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Objectives: The objective of this study was to assess the impact of complete transurethral resection of bladder tumors (TURBTs) before radical cystectomy on pathological and oncological outcomes of patients with muscle-invasive bladder cancer (MIBC) and high-risk non-MIBC. Materials and Methods: The charts of all patients who underwent radical cystectomy for bladder cancer in 2 academic departments of urology between 1996 and 2016 were retrospectively reviewed. Patients were divided into 2 groups according to the completeness of the last endoscopic resection before radical cystectomy: macroscopically complete transurethral resection (complete) or macroscopically incomplete transurethral resection (incomplete). The primary end point was the recurrence-free survival (RFS). Secondary end points included cancer-specific survival (CSS) and rates of pT0 and downstaging. Results: Out of 486 patients included for analysis, the TURBT immediately preceding radical cystectomy was considered macroscopically complete in 253 patients (52.1%) and incomplete in 233 patients (47.9%). In multivariate analysis, macroscopically complete TURBT was the strongest predictor of both pT0 disease (OR = 3.1; p = 0.02) and downstaging (OR = 7.1; p < 0.0001). After a median follow-up of 41 months, macroscopically complete TURBT was associated with better RFS (5-year RFS: 57 vs. 37%; p < 0.0001) and CSS (5-year CSS: 70.8 vs. 54.5%; p = 0.002). In multivariate analysis adjusting for multifocality, weight of endoscopic resection specimen, cT4 stage on preoperative imaging, interval between endoscopic resection and radical cystectomy, neoadjuvant chemotherapy, pT stage, and associated carcinoma in situ, macroscopically complete endoscopic resection remained the main predictor of better RFS (HR = 0.4; p = 0.0003) and the only preoperative factor associated with CSS (HR = 0.5; p = 0.01). Conclusion: A macroscopically complete TURBT immediately preceding radical cystectomy may improve pathological and oncological outcomes in patients with MIBC and high-risk MIBC.

Resume Objectif La maladie lithiasique est frequente et couteuse. Sa prise en charge a evolue et la chirurgie ambulatoire est devenue un enjeu majeur de qualite de soins et de depenses de sante. L’objectif etait d’evaluer la faisabilite de l’ureteroscopie souple pour calcul en ambulatoire. Methodes Une etude retrospective monocentrique a ete menee incluant tous les patients ayant eu une ureteroscopie souple pour calculs en ambulatoire entre janvier 2012 et decembre 2013. Etait defini comme un echec de l’ambulatoire une duree d’hospitalisation de plus de 12 heures ou la necessite de re-hospitaliser le patient dans les 48 premieres heures. Une analyse univariee a ete realisee pour rechercher les facteurs predictifs d’echec de l’ambulatoire. Resultats Cent cinquante-sept patients ont ete inclus pour un total de 174 interventions. Il s’agissait majoritairement d’hommes (57,5 %), avec un indice de masse corporelle (IMC) moyen de 25,2 kg/m2 ± 4,3. Les calculs etaient majoritairement uniques (64,3 %), avec une taille moyenne de 14,2 mm ± 11,2. Une sonde double J etait presente en preoperatoire pour 80 patients (46,5 %), et la duree operatoire moyenne etait de 64,2 minutes ± 34,1. Une gaine d’acces etait utilisee dans 39 interventions (22,4 %). Un drainage postoperatoire par sonde double J etait realise chez 103 patients (59,1 %). Au total, 165 interventions (94,8 %) ont pu etre realisees en ambulatoire avec succes. Sur l’imagerie de controle, 69,5 % des patients etaient sans fragment residuel. Des complications etaient observees dans 3,4 % des cas, majoritairement Clavien 1–2 (83,3 %). Les facteurs predictifs d’echec de la prise en charge ambulatoire en analyse univariee etaient le sexe masculin (p = 0,04), l’IMC (p = 0,03), et la prise d’anticoagulants (p = 0,003). Conclusion Dans cette serie, l’ureteroscopie souple pour calculs urinaires realisee en ambulatoire apparaissait comme une methode efficace et sure, presentant peu de complications (3,4 %) et avec un faible taux d’echec (5,1 %). Niveau de preuve 4.

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.

International audience; Objectives: To assess the impact of a prolonged follow-up schedule using computed tomography scan on oncological outcomes after radical cystectomy for bladder cancer. Methods: A single-center retrospective study was carried out. All patients who underwent a radical cystectomy for bladder cancer between 1992 and 2012 were included. The protocol for postoperative oncological follow up included a thoracoabdominal computed tomography scan twice per year for 2 years and then annually for life. The patients with tumor recurrence were divided into two groups: asymptomatic recurrences and recurrences diagnosed because of symptoms. Cancer-specific survivals were estimated using the Kaplan–Meier method and compared with the log–rank test. Cox proportional hazards regression models were used to determine the predictive factors of cancer-specific survival. Results: Overall, 331 patients were included in this analysis, and, of them, 48.5% had a cancer recurrence after a median follow up of 52.6 months. A total of 30 of these recurrences were diagnosed at routine follow up among asymptomatic patients (18.8%). A total of 50% of recurrences occurred during the first 6 months and 75% during the first year. Just 10 of the recurrences (6.3%) appeared more than 3 years after radical cystectomy. The 5-year cancer-specific survival was higher in patients with asymptomatic recurrences (15.7% vs 32.1%), but this difference was not statistically significant (P = 0.10). On multivariate analysis, detection of asymptomatic recurrence reached statistical significance (HR 0.55; P = 0.04). Conclusion: Routine computed tomography scan surveillance after radical cystectomy for bladder cancer might provide a survival benefit. The risk of recurrence beyond 3 years seems to be low, and further studies are required to determine the role of routine computed tomography scan in the follow up beyond this timeframe. © 2016 The Japanese Urological Association

International audience; BACKGROUND: Phthalic acid esters are widely used in the manufacture of plastics. Numerous studies have shown that these phthalates impair testicular testosterone production in the rat. However, the scarce and contradictory data concerning humans have cast doubt over whether these compounds are also anti-androgenic in man. We therefore investigated the direct effects of di-(2-ethylhexyl) phthalate (DEHP) and mono-(2-ethylhexyl) phthalate (MEHP) on organo-cultured adult human testis and a human cell line. METHODS: Adult human testis explants or NCI-H295R adrenocortical human cells were cultured with DEHP or MEHP. The effects of ketoconazole, used as a reference molecule, were also assessed. RESULTS: In both models, DEHP and MEHP significantly inhibited testosterone production. The effects of both phthalates appeared to be specific for steroidogenesis, as INSL3 production by Leydig cells was not altered. Furthermore, the phthalates of interest had no effect on inhibin B production by Sertoli cells or on germ cell apoptosis. As only a small fraction of the phthalates added was found in the testis explants, and as these compounds were found to be metabolized, we estimate that the anti-androgenic effects observed occurred at concentrations of phthalates that are of the same order of magnitude as exposures reported in the literature for men. CONCLUSIONS: We provide the first evidence that DEHP and MEHP can inhibit testosterone production in the adult human testis. This is consistent with recent epidemiological findings of an inverse correlation between exposure to MEHP and testosterone concentrations.

Objectifs L’importance d’une resection transuretrale de vessie (RTUV) macroscopiquement complete est largement etablie dans le traitement des tumeurs vesicales non infiltrant le muscle (TVNIM) et des tumeurs vesicales infiltrant le muscle (TVIM) dans le cadre d’un traitement multimodale associant RTUV et radiochimiotherapie. En revanche, l’impact d’une RTUV complete chez les patients traites par cystectomie pour tumeur de vessie n’a jamais ete evalue. L’objectif de cette etude etait d’evaluer l’impact d’une RTUV complete avant cystectomie radicale sur les resultats oncologiques. Methodes Une etude retrospective bicentrique a ete menee incluant tous les patients ayant eu une cystectomie pour tumeur de vessie de 1995 a 2016. Les patients etaient separes en deux groupes selon le caractere macroscopiquement complet ou non de la derniere RTUV avant cystectomie d’apres le compte rendu operatoire (CRO). Si la description sur le CRO etait douteuse le patient etait exclu. Les criteres de jugement etait la survie sans recidive (SSR), la survie specifique (SSpe) et le taux de diminution du stade (« downstaging ») et de pT0 entre l’anatomopathologie de la RTUV et de la piece de cystectomie. Resultats Cent-vingt et un patients sur les 607 operes sur la periode etudiee ont ete exclus par manque d’elements sur le CRO. Sur les 486 patients inclus, 253 avaient eu une RTUV complete contre 233 incomplete ( Tableau 1 ). En analyse multivariee, le taux de pT0 et de « downstaging » etait plus important dans le groupe RTUV complete (OR = 3,1 IC95 % [1,1–9,5] ; p = 0,02 et OR = 7,1 IC95 % [3,1–18,2], p p Fig. 1 )] de meme que la SSpe [SSpe a 5 ans : 70,8 % vs 54,5 % p = 0,002 ( Fig. 2 )]. En analyse multivariee ajustant notamment au poids de la tumeur et l’utilisation de chimiotherapie neoadjuvante, la resection complete etait le facteur le plus fortement associe a la SSR (HR = 0,4 ; p = 0,0003) et le seul facteur associe a la SSpe (HR = 0,5 ; p = 0,01). Conclusion Dans cette etude, une RTUV complete avant cystectomie etait associee a un benefice en termes de survie sans recidive et de survie specifique ; ainsi qu’a un taux plus important de pT0 et de diminution du stade.

Resume Objectif Presenter notre experience initiale de la nephrectomie laparoscopique par acces unique ombilical ( laparoendoscopic single-site surgery ou LESS selon la terminologie internationale). Methodes Neuf nephrectomies et une exerese de kyste ont ete realisees chez neuf patients entre mai 2009 et mars 2010. Toutes les donnees demographiques, peri- et postoperatoires ont ete analysees. La chirurgie etait realisee par trois trocarts de 5 mm mis en place dans la meme incision peri-ombilicale. Dans deux cas, un trocart unique avec trois canaux integres a ete utilise. Une optique de 5 mm avec une vision de 30° etait utilisee avec des instruments de cœlioscopie conventionnelle. La piece operatoire etait extraite dans un sac endoscopique de 10 mm via l’incision ombilicale. Resultats Il s’agissait majoritairement d’hommes dont l’âge moyen etait de 56 ans. L’IMC moyen etait de 23,5 (19–34). La duree operatoire moyenne etait de 149 min (80–240), et le saignement moyen de 90 mL (20–250). Aucune transfusion sanguine n’a ete necessaire. La duree moyenne d’hospitalisation etait de 4,1 jours (3–5). Une seule complication majeure (occlusion fonctionnelle) a ete observee. Une conversion en laparoscopie conventionnelle a du etre realisee du fait d’un rein detruit inflammatoire. L’examen histologique a montre des lesions benignes (kystes et reins detruits) dans sept cas et des carcinomes papillaires dans trois cas. Conclusion La nephrectomie par LESS est possible. Ses avantages ne sont pas encore evidents par rapport a la laparoscopie « classique ». Il s’agit d’une technique recente qui devrait beneficier des progres de l’instrumentation.

Resume Objectifs La famille des kinases Aurora a un role crucial dans la regulation de la mitose. La surexpression d’Aurora A et B a ete rapportee dans de nombreux cancers. L’objectif de cette etude etait d’analyser l’expression d’Aurora A et B dans le carcinome a cellules renales (CCR) et son association avec les parametres cliniques et pathologiques usuels. Methodes Nous avons etudie retrospectivement des echantillons tumoraux de 40 patients operes pour tumeur renale entre 2003 et 2006. L’ARN etait extrait des echantillons tumoraux congeles correspondants. Apres controle de la qualite de l’ARN, 31 echantillons ont ete retenus afin d’evaluer l’expression des genes Aurora A et B par RTPCR. Une analyse statistique a ete realisee utilisant le test du χ 2 afin de comparer les niveaux d’expression d’Aurora A et B. Resultats L’âge moyen des patients etait de 65 ans (35–82). Sept (22 %) d’entre eux presentaient un envahissement ganglionnaire et huit (26 %) des metastases a distance. La majorite des tumeurs (74 %) etaient classees grade 3 ou 4. Dix-huit patients (58 %) presentaient un carcinome a cellules claires, 12 (39 %) un carcinome papillaire et un une tumeur de Bellini. La surexpression d’Aurora A etait associee a l’envahissement ganglionnaire ( p = 0,001). La surexpression d’Aurora B etait associee a la fois a l’envahissement ganglionnaire ( p = 0,002) et au sous-type histologique, Aurora B etant significativement surexprimee dans le carcinome a cellules claires ( p = 0,001). Conclusions Les kinases Aurora A et B etaient significativement surexprimees dans les CCR presentant un envahissement ganglionnaire et pourraient donc avoir une valeur pronostique.

Resume Objectif Evaluer les performances diagnostiques et le benefice en terme de prise en charge de la tomodensitometrie (TDM) faible dose pour le bilan d’imagerie de la colique nephretique (CN) aux urgences. Patients et methodes Deux cent quatre-vingt-onze patients admis aux urgences pour CN ont ete inclus dans cette etude. Quatre-vingt-sept ont eu une TDM faible dose et 40 un abdomen sans preparation (ASP) et une echographie (ASPE). Differents parametres evaluant la performance diagnostique et l’efficacite de la prise en charge ont ete compares entre les deux groupes. Les variables quantitatives et qualitatives ont ete comparees par le test t de Student et le test de χ 2 , respectivement. Resultats La TDM et l’ASPE ont confirme le diagnostic de CN chez 76 % et 54 % des patients, respectivement ( p = 0,013). Les durees moyennes de sejour etaient de 408 minutes versus 520 ( p = 0,013) dans les groupes TDM et ASPE, respectivement. La TDM etait obtenu plus rapidement (139 minutes versus 224, p = 0,002). Il y avait plus de demandes d’avis specialise (30 % versus 20 %, p = 0,18) et de gestes endo-urologiques (9,5 % versus 5 %, p = 0,31) dans le groupe TDM par rapport au groupe ASPE. Enfin, les patients du groupe TDM ont eu moins de recidives douloureuses (6 % versus 12,5 %, p = 0,18) et moins d’examens d’imagerie de seconde intention (0 % versus 30 %, p Conclusion La TDM faible dose a ete plus performante que le couple ASPE pour diagnostiquer une CN. Elle a optimise la prise en charge des patients aux urgences en diminuant leur duree de sejour, leur temps d’attente et le taux de deuxiemes consultations.

INTRODUCTION: Optical spectroscopy refers to a group of novel technologies that uses interaction of light with tissues to analyze their structure and chemical composition. The objective of this article is to describe these technologies and detail their potential for assessing urological tumors. MATERIAL AND METHODS: It has been shown that optical spectroscopy can accurately analyse multiple solid tumors. Several publications specifically aimed at assessing prostate cancers, renal carcinomas and urothelial tumors. RESULTS: There are three types of spectroscopy that all use light focussed on a tissue and thereafter collect a specific reflected optical signal. Optical spectroscopy can differentiate benign (adenoma or inflammation) and malignant (adenocarcinoma) prostatic tissues. It can also distinguish normal bladder tissue from inflammatory or cancerous cells. Regarding renal tumors, spectroscopy can identify normal and tumoral tissue and differentiate benign and malignant tumors. Its diagnostic accuracy is about 85%. However, reported studies only concentrate on in vitro or ex vivo specimen and the numbers of patients are quite small. CONCLUSION: Optical spectroscopy can be envisioned as an "optical biopsy" tool. Potential applications in the clinical field are promising. Larger studies on in vivo specimen need to be undertaken to confirm phase I preliminary reports.

OBJECTIVES: Polyamines: Spermine (Spm) and Spermidine (Spmd), are essential for cell proliferation and differentiation. A measurement of erythocytes polyamines (EPA) was developed in our institution. Our objective was to evaluate this marker as a new prognostic factor in renal cell carcinoma. PATIENTS AND METHODS: A blood sample was prospectively taken before surgery, among 418 patients who had an enlarged nephrectomy (n=318) or a partial nephrectomy (n=100) to quantify EPA rates by using the HPLC technique. The qualitative and quantitative variables have been compared using chi(2) and Student statistical analyses. The survivals have been normalized by the Kaplan Meier and Cox methods. RESULTS: The average age of our population was 64 years (21-88). The average decline was 41 months (1-214). The median size of tumors was 6.5cm (1-24). The median rate of Spm and Spmd were respectively 4.7 (1-83) and 9 (2-86)nmol/8.10(9) erythrocytes. Spm and Spmd were linked to the T stage (p=0.001), and the ECOG (p=0.001 and 0,008). Spm was not linked at N and M stages but at the Fuhrman grade (p=0.001). Spmd was linked to the N, M stages (p=0.04). With univariate analysis, the tumor diameter, the TNM stage, the Fuhrman grade as well as Spm and Spmd (p

The study was performed to determine factors affecting successful sperm retrieval by testicular sperm extraction in patients with nonmosaic Klinefelter's syndrome (KS). From May 2001 to February 2007, 27 azoospermic patients were diagnosed as having nonmosaic KS. All patients underwent sperm testicular extraction. Patient's age, testicular volume, serum follicle-stimulating hormone (FSH) and inhibin B were assessed as predictive factors for successful sperm recovery. Of the 27 Klinefelter's patients examined, eight (29.6%) had successful sperm recovery. The comparisons of serum FSH, inhibin B and testicular volume between patients with and without successful sperm retrieval did not show any statistical significance. The patients with successful sperm recovery were significantly younger (28.6 +/- 3.11 years) than those with failed attempts (33.9 +/- 4.5 years, P = 0.002). The rate of positive sperm retrieval was significantly higher in patients younger than 32 years compared with patients older than 32 years (P = 0.01, chi-squared test). The study showed that clinical parameters such as FSH, inhibin B and testicular volume do not have predictive value for sperm recovery in patients with KS. The mean age of our patients with successful sperm recovery was significantly lower than that of men with unsuccessful results. Testicular sperm extraction or testicular sperm aspiration should be performed before the critical age of 32 years.

Resume Objectif Decrire la pratique de la nephrectomie partielle (NP) en France et evaluer ses resultats en terme de morbidite et de controle carcinologique. Materiel et methode Sept centres universitaires francais dont la chirurgie renale conservatrice representait au minimum 30 % des indications de nephrectomie pour tumeur ont participe a cette etude en incluant de facon la plus exhaustive possible toutes les observations de NP. Pour chaque patient, 70 variables ont ete recueillies, visant a caracteriser la population interessee, l’indication et la technique operatoires, la tumeur, les complications per- et postoperatoires, le suivi carcinologique et de la fonction renale. Resultats Sept cent quarante et une NP, dont 579 pour tumeurs malignes, ont ete analysees. La taille tumorale moyenne etait de 3,4 ± 2,1 cm (0,1–18) et 20,8 % des tumeurs operees mesuraient plus de 4 cm. Il s’agissait dans 30,1 % des cas d’une indication de necessite. Dans 12,2 % des cas la NP etait realisee sous cœlioscopie. La duree operatoire moyenne etait de 152 ± 54,2 minutes (55–420). Les taux de complications medicales et chirurgicales etaient respectivement de 15,2 et 14,7 %. Avec un recul moyen de 38 mois, les taux de recidive locale et de deces specifique etaient respectivement de 3,5 et 4,5 %. Conclusion La NP a connu ces 20 dernieres annees un essor progressif dans la pratique chirurgicale francaise. Les resultats le justifient et doivent conduire l’ensemble de la communaute urologique a la considerer desormais comme le traitement de reference des tumeurs renales de moins de 4 cm.

Resume Objectif Evaluer la morbidite de la nephrectomie partielle (NP) en fonction de la taille tumorale et du type d’indication a travers une etude multicentrique retrospective. Materiels et methodes Sept centres universitaires francais ont participe a l’etude. Les donnees concernant la taille tumorale, l’indication de la NP (elective ou de necessite), l’âge, le sexe, le stade TNM, le type histologique, le grade de Fuhrman, le score ASA et le performance status (ECOG) ont ete analysees. Les complications medicochirurgicales, les pertes sanguines peroperatoires, le taux de transfusion sanguine et la duree d’hospitalisation ont egalement ete etudies. L’analyse statistique des variables qualitatives et quantitatives a ete faite a l’aide du test de χ 2 (test de Fischer) et du test- t de Student. Resultats Six cent quatre-vingt onze patients ont ete inclus. La taille tumorale mediane etait de 3 cm [0,4–18]. Les tumeurs inferieures ou egales a 4 cm et incidentales representaient 77,7 et 80,7 % des cas, respectivement. Les carcinomes a cellules claires representaient 75,1 % des tumeurs malignes. Parmi, 89,1 % de tumeurs etaient T1, 1,6 % N+ et 2,3% M+. Dans les 486 indications electives, la duree operatoire ( p = 0,03), les pertes sanguines moyennes ( p = 0,04), le taux de fistules urinaires ( p = 0,01) etaient significativement augmentes dans les tumeurs superieures a 4 cm. Ces differences ne se traduisaient pas par une augmentation du taux de complications medicales ( p = 0,7) ou chirurgicales ( p = 0,2) ni de la duree d’hospitalisation ( p = 0,4). Conclusion Elargir les indications des NP electives implique une morbidite accrue, mais qui est acceptable. Cette donnee est importante pour l’information des patients et pour choisir la strategie chirurgicale en particulier chez les sujets âges, fragiles ou avec des comorbidites notables.

Objectives Partial nephrectomy by laparoscopy offers patients conservative surgery and a mini-invasive approach; however, clamping of the renal pedicle and the induced warm ischaemia can damage the renal parenchyma. We present a technique of laparoscopic partial nephrectomy with haemostasis obtained by clamping of the renal parenchyma. Methods The procedure was performed by an intraperitoneal or a retroperitoneal approach. After a working space is created by pneumodissection, Gerota's fascia is incised and the kidney convexity is dissected. An endoscopic Satinsky clamp is inserted percutaneously through a 1-cm incision. The renal parenchyma is clamped and the tumour is excised in a bloodless field. The cut renal parenchyma is coated with biologic glue. Results Five patients with elective indications were operated. Mean age was 67.8 yr and mean tumour diameter 3.06cm. One lesion was located at the upper pole and four at the lower pole. Mean preoperative serum creatinine level was 10.9mg/l. Postoperative serum creatinine level was unchanged. Mean operative time was 238min. There was no conversion. Mean blood loss was 250ml; no transfusions were necessary. The collecting duct system was repaired in one patient. No complication was noticed. Resection margins were tumour free in all cases. Final pathologic examination revealed clear cell carcinoma in three cases and angiomyolipoma and oncocytoma in one case each. Conclusion Laparoscopic partial nephrectomy with clamping of the renal parenchyma can be performed in selected patients with peripherally placed tumours. The procedure avoids warm ischaemia of the normal parenchyma while allowing the surgeon to operate in an almost bloodless field. This initial experience in five patients should be validated in a larger series.

Resume But de l’etude Determiner s’il existe une relation entre l’expression de VEGF et la progression dans la veine renale et dans la veine cave d’une tumeur renale de stade pT3 et evaluer l’impact sur la survie de l’expression de VEGF au sein des carcinomes a cellules renales pT3. Materiel et methodes Soixante dix huit patients avec une tumeur pT3a, pT3b sans envahissement de la veine cave et pT3b avec atteinte de la veine cave ont ete compares pour l’âge, le sexe, le grade de Furhman et l’expression immunohistochimique de VEGF. Toutes ces variables ont fait l’objet d’une analyse uni et multivariee afin d’etablir leur impact sur la survie. Resultats Les 3 groupes etaient comparables pour l’âge, le sexe, le grade tumoral et l’expression de VEGF. Seule la taille de la tumeur apparaissait comme significativeinent differente. En analyse univariee, l’envahissement de la graisse perirenale, l’atteinte ganglionnaire, les metastases a distance et l’expression de VEGF etaient associees de facon significative a la survie (p Conclusion La progression d’une tumeur pT3 dans la veine renale et dans la veine cave n’est pas associee a une augmentation de l’expression tumorale de VEGF. Cependant VEGF apparait etre un facteur pronostique independant dans ce groupe de tumeurs renales de mauvais pronostic.

Resume Objectifs Comparer les techniques de nephrectomie partielle (NP) par voie ouverte (NPO) et laparoscopique (NPL) au travers d’une serie multicentrique francaise. Materiel et methodes Les donnees correspondant a 741 NP (91 laparoscopies et 650 voies ouvertes) ont ete comparees, incluant les indications, les tailles des tumeurs, les donnees operatoires, les taux de complications et les durees d’hospitalisation. Resultats Les tumeurs etaient de plus petite taille dans le groupe NPL (2,7 vs 3,4 cm, p:0,001). Il y avait moins de tumeurs malignes dans le groupe NPL (71,1% vs 80% p: 0,05) et moins de NP de necessite (20,9% vs 31,4%, p: 0,04). Il y avait moins de tumeurs hilaires dans le groupe NPL que dans le groupe NPO (NPL: 4% vs NPO:14,8%, p: 0,03). Il a ete realise moins de clampage pediculaire dans le groupe NPL (33% vs 50,2%, p: 0,002) mais pour des durees significativement plus elevees (35 minutes vs 19 minutes, p: 0,0001). La duree operatoire moyenne etait plus elevee dans le groupe NPL (163 vs 150 minutes, p: 0,02). Les taux de complications chirurgicales (17,6% vs 14,3%), de transfusion (6,6% vs 10,5%) et les pertes sanguines moyennes (363 vs 434 ml) n’etaient pas significativement differents dans les 2 groupes. Il y a eu significativement plus de fistules uri-naires (12,1% vs 2,5%, p Conclusion II ressort de cette serie comparative refletant une experience initiale que la nephrectomie partielle laparoscopique a des resultats operatoires et peri-operatoires proches de ceux de la nephrectomie partielle ouverte. Cependant, les indications de la voie laparoscopique restent selectionnees, les durees de clampage pediculaire et les complications medicales sont superieures en chirurgie laparoscopique. L’experience et les progres techniques de la nephrectomie partielle laparoscopique devraient pouvoir rendre la technique operatoire comparable a celle de la chirurgie ouverte.

Resume But de l’etude L’objectif de cette etude prospective a ete de donner une description de la nature des lesions observees au cours des prelevements de rein en France, sur donneurs cadaveriques, en etat de mort encephalique; en second lieu d’identifier les facteurs predictifs favorisant ces lesions. Materiel et methodes Un questionnaire elabore par le Comite de Transplantation de l’AFU, relatif a la qualite des reins preleves sur donneurs decedes a ete adresse a tous les centres faisant de la transplantation renale en France durant l’annee 2000. Il s’agissait d’une etude prospective, se deroulant sur une duree de 1 an, et portant sur le deroulement global des prelevements multi-organes (PMO), toutes les donnees relatives au parenchyme renal, aux caracteristiques arterio-veineuses et ureterales, et a l’evolution des transplants. Resultats 12 centres auront repondu a l’enquete, permettant ainsi d’analyser les donnees de 201 reins preleves. 91% des preleveurs etaient des Urologues. Onze pour cent d’incidents furent signales au cours des PMO, mais 1/3 des anomalies n’avaient pas ete relevees par le preleveur. Le prelevement de reins seuls est apparu comme etant un facteur de risque (20% vs 8,6%). Le taux d’anomalies parenchymateuses etaient de 50%, dont 2/3 liees a un mauvais degraissage des reins. L’atherome etait un facteur favorisant les lesions arterielles lors des PMO (21% vs 6,5%). Sur le plan veineux, 9% d’anomalies etaient relevees, dont 89% dues au PMO, et 59% non identifiees par le preleveur. Le fait de ne pas etre transplanteur etait un facteur favorisant des lesions veineuses (21,9% vs 6,5%). Il y avait 4% de lesions ureterales, sans consequence pour le devenir du greffon. Conclusion Le degraissage des reins avant conditionnement n’est pas acquis. Les prelevements de rein seul et l’atherome favorisent les lesions parenchymateuses et arterielles respectivement. Les anomalies de prelevement veineux sont plus frequentes chez les non transplanteurs.

Item does not contain fulltext OBJECTIVES: To compare cancer-specific mortality in patients with unclassified renal cell carcinoma (URCC) vs clear cell RCC (CRCC) after nephrectomy, as URCC is a rare but very aggressive histological subtype. PATIENTS AND METHODS: Eighty-five patients with URCC and 4322 with CRCC were identified within 6530 patients treated with either radical or partial nephrectomy at 18 institutions. Of 85 patients with URCC, 55 were matched with 166 of 4322 for grade, tumour size, and Tumour, Node and Metastasis stages. Kaplan-Meier and life-table analyses were used to address RCC-specific survival. Subsequently, multivariate Cox regression analyses were used to test for differences in RCC-specific survival in unmatched samples. RESULTS: Of patients with URCC, 80% had Fuhrman grades III or IV, vs 37.8% for CRCC. Moreover, 36.5% of patients with URCC had pathologically confirmed nodal metastases, vs 8.6% with CRCC. Finally, 54.1% of patients with URCC had distant metastases at the time of nephrectomy, vs 16.8% with CRCC. Despite these differences in the overall analyses, after matching for tumour characteristics, the URCC-specific mortality rate was 1.6 times higher (P = 0.04) in matched analyses and 1.7 times higher (P = 0.001) in multivariate analyses. CONCLUSIONS: These findings indicate that URCC presents with a higher stage and grade, and even after controlling for the stage and grade differences, predisposes patients to 1.6-1.7 times the mortality of CRCC.

BACKGROUND. The role of nephron-sparing surgery (NSS) showed promise in patients with metastatic renal cell carcinoma (MRCC). The disease-specific survival of patients with MRCC was compared according to the type of surgery, NSS (N = 45) versus radical nephrectomy (RN) (N = 732), in unmatched and matched analyses. METHODS. Kaplan-Meier, life tables, log-rank test, and univariate as well as multivariate Cox regression analyses addressed disease-specific survival of NSS versus RN patients. Subsequently, up to 4 RN cases were matched with each NSS case for TNM stage, Fuhrman grade, and histology. Then, disease-specific survival differences were tested with the log-rank statistic. Finally, the sample size necessary to achieve 80% power in survival analyses between the 2 groups (NSS vs RN) was calculated. RESULTS. Of 45 NSS cases, 38 were matched with 99 of 732 RN cases. First, in multivariate unmatched analyses RN predisposes to 1.7-fold higher RCC-specific mortality rate; second, in matched analyses RN predisposes to 1.5-fold higher RCC-specific mortality rate; and third, both analyses failed to demonstrate statistically significant differences. Based on these findings it could be postulated that until further data become available, NSS does not appear to undermine RCC-specific survival in carefully selected patients with MRCC. The power analyses demonstrated that at least 146, 48, and 76 observations per arm are necessary at 1, 2, and 3 years, respectively, to confirm survival equivalence. CONCLUSIONS. Although the data were limited in size and completeness, they may indicate that RCC-specific survival may not be undermined if NSS is performed in properly selected cases. Cancer 2007. © 2007 American Cancer Society.

Item does not contain fulltext OBJECTIVES: To analyse the influence of age at diagnosis on tumour characteristics and cancer-specific survival in renal cell carcinoma (RCC). METHODS: Data on age, tumour characteristics, and survival for 4774 patients from 12 European RCC databases were recorded. Patients were divided into four groups according to age at diagnosis: < or =40, >40 and or =60 and or =80 yr. The following variables were analysed: TNM stage, Fuhrman grade, tumour size, symptoms at diagnosis, ECOG performance status (PS), and cancer-specific survival. The groups were compared for usual clinical and pathologic variables, and cancer-specific survival. RESULTS: The four groups accounted for 288 (6%), 1839 (38.5%), 2499 (52.3%), and 148 cases (3.2%), respectively. Differences were found among groups for tumour stage, symptoms at diagnosis, ECOG PS, Fuhrman grade (p

National audience; Objectifs L’apport de la chirurgie robotique en termes de diminution du risque de marges positives lors d’une prostatectomie radicale reste débattue. Notre objectif était de comparer les marges chirurgicales en zone tumorale lors d’une prostatectomie radicale rétropubienne, laparoscopique ou robot-assistée. Méthodes Il s’agit d’une étude rétrospective portant sur 725 patients avec un cancer de prostate traité par prostatectomie radicale ± lymphadenectomie dans un centre universitaire entre 1990 et 2014. Les modalités opératoires, les caractéristiques tumorales ainsi que le statut concernant les marges chirurgicales (localisation, taille, nombre) ont été recueillis. Les groupes de patients sans et avec marges chirurgicales en zone tumorale ont été comparés par les tests de Chi2 et de Student. Les facteurs prédictifs de marges chirurgicales positives ont été analysés par un modèle de régression logistique binaire. Résultats Parmi les patients, 44,3 %, 50,3 % et 5,4 % avaient un cancer de prostate de faible risque, risque intermédiaire, et haut risque selon D’Amico. Parmi les patients, 34,9 %, 42,9 % et 22,2 % ont été traités par PRRP, PRL et PRRA. Une marge chirurgicale en zone tumorale a été décrite pour 109 patients (15 %). En fonction de la voie d’abord utilisée, aucune différence significative n’a été observée en termes de taux de marges positives (p = 0,23) ou de taux de marges multifocales ou > 3 mm (p = 0,365). Les taux de marges positives à l’apex étaient respectivement de 12,7 %, 7,84 %, 6,9 % (p = 0,10) après PRRP, PRL et PRRA, et les taux de marges en zone moyenne de 0,64 %, 0,33 % et 2,44 % (p = 0,053). En analyse multivariée, seul le stade tumoral était associé à la présence d’une marge chirurgicale positive (p < 0,05). Conclusion Dans notre expérience, le taux global de marges chirurgicales en zone tumorale est identique quelle que soit la technique de PR. Cependant, comparé aux autres techniques, le taux de marges positives pourrait être supérieur à l’apex avec la PRRP et en zone moyenne avec la PRRA

We correlated platelet count to renal tumor characteristics, and evaluated the potential prognostic value of thrombocytosis in localized and metastatic tumors.A total of 804 patients operated on for a renal tumor in 2 French centers were included in this study. In all cases TNM stage, Fuhrman grade, tumor size, nodal invasion, ECOG score, histological subtype and platelet count were recorded. Survival estimates were compared with the Kaplan-Meier method and multivariate analysis was performed using a Cox model.There were 538 (66.9%) males and 266 (33%) females (ratio 2.02) in the patient group. Median age was 62 years. T stages were T1, T2, T3 and T4 in 284 (35.3%), 116 (14.4%), 387 (48.1%) and 17 (2.1%), respectively. There were 112 (13.9%) and 126 (15.7%) patients with nodal and metastatic invasion, respectively. Platelet count was strongly correlated with T stage (p0.001), Fuhrman grade (p0.001), tumor size (p0.001), nodal invasion (p0.001) and the presence of distant metastasis (p = 0.01). In univariate analysis all studied factors were significantly predictive of survival (p = 0.0001). Thrombocytosis had an impact on prognosis in localized (p0.001) and metastatic (p = 0.003) disease. Several factors were retained in multivariate analysis, namely TNM stage, Fuhrman grade, tumor size, ECOG score and platelet count. In cases with a platelet count of less than 450,000/mm3, the 5-year survival rate was 70%, compared to 38% when the platelet count was 450,000/mm3 or greater.Platelet count appears to be an independent prognostic factor in renal cell carcinoma. It reflects a cascade of biological events correlated with tumor aggressiveness. This observation opens new perspectives for exploring carcinogenesis mechanisms and tumor progression in renal cell carcinoma.

Summary Cribriform and/or papillary prostatic lesions observed on limited tissue, such as needle biopsy, can pose diagnostic dilemmas. One such area of difficulty is the distinction between papillary and/or cribriform prostatic high-grade prostatic intraepithelial neoplasia (HG-PIN) and ductal adenocarcinoma. Over 48 months, we identified 17 cases of ductal adenocarcinoma and 17 cases of HG-PIN from radical retropubic prostatectomy specimens. The HG-PIN lesions were in all cases associated with an acinar prostatic adenocarcinoma component. For each case, we evaluated the proliferative activity, assessed by Ki-67 immunohistochemistry. The majority (82%) of ductal adenocarcinomas were composed of mixed papillary and cribriform patterns, with the remaining demonstrating pure papillary or cribriform patterns. The HG-PIN lesions showed a papillary, cribriform, or mixed papillary/cribriform architecture. The proliferative activity, defined as Ki-67 labeling index, was statistically higher in ductal adenocarcinoma (mean 33%, range 21%-66%) as compared with HG-PIN (mean 6%, range 2%-15%), with no overlap in the Ki-67 indices ( P = 0001). A combination of histological features and measurements of cellular proliferation may be helpful to distinguish HG-PIN from ductal adenocarcinoma in limited prostatic tissue samples.

Purpose To analyze to what extent histologic subtype is of prognostic importance in renal cell carcinoma based on a large, international, multicenter experience. Patients and Methods Four thousand sixty-three patients from eight international centers were included in this retrospective study. Histologic subtype (1997 International Union Against Cancer [UICC] criteria of tumor response), age, sex, TNM stage, Fuhrman grade, tumor size, Eastern Cooperative Oncology Goup performance status (ECOG PS), and overall survival were determined in all cases. The prognostic values of clear cell, papillary, and chromophobe histologic features were assessed by uni- and multivariate analysis using the Kaplan-Meier method and Cox model, respectively. Results Clear cell, papillary, and chromophobe carcinomas accounted for 3,564 (87.7%), 396 (9.7%) and 103 (2.5%) cases, respectively. In univariate analysis, a trend toward a better survival was observed when clear cell, papillary, and chromophobe histologies were considered prognostic categories (log-rank P = .0007). However, in multivariate analysis, TNM stage, Fuhrman grade and ECOG PS, but not histology, were retained as independent prognostic variables (P < .001). Conclusion The stratification in three main renal cell carcinoma histologic subtypes as defined by the 1997 UICC–American Joint Committee on Cancer consensus should not be considered a major prognostic variable comparable to TNM stage, Fuhrman grade and ECOG PS.

Resume Les lesions traumatiques de l'uretre sont peu frequentes. La plupart des atteintes de l'uretre anterieur (uretre bulbaire) sont des lesions dues a un choc direct (chute a califourchon) qui sont traitees dans un premier temps par un drainage vesical par catheter sus-pubien, avec traitement retarde quand s'ensuit une stenose uretrale. Les dysfonctions traumatiques de l'uretre posterieur sont dans la plupart des cas liees a une fracture du bassin, et sont souvent associees a de multiples lesions a risque vital qui sont traitees en priorite. Leur prise en charge demeure un sujet extremement controverse : les traitements alternatifs consistent en un realignement uretral precoce sous controle endoscopique, une reparation chirurgicale precoce, la pose d'un catheter sus-pubien precedant une reparation chirurgicale differee. Nous decrivons ici la prise en charge des lesions de l'uretre ainsi que les differentes techniques operatoires en detail.

Objectifs Evaluer la faisabilite, la morbidite perioperatoire et les resultats fonctionnels a court terme de la photovaporisation prostatique XPS 180 W (PVP) et de l’enucleation endoscopique au laser Greenlight® (GreenLEP) comparees a l’adenomectomie voie haute (AVH) pour le traitement chirurgical des symptomes du bas appareil urinaire lies a une hypertrophie benigne de prostate (HBP) de gros volume. Methodes Entre janvier 2012 et septembre 2015, 150 patients, avec une HBP de volume prostatique > ou = 80 mL, ont ete traites par PVP, GreenLEP ou AVH (n = 50 par groupe) pour une HBP symptomatique dans deux institutions. Les donnees pre, per et postoperatoires ont ete recueillies prospectivement. Les complications postoperatoires ont ete rapportees selon les classifications Clavien-Dindo et GUGL (groupe d’utilisateurs du Greenlight®). Les donnees continues et categorielles ont ete comparees par test Anova. Resultats Les volumes prostatiques des groupes PVP, GreenLEP et AVH etaient de 120,0 mL, 120,5 mL et 122,2 mL (p = 0,952) respectivement. Les durees operatoires etaient plus longues dans les groupes PVP et GreenLEP (120 vs 102,4 vs 75,3 min, p

Hospital acquired infections represent a medical priority for surgeons as well as anesthetists and nursing staff. ANAES charged with national hospital accreditation program establishes protocols and objectives to be attained in terms of quality of care and patient satisfaction. According to available pilot studies, prevention of hospital acquired infections relies on surgical environment, preoperative patient preparation, sterilisation techniques, antibiotic prophylaxis and catheter care. Great improvements are under way in this domain and in management of multiresistant bacterial infections with a decrease in multiresistant kelbsiella infections. Our optimism is however tempered by the increase in methicillino-resistant Staphylococcus aureus (MRSA) infections. Many questions on nosocomial infections are still unanswered due to insufficient scientific evidence and difficulty in organising rigorous studies. Further progress will require a full involvement of hospital administrations and funding health organisations to provide the financial support required to implement preventive procedures and related architectural modifications.

To compare renal tumors with respect to initial clinical presentation and assess the prognostic value of a symptom based classification.Based on symptoms at diagnosis, 388 renal tumors were stratified into three groups: (1) asymptomatic tumors; (2) tumors with local symptoms (3) tumors with systemic symptoms. The three groups were compared for usual clinical and pathological variables using chi(2)-tests and Anova regression, for qualitative and quantitative variables, respectively. Survival assessment was made with univariate and multivariate analysis using the Kaplan-Meier method and Cox regression analysis.The three defined groups were significantly different for all analysed variables except for age, sex ratio and pathological subtype. In univariate analysis: ECOG performance status, symptom classification, tumour size, TNM stage and grade, adrenal, perinephric fat or vein invasion were significant prognostic factors (p0.001). In multivariate analysis, symptom classification, TNM stage, Fuhrman grade and perinephric fat invasion remained independent prognostic factors (p0.001).The proposed classification merits further validation through multi-institutional studies before integrating it in further prognosis algorithms.

evaluer l’efficacite et l’innocuite des biopsies testiculaires percutanees associees a l’ICSI dans la prise en charge de l’infertilite masculine. entre octobre 1995 et decembre 2001, 175 biopsies testiculaires ont ete realisees chez des hommes souffrant d’azoospermie pour fournir des spermatozoides en vue d’une fecondation in vitro (FIV) par injection intracytoplasmique de sperme (ICSI). L’azoospermie etait obstructive (AO) dans 41 cas et non-obstructive (ANO) dans 134. Les 15 premiers patients dans la serie ont beneficie d’une biopsie chirurgicale, et les autres avaient une biopsie percutanee comme technique de premiere intention. La biopsie percutanee etait realisee en hospitalisation de jour, sous anesthesie locale, avec un BioptyGun® aiguille 14G. Toutes les biopsies faites pour AO etaient positives, alors que 51/134 (38%) etaient positives dans le groupe ANO. Le materiel fourni par la biopsie percutanee, quand elle etait positive, etait toujours suffisant pour realiser l’ICSI. Quand la biopsie percutanee etait negative, la biopsie chirurgicale n’a pas donne de meilleurs resultats. Chez les hommes beneficiant de biopsies percutanees, cinq (3,12%) ont presente une complication mineure (hematocele aigue) necessitant une exploration scrotale pour hemostase. Il n’y avait aucune complication majeure. Les resultats etaient comparables en termes de fecondation et de grossesses, qu’il s’agisse de sperme frais ou congele. la biopsie testiculaire percutanee sous anesthesie locale est un moyen efficace, sur et peu couteux pour le prelevement de spermatozoides dans le cadre de la prise en charge de l’infertilite masculine liee a l’azoospermie.

Objective To evaluate the mode of detection of 400 renal tumours as a prognostic factor compared with the usual clinical and pathological prognostic variables. Patients and methods The data were reviewed for 400 patients operated for a renal tumour at our institution between 1984 and 1999, analysing the prognostic value of age, sex, tumour size, stage, grade, vein invasion, adrenal gland invasion, lymph node invasion, metastasis, and mode of detection (incidental or not). The survival rates were assessed using the Kaplan-Meier method and log-rank test, and the data evaluated using multivariate analysis with the Cox proportional-hazard model. Results In all, 151 (38%) renal tumours were discovered incidentally. There was no significant difference in the percentage of renal cell carcinoma found between the groups of patients discovered incidentally or not (94.4% vs 93.9%). Tumours were smaller in the incidental group (5.7 cm vs 8.7 cm, P

Spontaneous perirenal haematomas essentially raise the problem of the aetiological diagnosis, but can sometimes be inadequate. Arteriography is useful when CT scan is negative or in the case of vascular disease. The therapeutic attitude, nephrectomy or conservative treatment remains controversial, but in view of the frequency of renal neoplastic lesions, the authors recommend nephrectomy at the slightest doubt concerning renal integrity. When no case be found, the assessment must be completed postoperatively with long-term, close surveillance, due to the risk of an undiagnosed neoplastic lesion. The authors report two recent cases and try to propose a diagnostic and therapeutic strategy based on the aetiology.

We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy.From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis.Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC.Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

There is a lack of data concerning the fate of arterio-venous fistulas (AVF) after successful kidney transplantation. The objective of this study was to assess the evolution of AVF in transplanted patients and to discuss the management of such vascular access once dialysis has been stopped.We reviewed 160 renal transplant patients who had undergone an AVF 0 to 312 months (mean 29) before transplantation. 136 (85%) of AVF were created in the forearm/wrist region and 21 (13%) at the elbow.The mean follow-up was 69 months from renal transplantation and 95 months from constitution of the AVF. Vascular access had to be closed in 7.5% of cases. Thrombosis occurred in 31% of cases, mainly in distal fistulas (85%). AVF was still functional in 61% of patients at the end of follow-up.AVF remains functional in the majority of patients after renal transplantation and is not usually associated with any significant morbidity. Systematic closure of AVF does not seem warranted as it would deprive patients of a useful vascular access should dialysis become again necessary in the long term.

Objectives. To compare tumor recurrence, progression, and patient survival in T1G3 bladder tumors treated with transurethral resection (TUR) alone, early cystectomy, or TUR with an adjuvant 6-week course of bacille Calmette-Guerin (BCG) and followed up for a minimum of 5 years. Methods. Between 1979 and 1996, 94 patients with T1G3 bladder tumors (lamina propria invasion) were treated at nine different centers. The time to tumor recurrence, tumor stage and grade progression, number of delayed cystectomies, and patient survival were analyzed retrospectively in relation to the initial treatment. Results. The mean follow-up was 62 months. Thirty patients were treated by TUR alone (32%), 50 patients by TUR plus BCG (53%), and 14 patients by primary cystectomy (15%). The recurrence, progression, and cystectomy rates were significantly different between patients treated by TUR alone and TUR plus BCG (Fisher's exact test, P = 0.0005, P = 0.02, and P = 0.005, respectively). The disease-free survival was also significantly different when comparing TUR plus BCG with TUR alone or primary cystectomy (Kaplan-Meier analysis, log-rank test, P = 0.02). Conclusions. Endoscopic resection plus BCG treatment of pT1G3 tumors allows an 80% rate of disease-free 5-year survival with bladder preservation. This conservative option has been widely accepted as first-line treatment, offering good cancer control with excellent quality of life. Very accurate surgical and pathologic evaluations before treatment and lifelong follow-up are obviously required.

To evaluate the results of an endoscopic antireflux procedure in women with recurrent acute pyelonephritis and no evidence of vesicoureteral reflux (VUR) on voiding cystograms.From 1989 to 1999, 603 female patients were hospitalized for acute pyelonephritis with unilateral loin pain, chills, fever, and a positive urine culture. Of these patients, 48 (8%) had recurrent episodes of acute pyelonephritis and underwent a thorough diagnostic work-up including intravenous urography or renal CT scan, cystoscopy, and voiding cystourethrography (VCUG). Vesicoureteral reflux was demonstrated in 21 patients, who were then offered an antireflux procedure, either surgical or endoscopic. Another 27 patients had no reflux on VCUG; in 15 cases, the upper urinary tract was normal, and the ureteral orifices did not show any abnormality on cystoscopy. The other 12 patients in this group with a normal VCUG had one or more abnormal findings normally associated with VUR: renal scarring in five and ureteral duplication in two. Golf-hole ureteral orifices were noted in two patients. The intravesical ureter was short (5 mm) in five patients. In spite of the normal VCU, we offered these patients endoscopic treatment of VUR by submeatal injection of Teflon or microparticulate silicone (Macroplastic). The median follow-up before treatment was 4 years (range 1-15.3 years); 0.3 episodes of acute pyelonephritis per patient-month of follow-up were noted. The frequence of preoperative and postoperative episodes of acute pyelonephritis was compared with Wilcoxon's paired analysis. The median postoperative follow-up was 3.9 years (range 1.1 months-10.2 years).There were no significant postoperative complications. One patient had two episodes of acute pyelonephritis during pregnancy. On the whole, 11 patients (91%) were free of recurrent pyelonephritis after treatment. Overall, 0.003 episodes of acute pyelonephritis per patient-month of postoperative follow-up were observed. The result was statistically significant (P0.01).Recurrent acute pyelonephritis is frequently related to VUR. Intermittent reflux can be difficult to demonstrate on voiding conventional or nuclear cystograms but can be suspected in the presence of ureteral duplication, renal scarring, or abnormal ureteral orifices. Adult patients with recurrent episodes of upper urinary tract infection and normal cystograms should be considered for an endoscopic antireflux procedure in the presence of anatomic abnormalities commonly associated with reflux.

Objectives To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments. Patients and methods All patients treated conservatively who presented between 1990 and 1999 with major renal laceration (grade 4 and 5) were retrospectively reviewed to determine whether urinary extravasation and devitalized segments adversely affected the outcome. For each patient the data collected included the initial emergency department evaluation, findings on computed tomography, associated injuries, duration of hospital stay, transfusion requirements, complications and follow-up imaging. Results Of 20 patients who sustained blunt trauma resulting in a major renal laceration (five grade 5 and 15 grade 4) with urinary extravasation, 11 had coexisting devitalized segments. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P

The aim of the study was to determine whether a nonoperative approach is able to reduce renal parenchymal loss after renal trauma.Sixty-four consecutive patients with major blunt renal lacerations were treated from 1988 to 1999. Initial management was conservative. In group 1 (35 patients) delayed hemorrhage, persistent urinoma or hemodynamic instability were dealt with by open surgery. In group 2 (29 patients), most complications were dealt with using endoscopic procedures; open surgery was reserved exclusively for major complications.In group 1, 7 patients were not operated and 28 patients were managed surgically. Twenty (57%) patients underwent total (8) or partial (12) nephrectomy. In 8 patients the surgical intervention was open drainage of perinephric collection (6) and/or renorrhaphies (2). Four patients in this group developed urinary fistulae treated successfully with ureteral stents. Length of hospital stay was 9.6 days (3-25 days). In group 2, persistent hemodynamic instability led to nephrectomy in 1 case. The remaining 28 patients were managed conservatively, with endoscopic ureteric stenting in 5 cases. A persistent urinary extravasation with hyperthermia led to open drainage of perinephric urinoma (5) and renorrhaphy (2). No delayed nephrectomy was necessary. Average hospital stay was 12 days (5-21 days). Only 1 patient in this group developed hypertension.For most patients and with close follow-up available, conservative treatment represents a real alternative to open surgery in major blunt renal lacerations. In our experience, open surgery usually results in loss of renal parenchyma.

Fifteen patients with progressive metastatic renal cell carcinoma were treated with granulocyte-macrophage colony-stimulating factor and intravenous infusions of activated autologous macrophages (AAMs). The latter were prepared from leukapheresis-separated mononuclear cells cultured in the presence of granulocyte-macrophage colony-stimulating factor, exposed to gamma interferon, and submitted to elutriation to separate AAMs. Three intravenous injections of AAMs were performed within a 2-week interval. This treatment cycle was repeated once or twice, in cases of tumor response or stabilization. Ninety-seven preparations containing a mean 3 x 10(9) AAMs were administered and usually well tolerated. One partial response, eight stabilizations and six progressions were observed. The median time to progression and median overall survival time after inclusion were 7 and 9 months, respectively. The cells injected did not accumulate substantially in tumor lesions, as shown by scintigraphic imaging of indium-111-labeled AAMs. Thus, combined granulocyte-macrophage colony-stimulating factor and AAM treatment was well tolerated and resulted in transitory stabilization (n = 8) or partial regression (n = 1) in 9 of 15 patients.

Objectives. Nuclear grade and tumor stage are important prognostic factors in renal cell carcinoma, but tumors of similar stage and grade can exhibit a wide variation in biologic behavior and clinical outcome. In this retrospective study, we evaluated the immunologic markers, Ki-67 (MIB1) and p53, in 73 cases of conventional (clear cell) renal cell carcinoma and compared these markers with the accepted prognostic features of grade, stage, and tumor size in predicting outcome. Methods. Specimens of 73 renal cell carcinomas of different nuclear grade (20 Furhman I/II, 32 Fuhrman III, and 21 Fuhrman IV) and different stage (10 pT1, 23 pT2, 36 pT3, and 4 pT4) were immunostained with monoclonal antibodies against Ki-67 and p53. Results. Univariate statistical analysis showed that tumor size (P

Objectifs La cystectomie radicale robotique fait actuellement l’objet de controverses en terme de benefices perioperatoires en comparaison a la chirurgie ouverte, et du risque de carcinose peritoneale. L’objectif etait donc de rapporter les resultats perioperatoires et oncologiques de la RARC dans une serie monocentrique prospective. Methodes Entre mars 2012 et mars 2015, 32 patients operes d’une RARC pour une TVIM ont ete inclus prospectivement. Les donnees pre-, per- et postoperatoires ont ete recueillies. La survie a ete evaluee a la date du dernier suivi. Les resultats sont exprimes en moyenne pour les variables quantitatives continues, en mediane pour les variables quantitatives discontinues et en proportion pour les variables qualitatives. Les survies sans recidive, specifique et globale ont ete estimees selon la methode de Kaplan-Meier. Resultats L’âge moyen etait de 66,5 ans ; 84,6 % des patients ont eu une chimiotherapie neoadjuvante. La duree d’intervention etait en moyenne de 323 minutes (± 95,8). Les pertes sanguines moyennes etaient de 658,6 mL (± 297,6). Le nombre de ganglions preleves par curage etait en moyenne de 15,7 (± 10,3). Toutes les RARC realisees l’ont ete en marges saines. La duree moyenne d’hospitalisation etait de 12,3 jours (± 9,3). Le taux de complications postoperatoires etait de 44 %, toute gravite confondue. Le suivi moyen etait de 10,8 mois (± 8). Les survies globale, specifique et sans recidive etaient respectivement de 75,6 %, 82,2 % et 79,2 % a 1 an, 48,6 %, 70,4 % et 46,8 % a 2 ans. Un cas isole de carcinose peritoneale a ete relate, dans un contexte de progression multimetastatique. Conclusion Dans cette serie monocentrique, la RARC etait associee a des resultats peri-operatoires et oncologiques comparables a la chirurgie ouverte. Des resultats a long terme sont necessaires pour confirmer ces donnees ( Fig. 1 , Fig. 2 , Tableau 1 ).

OBJECTIVE Repair of large incisional lumbar hernias or muscular bulges is a challenge to the surgeon as reflected by the high recurrence rate. We evaluated a surgical procedure using a running strip of autogenous skin graft as a retention suture. METHODS Eight patients with large incisional lumbar hernias (> or = 20 cm, n = 6) or muscular bulges (n = 2) underwent a parietal reconstruction with this procedure. Two patients had previously been treated with synthetic meshes without success, and one had a colocutaneous fistula. RESULTS No recurrence was observed in 6 patients (75%) with a mean follow-up of 14 months. After significant weight gain, 2 repairs failed at 6 months and 1 year (partially in 1 case). No recurrence was noted for muscular bulges. CONCLUSION The use of a running strip of autogenous skin graft is a simple and reliable procedure for the repair of large lumbar hernias or muscular bulges for patients with stable weight conditions.