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To update the French guidelines on kidney cancer.- A systematic review of the literature between 2015 and 2020 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence.- Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultra-sound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. There is no recommended adjuvant treatment. In metastatic patients: cyto-reductive nephrectomy can be offered in case of good prognosis; medical treatment must be counseled first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First line recommended drugs in metastatic patients include the associations axitinib/pembrolizumab and nivolumab/ipilimumab. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness.- These updated recommendations should assist French speaking urologists for their management of kidney cancers.

BCG instillations are the gold-standard treatment for high-risk non-muscle-invasive bladder cancer (NMIBC) with a decreased risk of tumor recurrence and muscle infiltration. From 2012 to 2014, a stock shortage of the Connaught strain has led to the cessation of supply for immucyst in France. The objective of this study was to evaluate the potential impact of BCG shortage on the management of patients with NMIBC.We conducted a retrospective single-center study including patients followed from May 2005 to May 2015 with a high-risk NMIBC (primo-diagnosis). Patients were separated into two groups: not impacted by the shortage (NISG: 56 patients) and impacted by the shortage (ISG: 53 patients). Data on tumour recurrence (RFS), muscle progression (PFS) and overall and specific survival (OS and SS) were also analysed.The BCG induction schedule could not be carried out in 20.8% of cases in the ISG compared to only 5.3% of cases in NISG (P=0.02). Similarly, the maintenance treatment was incomplete for 56.6% of cases versus 37.5% in NISG (P=0.047). Nevertheless, it should be underlined that very high-risk NMIBC received a complete induction BCG schedule. The ISG seems to have benefited with the evolution of the guidelines with the use of diagnosis bladder fluorescence but without significant difference on the rate of second look bladder trans-uretral resection. The cystectomy rate was higher in ISG. No significant difference in RFS, PFS, OS, and SS between the two groups.In our experience, RFS, PFS, OS or SS were not impacted by the BCG shortage. These data may be explained by a better selection of very high-risk patients including the recommended BCG schedule and more frequently the use of diagnosis bladder fluorescence.3.

Renal traumas are common, observed in 10% of patients with abdominal trauma. Most renal traumas are blunt, resulting from a direct hit or from an abrupt deceleration.We realized a synthesis of renal trauma management for nurses.Clinical presentation often encompasses gross hematuria and lumbar pain. The best diagnostic tool is computed tomography (CT) urogram. Based on CT urogram images, renal traumas are classified according to the American Association for the Surgery of Trauma (AAST) classification in five grades of increasing severity. The management is conservative in the vast majority of cases and has been largely simplified over the past few years, being now mostly based on observation. Radiological interventional and endoscopic procedures are used only in very selected cases and surgical exploration has become extremely rare.The prognosis has also considerably improved and renal trauma rarely result in death or loss of the kidney nowadays.

Resume Objectifs Les publications recentes nord-americaines ont montre l’interet de la chirurgie robotique video-assistee. Nous rapportons la mise en place d’une telle technique dans un centre universitaire francais et les premiers resultats dans une unite avec volume d’activite modere. Methodes Etude retrospective monocentrique. Le programme a debute apres une periode de 6 mois d’apprentissage. Resultats De janvier 2012 a janvier 2013, 30 patients (17 hommes) d’âge median 54 ans [Q1–Q3 : 48–63] et de score ASA 2 [1,2] ont ete operes par chirurgie mini-invasive robot-assistee. Les procedures realisees ont ete : 9 thymectomies (30 %), 11 lobectomies avec curage (38 %), 4 segmentectomies (14 %), 3 lymphadenectomies diagnostiques (10 %), 2 kystes bronchogeniques (5 %) et une resection mediastinale posterieure (3 %). Aucune conversion en thoracotomie n’a ete necessaire. La perte sanguine mediane etait de 50 mL [10–100]. Le temps operatoire median etait de 135 min [105–165] avec 30 min [20–40] pour l’installation du robot, 90 min [70–120] pour le temps a la console et 15 min [10–15] pour l’extraction de la piece operatoire et la fermeture. La duree d’hospitalisation a ete de 4 jours [4–6] avec 6 (20 %) complications mineures (Grade 1 selon la classification de Clavine-Dindo). Apres un suivi median de 4 mois [2–7], tous les patients etaient vivants et attestaient d’une qualite de vie satisfaisante. Conclusion Cette serie suggere que la chirurgie thoracique robotique est une technique sure et efficace pour la prise en charge de diverses pathologies, avec une faible morbidite et sans courbe d’apprentissage significative, meme dans un centre avec volume d’activite modere. Cette technologie devrait accompagner le developpement de la chirurgie thoracique mini-invasive. L’importance de l’apprentissage a la chirurgie robotisee doit etre soulignee, de facon a optimiser les procedures et les couts.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.004. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.004. That newer version of the text should be used when citing the article.

The previous guidelines from the Cancer Committee of the Association Française d'Urologie were published in 2013. We wanted this new version to be simple, clear and straightforward. All significant recent publications on kidney cancer have been included. The main changes compared to 2013 are the following: © 2016 Elsevier Masson SAS. All rights reserved.

The usefulness of partial nephrectomy (PN) has been demonstrated for the treatment of renal tumor7cm and it is now the standard treatment for such lesions. However, few studies are available regarding tumors≥T2. The objective of this study was to assess PN results for the treatment of renal tumors7cm.A retrospective two-center study was performed, including 170 patients treated. Thirty-two patients underwent PN and 138 radical nephrectomy (RN) for renal cT2 tumors between 2004 and 2014. The biological and clinical characteristics including perioperative morbidity as well as the survival rate were compared between these 2 groups.The median age was 59.5 years and the median follow-up was 47 months. More cT2b tumors were treated through RN (34.1% vs. 12.5%, P=0.01). The postoperative decrease in creatinine clearance was higher for the RN group (-24.3mL/min vs. -16.8; P=0.04). This difference was no longer significant at last follow-up. Perioperative complications were more frequent in the PN group (50.0% vs. 18.1%; P=0.008), and more severe (Clavien≥3 18.7% vs. 5.1%, P=0.01). No difference was found regarding the overall survival. Surgical margins were more frequent in the PN group (9.1% vs. 0.85%; P=0.01).Our results suggested the feasibility of PN for renal tumors7cm, involving however a higher perioperative complication risk. Cautious patient selection appeared to be required for the indication of PN for large tumors.4.

Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification.Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group.Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3.The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair.4.

The study objectives were to analyze the resident's laparoscopic surgery performance in order to build a self-assessment data set, to identify discriminatory exercises and to investigate the suturing time changes.From 2007 to 2014, the French Association of Urologist in Training (AFUF) organized 7 pelvitrainer contests. Participant scores on 11 laparoscopic surgery exercises were evaluated.Sixty-six residents participated to these contests and performed 11 exercises each. Twenty-two (33.3 %) participants were beginners, 26 (39.4 %) intermediates et 18 (27.3 %) experienced. The participant scores were gathered into a data set including the average time per exercise. We found a time scoring improvement related to the resident experience for all exercises. A significant decline in time was noted for exercise 8 and 9 between beginners and intermediates (139s [±71]), (173.9s [±118.3]) and between beginners and experienced (80.6s [±26.7]), (94,1s [±42.7]) with a P0.05. The correlation coefficient for the exercise 11 duration (vesico-uretral anastomosis) was 0.04 over a 7-year period (P=0.44).The study provided a data set on 11 laparoscopic surgery tasks which can be consulted by all residents as a reference in a self-assessment process. Two exercises (8 and 9) discriminated beginners from intermediates and experienced groups and could be used as a benchmark ahead of an operating room procedure. The vesico-uretral anastomosis duration (exercise 11) did not improve significantly between 2006 and 2014.4.

Holmium laser enucleation of prostate (HoLEP) is renowned for the difficulty of its learning curve. Our aim was to evaluate the interest of a three-step tutorial in the HoLEP learning curve, in a university center.It is a retrospective, monocentric study of the 82 first procedures done consecutively by the same operator with a proctoring in early experience and after 40 procedures. For all patients were noted: enucleation efficiency (g/min), morcellation efficiency (g/min), percentage of enucleated tissue (enucleated tissue/adenome weigth evaluated by ultrasonography. g/g), perioperative morbidity (Clavien), length of hospital stay, length of urinary drainage, functional outcomes at short and middle term (Qmax, post-void residual volume [PVR], QOL scores and IPSS at 3 and 6months).Enucleation and morcellation efficiency were significantly higher after the second proctoring (0.87 vs 0.44g/min; P0.0001 and 4.2 vs 3.37g/min, P=0.038, respectively) so as the prostatic volume (43.5 vs 68.1mL, P=0.0001). Percentage of enucleated tissue was higher in the second group, however, the difference was not significant (69.5% vs 80.4%, P=0.03). Per- and postoperative complications, hospital length of stay, urinary drainage length and functional results at 3 and 6months were not significantly different.The learning curve did not interfere with functional results. The second proctoring was essential to us in order to grasp the technique. These data underlined the necessity of a pedagogic reflexion in order to built a standardized formation technique to the HoLEP.4.

The aim of this study was to assess the feasibility, efficacy and tolerance of Greenlight™ and Holmium sphincterotomy for treating detrusor-sphincter dyssynergia.All men treated with this two techniques between may 2012 and june 2015 were analyzed. Preoperative evaluation included kidney ultrasound scan, urodynamic, retrograde and voiding urethrocystography. Postoperative assessment was composed of a post-void residual volume measurement when the urethral catheter was removed and 1 year after the procedure, a retrograde and voiding urethrocystography at 3 months and telephonic Likert scale questionnaire.Twelve patients were operated with Greenlight™ and 12 with Holmium. Eleven had a memocath urethral stent preoperatively. Post-void residual volume median for both techniques was 285 cc preoperatively vs 137.5 cc postoperatively (P0.001). Likert scale global satisfaction was 75%. Five stenosis (20.8%) were observed within a median of 4 months.Greenligth™ and Holmium procedures are efficient techniques with low morbidity. However, superiority toward monopolar incision remains to be demonstrated through complementary studies.4.

Resume Introduction La restauration d’une miction physiologique est un objectif majeur pour les patients presentant une lesion medullaire que les traitements actuels ne permettent pas. Plusieurs etudes recentes ont propose des techniques de reinnervation vesicale. Leur but etait de provoquer une miction volontaire par la stimulation d’un arc reflexe artificiel cree par l’anastomose d’une racine efferente somatique avec une racine sacree a destinee vesicale. Materiels et methodes Une revue de la litterature en anglais a ete realisee sur les moteurs Pubmed et Cochrane avec les mots cles : bladder reinnervation, spinal cord injury neurogenic bladder, reflex pathway for micturition. Resultats Les etudes rapportaient une efficacite variable allant jusqu’a 85 % des patients traites. Ils pourraient alors declencher volontairement une miction associee a une amelioration significative des parametres urodynamiques postoperatoires. En effet, il etait mis en evidence une amelioration de la dyssynergie vesico-sphincterienne et ou de l’hyperactivite vesicale et les patients presentaient une meilleure qualite de vie par le controle de leur miction associee a une amelioration de la continence et un sevrage du sondage uretral. Mais ces resultats etaient variables d’une etude a l’autre, et certains paraissaient difficiles a expliquer, notamment concernant l’abolition de l’hyperactivite vesicale et la disparition de la dyssynergie vesico-sphincterienne. Conclusion Une poursuite des experimentations est encore necessaire notamment chez l’animal afin de confirmer les resultats encourageants de ces premieres etudes et de mieux en comprendre le mecanisme avant une eventuelle utilisation a plus grande echelle.

To assess the prognostic value of clinical and biological features in patients treated with second-line targeted therapies (TT) for a metastatic renal cell carcinoma (mRCC).A retrospective study was performed including 60 patients treated with second-line TT from 2006 to 2013. Clinical and biological features were collected, including TT-induced toxicities, Heng and MSKCC prognostic scores, and renal function. Overall survival (OS) and progression-free survival (PFS) were assessed using univariate and multivariate analysis.The median age was 61 years [39-81]. MSKCC and Heng scores were significantly prognostic for OS and PFS (P0.05). Hypo-albuminemia, anemia and brain metastasis were associated with poorer OS and PFS (P0.05). Severe induced toxicities had a prognostic impact with higher OS (26 months vs 10 months, P=0.003) and PFS (5 months vs 4 months, P=0.047). Renal function impairment at the initiation of the second line was also associated with higher survival (OS=24 months vs 9 months, P=0.035 and PFS=7 months vs 4 months, P=0.043). On multivariate analysis, induced toxicity was found as an independent factor of good prognosis for OS (HR=0.36; P=0.01).Our results suggested that renal function impairment and TT-induced toxicities in the second line of treatment for mRCC have a potential prognostic interest as it had previously been reported for the first line of TT.5.

To assess the impact of a tumor size higher than 7cm on partial nephrectomy (PN) outcomes compared to a tumor size ranging between 4 and 7cm and to compare this impact to one of the RENAL score.Data from patients who underwent PN between 2006 and 2013 were retrospectively analysed. Patients with cT1b tumors and cT2 were included. Functional and oncological outcomes were compared. Analysis of the achievement of Trifecta (defined as a combination of warm ischemia time25min, negative surgical margins and no perioperative complications) was performed according to the tumor size and the RENAL score.Among 334 PN, 57 patients were included, (41 cT1b and 16 cT2), with a median follow-up of 23.5 months (6-88). There was no difference between the groups regarding intraoperative parameters except for the conversion rate, which was higher in the cT2 group (30% vs. 4.3%; P=0.02). The cT2 group also presented higher renal function impairment at postoperative day 4 (P=0.04) which did not persist at 6 months. There was no significant difference in oncologic outcomes between the 2 groups. The rate of achievement of the Trifecta did not differ between cT1b and cT2 groups. Conversely, Trifecta rate was higher in case of low complexity renal masses (RENAL score 4-6) compared to complex renal tumors (RENAL score 7-9 and 10-12).Our results showed that a tumor size higher than 7cm had no impact on PN outcomes in selected tumors according to complexity scores such as the RENAL score. Furthermore, a lower RENAL score appeared to be significantly associated with the Trifecta achievement.5.

Partial nephrectomy (PN) has become the gold standard for the treatment of small tumors confined to the kidney. As result, the number of PN procedures increased during the last years. Subsequently, we have more often to deal with the complications of this surgery. Among these, pseudoaneurysms are rare but potentially life-threatening due to a risk of bleeding. Therefore, pseudoaneurysms have to be treated according to a relevant strategy.We performed a literature review of the cases of pseudoaneurysm after PN was reported as well as a focus on the different treatment strategies and their outcomes.The incidence of pseudoaneurysm is low, ranging from 0.5% to 4%. Radio-embolization represents the gold standard treatment, used in 98% of the cases reported in the literature, allowing high success rate and rare morbidity. However, in some selected cases, surveillance could be an alternative.

Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume.Retrospective review of a single institution database. The program was launched after a 6-month preparation period.From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life.This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs.

In departments of urology, intradetrusor botulinum toxin injections are routinely performed in ambulatory outpatient clinic. The aim of the study was to assess the satisfaction level of patients treated with this technique.A satisfaction questionnaire was carried out by telephone for all patients treated in ambulatory outpatient clinic from 2009 to 2010.Twenty-six patients were treated in consultation during the studied period for a total of 46 sessions of injections. The average age was 48.81 (±16.78) years. An injection programme containing 20 or 30 points was performed after a local anesthetic. Twenty patients answered the questionnaire. As regards the organization of the injections, 12 patients (60%) declared to have been satisfied and seven very satisfied (35%). Eight patients (40%) were very satisfied with the management of the pain and six (30%) satisfied versus only one (5%) not satisfied at all. For the time spent in the hospital during the injections, 10 (50%) were satisfied and seven (35%) very satisfied. Only 4 patients (20%) would have preferred to be hospitalized in an outpatient facility. In cases of new injections, 18 (90%) patients would have preferred an identical coverage. Finally, 17 (85%) would recommend this procedure to one of their close relations.Our results showed that the majority of patients were completely satisfied with the injection programme. However, as patients are not currently covered by the national health system for these injections, this might hinder the development of this procedure.

Urinary and faecal incontinence (defining double incontinence) are common conditions, which are frequently associated and can altered sexuality. The effectiveness of the sacral nerve modulation (NMS) in the treatment of the urge urinary incontinence, faecal incontinence and double incontinence was shown.The present article aims to determine the impact of SNM on female sexual function in twenty women suffering from a double incontinence.All patients who received sacral neuromodulation for urge urinary and/or faecal incontinence between 2005 and 2010 and who still had the implant were included. Only 20 sexually active patients suffering from double incontinence were considered eligible. They completed a questionnaire on follow-up examinations.The initial indication of NMS was the urge urinary incontinence for 15 patients and the faecal incontinence for five patients. Ten patients (50%) were improved on two incontinence. All patients preserved sexual activity after the treatment of NMS. NMS improves the quality of sexual activity in 45% patients. The numbers of urinary and faecal episodes of incontinence are decreased respectively for 50% and 15% patients during sexual activity. The quality of sexual's life and orgasm score are significantly increased in the group of patients improved on the DI.This study confirms the effectiveness of NMS in the treatment of double incontinence which half patients are improved on the two incontinence. This study shows that improvement of urinary or faecal incontinence could have a positive impact on sexuality of these patients, especially for patients improved double incontinence. It is difficult to know if these results are related to its direct action on the neurological ways of sexual function or on its benefit on the continence.

The restoration of physiological micturition is a major objective for patients presenting a medullary injury, which is not possible with current treatment. Several recent studies have purposed some techniques for bladder reinnervation. Their purpose was to begin a voluntary micturition by the stimulation of an artificial reflex arc created by the anastomosis of a somatic root with a root innervating the bladder.We searched on Medline and Cochrane for articles in English. The keywords used were: bladder reinnervation, spinal cord injury neurogenic bladder, reflex pathway for micturition.These studies reported a variable efficacy as high as 85% of the treated patients. These patients could begin micturition voluntarily, associated with a significant improvement observed in their postoperative urodynamic evaluation. In fact, an improvement of the detrusor external sphincter dyssynergia and/or bladder overactivity was reported, and the patients presented a better quality of life by the control of their micturition associated with an improvement in continence with no need for intermittent catheterisation. However, these results were variable from one study to the other, and certain results seem difficult to explain notably concerning the abolition of bladder overactivity and the improvement of the detrusor external sphincter dyssynergia.Further experimental studies are still required, notably with animals to confirm the encouraging results of these initial studies, and to better understand the mechanism before possible routine patient use.