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The prognostic impact of renal cell carcinoma (RCC) morphotype remains unclear in patients who undergo partial nephrectomy (PN). Our objective was to determine the risk factors for recurrence after PN, including RCC morphotype.Patients with RCC who had undergone PN were extracted from the prospective, national French database, UroCCR. Patients with genetic predisposition, bilateral or multiple tumours, and those who had undergone secondary totalization were excluded. Primary endpoint was 5-year, recurrence-free survival (RFS), and secondary endpoint was overall survival (OS). Risk factors for recurrence were assessed by multivariable Cox regression analysis.Overall, 2,767 patients were included (70% male; median age: 61 years [interquartile range (IQR) 51-69]). Most (71.5%) of the PN procedures were robot-assisted. Overall, 2,573 (93.0%) patients were recurrence free, and 74 died (2.7%). Five-year RFS was 84.9% (IQR 82.4-87.4). A significant difference in RFS was observed between RCC morphotypes (p0.001). Surgical margins (hazard ratio [HR] = 2.0 [95% confidence interval (CI): 1.3-3.2], p0.01), pT stage1 (HR = 2.6 [95% CI: 1.8-3.7], p0.01]) and Fuhrmann grade2 (HR = 1.9 [95% CI: 1.4-2.6], p0.001) were risk factors for recurrence, whereas chromophobe subtype was a protective factor (HR = 0.08 [95% CI: 0.01-0.6], p = 0.02). Five-year OS was 94.0% [92.4-95.7], and there were no significant differences between RCC subgroups (p = 0.06). The main study limitation was its design (multicentre national database), which may be responsible for declarative bias.Chromophobe morphotype was significantly associated with better RFS in RCC patients who underwent PN. Conversely, pT stage, Fuhrman group and positive surgical margins were risk factors for recurrence.

The management of solitary kidney tumors is a surgical challenge, requiring irreproachable results on both oncological and functional outcomes. The goal of our study was to compare the perioperative results of robotic-assisted partial nephrectomy (RAPN) to open surgery in this indication.We led a multicentric study based on the prospectively maintained French national database UroCCR. Patients who underwent partial nephrectomy on a solitary kidney between 1988 and 2020 were included. Clinical and pathological data were retrospectively analyzed. The main outcome of the study was the analysis of the variation of the estimated glomerular filtration rate (eGFR) calculated according to MDRD at 3, 6, 12, and 24 months depending on the chosen surgical approach. The secondary outcomes were the comparison of Trifecta success, perioperative complications, and length of hospital stay.In total, 150 patients were included; 68 (45%) in the RAPN group and 82 (55%) in the open surgery group. The two groups were comparable for all data. The variation of eGFR at 3, 6, 12, or 24 months was comparable without any significant difference between the 2 groups (p = 0.45). Trifecta was achieved in 40% of the patients in the RAPN group and 33% in the open group (p = 0.42). A significant difference was observed for the length of stay, 5 days for the robot group versus 9 days for the open surgery group (p 0.0001).In our study, the surgical approach did not modify functional results and we noted a significant decrease in hospital stay and complications in the RAPN group. RAPN is a safe and efficient method for management of kidney tumors in solitary kidneys.

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.

Introduction The aims of this narrative review was to report on the contemporary data of renal colic (RC) in terms of epidemiology and pressure on emergency structures and also to describe the latest therapeutic developments about uncomplicated RC, depending on the pediatric, adult and pregnancy population. Material and methods A request to the health surveillance network for emergencies and deaths (SurSaUD®, Sante Publique France) revealed original data on the contemporary epidemiology of renal colic. A narrative synthesis of the articles (French, English) available on the Pubmed database was produced in June 2021. Results Renal colic represents 1.1% of the annual total of emergency room visits. The mean age at admission was 45 years and 62% of patients were men. NSAIDs and Paracetamol are the most effective analgesic treatments and should be given priority over opioids. Non-drug analgesic treatments by tactile stimulation probably have a place in the CN management, particularly in case of contraindications. Among the validated treatments, alphablockers allow better expulsion when the stone is located in the pelvic ureter and if its size is between 5 and 10mm in diameter. In pregnant women, the predominant problem is to confirm the diagnostic. If there is a strong suspicion, MRI or a low-dose CT scan is possible. Ureteroscopy is feasible in particular in the first part of pregnancy to avoid iterative ureteral catheter changes. The care for children is now based on that of adults. Conclusion The renal colic care pathway in 2021 can benefit from various optimizations in the field of expulsion and analgesic treatments. Good knowledge of the specific situations in pregnant women and children allowing to improve the quality of care.

Resume Introduction Les complications emaillant un traumatisme du rein et de l’uretere sont directement dans le domaine de l’urologue. Si celles-ci viennent au second plan dans le pronostic vital, une bonne connaissance de ces pathologies est essentielle. Methodes Une revue systematique de la litterature a ete effectuee en utilisant la base Medline afin de degager les articles les plus pertinents en langue anglaise et francaise. Resultats L’extravasation urinaire dans le cadre des traumatismes fermes du rein a un bon pronostic fonctionnel. L’alteration de la fonction du rein traumatise est liee aux lesions vasculaires associees au grade IV. La surveillance est le traitement de choix avec une prise en charge differee en cas de degradation septique ou douloureuse. Les lesions de l’uretere sont majoritairement iatrogenes. Si les lesions incompletes peuvent etre traitees par endoscopie, les lesions completes (stenose ou plaie) requierent une intervention chirurgicale. Les lesions de l’uretere distal, les plus frequentes sont facilement traitees par reimplantation uretero-vesicale. Les larges pertes de substance peuvent necessiter un remplacement ileal. Conclusion Les traumatismes fermes du rein occasionnant une extravasation urinaire, d’excellent pronostic sont traites de maniere conservatrice. A l’inverse, les lesions de l’uretere necessitent dans la majorite des cas une intervention de remise en continuite.

Resume Introduction L’objectif de cette revue narrative etait de rapporter les donnees les plus pertinentes sur la prise en charge contemporaine des Retentions aigues d’urines (RAU). Methodes Une synthese narrative des articles (francais, anglais) disponibles sur la base Pubmed a ete realisee en juin 2021. Une requete aupres du reseau de surveillance sanitaire des urgences et des deces (SurSaUD®, Sante Publique France) a mis en evidence des donnees originales sur l’epidemiologie de la RAU. Resultats La RAU est une urgence therapeutique, necessitant un drainage vesical rapide. L’âge moyen est de 71 ans, 87 % sont des hommes et le temps de passage aux urgences est > 4 heures. En France, le taux d’hospitalisation des RAU est en diminution constante de 42 % en 2014 a 32 % en 2019. L’introduction d’un α-bloquant augmente de 47 a 77 % les chances de sevrage de la sonde urinaire vs. placebo. La mise en place d’une filiere RAU post-urgence permet de raccourcir la duree de sondage. La premiere epreuve de desondage doit etre organisee dans les 48-72 heures suivant la RAU. En cas d’echec de desondage, il est recommande d’orienter le patient vers un apprentissage des autosondages propres et intermittents (ASPI). La mise en place d’un stent prostatique temporaire est une alternative prometteuse en cours d’evaluation. La chirurgie de desobstruction immediate vs. differee est associee a une augmentation de la morbi-mortalite. Conclusion Le parcours de soin de la RAU en 2021 peut beneficier de multiples optimisations permettant d’ameliorer le delai et la qualite de prise en charge.

INTRODUCTION Among trauma emergencies, kidney damage is uncommon. The urologist is frequently on the second line in the management of patients with multiple traumatic lesions. Knowledge of treatment is necessary to be able to integrate the different teams involved in an approach that is both vital in the context of damage control and functional with a concern for parenchymal preservation. METHODS A systematic review of the literature was carried out using the Medline database in order to identify the most relevant articles in English and French. RESULTS Kidney trauma occurs either by direct shock or by a deceleration mechanism. They are classified by severity according to the AAST classification. Management is mostly conservative by avoiding surgery and controlling bleeding by arterial embolization. Surveillance checks for complications occurrence in high-grade trauma. Traumatic dissection of the renal artery, with a poor functional prognosis requires a short delay before treatment. CONCLUSION The prognosis for trauma to the kidney, regardless of the grade, is currently good, with improvements of effective resuscitation and embolization in the event of bleeding.

Resume Introduction L’objectif de cet article etait de citer des urgences rares mais parfois graves, pouvant etre rencontrees par tout urologue au cours de son exercice, et d’en exposer les grands principes de prise en charge. Materiel et methode Une revue systematique de la litterature a partir de PubMed, Embase et Google Scholar a ete menee, entre janvier 2000 et juin 2021. Les articles obtenus ont ete selectionnes en fonction de leur anciennete et leur type. Les articles originaux, les meta-analyses, les recommandations et les articles de revues les plus recents publies en francais et en anglais ont ete conserves. Au total, 312 articles ont ete recenses et 58 selectionnes a partir de leurs resumes. Les articles ont ete ensuite analyses exhaustivement par les auteurs, et 24 references ont finalement ete retenues. Resultats Plusieurs urgences rares de nature infectieuse (pyelonephrite xanthogranulomateuse, cystite et pyelonephrite emphysemateuse, malacoplasie, hydatidurie), ischemique (gangrene de Fournier, calciphylaxie penienne), hemorragiques (hemospermie, hemorragies du haut appareil urinaire, Wunderlich Syndrome, hematomes surrenaliens spontanes) ou a l’origine de manifestations douloureuses (colique spermatique, thromboses veineuses du penis) peuvent poser des difficultes diagnostiques et therapeutique, en l’absence de consensus concernant leur prise en charge. Conclusion Ces pathologies, rares mais parfois graves, doivent etre reconnues afin de ne pas retarder la prise en charge et de diminuer leur morbi-mortalite. Conjuguee a l’amelioration constante de notre arsenal diagnostique et therapeutique, une meilleure connaissance de ces urgences rares contribuera a preserver le pronostic fonctionnel et vital des patients.

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

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

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.

To describe clinical outcomes of patients aged 75 years and above after partial nephrectomy (PN), and to assess independent factors of postoperative complications. We retrospectively reviewed information from our multi-institutional database. Every patient over 75 years old who underwent a PN between 2003 and 2016 was included. Peri-operative and follow up data were collected. Multivariate logistic regression was performed to determine independent predictive factors of postoperative complications. We reviewed 191 procedures including 69 (40%) open-surgery, and 122 (60%) laparoscopic procedures, of which 105 were robot-assisted. Median follow-up was 25 months. The mean age was 78 [75–88]. The American Society of Anesthesiologist’s score was 1, 2, 3 and 4 in 10.5%, 60%, 29% and 0.5% of patients respectively. The mean tumor size was 4.6 cm. Indication of PN was elective in 122 (65%) patients and imperative in 52 patients (28%). The median length of surgery was 150(± 60) minutes, and the median estimated blood loss 200 ml. The mean glomerular filtration rate was 71.5 ml/minute preoperatively, and 62 ml/min three months after surgery. The severe complications (Clavien III-V) rate was 6.2%. On multivariate analysis, the robotic-assisted procedure was an independent protective factor of medical postoperative complications (Odds Ration (OR) = 0.31 [0.12–0.80], p = 0.01). It was adjusted for age and RENAL score, robotic-assisted surgery (OR = 0.22 [0.06–0.79], p = 0.02), and tumor size (OR = 1.13 [1.02–1.26], p = 0.01), but the patients age did not forecast surgical complications. Partial nephrectomy can be performed safely in elderly patients with an acceptable morbidity, and should be considered as a viable treatment option. Robotic assistance is an independent protective factor of postoperative complications.

The aim of this narrative review was to report the most relevant data on the contemporary management of Acute Urine Retention (AUR).A narrative synthesis of the articles in French and English available on the Pubmed database was carried out in June 2021. We explored the registry of Surveillance sanitaire des urgences et des décès (SurSaUD®, Santé Publique France) to rise original data regarding the epidemiology of AUR in France.AUR is a therapeutic emergency that requires a rapid bladder drainage. The average age is 71 years, 87 % are men and the stay in the emergency department is4hours. In France, the hospitalization rate for UAR is steadily decreasing from 42% in 2014 to 32% in 2019. The introduction of an α-blocker increases the chances to get rid of the urinary catheter of 47% to 77% versus placebo. A post-emergency AUR pathway allows lowering the number of people lost with follow-up and shortening the duration of bladder drainage. The first try for catheter removal should be organized within 48-72hours of the AUR. In case of unsuccessful catheter removal, it is recommended to teach self-catheterization to the patient. The placement of a temporary prostatic stent is a promising alternative that is under evaluation. Immediate surgery is associated with increased morbidity/mortality and is not recommended.AUR is a common disease. The management has been optimized in recent years to improve the prognosis and the quality of life of patients.

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.

Objectifs La preservation nerveuse lors de la prostatectomie totale a ete associee a un risque superieur de marges positives. Nous presentons les Resultats preliminaires et difficultes rencontrees au cours d’une etude translationnelle ex-vivo visant a caracteriser le tissu residuel comme prostatique ou non-prostatique, a l’aide d’une sonde innovante et d’un anticorps anti-PSMA conjugue a un fluorophore. Methodes Deux etudes prospectives ont ete montees pour permettre la collecte de tissu prostatique frais de maniere prospective. Une sonde pouvant etre adaptee a la laparoscopie a ete developpee pour la detection de la fluorescence en temps reel ( Fig. 1 ). La microscopie confocale etait utilisee comme gold-standard pour la comparaison. Les echantillons preleves etaient marques soit avec un anticorps anti-PSMA conjugue avec un fluorophore (Alexa Fluor 488), soit utilises comme controles. Resultats Aucune difference significative n’a ete notee entre l’intensite et le signal de fluorescence des echantillons issus de RTUP marques (n = 4) ou controles (n = 4), en lien avec une auto fluorescence marquee secondaire a l’electrocoagulation ( Fig. 2 ). Trois biopsies ont ensuite ete obtenues chez 7 patients operes d’une prostatectomie radicale, montrant egalement une auto fluorescence significative, mettant en doute la reproductibilite de la fixation des anticorps anti-PSMA sur les echantillons. De plus, la comparaison entre les mesures de fluorescence et l’anatomopathologie s’est averee difficile du fait de la taille reduite des prelevements et l’alteration tissulaire. Conclusion Nous n’avons pas reussi a demontrer la faisabilite de la detection peroperatoire des marges utilisant un marquage avec un anticorps anti-PSMA, notamment du fait d’une importante auto fluorescence des tissus. Nous avons en revanche developpe une sonde de detection de fluorescence compatible avec la laparoscopie. L’utilisation d’un fluorophore emettant dans l’infra-rouge, ou de nouveaux anticorps, sont a l’etude.

Objectifs L’obesite pourrait avoir un impact sur la periode peri-operatoire des tumeurs du rein, en termes de morbidite, de resultats operatoires, mais egalement une influence sur les choix therapeutiques notamment chirurgicaux. Les modifications morphologiques liees a l’obesite, la morbidite propre s’y rapportant et les comorbidites liees a celle-ci pourraient impacter les resultats peri-operatoires d’une chirurgie renale et influencer le choix de la strategie therapeutique. Methodes Une etude multicentrique a ete realisee au sein de la base Uro-CCR chez les patients traites pour une tumeur du rein entre 2007 et 2020. L’obesite a ete definie par un indice de masse corporel (IMC) ≥ 30. L’objectif principal de l’etude etait de comparer la prise en charge des lesions renales selon le statut obese ou non du patient : biopsies, type de traitement, voie d’abord. Les Objectifs Secondaires etaient les donnees peri-operatoires. Les caracteristiques des groupes et les variables etudiees de patients obeses (PO) vs. non obeses (PNO) ont ete comparees par les tests de Student ou du Chi2. Resultats Un total de 8893 patients ont ete inclus avec 26,1 % de PO. Selon le RENAL score, les lesions apparaissaient comme plus complexes chez les PO (p = 0,023). La prise en charge differait avec un taux superieur de biopsies (4,6 % vs 3,4 % p = 0,0019) chez les PO tout comme la proportion de nephrectomies partielles (NP) (66,9 %vs 62,1 % p Tableau 1 , Tableau 2 ). Conclusion Les resultats de cette etude mettent en avant que si l’obesite ne semble pas influencer de facon significative le type de traitement propose pour une tumeur du rein mais une potentielle meilleure selection des patients. La chirurgie etait cependant impactee avec une duree operatoire superieure, une duree de clampage allongee, un saignement plus important et un risque de conversion superieur.

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.

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.

INTRODUCTION AND OBJECTIVE:Obesity is a public health problem in industrialized countries and is a known risk factor for kidney cancer.At the same time, partial nephrectomy has become the gold stan...

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

Objective To develop French guidelines on the management of patients with severe abdominal trauma. Design A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Societe francaise d’anesthesie et de reanimation, SFAR), the French Society of Emergency Medicine (Societe francaise de medecine d’urgence, SFMU), the French Society of Urology (Societe francaise d’urologie, SFU) and from the French Association of Surgery (Association francaise de chirurgie, AFC), the Val-de-Grâce School (Ecole du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Federation de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. Methods The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a “damage control surgery” strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. Results The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. Conclusions Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.

Objective To update the French guidelines on kidney cancer. Methods A systematic review of the literature between 2015 and 2018 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence. Results Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultrasound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. In metastatic patients: cytoreductive nephrectomy is recommended in case of good prognosis; medical treatment must be offered first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First-line recommended drugs in metastatic patients include sunitinib, pazopanib, and the association nivolumab/ipilimumab. Cabozantinib can be offered in option in intermediate and bad prognostic patients. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness. Conclusion These updated recommendations should assist French speaking urologists for their management of kidney cancers.

Objectifs La simulation chirurgicale s’impose comme une option permettant l’apprentissage a une technique chirurgicale tout en diminuant l’impact de la courbe d’apprentissage sur le patient. Le simulateur Biopsym propose un environnement pedagogique complet pour l’apprentissage du geste de biopsie prostatique. Nous presentons ici les resultats de la validation externe de ce simulateur, conduite aupres d’internes en urologie recrutes a l’occasion d’une journee de formation regionale. Methodes Des internes de 4 services universitaires d’urologie de la region Auvergne-Rhone-Alpes, n’ayant pas pris part aux precedentes etudes de validation du simulateur, ont ete inclus. Apres une courte presentation et une etape d’initiation standardisee, les internes realisaient une procedure de 12 biopsies randomisees simulees, puis remplissaient un questionnaire recueillant leurs attentes et l’evaluation du simulateur Biopsym. Le nombre de biopsies atteignant chaque secteur prostatique, le score total donne par le simulateur et la duree de la procedure simulee etaient recueillis. Resultats Vingt-trois internes ont ete inclus. L’apport global pour la formation (/100) etait evalue a une mediane de 100 (ecart interquartile 83-100), le realisme global de la procedure a 80 (69-89). Le pourcentage median de biopsies atteignant la zone visee etait de 66,7 % (62-75). Le score median attribue par le simulateur etait de 50 % (37-60). La difference pour ces deux scores selon l’existence ou non d’une experience prealable des biopsies prostatiques n’etait pas statistiquement significative. La duree mediane d’une procedure etait de 4 :58(minutes :secondes) (3 :49–6 :00). Les internes plus experimentes etaient plus rapides que les internes non ou peu experimentes 3 :53s (3 :39–4 :56) vs 5 :10 (4 :59–7 :10), p = 0,01 ( Fig. 1 , Fig. 2 ). Conclusion Cette etude de validation externe confirme une forte acceptation du simulateur par ses utilisateurs cibles. A notre connaissance, le simulateur Biopsym est le seul simulateur de biopsies prostatiques ayant fait la preuve de sa validite en dehors du centre a l’origine de son developpement.

Objectifs Les tumeurs malignes du rein ont une incidence croissante et l’obesite en est l’un des facteurs de risque connus. L’obesite serait associee a des types histologiques differents qui pourraient egalement impacter le pronostic voire la prise en charge des patients. Methodes L’objectif principal de l’etude etait d’evaluer l’influence de l’obesite sur le type histologique des tumeurs renales. L’objectif secondaire etait d’evaluer l’impact de l’obesite sur la survie sans recidive apres chirurgie d’une tumeur renale. Une etude descriptive comparative multicentrique a ete realisee au sein du reseau Uro-CCR. Les caracteristiques histologiques des tumeurs renales operees chez les patient inclus entre 2007 et 2020 ont ete comparees selon leur statut obese ou non, defini par un IMC > = 30 kg/m2, a l’aide du test de Chi2 et admettant pour significativite p Resultats Un total de 6749 tumeurs renales ont ete inclues, dont 1687 (25 %) etaient obeses. Ces derniers etaient plus souvent diabetiques et hypertendus (respectivement 27,2 % versus 11,4 % et 61,2 % versus 41,2 %, tous deux p 30 kg/m2: 50,9 % de grades 1–2 versus 43,4 % (p Conclusion A notre connaissance, nous rapportons les Resultats de la plus importante cohorte sur ce sujet. L’obesite serait associee a un taux plus eleve de carcinomes a cellules claires et des caracteristiques tumorales moins agressives. Bien que ces donnees histologiques suggerent des lesions moins agressives chez les patients obeses, cela ne semble pas confirme par une meilleure survie sans recidive.

Resume Introduction L’objectif a ete de decrire la prise en charge des pseudo-anevrismes (PA) post-traumatiques, intraparenchymateux, dans notre centre ; de la comparer aux donnees de la litterature afin de proposer un algorithme de prise en charge. Materiel et methodes Les dossiers de 325 traumatises renaux inclus dans une base de donnees prospective entre janvier 2004 et mai 2016 ont ete revus. Une revue des cas publies de PA a ete realisee sur Pubmed a l’aide des termes « blunt renal trauma » et « pseudoaneurysm » (excluant les cas de fistules arterioveineuses, de traumatismes ouverts et de PA extraparenchymateux) a permis l’analyse de 29 cas supplementaires. La prise en charge des traumatises renaux dans notre centre est decrite. Resultats Parmi les 325 patients traumatises renaux, 160 (49,3 %) etaient des traumatismes de grade IV et V. Un traitement conservateur a ete realise dans 93,2 % des cas. Huit cas de PA ont ete recenses, soit une incidence de 2,5 %. Quatre ont ete embolises d’emblee. Parmi les 4 cas surveilles, on a note 2 cas de thrombose spontanee, 1 cas d’absence de regression motivant une embolisation et 1 cas de recidive hemorragique occulte. Les PA surveilles ayant evolue favorablement avaient tous une taille inferieure a 1 cm. La fonction relative scintigraphique moyenne a 6 mois des reins ayant presente un PA embolise etait de 71,6 %. La revue de la litterature a permis de rapporter 29 cas publies, embolises pour 26 d’entre eux, avec un taux de succes de 84,6 %. Deux patients ont ete surveilles, mais l’un a finalement ete embolise devant la persistance de la lesion. Conclusion La formation d’un PA post-traumatique est une complication rare (2,5 %) des traumatismes fermes du rein. L’embolisation en presence de symptomes ou a fortiori d’une instabilite hemodynamique permet une bonne preservation renale. Les PA detectes de maniere fortuite (imagerie de suivi) et de taille inferieure a 1 cm semblent pouvoir etre surveilles. Niveau de preuve 5.

Objectifs Le clampage supra-selectif (CSS) des arteres a destinee tumorale au cours d’une nephrectomie partielle robot-assistee (NPRA) vise a reduire l’impact fonctionnel a long terme de l’ischemie sans degrader les conditions de vision et les pertes sanguines. L’objectif de cet essai controle randomise est de comparer la perte de fonction renale a 6 mois, entre CSS et clampage total (CT) avec declampage precoce. Methodes Essai controle randomise simple aveugle monocentrique, mono-operateur. Les candidats a une NPRA pour tumeur unique etaient randomises (1 :1) entre CSS et CT. Une reconstruction 3D-CT preoperatoire identifiait les pedicules a destinee tumorale. La devascularisation peroperatoire etait verifiee par fluorescence au vert d’indocyanine. Le critere principal etait le pourcentage de variation du debit de filtration glomerulaire (DFG) du rein opere en preoperatoire puis a 6 mois, par multiplication du DFG global (CDK-EPI) par la fonction relative par scintigraphie 99mTc-DMSA. Une volumetrie tomodensitometrique estimait la conservation du volume parenchymateux. L’essai EMERALD (ClinicalTrials.gov NCT03679572 ) a ete dimensionne pour inclure 50 patients avec une analyse intermediaire apres 30 cas. Resultats De fevrier 2018 a aout 2019, 31 patients ont ete inclus (15 CT, 16 CSS) a l’analyse intermediaire. Les caracteristiques demographiques et tumorales etaient comparables. Il n’existait pas de difference significative an termes de pertes sanguines (200 vs 300 mL), de variation d’hemoglobine, de transfusion, de complications postoperatoires, de conversion en nephrectomie totale (0 vs 2) ou en chirurgie ouverte (0 vs 1). Le pourcentage de variation de DFG du rein opere a 6 mois etait non statistiquement different (−21,4 % vs −23,4 %, p = 0,66). Cette absence de difference persistait apres ajustement au pourcentage de volume preserve qui etait un facteur predictif independant de preservation fonctionnelle. Malgre une courbe d’inclusion conforme aux previsions, le comite de pilotage a stoppe l’etude apres l’analyse intermediaire pour futilite eu egard a l’absence de tendance a la superiorite fonctionnelle du CSS ( Fig. 1 , et Tableau 1 , Tableau 2 ). Conclusion Le clampage supra-selectif des arteres a destinee tumorale en chirurgie robot-assistee avec fluorescence au vert d’indocyanine ne permet pas une meilleure preservation de la fonction renale en comparaison du clampage de l’artere renale montrant l’absence d’interet de la technique au regard des risques vasculaires pris.

Objectifs Nous presentons le cas d’une patiente de 63 ans ayant beneficie d’une cure de cystocele et de rectocele par voie basse 15 ans auparavant. Elle presente des infections urinaires depuis 12 mois avec une hyperactivite vesicale et un handicap fonctionnel notable. En echographie, il existe un calcul vesical immobile sur la face posterieure, lateralise a gauche. En cystoscopie, on visualise de la prothese et le calcul au contact de l’orifice ureteral gauche. Methodes Apres un premier traitement endoscopique par lithotritie laser et extraction de la partie visible de la bandelette, recidive douloureuse et infectieuse rapide pour lequel une tentative de 2e traitement endoscopique est realise. Persistance de la symptomatologie et absence de cicatrisation de la vessie. On propose une ablation de la prothese par voie coelioscopique robot assistee. Resultats L’intervention comprend une ablation de la prothese inter-vesico-vaginale, avec suture de la vessie et reimplantation uretero-vesicale. La duree operatoire etait de 115 minutes, les pertes sanguines etaient nulles. La sonde vesicale a ete retiree au 5eme jour post-operatoire. Les suites ont ete marquees par une fievre post-operatoire avec des prelevements bacteriologiques negatifs et un scanner abdominal n’objectivant pas de complications post-operatoires. La sonde JJ a ete retiree a 1 mois post-operatoire. Conclusion La voie coelioscopique robot-assistee est une alternative interessante pour une ablation de prothese de cystocele compliquee. Elle permet d’allier une voie d’abord mini-invasive avec la precision de la dissection et la facilite de reconstruction inherentes aux instruments articules et la vision 3D.