de fistule vesico-vaginale avec interposition d’un lambeau de Martius par voie vaginale en position du Jockey est une technique faisable qui parait interessante pour les fistules tres distales/cervicales qui offre le benefice d’une meilleure visualisation de l’orifice fistuleux et de la paroi vaginale dans son ensemble.

Objectifs Evaluer la performance de l’analyse de texture pour predire la survie sans progression (SSP) et la survie globale (SG) chez les patients atteints d’un carcinome renal a cellules claire metastatique (CCRm) traites par nivolumab. Methodes Il s’agit d’une etude retrospective monocentrique qui a analyse les donnees cliniques et radiomiques de patients atteints de CCRm traites par nivolumab. L’analyse radiomique des lesions metastatiques a ete effectuee sur des scanners injectes obtenus dans le mois precedant l’administration du traitement. Les caracteristiques de texture liees a l’histogramme de niveau de gris, a la cooccurrence de niveau de gris, aux caracteristiques de la matrice de longueur d’onde, aux caracteristiques du modele autoregressif et a la caracteristique des ondelettes de Haar ont ete extraites. Des analyses de regression de Cox penalisees ont ete effectuees pour identifier des predicteurs de la SSP et SG. Resultats Au total, 48 patients ont ete analyses. Les survies medianes sans progression et globale etaient de 5,7 et 13,8 mois. Trente-neuf patients ont eu une progression et 27 sont decedes. L’analyse de regression penalisee a identifie trois parametres radiomiques comme predicteurs potentiels de la SSP : l’asymetrie, S.2.2. Correlat et S.1.1. SumVarnc. L’analyse multivariee a montre que l’asymetrie (HR [IC95 %] = 1,49 [1,21–1,85], p Conclusion Les resultats de cette etude preliminaire suggerent que la radiomique pourrait etre un outil d’imagerie quantitative prometteur permettant de predire les resultats oncologiques des patients ayant un CCRm traites par nivolumab.

Objectifs Analyser les resultats oncologiques et fonctionnels de la chirurgie vs les therapies ablatives (TA) pour le traitement d’une recidive locale (RL) apres nephrectomie partielle (NP). Methodes Etude multicentrique realisee a partir de la base de donnees prospective uro-CCR et qui a inclus des patients ayant eu une RL apres NP pour un carcinome renal localise traites entre 2013 et 2019. La recidive locale a ete definie comme l’apparition d’une masse au contact du lit de resection ou dans la fosse renale operee ou le developpement d’une tumeur dans la meme region du rein homolateral que le site de NP d’origine. Les survies sans progression (SSP) et globale (SG) apres traitement de la RL ont ete evaluees par la methode de Kaplan–Meier et comparees par le test du Log-Rank. Resultats Nous avons inclus 56 patients. Le delai median avant la RL etait de 19 mois (11–30). Les traitements de la RL etaient : 22 (39 %) TA, 28 (50 %) nephrectomie elargies (NEL) et 6 (11 %) NP. Apres un suivi median de 23 (10–51) mois, 11 (20 %) patients ont presente une nouvelle RL, 17 (30 %) ont eu une progression metastatique et 5 (9 %) sont decedes. L’analyse des SG et SSP n’a pas retrouve de difference entre les approches therapeutiques (p = 0,46 et 0,32) ( Fig. 1 ). En analyse multivariee, l’approche therapeutique (chirurgie vs TA) n’etait pas associe a la SSP (p = 0,83). La perte de DFG etait de −29 mL/min pour la NEL, de −16 mL/min pour la NP et de −1,5 mL/min pour les TA (p = 0,005). Conclusion Dans cette serie, la chirurgie ne semble pas etre superieure aux TA pour le traitement de la RL apres NP en termes de survie. La perte de fonction renale etait plus importante dans le groupe chirurgie que TA.

Objectifs Les personnes trans sont moins bien prises en charge par la communaute medicale que la population cisgenre probablement a cause d’un manque de connaissance, d’enseignement et de confort de la part des professionnels de sante. Le but de cette etude etait d’evaluer les connaissances et le confort ressentis par les professionnels de sante dans la prise en charge des personnes transgenres dans un CHU francais. Methodes Un auto-questionnaire a ete envoye par mail a des professionnels de sante travaillant dans des services habituellement impliques dans la prise en charge de personnes transgenres dans un CHU francais « non specialise » dans la transition hormono-chirurgicale trans. Le questionnaire portait sur des questions demographiques et sur des echelles de Likert concernant leur connaissance et leur confort ressentis. Les reponses des echelles de Likert de 7 degres etaient reparties selon des groupes « faible », « moyen » et « eleve » et celles de 5 degres etaient reparties selon des groupes « en faveur », « neutre » et « en defaveur ». Resultats Quatre-vingt-huit (25 %) professionnels ont repondu au questionnaire. La moitie travaillaient en chirurgie (urologie, chirurgie plastique, gynecologie), 25 % travaillaient en medecine (endocrinologie, PMA, cytogenetique) et 25 % travaillaient en psychiatrie. Soixante et un pour cent evaluaient leurs connaissances comme « faible », 39 % comme « moyen ». Dix-sept pour cent evaluaient leur niveau de confort comme « faible », 70,5 % comme « moyen » et 12,5 % comme « eleve ». Une majorite (78,4 %) etaient en faveur d’une prise en charge par la securite sociale de la transition hormonale, chirurgicale ou d’un soutien psychologique, 14,9 % etaient neutres et 6,7 % etaient en defaveur. Les sentiments concernant la transition hormono-chirurgicale etaient tres majoritairement (≥ 95 %) en faveur ou neutre. Quatre-vingt-douze pour cent souhaitaient plus de formation ( Fig. 1 , Fig. 2 , Fig. 3 ). Conclusion Le manque de confort des professionnels de sante dans la prise en charge des personnes transgenres semble etre en rapport avec un manque de connaissance et de formation et non pas avec un desaccord concernant la necessite de l’offre de soins aux personnes transgenres.

Objectifs La cystectomie et derivation cutanee non continente par conduit ileal–Bricker (CB) est parfois indiquee chez les patients ayant une vessie neurologique. Des taux de complications relativement eleves ont ete rapportes chez ces patients fragiles. La CB robotique intracorporelle pourrait reduire la morbidite perioperatoire mais n’a jamais ete decrite chez les patients neurologiques, ceci constitue l’objectif de cette video. Methodes Nous presentons le cas d’une patiente de 50 ans atteinte de paralysie cerebrale presentant une retention chronique d’urine avec incapacite d’autosondage que ce soit par l’uretre ou par cystostomie continente. Le bilan urodynamique revele une hyperactivite detrusorienne avec un regime de pression eleve suggerant une dyssynergie vesico-sphincterienne. Malgre 4 heterosondages/j et un traitement anticholinergique il existe un retentissement sur le haut appareil urinaire avec de multiples calculs, une uretero-hydronephrose et une degradation de la fonction renale (DFG 26 mL/min) Resultats Installation en Trendelenburg, 6 trocarts sont positionnes (dont 2 assistants) et le robot Da Vinci Xi est amarre. On commence la dissection ureterale droite puis gauche en veillant a preserver la graisse periureterale. L’uretere gauche est decroise sous le mesosigmoide. On effectue ensuite la cystectomie. Une sonde transuretrale permet un drainage pelvien post operatoire. On realise le conduit ileal selon Bricker. La vascularisation du mesentere est reperee a l’aide d’une injection de vert d’indocyanine (Vind). Une anastomose grelo-grelique mecanique est realisee. On ouvre le moignon proximal de la poche ileale et realise l’anastomose uretero ileale (wallace 1) apres avoir verifie la bonne vascularisation des ureteres par injection de Vind. Deux sondes mono J sont mises en place et le conduit ileal est exteriorise par un orifice de trocart. Conclusion La realisation d’une cystectomie et derivation cutanee non continente par conduit ileal pour vessie neurologique par chirurgie laparoscopique robot-assistee totalement intracorporelle est faisable et pourrait permettre de diminuer la morbidite perioperatoire en diminuant la taille des incisions et en evitant l’exteriorisation ileale et la tension sur les mesos qui sont necessaires lorsque la derivation est effectuee en extracorporelle.

Objectifs La cystectomie et derivation cutanee non continente par conduit ileal–Bricker (CB) est parfois indiquee chez les patients ayant une vessie neurologique. Cependant les stenoses des anastomoses uretero-ileales sont une complication non exceptionnelle de cette chirurgie. La refection chirurgicale robot assistee totalement intracorporelle de ces anastomoses pourrait hypothetiquement reduire la morbidite perioperatoire. L’objectif de cette video est de demontrer la faisabilite de cette intervention. Methodes Nous presentons le cas d’une patiente de 47 ans atteinte de sclerose en plaque depuis 1987 et ayant eu une CB en 2018 avec une anastomose uretero-ileale de type Wallace 1. Elle presente des sepsis urinaires a repetition, necessitant des hospitalisations iteratives et finalement la pose de nephrostomies bilaterales. Une opacification antegrade retrouve une stenose de l’anastomose uretero-ileale gauche. Resultats La patiente est placee en Trendelenburg a 23°, 6 trocarts sont positionnes (4 robots et 2 assistants) et le robot Da Vinci Xi est amarre. On commence par la liberation des adherences et la dissection du conduit ileal. On prend soin de preserver la graisse peri-ureterale afin de ne pas compromettre la vascularisation. On sectionne les ureteres a leurs extremites distales. La vascularisation ureterale est controlee a l’aide d’une injection de vert d’indocyanine avant de les recouper et de les spatuler. Une nouvelle anastomose uretero ileale est effectuee selon wallace 1 entre la « plaque » ureterale et le moignon proximal du conduit ileal Deux sondes mono J sont mises en place et exteriorisees par la stomie. Conclusion La refection des anastomoses uretero-ileales par chirurgie laparoscopique robot assistee totalement intracorporelle est une procedure faisable. L’absence de traction sur les mesos et la qualite de la vision pourrait permettre le maintien d’une vascularisation optimale. L’absence de large incision pourrait favoriser une recuperation plus rapide.

Objectifs La sclerose de col vesical apres traitement endoscopique d’hypertrophie prostatique est une complication courante allant jusqu’a 12 % des patients. La prise en charge de premiere ligne est generalement basee sur un traitement endoscopique qui presente un taux d’echec eleve. L’objectif de cette video etait de decrire une technique de plastie V-Y et de plastie posterieure robotique pour une sclerose de col vesical post-photovaporisation prostatique. Methodes La technique complete est decrite dans cette video. Nous presentons le cas d’un homme de 63 ans qui a developpe une sclerose de col apres une photovaporisation en 2017 traitee par deux RTUP. Il souffrait de retention chronique necessitant 4 a 5 autosondages par jour. Les passages de sonde se faisaient a frottement. Il avait une hypocontractilite vesicale au bilan urodynamique. La decision d’effectuer une plastie YV robotique a ete prise afin d’elargir le passage en apportant du tissu sain. Resultats L’intervention est realisee sous anesthesie generale. Le patient est place dans une position de Trendelenburg a 23°. Une approche transperitoneale laparoscopique est utilisee et cinq ports sont places au total, dont trois ports pour les bras robotises et un port de 12 mm pour le chirurgien assistant. Un fibroscope flexible est utilise afin d’identifier le niveau du retrecissement par transillumination. Le col de la vessie est disseque et ouvert. Le V de la vessie est ensuite cree et suture a l’ouverture du col de la vessie a l’aide d’un surjet. Une plastie d’elargissement posterieure est realisee en points separes. Le patient est sorti a J2. La sonde vesicale a ete otee a 2 semaines. Le patient a repris des mictions spontanees avec des residus en diminution. Conclusion La plastie YV robotique est une technique faisable et peut apporter des resultats satisfaisants chez des patients ayant une sclerose de col recidivante.

Objectifs Etudier les caracteristiques cliniques, radiologiques et anatomopathologiques des patients ayant une recidive locale (RL) apres nephrectomie partielle (NP) pour un cancer du rein. Methodes Etude descriptive retrospective multicentrique realisee dans le cadre du reseau Uro-CCR qui a inclus les patients ayant eu une RL apres NP pour un carcinome renal localise. Les patients ayant une progression metastatique synchrone de la RL et un antecedent de nephrectomie pour cancer ont ete exclus. Les resultats sont exprimes en mediane pour les variables quantitatives et en frequence pour les variables qualitatives. La survie sans metastase etait estimee par la methode de Kaplan–Meier. Une analyse multivariee selon le modele de Cox a ete realisee pour rechercher les facteurs associes a l’evolution metastatique apres la RL. Resultats Au total, 73 patients ont ete inclus. Le delai entre la NP et la RL etait de 19 mois. La taille des tumeurs initiale etait de 40 mm et le RENAL score etait de 7. Soixante-dix pour cent des tumeurs etaient des T1. Le type histologique les plus frequent etait le carcinome a cellules claires (83 %). Le grade de Furhman etait de 3–4 dans 48 % des cas. Le taux de composante sarcomatoide (CS) et de marge chirurgicale positive etaient de 10 % et de 14 %, respectivement. Le suivi median apres la recidive etait de 21 mois. Le taux de metastase etait de 30 % apres traitement de la RL. La presence d’une CS sur la piece de NP etait le seul facteur associe a une progression metastatique apres une RL en analyse multivariee. Conclusion La presence d’une composante sarcomatoide et les marges chirurgicales positives semble etre des facteurs associes a une RL apres NP. De plus, la composante sarcomatoide semble etre un facteur predictif de progression metastatique dans cette sous-population.

Objectifs Le traitement des prolapsus pelviens par promontofixation expose a certaines complications inherentes a la mise-en-place de materiel prothetique. Les erosions vesicales se traduisent essentiellement par des infections urinaires a repetition, des douleurs et/ou une hematurie. La mise en place d’une bandelette sous-uretrale de type TVT peut etre a l’origine d’une dysurie. La voie robotique pourrait simplifier l’explantation du materiel prothetique lorsque celle-ci est necessaire. Methodes Nous presentons le cas d’une patiente de 69 ans, presentant des infections urinaires febriles recidivantes et des douleurs lombaires bilaterales associees a une hematurie macroscopique en rapport avec l’erosion vesicale d’une bandelette de promontofixation anterieure mise en place en 2012 et une bandelette sous uretrale de type TVT dysuriante. L’objectif de cette video etait de decrire la technique chirurgicale de l’explantation d’une prothese de promontofixation par voie transvesicale avec d’exerese des bras d’une bandelette TVT par laparoscopie robot-assistee. Resultats Une explantation en monobloc de la totalite de la prothese de promontofixation a ete realisee, ainsi que l’exerese des portions retro-pubiennes des bras de la bandelette sous uretrale. L’intervention a ete realisee sous laparoscopie robot-assistee en 180 minutes. L’intervention commence par une cystotomie mediane jusqu’a la zone d’erosion retro-trigonale. La dissection inter-vesico-vaginale permet de liberer la bandelette des parois vesicales et vaginales, puis se poursuit en suivant la prothese dans son passage a travers le parametre, jusqu’a sa fixation au promontoire. La vessie est suturee par 2 hemi-surjets verticaux de V-lock apres mise en place de sondes JJ. Les portions retro-pubiennes de la bandelette TVT sont disseques en partant de l’espace de Retzius jusqu’a l’aponevrose pelvienne. Il n’y a pas eu de complication peroperatoire. La patiente a quitte le service a J2 mais a du etre rehospitalisee pour pyelonephrite a J10 pendant 3 jours (Clavien 2). Conclusion L’explantation d’une bandelette de promontofixation anterieure par laparoscopie robot-assistee est une technique faisable qui pourrait diminuer la morbidite perioperatoire l’ouverture vesicale securise le geste en permettant une bonne visibilite.

Objectifs La surrenalectomie est le traitement de reference en cas de diagnostic de pheochromocytome. Toutefois cette chirurgie est a risque, notamment de poussee d’hypertension arterielle (HTA) peroperatoire. L’objectif de cette etude etait de rapporter les complications de la surrenalectomie pour pheochromocytome et de rechercher les facteurs predictifs de poussee d’HTA peroperatoire. Methodes Tous les patients ayant eu une surrenalectomie pour pheochromocytome dans un centre entre 2006 et 2019 ont ete inclus dans une etude retrospective. Le protocole de preparation preoperatoire incluait de l’Eupressyl IVSE. Le critere de jugement principal etait la survenue de fluctuations hemodynamiques (FLUCTHEM) definies comme pression arterielle (PA) systolique > 160 mmHg ou diastolique Resultats Soixante-quinze patients ont ete inclus. Cinquante-huit patients ont presente des FLUCTHEM (77,3 %) avec une mediane de 2 episodes par patients d’une duree moyenne totale de 23 minutes. Trois patients ont presente un DYSRYTHM peroperatoire. Il y a eu 14 complications postoperatoires (18,7 %), mais uniquement cinq Clavien 3 (6,7 %). Il y a eu cinq complications cardiovasculaires postoperatoires : une embolie pulmonaire (1,3 %), deux syndromes coronariens aigus (2,7 %) et deux œdemes aigues du poumons (2,7 %). Ces patients avaient un nombre median d’episodes de FLUCTHEM plus important (3 vs 2 ; p = 0,11). Les seuls facteurs associes a la survenue de FLUCTHEM en analyse univariee etait la taille de la lesion (OR = 1,03 ; p = 0,03), le taux de normetanephrines urinaires (OR = 1,01 ; p = 0,03) et l’existence d’une HTA anterieure (OR = 4,41 ; p = 0,04) ( Tableau 1 ). Conclusion La survenue de FLUCTHEM durant la surrenalectomie pour pheochromocytome est frequente mais ne s’accompagne que de rares complications en particulier cardiovasculaires. Toutefois, il pourrait exister un lien entre FLUCTHEM et complications cardiovasculaires postoperatoires et les mesures permettant de limiter les FLUCTHEM paraissent donc d’interet.

Objectifs Le cancer de la prostate de risque intermediaire est desormais classe en pronostic favorable et defavorable, en fonction du score ISUP, du PSA, du toucher rectal et du pourcentage de biopsies positives. Notre objectif etait d’evaluer l’apport de l’imagerie et des biopsies ciblees pour ameliorer cette classification a partir de l’analyse du stade histopathologique apres prostatectomie totale. Methodes Il s’agit d’une etude retrospective unicentrique ayant inclus les patients avec un CaP de risque intermediaire traites par prostatectomie radicale (PR) entre janvier 2016 et decembre 2019. Une imagerie prostatique par resonance magnetique (IRM) 1,5 T preoperatoire etait realisee. Le CaP avec des criteres histopathologiques defavorables (CHD) a ete defini par tout pT3-4 et/ou pN1 et/ou de grade (ISUP) ≥ 3 sur la piece de prostatectomie. Les performances de la classification standard du risque intermediaire et de differents modeles bases sur les donnees cliniques, d’imagerie, anatomopathologiques et radiomiques pour la prediction de CHD ont ete evaluees par regression logistique binaire. Resultats Au total, 419 patients ont ete analyses. Le risque intermediaire defavorable etait associes aux CHD du CaP (p Conclusion L’integration des caracteristiques d’imagerie et des biopsies standards et ciblees permet d’ameliorer la sous-classification standard du risque intermediaire et de mieux predire la presence de criteres defavorables sur la piece de prostatectomie.

707 Background: In the current era of Immune checkpoint inhibitors (ICI), the role and timing of nephrectomy in the case of complete response on metastatic sites is still unknown. We aimed to evaluate the feasibility of nephrectomy for residual disease in patients with metastatic renal cell carcinoma (mRCC) and complete response (CR) on metastatic sites following ICI. Methods: Patients who underwent partial or radical nephrectomy after prior ICI between 2015 and 2018 were retrospectively included and clinicopathological data were reviewed. Perioperative data and postoperative outcomes were recorded. Results: Eleven patients without initial cytoreductive nephrectomy at diagnosis underwent delayed nephrectomy after long ICI administration because of complete response on metastatic sites. Median age was 59.8 years [38-67]. All patients had clear cell RCC on the initial biopsy. IMDC prognostic group was intermediate (81.8%) or poor (18.2%). ICI was administered as first-line therapy in 36.4% of cases (4/11) and as second-line option after TKI in 63.6% of cases (7/11). Treatments regimens were: nivolumab + ipilimumab (n = 3), nivolumab + tivozanib (n = 2) or nivolumab alone (n = 6). The median duration of ICI treatment was 10 months (range: 3-38 months) and the mean number of cycles was 27 (range: 6-75). Median operative time was 243 minutes [135-345] and mean blood loss was 909 cc [40-4000]. In 81.8% (n = 9) of the cases, surgeons experienced challenges for finding dissection planes due to inflammatory infiltration. The 30-day Clavien-Dindo postoperative complication rate was 54.6%, including 1 surgery-related death. Pathological report showed lymphocyte and/or macrophage infiltration in 54.6% and complete pathological response in 2 cases. Median follow-up was 15 months, with 73% of patients free from progression and 54% free from systemic treatment at 1 year. Conclusions: Nephrectomy following ICI for mRCC could allow achieving CR in selected patients. Due to technically complexity and complications rates, this surgery should be performed in centers with extensive experience.

Resume Objectif Proposer une mise a jour des recommandations de la prise en charge des cancers du rein. Methodes Une revue systematique de la litterature a ete faite sur la periode allant de 2015 a 2018. Les articles juges les plus pertinents concernant le diagnostic, la classification, le traitement chirurgical, le traitement medical et le suivi du cancer du rein ont ete selectionnes et incorpores aux recommandations. Les recommandations ont ainsi ete actualisees en specifiant le niveau de preuve. Resultats L’examen de reference pour faire le diagnostic et le bilan d’extension des cancers du rein est le scanner thoraco-abdominal injecte. L’IRM et l’echographie de contraste sont indiquees dans certains cas particuliers. La biopsie percutanee est recommandee dans les situations ou ses resultats influenceront la decision therapeutique. Les tumeurs du rein doivent etre classees selon la classification pTNM 2017 et le grade nucleolaire de l’ISUP. Les cancers du rein metastatiques doivent etre classes selon les criteres de l’IMDC. La nephrectomie partielle est le traitement de references des tumeurs T1a et peut etre faite par voie ouverte, laparoscopique ou robotique. Les therapies ablatives et la surveillance active sont des options chez les patients âges avec des comorbidites. Les tumeurs T1b doivent etre traitees par nephrectomie partielle ou totale en fonction de la complexite tumorale. La nephrectomie totale est le traitement de premiere intention des cancers localement avances localises. Chez les patients metastatiques : la nephrectomie est recommandee en cas de bon pronostic ; le traitement medical doit etre propose en premiere intention en cas de pronostic mauvais ou intermediaire. Le traitement chirurgical ou local des metastases peut etre propose en cas de lesion unique ou d’oligo-metastases. Les molecules recommandees en premiere ligne chez les patients metastatiques sont le sunitinib, le pazopanib et l’association nivolumab/ipililumab. Le cabozantinib peut etre propose en option chez les patients de risque intermediaire et mauvais. Les tumeurs kystiques doivent etre classees selon la classification de Bosniak. L’exerese chirurgicale doit etre proposee en priorite aux lesions Bosniak III et IV. Il est recommande de suivre les patients sur les plans cliniques et radiologiques en adaptant les modalites a l’agressivite tumorale. Conclusion L’actualisation des recommandations doit permettre aux praticiens francais et francophones d’encadrer au mieux leur prise en charge des cancers du rein.

OBJECTIVE To evaluate the ability of neoadjuvant axitinib to reduce the size of T2 renal cell carcinoma (RCC) for shifting from a radical nephrectomy (RN) to a partial nephrectomy (PN) indication, offering preservation of renal function. PATIENTS AND METHODS Patients with cT2aN0NxM0 clear-cell RCC, considered not suitable for PN, were enrolled in a prospective, multicentre, phase II trial (AXIPAN). Axitinib 5 mg, and up to 7-10 mg, was administered twice daily, for 2-6 months before surgery, depending on the radiological response. The primary outcome was the number of patients receiving PN for a tumour