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Introduction: An increase in the number of organ harvesting procedures remains an essential prerequisite to meet the growing demands of patients on transplantation waiting lists. Few publications have described the workload related to this surgical activity and the human resources, equipment and organization involved. In the context of a review by public authorities of the needs for transplantation teams, the authors propose a qualitative and quantitative study of this activity as well as its impact on the functioning of a urology department., Material and Method: From January 1997 to December 2005, the Grenoble hospital urology department performed 390 organ harvesting procedures for a network of 5 hospitals located in three departments. Arrival and departure times, duration and the type of each procedure were recorded. The surgical team was composed of 5 surgeons until November 2003, with the arrival of a sixth surgeon., Results: During this period, 1,333 organs were harvested, including 775 kidneys. A typical organ harvesting procedure required the presence of the harvesting team from 8:15 p.m. to 1:45 a.m. and lasted a mean of 5 hours. It was performed outside of the teaching hospital within the network in 29.7% of cases, after hours in 96.9% of cases and required a mandatory rest period on the following day in 60% of cases., Conclusion: Organ harvesting is an essential surgical procedure, but it is urgent, frequent, long, and interferes with organization of the urology department. In the age of redefinition of public health objectives in transplantation and application of mandatory rest periods, surgical teams need to be reinforced in order to maintain a constant level of elective urological surgery.

Currently, kidney cancer is in most cases fortuitously diagnosed by ultrasound or abdominal computed tomography, performed for non-specific clinical signs. The late-developing clinical signs are suggestive of an advanced tumour stage. Abdominal computed tomography is the key examination; it enables to establish the diagnosis and assess tumour extension. Performing a tumour biopsy is useful in patients with small tumours, when diagnostic certainty is required or when metastases or a lymphoma are suspected.

An unexpected and exceptional observation was made during the biological follow-up of a patient who had undergone a radical prostatectomy for a prostate adenocarcinoma. A residual PSA level was first considered as a reliable marker of relapse. Certain limits are highlighted concerning the reliability of the PSA assay, which must be interpreted along with all the other prognostic information on the tumor and possibly verified using other biological techniques.

Objectives: To evaluate sexuality and erectile function of candidates for radical prostatectomy in order to assess the place of nerve-sparing surgery in the preoperative discussion., Material and Methods: From June 2004 to January 2005, 75 consecutive patients, candidates for radical prostatectomy, were prospectively evaluated. Their erectile function and sexuality were evaluated after announcing the diagnosis. Patients completed the IIEF (International Index of Erectile Function), EQS (Erection Quality Scale) and the sexual satisfaction score (SSS). The mean age of the patients was 65 years and 50% were younger than 65., Results: Erectile dysfunction according to the IIEF-5 scale was observed in 64% of cases (43% of patients younger than 65 and 84% of patients over 65). Erectile dysfunction was considered to be severe in 5% of young patients versus 34% of patients over 65. The majority of patients (69%) had a sexual activity more than twice a month. Only 31% of patients under 65 and 8% of older patients considered their erections to be very satisfactory according to the EQS. Despite this high frequency of erectile dysfunction in men over the age of 65, sexual satisfaction was not influenced by erectile dysfunction. In contrast, patients younger than 65, erectile dysfunction clearly altered the SST sexual satisfaction score., Conclusion: Erectile dysfunction was present in a large proportion of candidates for radical prostatectomy. The presence of erectile dysfunction in patients over the age of 65 did not modify their sexual satisfaction score. A detailed clinical interview concerning sexuality should be conducted to select patients likely to benefit from nerve-sparing surgery. Nerve-sparing surgery would be beneficial in young patients in whom sexual satisfaction is dependent on erectile function. In the older men, erectile dysfunction can be present without affecting sexual satisfaction.

Objective: To evaluate the current place of robotics in laparoscopic urological surgery., Material and Methods: A review of the international literature was conducted to evaluate the various available endoscope robot systems and telemanipulator robots and to establish their practical limitations and their contribution to surgery., Results: Robotic systems are based on various structures, which each present specific disadvantages. Two types of systems can be distinguished: endoscope robots and telemanipulator robots (complete robotic systems) with different degrees of complexity, dimensions and costs. Each system is different in terms of service rendered. Endoscope robot systems (EndoAssist, AESOP, LapMan) are reliable and eliminate the need for an assistant to hold the camera. Man-machine interfaces can be manual, by pedal or by voice recognition. They are relatively large and expensive, limiting their diffusion at the present time. Complete instrument-handling robots (master-slave manipulators) are currently represented by 2 robots (Zeus and Da Vinci) which have demonstrated their efficacy in many difficult operations. Their very high cost and their large dimensions also constitute limitations to their diffusion, making them inaccessible to the majority of centres. The urological community has largely contributed to the evaluation of robots in laparoscopic operations, as reflected by the large number of publications., Conclusion: Considerable technological progress has been made over recent years to make laparoscopic surgery more accessible. Current robotized tools are still imperfect systems, but, in the future, may possibly facilitate difficult laparoscopic operations, particularly in urology.

Introduction: The authors participated in the development of an innovative endoscope robot in laparoscopic surgery designed by TIMC-GMCAO, providing a solution to the disadvantages of currently available systems, i.e. their cost and large dimensions., Material and Methods: A compact robot (LER) placed on the patient's skin that can be used in the lateral and dorsal supine position was tested on cadavres and laboratory pigs in order to allow successive modifications. The current control system is based on voice recognition. The amplitude of vision is 360 degrees with an angle of 160 degrees. Twenty three procedures were performed (2 radical prostatectomies, 4 pelvic lymph node dissections, 6 nephrectomies, 2 adrenalectomies, 3 cholecystectomies, 1 small bowel resection-anastomosis, 1 cystectomy, 1 splenectomy, and 3 appendicectomies)., Results: Among the various control systems tested, we adopted voice recognition on the basis of its intuitive nature and the fact that it leaves one hand free. In the light of these studies, several aspects of the prototype were modified: reliability, fixation, ergonomy and dimensions. The ease of installation, which takes only 5 minutes, and the easy handling of the robot allowed 21 out of 23 laparoscopic procedures to be performed without the need for an assistant., Conclusion: The LER robot is an endoscope robot guided by the surgeon's voice that can eliminate the need for an assistant to hold the camera during laparoscopic surgery in the lateral and dorsal supine positions. The ease of installation and manufacture should make this an effective and inexpensive system. The gain in operating time was not evaluated during these trials on cadavres and pigs, as various prototypes were tested and several problems of reliability were successively resolved. Ongoing randomized, prospective clinical trials should soon validate this robot prior to marketing.

The use of a robotized camera holder in laparoscopic surgery allows a surgeon to control the endoscope without the intervention of an assistant. Today, the orders that the surgeon can give to robotized camera holders remain limited. In order to provide higher level interactions between the surgeon and a robotized camera holder, we have developed a new method for the automatic tracking of laparoscopic instruments which works in near real-time. The method is based on the measurement of the 3D positions of the insertion points of the instruments in the abdominal cavity and a simple shape model of the laparoscopic instruments. We present the results of our first experimentation on a cadaver.

Objective: To determine the tolerance of prostate biopsies in the case of co-administration of an analgesic gas composed of a ready for use mixture of nitrogen monoxide and oxygen (MEOPA) (marketed under the trade name of Kalinox), and intrarectal instillation of xylocaine gel by comparing the results with those obtained in a control group only receiving intrarectal xylocaine instillation., Material and Methods: Non-randomized, prospective study conducted on 100 cases, with a control group composed of the first 22 patients (before availability of MEOPA in the department), followed by 78 patients treated with MEOPA. A questionnaire was completed by the patient and by the outpatient nurse caring for the patient., Results: A very significant reduction (p=0.003) of the VAS pain score (from 3.86 to 2.38) and a highly significant improvement (p<0.001) of global tolerance of the procedure based on the nurse's estimation of pain (VAS scale) were observed. The MEOPA group also presented a significant improvement of pain in patients who had previously undergone a series of prostate biopsies (p=0.043). The satisfaction rate was higher in patients receiving MEOPA, although 28.2% of patients experienced adverse effects, all minor and bothersome in only 3.81% of cases., Conclusion: The MEOPA analgesic method as a complement to intrarectal xylocaine instillation considerably improved tolerance of the procedure with no major adverse effects and without prolonging the procedure or the surveillance. It is simple to use, safe and effective.

Objective: To evaluate the medium-term results of treatment for traumatic dissection of the renal arteries in a series of 12 cases and to propose emergency management based on recent endovascular revascularization techniques., Material and Methods: Between January 1999 and July 2003, 12 patients were admitted for closed trauma of the renal artery. There were 11 dissections with thrombosis and 1 intimal flap without distal thrombosis. Six patients were revascularized surgically (3 reno-renal bypass grafts, 3 auto-transplantations), 4 patients were treated by an endovascular procedure and 2 patients were treated conservatively with simple surveillance. Renal function, renal artery patency and blood pressure were evaluated immediately and at 3 months by clinical examination, Doppler ultrasound of the renal artery or CT angiography, and renal scintigraphy., Results: In the group of 6 patients undergoing surgical revascularization (mean warm ischaemia time: 8 hours 30 minutes), 2 nephrectomies were performed (1 failure of revascularization, 1 sepsis in a non-functioning kidney). The other 4 patients presented negligible renal function on scintigraphy at 3 months despite patent renal arteries. Among the 4 patients undergoing endovascular revascularization (mean warm ischaemia time: 8 hours 50 minutes), 2 died from associated lesions and 2 had a non-functioning kidney (1 stent thrombosis, 1 silent kidney despite a patent renal artery). No cases of hypertension were observed regardless of the type of management., Conclusion: Renal revascularization after thrombosis due to traumatic dissection of the renal artery must not be performed systematically after a warm ischaemia time of more than 4 hours in view of the poor recovery of renal function and the absence of morbidity associated with simple surveillance. When a procedure is performed, evaluation of the results must be based on morphological as well as functional parameters (scintigraphy).

Control of the renal vascular pedicle in a context of severe renal trauma in a haemodynamically unstable patient is difficult due to the large retroperitoneal haematoma. Laparotomy in these exsanguinated patients is associated with a risk of cardiac arrest due to hypovolaemia. The authors describe an endovascular aortic balloon catheter occlusion technique prior to laparotomy for haemostasis nephrectomy in a haemodynamically unstable patient presenting an abdominal compartment syndrome. In the light of this case, the authors discuss vascular control in the context of surgical management of severe renal trauma.