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Clear cell Renal Cell Carcinoma (ccRCC) is one of the most prevalent kidney cancers, which is often asymptomatic and thus discovered at a metastatic state (mRCC). mRCC are highly heterogeneous tumors composed of subclonal populations that lead to poor treatment response rate. Several recent works explored the potential of ccRCC tumoroids culture derived from patients. However, these models were produced following a scaffold-based method using collagen I or Matrigel that exhibit lot variability and whose complexity could induce treatment response modifications and phenotypic alterations. Following the observation that ccRCC tumoroids can create their own niche by secreting extracellular matrix components, we developed the first scaffold-free tumoroid model of ccRCC tumors. Tumoroids from mice as well as from human tumors were generated with high success rate (≥90 %) using a magnetic suspension method and standard culture media. Immunofluorescence analysis revealed their self-organization capacities to maintain multiple tumor-resident cell types, including endothelial progenitor cells. Transcriptomic analysis showed the reproducibility of the method highlighting that the majority of gene expression patternswas conserved in tumoroids compared to their matching tumor tissue. Moreover, this model enables to evaluate drug effects and invasiveness of renal cancer cells in a 3D context, providing a robust preclinical tool for drug screening and biomarker assessment in line with alternative ex vivo methods like tumor tissue slice culture or in vivoxenograft models.

Summary Background Whether multiparametric MRI improves the detection of clinically significant prostate cancer and avoids the need for systematic biopsy in biopsy-naive patients remains controversial. We aimed to investigate whether using this approach before biopsy would improve detection of clinically significant prostate cancer in biopsy-naive patients. Methods In this prospective, multicentre, paired diagnostic study, done at 16 centres in France, we enrolled patients aged 18–75 years with prostate-specific antigen concentrations of 20 ng/mL or less, and with stage T2c or lower prostate cancer. Eligible patients had been referred for prostate multiparametric MRI before a first set of prostate biopsies, with a planned interval of less than 3 months between MRI and biopsies. An operator masked to multiparametric MRI results did a systematic biopsy by obtaining 12 systematic cores and up to two cores targeting hypoechoic lesions. In the same patient, another operator targeted up to two lesions seen on MRI with a Likert score of 3 or higher (three cores per lesion) using targeted biopsy based on multiparametric MRI findings. Patients with negative multiparametric MRI (Likert score ≤2) had systematic biopsy only. The primary outcome was the detection of clinically significant prostate cancer of International Society of Urological Pathology grade group 2 or higher (csPCa-A), analysed in all patients who received both systematic and targeted biopsies and whose results from both were available for pathological central review, including patients who had protocol deviations. This study is registered with ClinicalTrials.gov, number NCT02485379, and is closed to new participants. Findings Between July 15, 2015, and Aug 11, 2016, we enrolled 275 patients. 24 (9%) were excluded from the analysis. 53 (21%) of 251 analysed patients had negative (Likert ≤2) multiparametric MRI. csPCa-A was detected in 94 (37%) of 251 patients. 13 (14%) of these 94 patients were diagnosed by systematic biopsy only, 19 (20%) by targeted biopsy only, and 62 (66%) by both techniques. Detection of csPCa-A by systematic biopsy (29·9%, 95% CI 24·3–36·0) and targeted biopsy (32·3%, 26·5–38·4) did not differ significantly (p=0·38). csPCa-A would have been missed in 5·2% (95% CI 2·8–8·7) of patients had systematic biopsy not been done, and in 7·6% (4·6–11·6) of patients had targeted biopsy not been done. Four grade 3 post-biopsy adverse events were reported (3 cases of prostatitis, and 1 case of urinary retention with haematuria). Interpretation There was no difference between systematic biopsy and targeted biopsy in the detection of ISUP grade group 2 or higher prostate cancer; however, this detection was improved by combining both techniques and both techniques showed substantial added value. Thus, obtaining a multiparametric MRI before biopsy in biopsy-naive patients can improve the detection of clinically significant prostate cancer but does not seem to avoid the need for systematic biopsy. Funding French National Cancer Institute.

Living donor nephrectomy is a high-stake procedure involving healthy individuals, therefore every effort should be made to define each patient’s individualized risk and improve potential donors’ information. The aim of this study was to evaluate the interest of the Mayo adhesive probability (MAP) score, an imaging-based score initially designed to estimate the risk of adherent perinephric fat in partial nephrectomy, to predict intra- and postoperative complications of living donor nephrectomy. We retrospectively reviewed the imaging, clinical, and follow-up data of 452 kidney donors who underwent laparoscopic donor nephrectomy in two academic centers. Imaging and follow-up data were available for 307 kidney donors, among which 44 (14%) had a high MAP score (≥ 3). Intraoperative difficulties were encountered in 50 patients (16%), including difficult dissection (n = 35) and bleeding (n = 17). Conversion to open surgery was required for 13 patients (4.2%). On multivariate analysis, a MAP score ≥ 3 was significantly associated with the risk of intraoperative difficulty [OR 14.12 (5.58–35.7), p

Background To assess whether whole-body (WB) bone SPECT/CT provides additional diagnostic information over [18F]-FCH PET/CT for the detection of bone metastases in the setting of prostate cancer biochemical recurrence (PC-BR). Methods Patients referred for a PC-BR and whom benefited from a WB bone SPECT/CT and FCH PET/CT were retrospectively included. Tests were classified as positive, equivocal, or negative for bone metastases. A best valuable comparator (BVC) strategy including imaging and follow-up data was used to determine the metastatic status in the absence of systematic histological evaluation. Results Between January 2011 and November 2017, 115 consecutive patients with a PC-BR were evaluated. According to the BVC, 30 patients had bone metastases and 85 patients did not present with bone lesions. The sensitivity, specificity, positive and negative predictive values were respectively 86.7% [69.3–96.2], 98.8% [93.6–100.0], 96.3% [78.7–99.5], and 95.5% [89.4–98.1] for WB bone SPECT/CT and 93.3% [77.9–99.2], 100.0% [95.8–100.0], 100.0 and 97.7% [91.8–99.4] for FCH PET/CT. There was no significant difference in diagnostic accuracy of bone metastases between WB Bone SPECT/CT (AUC 0.824 [0.74–0.90]) and FCH PET/CT (AUC 0.829 [0.75–0.90], p = 0.41). Conclusion Despite good performances for the diagnosis of bone metastases in PC-BR, WB bone SPECT/CT does not provide additive diagnostic information over concomitant FCH PET/CT.

INTRODUCTION AND OBJECTIVE:Multiparametric MRI is nowadays paramount for prostate cancer (PCa) diagnosis and local staging. When choosing between focal or radical treatment, however, MRI accuracy i...

INTRODUCTION AND OBJECTIVE:According to the literature, PIRADS 3 lesions are associated with prostate cancer (PCa) in 30 to 50% of cases. Our aim was to assess the cancer detection rate (CDR) of el...

INTRODUCTION AND OBJECTIVE:We evaluated the accuracy of elastic fusion biopsy in different European Centers using a standardized approach with the Koelis system. Our aim was to assess the added val...

Background: The relative cardiovascular safety of gonadotropin-releasing hormone (GnRH) antagonists compared with GnRH agonists in men with prostate cancer and known atherosclerotic cardiovascular disease remains controversial. Methods: In this international, multicenter, prospective, randomized, open-label trial, men with prostate cancer and concomitant atherosclerotic cardiovascular disease were randomly assigned 1:1 to receive the GnRH antagonist degarelix or the GnRH agonist leuprolide for 12 months. The primary outcome was the time to first adjudicated major adverse cardiovascular event (composite of death, myocardial infarction, or stroke) through 12 months. Results: Because of slower-than-projected enrollment and fewer-than-projected primary outcome events, enrollment was stopped before the 900 planned participants were accrued. From May 3, 2016, to April 16, 2020, a total of 545 patients from 113 sites across 12 countries were randomly selected. Baseline characteristics were balanced between study groups. The median age was 73 years, 49.8% had localized prostate cancer; 26.3% had locally advanced disease, and 20.4% had metastatic disease. A major adverse cardiovascular event occurred in 15 (5.5%) patients assigned to degarelix and 11 (4.1%) patients assigned to leuprolide (hazard ratio, 1.28 [95% CI, 0.59–2.79]; P =0.53). Conclusions: PRONOUNCE (A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease) is the first, international, randomized clinical trial to prospectively compare the cardiovascular safety of a GnRH antagonist and a GnRH agonist in patients with prostate cancer. The study was terminated prematurely because of the smaller than planned number of participants and events, and no difference in major adverse cardiovascular events at 1 year between patients assigned to degarelix or leuprolide was observed. The relative cardiovascular safety of GnRH antagonists and agonists remains unresolved. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02663908.

Summary Introduction Simulation-based training has proven to be a promising option allowing for initial and continuous training while limiting the impact of the learning curve on the patient. The Biopsym simulator was developed as a complete teaching environment for the prostate biopsy procedure. This paper presents the results of an external validation of this simulator, involving urology residents recruited during a regional teaching seminar. Methods Residents from 4 academic urology departments of the French Auvergne Rhone-Alpes region, who did not take part in the previous simulator validation studies, were enrolled. After a short presentation and standardized initiation session, residents carried out a simulated systematic 12-core biopsy procedure and were asked to fill in a questionnaire collecting their expectations and evaluation of the Biopsym simulator. The number of biopsies reaching each targeted sector, the total score provided by the simulator and the duration of the procedure were recorded. Results Twenty-three residents were recruited. The overall added value (/100) for learning was rated at a median of 100 (interquartile range 83-100), overall realism of the biopsy procedure at 80 (65-89). The median percentage of biopsies reaching the targeted sector was 66.7% (62-75). The median score provided by the simulator was 50% (37-60). For both, the difference between residents with or without prior biopsy experience was not statistically significant. The median duration of the simulated biopsy procedure was 4:58 (minutes: seconds) (3:49–6:00). Resident with prior experience required less time to complete the biopsy procedure 3:53 (3:39–4:56) vs. 5:10 (4:59–7:10), P = 0.01. Conclusion This external validation study confirms a high acceptance of the simulator by the target audience. To our knowledge, the Biopsym simulator is the only prostate biopsy simulator that demonstrated such validity as evaluated by clinicians, outside the center involved in its early development. Level of evidence 3.

Miniaturization of percutaneous nephrolithotomy techniques have led to their increased consideration for lower pole renal stones that can prove more challenging to reach using retrograde intrarenal surgery. The objectives of the present study were to evaluate and compare the outcomes of miniaturized percutaneous nephrolithotomy (miniPCNL) and retrograde intrarenal surgery (RIRS) for the treatment of lower pole renal stones.A retrospective study was performed in two academic urology departments between January 2016 and June 2019. Patients presenting with one or multiple stones of the lower calyx and/or renal pelvis, between 10 and 40mm based on CT-scan treated by miniPCNL or RIRS were included.In all, 115 miniPCNL and 118 RIRS procedures were included. The rate of patients with no significant residual fragment (stone free rate) after the first procedure was higher in the miniPCNL group (69% vs. 52% P=0.01), especially for stones20mm (63% vs. 24% respectively, P0.001) and stones with a density≥1000HU (69% vs. 42% respectively, P=0.009). The higher stone free rate of miniPCNL was confirmed in multivariate analysis, adjusting for stone size and number of stones, OR 4.02 (95% CI 2.08-8.11, P0.0001). The overall postoperative complication rate was higher in the miniPCNL group than in the RIRS group (23% vs. 11%, P=0.01). A second intervention for the treatment of residual fragments was necessary for 9.6% of patients in the miniPCNL group versus 30.5% of patients in the RIRS group (P0.001). Pre-stenting rate and duration of ureteral drainage (2 [1-8] vs. 25 days [7-37], P0.001) were lower in the miniPCNL group.The stone free rate was higher after miniPCNL, especially for stones20mm and with a density1000 HU, but was associated with a higher risk of postoperative complications and a longer hospital stay. RIRS resulted in fewer complications at the cost of a higher retreatment rate and longer ureteral stenting.3.

Background Superselective clamping of tumor-targeted arteries aims to eliminate ischemia of the remnant kidney while keeping tumor bed bloodless during excision. Objective To evaluate the impact of superselective clamping on long-term renal function, compared with renal artery early unclamping. Design, setting, and participants A randomized monocentric single-blind trial (1:1) was conducted from February 2018 to August 2019. Patients with a single renal tumor were candidates for a robot-assisted partial nephrectomy (RAPN) in a referral center. EMERALD (NCT03679572) was powered to include 50 patients with an interim analysis after 30 cases. Intervention Superselective RAPN (SS-RAPN) with near-infrared fluorescence (NIRF) or conventional RAPN with renal artery early unclamping. Outcome measurements and statistical analysis The primary endpoint was the percent change of estimated glomerular filtration rate (eGFR) in the operated kidney after 6 mo (combination of eGFR and relative function on 99mTc-DMSA scintigraphy). Secondary endpoints assessed feasibility and safety of the technique. Results and limitations Relative eGFR reduction in the operated kidney at 6 mo did not differ significantly (–21.4% vs –23.4%, p = 0.66). This absence of difference remained after adjusting on percentage of kidney volume preserved, which was an independent predictor of functional preservation. There were no significant differences in terms of blood loss, change in hemoglobin, postoperative complications, transfusion, and conversion to radical nephrectomy (two vs zero) or to open surgery (one vs zero). Despite a good accrual, the steering committee interrupted the trial after the interim analysis for futility given the absence of trend in favor of SS-RAPN. Conclusions SS-RAPN using NIRF does not provide better renal function preservation than renal artery clamping, questioning the interest of this technique at a higher risk of bleeding. Patient summary In this randomized controlled trial, superselective clamping of tumor feeding arteries did not show any advantage in terms of long-term renal function compared with conventional artery clamping.

Simple Summary Renal cell carcinoma (RCC) is the eighth leading malignancy in the world, accounting for 4% of all cancers with poor outcome when metastatic. Protein kinases are highly druggable proteins, which are often aberrantly activated in cancers. The aim of our study was to identify candidate targets for metastatic clear cell renal cell carcinoma therapy, using chemo-genomic-based high-throughput screening. We found that the combined inhibition of the CK2 and ATM kinases in renal tumor cells and patient-derived tumor samples induces synthetic lethality. Mechanistic investigations unveil that this drug combination triggers apoptosis through HIF-2α-(Hypoxic inducible factor HIF-2α) dependent reactive oxygen species (ROS) overproduction, giving a new option for patient care in metastatic RCC. Abstract Kinase-targeted agents demonstrate antitumor activity in advanced metastatic clear cell renal cell carcinoma (ccRCC), which remains largely incurable. Integration of genomic approaches through small-molecules and genetically based high-throughput screening holds the promise of improved discovery of candidate targets for cancer therapy. The 786-O cell line represents a model for most ccRCC that have a loss of functional pVHL (von Hippel-Lindau). A multiplexed assay was used to study the cellular fitness of a panel of engineered ccRCC isogenic 786-O VHL− cell lines in response to a collection of targeted cancer therapeutics including kinase inhibitors, allowing the interrogation of over 2880 drug–gene pairs. Among diverse patterns of drug sensitivities, investigation of the mechanistic effect of one selected drug combination on tumor spheroids and ex vivo renal tumor slice cultures showed that VHL-defective ccRCC cells were more vulnerable to the combined inhibition of the CK2 and ATM kinases than wild-type VHL cells. Importantly, we found that HIF-2α acts as a key mediator that potentiates the response to combined CK2/ATM inhibition by triggering ROS-dependent apoptosis. Importantly, our findings reveal a selective killing of VHL-deficient renal carcinoma cells and provide a rationale for a mechanism-based use of combined CK2/ATM inhibitors for improved patient care in metastatic VHL-ccRCC.

The nomogram reported by Gandaglia et al (The key combined value of multiparametric magnetic resonance imaging, and magnetic resonance imaging-targeted and concomitant systematic biopsies for the prediction of adverse pathological features in prostate cancer patients undergoing radical prostatectomy. Eur Urol 2020;77:733-41) predicting extracapsular extension (ECE) or seminal vesicle invasion (SVI) has been developed using multiparametric magnetic resonance imaging (MRI) parameters and MRI-targeted biopsy. We aimed to validate this nomogram externally by analyzing 566 patients harboring prostate cancer diagnosed on MRI-targeted biopsy followed by radical prostatectomy. At final pathology, 37% and 12% patients had ECE and SVI, respectively. Performance of the nomogram, in comparison with the Memorial Sloan Kettering Cancer Center (MSKCC) model and Partin tables, was evaluated using discrimination, calibration, and decision curve analysis. Regarding ECE prediction, the nomogram showed higher discrimination (71.8% vs 69.8%, p = 0.3 and 71.8% vs 61.3%, p

Summary Introduction To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair. Material and methods Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected. Results Thirty-six women were included (mean age: 72 ± 7 years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41 ± 12 min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n = 6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR = 2.0 [95% CI: 0.8175–4.8928]; P = 0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy. Conclusion Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy. Level of evidence 4.

Background The current pathological tumour-node-metastasis (pTNM) classification for upper tract urothelial carcinoma (UTUC) does not include any risk stratification of pT3 renal pelvicalyceal tumours. Objective To assess the prognostic impact of pT3 subclassification in a multicentre cohort of patients with UTUC of the renal pelvicalyceal system undergoing radical nephroureterectomy (RNU). Design, setting, and participants Data from all consecutive patients treated with RNU for pT3 renal pelvicalyceal UTUC at 14 French centres from 1995 to 2013 were reviewed retrospectively. Intervention A central pathology review (CPR) was used to stratify pT3 patients into those with infiltration of the renal parenchyma on a microscopic level (pT3a) versus those with infiltration of the renal parenchyma visible on gross inspection of the resection specimen and/or invasion of peripelvic fat (pT3b). Outcome measurements and statistical analysis Inverse probability weighting (IPW)-adjusted Cox regression analyses were used to compare recurrence-free survival (RFS) and cancer-specific survival (CSS) between pT3a and pT3b patients. Results and limitations Overall, 202 patients were included and further stratified into pT3a (n = 98; 48.5%) and pT3b (n = 104; 51.5%) subgroups. Median time to follow-up in the weighted population was 68 (interquartile range, 50–95) mo. In IPW-adjusted Cox regression analyses, pT3b versus pT3a substage was associated with a significant adverse effect on RFS (hazard ratio [HR] = 2.02; 95% confidence interval [CI] = [1.36–3.01]; p Conclusions Using IPW-adjusted analyses after the CPR, we observed that RNU patients with pT3b renal pelvicalyceal UTUC had adverse prognosis as compared with those with pT3a disease. As such, this subclassification could help refine the current pTNM system for UTUC. Patient summary In this report, we looked at the prognostic interest of stratifying patients with pT3 renal pelvicalyceal upper tract urothelial carcinoma based on the extent of local invasion. We found that those with extensive infiltration (pT3b) had adverse prognosis as compared with those with limited infiltration (pT3a). This information could be provided on pathology reports to further guide clinical decision making.

International audience; OBJECTIVES: To evaluate the ability of students to reproduce the skills acquired on a prostate biopsy simulator in a real-life situation. DESIGN: A prospective randomized controlled study was conducted. Medical students with no experience of prostate biopsy were randomized between arm A « conventional training » and arm B « simulator-enhanced training. » The training was performed for both groups on the simulator. The students in arm B were provided with visual and numerical feedback. The transfer of skills was assessed by recording the position of the 12 biopsies performed by each student on an unembalmed human cadaver using a 3D ultrasound mapping device. SETTING: The study was conducted in an academic urol-ogy department and the cadaver experiments in the adjoining anatomy laboratory. RESULTS: Twenty-four students were included, and 22 completed the study. The median score obtained on the simulator at the end of the training was 57% (53-61) for arm A and 66% (59-71) for arm B. The median score obtained on the cadaver by students trained with the simulator was 75% (60-80), statistically superior to the score obtained by students trained conventionally of 45% (30-60), p < 0.0001. The median score obtained by all students when performing biopsies in a real-life situation was 63% (50-80) versus 60% (56-70) for their last training on the simulator. CONCLUSION: These results support the transfer of skills acquired on the simulator, and the superiority of a training curriculum integrating simulation, and performance feedback. (J Surg Ed 77:953À960. Ó 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

International audience; Purpose: The Briganti nomogram can be used with a threshold of 5% to decide when to offer lymph node dissection during radical prostatectomy. The objective of the study was to assess the accuracy of the Briganti nomogram on intermediate-risk prostate cancer patients managed in a single academic department. Methods: We retrospectively reviewed the files of all patients managed by radical prostatectomy (RP) and bilateral pelvic lymph node dissection (BPLND) in our center between 2005 and 2017. The overall accuracy of the model in predicting metastatic lymph node disease was quantified by the construction of a receiver-operator characteristic (ROC) curve. A calibration plot was drawn to represent the relationship between the predicted and observed frequencies.Results: We included 285 patients, among whom 175 (61.4%) were classified as intermediate risk as defined by D’Amico. The median follow-up was 60 (34-93) months. Twenty-seven patients (9.5%) were diagnosed with lymph node metastases. The median number of lymph nodes removed was 10 (7-14). The mean Briganti score was 19.3% in patients with lymph node involvement (LNI) and 6.3% in patients without LNI. Focusing on intermediate-risk patients, 91(52%) and 84 (48%) had a Briganti score

Intermediate-risk prostate cancer regroups heterogeneous patients with different oncologic outcomes. Aim of the study is to validate a novel intermediate-risk subclassification ("magnetic resonance imaging [MRI] subclassification") that defines favorable and unfavorable diseases based on multiparametric MRI parameters and compare it to NCCN and AUA intermediate-risk subclassifications.A total of 429 patients treated with radical prostatectomy for NCCN intermediate-risk prostate cancer were identified. Using MRI subclassification, a favorable disease was defined as an organ-confined disease on MRI and international society of urological pathology Grade Group 1 to 2 on targeted biopsy. Remaining was classified as unfavorable. Univariable and multivariable analysis tested MRI subclassification in predicting overall unfavorable disease (OUD: pT3-4 and/or pN1 and/or International Society of Urological Pathology Grade Group ≥ 3), the need for adjuvant therapy and early biochemical recurrence (eBCR). Performance of NCCN, AUA, and MRI models was compared in term of OUD proportion and eBCR prediction using Harrell's c-index, calibrations plots, and decision curve analysis.Median (interquartile range) follow-up was 12 months (4-28). In multivariable analysis, MRI subclassification was an independent factor for OUD (odds ratio [OR]: 4.54 [2.85-7.22], P0.001), the need for adjuvant therapy (OR: 3.42 [1.36-8.57], P = 0.009), and eBCR (HR: 2.62 [1.18-5.83], P = 0.018). Using this model, the proportion of unfavorable disease decreased from 73.7% and 63.9% to 35.9% (P0.001) associated to an increasing proportion of OUD when compared to NCCN and AUA models (63.9% and 67.1%-77.9% respectively, P0.001). Performance of the 3 models for eBCR prediction tended to be similar with a poor accuracy ranged from 58.7% to 66.7% (P0.05), permanent miscalibration and a net benefit at decision curve analysis.We validated an intermediate-risk subclassification based on MRI and targeted biopsy that potentially improves patient selection by reducing the number of patients considered at unfavorable risk while increasing proportion of patients harboring poor oncologic outcomes. Its performance for eBCR detection was comparable to NCCN and AUA models.

Resume Objectifs Les progres de l’imagerie et l’avenement de l’IRM multiparametrique ont rendu possible la definition de cibles et la realisation de biopsies ciblees de la prostate. Celles-ci peuvent etre realisees selon differentes methodes. Les objectifs de ce travail etaient de faire le point sur les techniques de fusion echographie-IRM et les dispositifs disponibles en 2018. Methodes Une revue ciblee de la litterature a ete realisee afin de relever les differents dispositifs disponibles. Les industriels ont ete ensuite contactes en cas de besoin pour preciser les informations manquantes. Nous nous sommes attaches a decrire le mode de fonctionnement de chaque dispositif ainsi que ses avantages et inconvenients. Resultats La fusion cognitive suppose une courbe d’apprentissage et une expertise importante. Elle est limitee par le risque d’erreur important qu’elle engendre et l’absence de controle qualite. Les systemes disponibles peuvent etre classes selon la methode utilisee pour le ciblage des zones suspectes : suivi de la sonde, de la biopsie, de la prostate et de la biopsie. Les dispositifs suivant la sonde sont les moins onereux, modifient peu les pratiques et permettent un guidage temps reel, au prix d’une precision moindre. Les dispositifs suivant la biopsie et la prostate offrent une precision de l’ordre de 3–4 mm en permettant de prendre en compte les deplacements de la prostate, au prix d’un cout plus important et d’une duree operatoire plus longue. Les biopsies peuvent etre realisees par voie transrectale ou transperineale selon les dispositifs. Conclusion Les progres de l’imagerie prostatique actuels et a venir et le developpement des traitements focaux sont en voie de faire des biopsies prostatiques ciblees une etape incontournable dans la prise en charge initiale du cancer de prostate. Le marche des dispositifs de fusion est en plein developpement et permet actuellement de faire un choix en mettant dans la balance precision, cout, modification des pratiques et duree operatoire.

RESUME Le concept des gestes robot assistes, qui ne se limite pas au tele-manipulateur Da vinci, envahit progressivement les blocs operatoires des pays industrialises. Dans un contexte budgetaire de plus en plus contraint, la chirurgie robot assistee avec le robot Da vinci s’est largement developpee en particulier pour les interventions urologiques. Les modifications induites par l’arrivee de cette innovation technologique assez revolutionnaire sont importantes, tant sur le plan technique pour l’equipe chirurgicale et paramedicale que sur le plan organisationnel et financier pour les structures de soins et pour notre systeme de sante. Cette publication qui reprend les principaux resultats oncologiques et fonctionnels des deux interventions pour lesquelles la chirurgie robot assistee s’est largement developpee en urologie (prostatectomie totale et chirurgie conservatrice du rein) , met en exergue les resultats encourageants mais le Service Medical Rendu considere comme faible dans le rapport de la Haute Autorite de Sante de novembre 2016 sur la dimension clinique et organisationnelle de la chirurgie robot assistee pour la prostatectomie totale souleve encore de nombreuses interrogations face au developpement inexorable de cette technologie qui prend le pas sur les autres voies d’abord. Nous proposons dans ce document de donner quelques reponses a vos interrogations sur « l’explosion » de cette technologie en urologie.

INTRODUCTION AND OBJECTIVES:In a large multicenter series, we assessed the impact of performing a standard systematic sampling of the prostate in addition to mpMRI-targeted biopsies, in terms of pr...

International audience; OBJECTIVE:To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both (SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens.MATERIALS AND METHODS:Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation® and Trinity®) prior to radical prostatectomy between 2010 and 2017. Cochran's Q test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies.RESULTS:Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (p

International audience; Objectives: The Biopsym simulator, a virtual-reality simulator for prostate biopsies, was designed to offer enhanced teaching of the biopsy procedure. The objectives of the present article are to describe the new version of the simulator and report the results of a new validation study. Material and methods: A prospective validation study was conducted between January and March 2017. The new version of the simulator, with improved physical realism, ultrasound image deformation, and a new scoring system, was evaluated by novice and confirmed users. Results: Twenty-one users evaluated the simulator, including ten novices and 11 confirmed users. The overall realism of the biopsy procedure was rated at 7.7/10 (IQR 5.7-9). The differences between the rates given by confirmed users and novices were not statistically significant. The median overall score obtained for the performance of 12 systematic ultrasound-guided biopsies was 43% (IQR 33-55). The median score obtained by confirmed users was 54% (IQR 46-62), and the median score obtained by novices was 31% (IQR 20-35). The difference between the scores was statistically significant (p = 0.005). Conclusions: This study allowed us to gather evidence towards the validation, and particularly towards the construct validation of the new version of the Biopsym simulator.

Lower urinary tract symptoms related to benign prostatic obstruction (BPO) are frequent in men aged > 50 years. Based on the use of innovative medical devices, a number of transurethral ablative techniques have recently been developed for the surgical treatment of BPO. In recent years, GreenLight photoselective vaporization of the prostate (PVP) has been considered as a non-inferior alternative to transurethral resection of the prostate. The GreenLight PVP is usually considered as an interesting surgical option for patients treated via oral anticoagulants (OACs) with regard to its haemostatic properties. The aim of this study was to assess the impact of maintaining OAC treatment in patients undergoing PVP. This study is a multicentre, open-label, randomized controlled trial (RCT) designed to show the non-inferiority of PVP surgery in patients with BPO treated with OACs. This study is designed to enrol 386 OAC-treated patients (treated with vitamin K antagonists and direct oral anticoagulants) who are undergoing PVP for BPO. Patients will be randomized (1:1) to either maintain or stop OAC treatment during the perioperative course. The intervention group will maintain OAC treatment until the day before surgery and resume OAC treatment the day after surgery, whereas the control group will stop OAC treatment (with or without low-molecular-weight heparin bridging therapy) according to the anaesthesia guidelines. The primary outcome of interest to be assessed is the 30-day complications rate according to the Clavien-Dindo classification. The secondary endpoint will examine the 30-day rate of haemorrhagic and thrombotic events. This study will provide 80% power to show non-inferiority, defined as not worse than a 10% (non-inferiority margin) inferior change in the proportion of patients with good outcomes (Clavien-Dindo score

Resume Introduction La generalisation de la prescription du dosage de l’antigene specifique de la prostate (PSA) et la banalisation des techniques d’analyse sur des systemes automatises ne doivent pas faire oublier que les immuno-dosages peuvent etre pris en defaut lors de la presence d’anticorps heterophiles (AH). Ils peuvent etre responsables d’une interference analytique qui peut perturber le resultat du dosage par exces ou par defaut. Materiel et methodes Cette mise au point s’appuie sur des cas cliniques exemplaires, detaille les mecanismes mis en cause lors des interferences et surtout les moyens de remedier a ce probleme. Resultats Les interferences rapportees et documentees ont conduit a des explorations inutiles, voire des diagnostics errones. Conclusion Devant toute valeur inattendue de PSA au regard de la clinique, il est crucial d’initier un dialogue direct, reel, entre cliniciens et biologistes avant toute intervention therapeutique.

Objectifs Le cancer de la prostate metastatique (CaPm) est une situation clinique d’evolution souvent longue, complexe, faisant intervenir plusieurs lignes de traitements successifs. L’objectif principal etait de realiser une image des pratiques francaises concernant le diagnostic et le traitement du CaP d’emblee metastatique a partir des donnees de « vraie vie » recueillies dans des RCP sentinelles (RCPs) selon le modele AFU. Methodes Etude prospective, descriptive, multicentrique realisee en France de janvier 2018 a novembre 2018. L’ensemble des patients atteints d’un CaPm a ete inclut sur un serveur informatique national a partir de 72 RCPs dans des centres publics et prives (accord de la CNIL). Le groupe des CaP d’emblee metastatiques a ete analyse. Les donnees cliniques, radiologiques, anatomopathologiques et les decisions therapeutiques ont ete recueillies au diagnostic du CaPm (a M0) puis lors du suivi a 3 mois (M3) et 6 mois (M6). L’export des donnees informatiques a ete realise sur un tableur Excel permettant l’analyse statistique. Resultats Sur 780 CaPm recenses dans 39 centres, 408 (52,1 %) etaient d’emblee metastatiques. Le suivi a M3 et M6 a ete obtenu chez respectivement 209 et 194 patients. L’âge median etait de 73,5 ans et les motifs principaux de consultation etaient l’elevation du PSA et les troubles mictionnels ( Tableau 1 ). Un bilan d’extension standard etait realise dans 51,5 % des cas et une imagerie metabolique dans 14,7 % ( Fig. 1 ). Les patients etaient a haut risque (LATITUDE) et a haut volume (CHARTEED) dans respectivement 41,9 et 56,1 % des cas. Le traitement initie est presente sur la Fig. 2 . A M3 et M6, le PSA moyen etait respectivement de 27,9 et 32,2 ng/mL. A M3, 20 % des patients et 25 % a M6 necessitaient un changement therapeutique. Seuls 6 deces etaient rapportes sur la periode. Conclusion Les RCPs permettent le recueil rapide de donnees fiables et exhaustives contribuant ainsi a la caracterisation de populations ciblees. Cette premiere etude AFU a permis l’evaluation de 780 dossiers de CaPm sur l’annee 2018. Elle montre l’importance du partage de l’information et renforce l’interet pour la creation de registres nationaux accessibles a tous.

ARTICLE InFO ______________________________________________________________ ______________________ Introduction: Super-selective clamping of tumor-specific segmental arteries was developed to eliminate ischemia of the remnant kidney while limiting hemorrhage during partial nephrectomy. The objective is to evaluate the benefice of super-selective clamping on renal functional outcome, compared to early-unclamping of the renal artery. Materials and Methods: From March 2015 to July 2016, data from 30 patients undergoing super-selective robot-assisted PN (RAPN) for a solitary tumor by a single surgeon were prospectively collected. Tumor devascularization was assessed using indocyanine green near-infrared fluorescence. A matched-pair analysis with a retrospective cohort undergoing early-unclamping was conducted, adjusting on tumor complexity and pre-operative eGFR. Perioperative, oncologic and functional outcomes using DMSA-renal scintigraphy were assessed. Multivariate analysis was performed to identify predictors of postoperative renal function and de novo chronic kidney disease (CKD). Results: Super-selective RAPN was successful in 23/30 patients (76.7%), 5 requiring secondary main artery clamping due to persistent tumor fluorescence. Matched-pair analysis showed similar operating time, blood loss, positives margins and complication rates. Super-selective clamping was associated with an improved eGFR variation at discharge (p=0.002), 1-month (p=0.01) and 6-month post-op (-2%vs-16% p=0.001). It also led to a better relative function on scintigraphy (46%vs40% p=0.04) and homo-lateral eGFR (p=0.04), and fewer upstaging to CKD stage ≥3 (p=0.03). On multivariate analysis, super-selective clamping was a predictor of postoperative renal function. Conclusion: Super-selective RAPN leads to an improved preservation of renal function and a reduced risk of de novo CKD stage≥3, while keeping the benefit of main artery clamping on perioperative outcomes.

Resume Objectif Les reseaux sociaux (SoMe) ont revolutionne la pratique de la medecine. Notre objectif etait de faire un etat des lieux sur l’utilisation des SoMe par les urologues de l’Association francaise d’urologie (AFU). Materiel et methodes Une enquete comportant 15 questions a ete adressee par e-mail 2 mois avant le 108 e congres francais d’urologie (#CFU2014) aux urologues membres de l’AFU. Parallelement, l’activite des urologues utilisant Twitter etait analysee sur la periode du congres a l’aide du logiciel symplur ( www.symplur.com ). Resultats Au total, 270 (17,3 %) urologues ont repondu au sondage mais seulement 50 % ont indique avoir un compte SoMe. Les plateformes SoMe les plus couramment utilisees ont ete : Facebook (36,1 %) suivie par LinkedIn (28,2 %), Google+ (19,6 %), YouTube (18,7 %) et Twitter (17,4 %). L’utilisation des SoMe a ete plus importante dans les tranches d’âge 30–40 et 40–50 ans que dans les tranches d’âge superieures (83 % contre 36 %). Seulement 38,7 % des repondants ont declare utiliser les SoMe dans un domaine professionnel. Lors du congres #CFU2014, il y a eu plus de 1000 tweets generes par 173 contributeurs distincts. Conclusion Seule une minorite d’urologues de l’AFU ont rapporte etre connectes aux reseaux sociaux et pour une utilisation majoritairement personnelle. L’apparition de Twitter aux reunions urologiques organisees par l’AFU est tres recente mais semble prometteuse. Une etude plus approfondie s’impose, notamment aupres des membres de l’AFU, afin de mieux caracteriser le veritable impact des reseaux sociaux en urologie. Niveau de preuve 4.

Introduction: The aim of this study was to compare the results of ultrasound-guided prostate biopsies (US-PB) and magnetic resonance imaging-ultrasound fusion biopsies (MRI-PB) in two contemporary cohorts and to describe the parameters orienting the choice of technique.Methods: Two contemporary cohorts of patients undergoing US-PB or MR-PB using the Urostation® (Koelis, Grenoble, France) between November 2010 and July 2015 were analyzed retrospectively. Patients with metastatic cancer or recurrence after treatment, saturation biopsies, and US-PB performed after a negative MRI were excluded. Comparison of populations, biopsy results, and clinical and biological parameters guiding the choice of technique were studied on multivariate analysis (logistic regression) taking into account the following confounding factors: age, prostate-specific antigen (PSA) rate, prostatic volume, number of previous biopsies, and abnormal digital rectal examination.Results: One hundred fourteen patients were included in the US-PB group and 118 in the MR-PB group. Prostate cancer was diagnosed among 65 patients in the US-PB group (detection rate 57.0%) and 70 patients in the MR-PB group (detection rate 59.3%) (odds ratio [OR] 3.00; 95% confidence interval [CI] 1.52–6.17; p=0.002). Among the cancers diagnosed in the MR-PB group, 21 were diagnosed by the two targeted biopsy cores only (15.5%). Patients undergoing MR-PB were significantly younger (p=0.0005), with a higher number of previous biopsy sessions (p

International audience; Purpose - To compare partial nephrectomy (PN) and percutaneous ablative therapy (AT) for renal tumor in imperative indication of nephron-sparing technique (NST). Materials and methods - Between 2000 and 2015, 284 consecutive patients with a kidney tumor in an imperative indication of NST were retrospectively included in a multicenter study. PN [open (n = 146), laparoscopic (n = 9), or robotic approach (n = 17)] and AT [radiofrequency ablation (n = 104) or cryoablation (n = 8)] were performed for solitary kidney (n = 146), bilateral tumor (n = 78), or chronic kidney disease (CKD) (n = 60). Results - Patients in the PN group had larger tumors and a higher RENAL score. There were no differences between the two groups with respect to age, reasons for imperative indication, and preoperative eGFR. Patients in the AT group had a higher ASA and CCI. PN had worse outcomes than AT in terms of transfusion rate, length of stay, and complication rate. Local radiological recurrence-free survival was better for PN, but metastatic recurrence was similar. Percentage of eGFR decrease was similar in the two groups. Temporary or permanent dialysis was not significantly different. On multivariate analysis, PN and AT had a similar eGFR change when adjusted for tumor complexity, reason of imperative indication and CCI. Conclusion - In imperative indication of nephron-sparing treatment for a kidney tumor, either PN or AT can be proposed. PN offers the ability to manage larger and more complex tumors while providing a better local control and a similar renal function loss.

Prostate cancer is the second most common cancer in men worldwide. Most information concerning clinical presentation are available with analysis of countries databases (SEER database for United states [1]; SEER database points out sociodemographic differences in screening and treatments in the world and the lack on the risk profile of patients with localized prostate cancer in the United States which represents the current clinical presentation of patients in countries where PSA screening has been developed.

Objectifs En France, l’analyse des bases de donnees medico-economiques en onco-urologie ne detaille generalement pas la motivation des prises de decision. Les RCP rassemblent plusieurs disciplines medico-chirurgicales hautement specialisees dont la collaboration permet le recueil de donnees fiables et exhaustives. L’objectif des RCPs etait le denombrement et l’etude descriptive epidemiologique de situations de soins complexes et des modalites de leur prise en charge en onco-urologie. Methodes Le recrutement des RCPs s’appuie sur le volontariat et la determination des RCP a etudier une thematique selectionnee. Une fois la RCP selectionnee pour un projet, une demande de participation a ete adressee aux coordinateurs de celle-ci. Le premier sujet d’etude retenu a ete le cancer de la prostate metastatique (CaPm). La selection des RCPs s’est echelonnee entre le 1er septembre 2017 et le 31 decembre 2017. Une fois l’accord de la CNIL et du CPP obtenu une etude pilote nationale epidemiologique descriptive a pu etre lancee sur le theme du CaPm. Resultats Sur les 150 RCP contactees, 72 RCP ont repondu favorablement a leur inclusion dans le projet d’etude du CaPm. Il s’agissait de 35 centres prives et 37 centres publics. Tous les patients nouvellement ou secondairement metastatiques presentes en RCP entre janvier 2018 et novembre 2018 ont ete inclus (650 dossiers analyses en mai 2019). L’objectif etait de faire une image des pratiques en France concernant le diagnostic, le traitement et le suivi des patients. Un questionnaire comportant des donnees cliniques, biologiques, d’imagerie et les decisions prises lors de la RCP a ete remis aux differents centres. Les donnees ont ete collectees a l’inclusion, au 3e et au 6e mois de suivi. Une base de donnees informatisee nationale a ete creee permettant l’export des donnees anonymisees et leur analyse. Conclusion Les RCP sentinelles permettent de fournir des informations specialisees de « vraie vie » permettant de caracteriser la frequence de survenue et les prises en charges proposees pour certaines situations en onco-urologie. Plusieurs projets sont en cours (enquetes, examen de cas cliniques complexes) suivant ce concept, le premier concernant le CaPm devrait fournir ses resultats d’ici la fin de l’annee.

International audience; Prostate cancer is the most frequent male cancer and the second cause of male cancer mortality in developed countries. Therefore, it represents a major public health issue. Health problem and the development of new therapeutic strategies to address this issue is essential. During a prostatectomy, the surgeon looks for a compromise between an exhaustive removal of pathologic tissue (to achieve the best carcinogenic prognosis) and the functional consequences linked to a wide excision (i.e.: avoid as much as possible urinary incontinence and sexual dysfunction). In this context, the ANR TecSan DEPORRA project regroups French research laboratories (TIMC-IMAG, FEMTO-ST), companies (Endocontrol-Medical, VERMON) and hospital departments (CIC-IT, Urology & pathology Department of the Grenoble University Hospital) to bring innovative tools for radical prostatectomy. These tools will provide to the surgeon new information from several imaging modalities (video, fluorescence and US imaging), and combine them in an augmented environment. We believe that this augmented environment will ultimately help the surgeon to perform his surgical gesture "optimally" and will improve the patient's carcinogenic and functional prognosis.

Collecting duct carcinoma (CDC) is a kidney cancer subtype that is thought to arise from principal cells in distal parts of the collecting ducts. Some studies suggested an overlap of CDC with upper tract urothelial carcinoma (UTUC), making the pathological diagnosis challenging. Herein, we performed for the first time transcriptome sequencing of CDC and compared them to UTUC and renal cell carcinoma subtypes. We discovered that CDC displays a unique transcriptomic signature among kidney cancer subtypes, with a putative cell of origin in the distal convoluted tubules. Hierarchical unsupervised clustering reveals that the CDC signature is closer to that of other RCC subtypes than to UTUC, which is similar to that of bladder carcinoma. CDC is characterized by a metabolic shift, with impairment of oxidoreductase activity, pyruvate metabolism and the tricarboxlyic acid cycle, as well as an immunogenic response consistent with increased tumor infiltrating lymphocytes, particularly within metastatic cases. In addition, pathways differentially altered between CDC and UTUC point to a basal-like phenotype of CDC in contrast to the luminal-like signature of UTUC. We conclude that CDC harbors a pathognomonic transcriptomic signature characterized by immunogenic and a metabolic aberrations, indicating that targeting these processes might provide therapeutic options for patients.

International audience; PURPOSE:The management of major renal trauma has shifted in the last decade in favor of a nonoperative approach. Our level 1 trauma center promotes this approach with the objective of renal function preservation. However, certain situations still require surgery. In this study we analyze predictors of surgery and long-term outcomes after conservative management.MATERIALS AND METHODS:From January 2004 to March 2015 we prospectively collected data from all patients admitted to our institution for high grade blunt renal trauma (grades IV and V). Nonoperative management was considered successful when patients did not undergo surgical exploration, regardless of angioembolization or endoscopic treatment.RESULTS:Of 306 patients with renal trauma 151 presented with major injuries, including 124 grade IV and 27 grade V. Nonoperative management was successful in 110 (89%) cases of grade IV and 14 (52%) cases of grade V lesions. Deceleration mechanism (p=0.03), associated lesions (p=0.001), percentage of devitalized parenchyma (p=0.012), angioembolization (p

Resume Introduction Les avancees de l’IRM pour la detection des tumeurs de prostate permettent des biopsies ciblees sur des zones suspectes. Materiel et methodes Une revue de la litterature a ete realisee sur Medline ® en utilisant les termes targeted , prostate biopsy et leurs articles relatifs. Soixante-cinq abstracts ont ete etudies ainsi que 102 associes, 38 articles ont ete lus et 27 retenus. Resultats La reconstruction mentale laisse place aux biopsies avec guidage direct dans l’IRM et la fusion d’image echographie-IRM. Les premieres permettent une grande precision mais restent limitees par l’accessibilite, le cout et la duree. La fusion d’images est un compromis prometteur. Les taux de detection de cancer varient de 15 a 64 %. Conclusion La realisation de biopsies prostatiques ciblees sur des zones suspectes a l’IRM est prometteuse pour ameliorer la sensibilite et le rendement des biopsies prostatiques.

Study Type – Therapy (outcomes) Level of Evidence 2b What's known on the subject? and What does the study add? High-grade renal trauma seems to be eligible for conservative management. Ureteric stent placement raises issues about its usefulness and its timing. Predictive factors of post-trauma function and surgery need to be known. Urinary extravasation is not associated with poor functional outcome. Ureteric stenting is needed only in case of sepsis and ureteric clot retention. The only independent predictor of long-term renal function is the importance of devascularised renal fragments. OBJECTIVE • To predict the outcomes of a non-operative approach to managing urinary extravasation after blunt renal trauma. PATIENTS AND METHODS • A prospective observational study was conducted between January 2004 and October 2011. First-line non-operative management was proposed for 99 patients presenting with a grade IV blunt renal injury according to the revised American Association for the Surgery of Trauma (AAST) classification. Among them, 72 patients presented with a urinary extravasation. • Management and outcomes were recorded and compared between patients presenting and those who did not present with urinary leakage. Relative postoperative renal function was assessed 6 months after the trauma using dimercapto-succinic acid renal scintigraphy. • Predictors of the need for endoscopic or surgical management and long-term renal function were evaluated on multivariate analysis. RESULTS • Among patients with urinary leakage, endoscopic ureteric stent placement and open surgery were required in 37% and 15%, respectively. • On multivariate analysis, fever of >38.5 °C and ureteric clot obstruction were independent predictors of the need for ureteric stent placement. The only predictor of open surgery was the percentage of devitalised parenchyma. • Long-term renal function loss was correlated to the percentage of devitalised parenchyma and associated visceral lesions. Urinary extravasation did not predict surgical intervention or long-term renal function loss. CONCLUSIONS • Urinary extravasation after blunt renal trauma can be successfully managed conservatively and does not predict long-term decreased renal function or surgery requirement. • A devascularised parenchyma volume of >25% predicts a higher rate of surgery and poorer renal function.

What's known on the subject? and What does the study add? Using a standardized classification for renal tumours is a major step towards an objective comparison of the indications and expected outcomes of partial nephrectomy (PN). Several scores have been described, including the RENAL nephrectomy score (RNS), to evaluate the anatomical features of a renal tumour and predict the surgical challenges with particular regard to PN. Previous studies show discrepancies with regard to the effectiveness of using the RNS to predict postoperative outcomes. Although we showed that conversion to radical nephrectomy was predicted by the RNS, the occurence of complications was more difficult to predict. Objective To evaluate the RENAL nephrometry score (RNS) as a predictor of the perioperative outcomes of a partial nephrectomy. Patients and Methods A retrospective review of 177 consecutive patients who were candidates for an open partial nephrectomy (OPN, n = 159) or a laparoscopic partial nephrectomy (LPN, n = 18) from August 2008 to January 2011 was undertaken. Tumour complexity was stratified into three categories: low (4–6), moderate (7–9) and high (10–12) complexity. Complications, and surgical and renal outcomes were recorded and analysed. Predictors of conversion to radical nephrectomy (RN) and complications were assessed using univariate and multivariate logistic regression. Multiple linear regression was used to evaluate the prediction of postoperative estimated glomerular filtration rate (eGFR) and warm ischaemia time (WIT). Results The median RNS was 7 (interquartile range 6–9). Tumour complexity was assessed as low in 72 (40.6%), moderate in 87 (49.2%) and high in 18 patients (10.2%). There were no significant differences among the three groups with respect to demographic characteristics, operating time, estimated blood loss, transfusion, length of stay, complications and positive surgical margins. Conversion to RN occurred in 29 patients (16.3%). RNS was significantly associated with an increased risk of conversion to RN (odds ratio [OR] = 3.5, P = 0.01 and OR = 6.7, P = 0.005, respectively, for moderate vs low, and high vs low complexity groups). On multivariate analysis, RNS was the only independent predictor of WIT (P = 0.03) and conversion to RN (P = 0.008), but failed to predict postoperative eGFR (P = 0.84) and the occurrence of major complications (P = 0.91). Conclusions In the present series, RNS predicted an increased risk of conversion to RN and prolonged WIT. RNS was not a predictor of complications and postoperative renal function.

Resume La prise en charge conservatrice des traumatismes fermes du rein s’est considerablement developpee ces dernieres annees en raison des progres dans la prise en charge initiale des patients. Cette evolution non chirurgicale est le fruit d’une meilleure collaboration entre les urologues, les autres chirurgiens impliques dans la gestion des lesions secondaires et les reanimateurs ; elle est aussi l’aboutissement d’une conduite a tenir plus standardisee liee a un bilan initial precis et exhaustif par scanner thoraco-abdominopelvien, et aux progres de la radiologie interventionnelle et des gestes endoscopiques sur la voie urinaire. L’objectif de cette mise au point est de rappeler les differentes phases de prise en charge de ces patients, avec un algorithme simplifie qui resume la place des differents acteurs de cette prise en charge multidisciplinaire. Ce document doit aussi nous faire reflechir sur la place de la chirurgie dans ces traumatismes severes, souvent realisee lorsque le risque vital est en jeu, aboutissant le plus souvent un geste de nephrectomie.

Resume Les enjeux de la reflexion medicale en reunion de concertation pluridisciplinaire (RCP) en cancerologie sont de proposer un avis adapte a la situation du patient en reunissant des competences medicales complementaires afin d’optimiser les choix therapeutiques tout en prenant en compte le benefice pour le patient. L’objectif principal de notre etude etait de mesurer des criteres de qualite de l’organisation de la RCP, la mise en application de la decision medicale collegiale et des « recommandations » s’y rapportant. A partir des resultats de cette etude, nous ouvrons une reflexion sur nos methodes de soins actuelles. Dix RCP de specialites differentes ont ete evaluees. Le respect du quorum varie selon les specialites entre 55 et 100 %. L’application de l’avis emis par la RCP est de 86,3 % et les motifs les plus frequents de non-application sont le refus du patient ou l’apparition d’elements cliniques nouveaux ou meconnus. La proportion d’avis prise en adequation avec les referentiels est de 74 %. Le motif le plus frequent d’avis hors referentiel est l’existence d’une situation clinique complexe. La tenue des RCP consomme un temps medical important en partie lie a la tentative de respecter l’exhaustivite demandee par le plan cancer. L’evolution vers l’exhaustivite souleve le probleme du temps medical et du sens des RCP pour les cas cliniques standards. Une RCP ou la multidisciplinarite est respectee semble une priorite par rapport a un enregistrement exhaustif.

The results of a local survey sent to urologists, oncologists and radiotherapeutists working in Rhone-Alpes have been reported to assess the value of multidisciplinary oncological meetings (RCP) in Urology. The results of this short study have been analyzed and compared to the national results published by the Inspection Generale des Affaires Sociales report. Meanwhile, we have created a professional electronic directory collecting all RCP of Rhone-Alpes, which will be accessible soon.

Item does not contain fulltext PURPOSE: Fuhrman grade represents a key determinant of the natural history of small renal masses that represent renal cell carcinoma. We tested whether renal mass biopsy prediction of Fuhrman grade in the nephrectomy specimen could be safely substituted for by an accurate statistical model. To date the best available model has shown poor accuracy (55.6%), which is close to flipping a coin (50%) and clearly inadequate for use in clinical practice. MATERIALS AND METHODS: We identified 1,139 patients with T1aN0M0 renal cell carcinoma treated with partial or radical nephrectomy at 11 participating institutions from 1989 to 2004. This cohort was used in univariate and multivariate logistic regression models predicting high Fuhrman grade (III-IV) at nephrectomy. Predictors included age at diagnosis, gender, tumor size and symptom classification. Multivariate logistic regression coefficients were used to generate a nomogram. RESULTS: The rate of Fuhrman grade III-IV in patients with T1aN0M0 renal cell carcinoma was 12.3%. Stratifying patients with Fuhrman grade III-IV by age, gender, histological subtypes and sample size failed to reveal statistically significant differences. On univariate analysis predicting Fuhrman grade III-IV at nephrectomy only tumor size was a statistically significant predictor (p = 0.05). The most accurate multivariate nomogram for Fuhrman grade III-IV prediction was 58.3% (95% CI 57.8-58.9) accurate. Of all tested predictors only tumor size achieved independent predictor status (p = 0.009). CONCLUSIONS: Our analysis derived in European patients shows that statistical models cannot safely replace renal mass biopsy based prediction of Fuhrman grade III-IV at nephrectomy. Our findings corroborate a report from the United States in which a similar model had 55.6% accuracy. Jointly the studies indicate that statistical models are unreliable and cannot safely be substituted for renal mass biopsy in North American or European patients.

Background: Currently two pretreatment prognostic models with limited accuracy (65-67%) can be used to predict survival in patients with localized renal cell carcinoma (RCC). Objective: We set out to develop a more accurate pretreatment model for predicting RCC-specific mortality after nephrectomy for all stages of RCC. Design, setting, and participants: The data originated from a series of prospectively recorded contemporary cases of patients treated with radical or partial nephrectomy between 1984 and 2006. Model development was performed using data from 2474 patients from five centers and external validation was performed using data from 1972 patients from seven centers. Measurements: The probability of RCC-specific mortality was modeled using Cox regression. The significance of the predictors was confirmed using competing risks analyses, which account for mortality from other causes. Results and limitations: Median follow-up in patients who did not die of RCC-specific causes was 4.2 yr and 3.5 yr in the development and validation cohorts, respectively. The freedom from cancer-specific mortality rates in the nomogram development cohort were 75.4% at 5 yr after nephrectomy and 68.3% at 10 yr after nephrectomy. All variables except gender achieved independent predictor status. In the external validation cohort the nomogram predictions were 88.1% accurate at 1 yr, 86.8% accurate at 2 yr, 86.8% accurate at 5 yr, and 84.2% accurate at 10 yr. Conclusions: Our model substantially exceeds the accuracy of the existing pretreatment models. Consequently, the proposed nomogram-based predictions may be used as benchmark data for pretreatment decision making in patients with various stages of RCC. (c) 2008 Published by Elsevier B.V. on behalf of European Association of Urology.