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INTRODUCTION AND OBJECTIVE:A prospective non randomized study was conducted in 3 centers to evaluate 1: the feasibility of the insertion of a single size temporary prostatic stent under local anest...

Objective To describe a technique combining the implantation of fiducials and a prostatic spacer (hyaluronic acid [HA]) to decrease the rectal toxicity after an image-guided external beam radiotherapy (EBRT) with hypofractionation for prostate cancer and to assess the tolerance and the learning curve of the procedure. Materials and Methods Thirty patients with prostate cancer at low or intermediate risk were included in a phase II trial: image-guided EBRT of 62 Gy in 20 fractions of 3.1 Gy with intensity-modulated radiotherapy. A transrectal implantation of 3 fiducials and transperineal injection of 10 cc of HA (NASHA gel spacer, Q-Med AB, Uppsala, Sweden) between the rectum and the prostate was performed by 1 operator. The thickness of HA was measured at 10 points on magnetic resonance imaging to establish a quality score of the injection (maximum score = 10) and determine the learning curve of the procedure. Results The quality score increased from patients 1-10, 11-20, to 21-30 with respective median scores: 7 [2-10], 5 [4-7], and 8 [3-10]. The average thicknesses of HA between the base, middle part, and apex of the prostate and the rectum were the following: 15.1 mm [6.4-29], 9.8 mm [5-21.2], and 9.9 mm [3.2-21.5]. The injection of the HA induced a median pain score of 4 [1-8] and no residual pain at mid-long term. Conclusion Creating an interface between the rectum and the prostate and the implantation of fiducials were feasible under local anesthesia with a short learning curve and could become a standard procedure before a hypofractionated EBRT for prostate cancer.

Study Type – Therapy (multi-centre cohort) Level of Evidence 2b OBJECTIVE To evaluate the early functional outcomes of transurethral plasma vaporization of the prostate (TUVis) in a multicentre study. PATIENTS AND METHODS A prospective multicentre observational study was conducted in eight urology departments. The inclusion criterion was benign prostatic hyperplasia (BPH) requiring surgical treatment. Patients on anti-coagulant therapy were not excluded. The TUVis procedure was performed according to a classic transurethral resection of the prostate (TURP) scheme following the manufacturer’s recommendations. We evaluated subjective functional outcome using self-questionnaires (International Prostate Symptom Score [IPSS] and five-item International Index of Erectile Function [IIEF-5]) and objective criteria (prostate volume, prostate-specific antigen [PSA], uroflowmetry, post residual volume) at baseline and at 1- and 3-month follow-ups. All types of complications were systematically recorded. RESULTS Despite 52% of patients receiving anticoagulant therapy before surgery, we reported only 3% with haemorrhagic complications, no blood transfusion, a mean catheterization time of 44 h and a mean postoperative stay of 2.9 nights. No significant change in irrigation time, catheter time or hospital stay was observed in patients with or without anticoagulant therapy. The IPSS and bother scores significantly decreased after the 3-month follow-up (57% and 59%, respectively), but the average remaining prostate volume was 29 cc and the tissue ablation rate was only 0.5 cc/min. Three major complications occurred, consisting of two urinary fistulas and one partial bladder coagulation. CONCLUSIONS The TUVis procedure has a proven fast postoperative recovery time, good short-term functional outcome and good haemostatic efficiency. However, the tissue ablation rate was lower than expected and we encountered three major complications, the mechanisms of which remain unclear. Considering the high energy level required to create the plasma effect, the generator, cable and resectoscope must be carefully checked before each procedure.

To evaluate blood loss during transurethral resection of the prostate (TURP), and its predictive factors, using the chromium 51 (51Cr) labeling method.From January to June 2008, 41 patients who underwent TURP for symptomatic benign prostatic hyperplasia (BPH) at four French urology centers were included in the analysis. Red cells volume was measured by the 51Cr method 1 day before TURP, and on postoperative day 3. Overall blood loss was estimated by multiplication of red cells volume loss and preoperative venous hematocrit value.Mean preoperative red cells volume was 1997 mL. Mean loss of red cells volume was 209 ml, which corresponds to an estimated blood loss of 507 mL. Mean delta of hematocrit and hemoglobin were 1.4% and 0.71 g/dL, respectively. In univariate analysis, prostate volume, weight of resected tissue, preoperative red cells volume, and resection time were significantly and directly associated with loss of red cells volume (P = 0.038, P = 0.004, P = 0.002, and P = 0.039, respectively). Bipolar and monopolar TURP did not lead to significant difference of red cells loss. In multivariate analysis, both preoperative red cells volume and weight of resected tissue were independent predictors of red cells loss (P = 0.017 and P = 0.048 respectively).We present the first study to measure blood loss secondary to TURP using the 51Cr method. This technique allowed evaluating blood loss not only during the surgical procedure but also during the postoperative period. We learned from this study that, on average, blood loss from the procedure until postoperative day 3 was more than 500 mL, which is larger than previously reported amounts as measured by other methods. Because significant blood loss might occur during the postoperative period, the 51Cr method should be used to measure blood loss when evaluating new emerging techniques to manage BPH.

The prostate cancer 3 (PCA3) gene was discovered in 1999, on the basis of differential expression between cancer and noncancerous prostate tissue. Including the first study published in 2003, 11 clinical studies have evaluated its utility for the diagnosis of prostate cancer by measuring the number of PCA3 RNA copies in urine enriched with prostate cells. Although the sensitivity of the PCA3 test was less than that of serum prostate-specific antigen (PSA), its specificity appeared to be much better, particularly in patients with a previous negative biopsy. Recent studies also have suggested that this test could be used to predict cancer prognosis.

Resume Recemment, de nouvelles voies therapeutiques ont ete explorees afin d’ameliorer les troubles mictionnels des patients presentant des troubles urinaires du bas appareil lies a une hyperplasie benigne de la prostate. L’objectif de cet article est de realiser une mise au point sur ces traitements : anti-inflammatoire, antidiuretique, anticholinergique et toxine botulinique. Les anticholinergiques, associes au risque de retention urinaire se revelent efficaces pour les troubles irritatifs en association a un alpha-bloquant. Les antidiuretiques peuvent etre proposes chez les patients de moins de 65 ans presentant une polyurie confirmee par un calendrier mictionnel, invalidante, liee a une HBP et refractaire au traitement classique de I’HBP. L’interaction entre l’inflammation et HBP n’est pas encore clarifiee. Les anti-inflammatoires semblant ameliorer les symptomes trouveraient peut etre une place dans un traitement ponctuel de 1’HBP car leur utilisation au long cours n’est pas recommandee. Les inhibiteurs de cox-2 ont ete retires du marche. Enfm, la toxine botulinique pourrait avoir une place dans le traitement des troubles lies a I’HBP si les etudes cliniques confirment les resultats prometteurs recemment publies. Ces nouvelles approches seront probablement a integrer dans les recommandations et les arbres decisionnels du traitement des troubles mictionnels lies a I’HBP.

Resume Les tumeurs urotheliales de vessie necessitent une surveillance reguliere : la cystoscopie associee a la cytology urinaire en sont les examens de reference. Recemment, plusieurs nouveaux marqueurs valides ou en cours d’evaluation ont ete proposes afin de remplacer la cytologie et potentiellement de reduire, voire de remplacer les cystoscopies inutiles. Le liquide biologique etudie pour tous ces marqueurs est le meme que la cytologie urinaire, c’est a dire l’urine. Dans ce travail, nous avons fait le point sur les resultats des travaux recents concernant ces nouveaux marqueurs urinaires. Les resultats de ces marqueurs montrent une meilleure sensibilite globale que la cytologie urinaire, mais souvent une specificite moins bonne. Dans la majorite des cas, ces tests sont realises lors du suivi des patients (NMP22, BTA, CYFRA 21-1 …), mais ne remplacent pas la cystoscopie, du fait d’un nombre eleve de faux-positifs. D’autres techniques, tels que la FISH, le uCyt+ ou les microsatellites semblent etre des tests plus prometteurs, notamment dans le diagnostic des tumeurs de bas grade. Dans la pratique, la solution viendra peut-etre de l’association de plusieurs marqueurs pour ameliorer encore la sensibilite, et diminuer le taux de faux-positifs responsables des cystoscopies inutiles.

p53 could help identify bladder tumour cases with a risk of progression from superficial to invasive disease. Semiautomatic, liquid-based cytology (LBC) techniques offer an opportunity to standardise molecular techniques. The aim of our study was to investigate whether LBC could improve p53 immunolabelling, and to assess whether urinary p53 could have a prognostic value. Immunoreactivity for p53 was studied in 198 urine samples after treatment with the Cytyc Thinprep processor. After antigen retrieval, cells were labelled with a monoclonal antibody that recognises both wild-type and mutant form of the p53 protein (Clone DO-7, Dako), 1/1000. Positivity for p53 was assessed in 17.2% of the cases. High-grade (G3) tumours were positive in 74.1% of the cases. Comparatively, low-grade (G1-2) urothelial carcinomas were positive in 23.5% of the cases. During a median follow-up period of 26 months, recurrence was observed in 52.9% of the cases with p53 overexpression, and in only 10.9% of negative cases (P0.001). The progression rate was 35.3% of p53-positive cases vs 5.5% of p53-negative cases (P0.001). Progression-free survival was significantly shorter in patients with p53 accumulation (P = 0.007). In a multivariate analysis stratified on grade and stage, p53 was an independent predictor of overall survival (P = 0.042). The results show that using Thinprep LBC, p53 immunolabelling of voided urothelial cells allows most high-grade tumours to be detected and may help identify cases with a higher risk of recurrence and progression.

Objectifs Etudier les resultats des nephrectomies partielles du greffon renale (NPGR) pour tumeur renale de novo. Methodes Etude retrospective nationale, multicentrique. Les donnees ont ete recueillies dans 32 centres de transplantation francais. De janvier 1988 a avril 2012, les patients traites pour tumeur renale d’un greffon fonctionnel ont ete inclus. Soixante-dix -neuf tumeurs de novo du greffon renal ont ete diagnostiquees. Resultats 43 patients ont eu une NPGR. Le temps moyen entre la transplantation et le diagnostic de la tumeur etait de 142,6 mois (12,2 a 300). Quinze tumeurs etaient des carcinomes a cellules claires (34,9 %), vingt-cinq (58,1 %) des carcinomes papillaires. Respectivement 10 (24,4 %), 24 (58,3 %) et 8 (19,5 %) tumeurs etaient Fuhrman grade 1, 2 et 3. Neuf patients ont eu des complications post-operatoires (20,9 %) dont 4 necessitant une intervention chirurgicale (Clavien IIIb) et sans retour en dialyse dans les suites de la NPGR. Toutes les marges chirurgicales etaient negatives avec un diametre moyen de 26 mm. La duree moyenne de suivi etait de 29,6 mois (0,65 - 100,6) et 41 patients avaient un greffon renal fonctionnel, sans dialyse et sans complications a long terme. Conclusion La NPGR est une indication sure et appropriee pour toutes les petites tumeurs du rein transplante avec des resultats fonctionnels et oncologiques tres bons a long terme evitant aux patients un retour en dialyse.

To try and identify a molecular signature for pathological staging and/or grading. through microarray analysis.We performed a prospective multicentre study between September 2007 and May 2008 that included 108 bladder tumours (45 pTa, 35 pT1 and 28pT1). Microarray analysis was performed using Agilent Technologies Human Whole Genome 4 × 44K oligonucleotide microarrays (Agilent, Santa Clara, CA, USA). A 'dual colour' method was used vs a reference pool of tumours. From the lists of genes provided by the Biometric Research Branch class comparison analyses, we validated the microarray results of 38 selected differentially expressed genes using reverse transcriptase quantitative PCR in another bladder tumour cohort (n = 95).The cluster 'superficial vs invasive stage' correctly classified 92.9% of invasive stages and 66.3% of superficial stages. Among the superficial tumours, the cluster analysis showed that pT1b tumours were closer to invasive stages than pT1a tumours. We also found molecular differences between low and high grade superficial tumours, but these differences were less well defined than the difference observed for staging.We confirmed that the histopathological classification into subgroups pTa, pT1a and pT1b can be translated into a molecular signature with a continuous progression of deregulation (overexpression or repression of these genes) from superficial (pTa) to more invasive (pT1a then b) stages.

While now recognized as an aid to predict repeat prostate biopsy outcome, the urinary PCA3 (prostate cancer gene 3) test has also been recently advocated to predict initial biopsy results. The objective is to evaluate the performance of the PCA3 test in predicting results of initial prostate biopsies and to determine whether its incorporation into specific nomograms reinforces its diagnostic value. A prospective study included 601 consecutive patients addressed for initial prostate biopsy. The PCA3 test was performed before ≥12-core initial prostate biopsy, along with standard risk factor assessment. Diagnostic performance of the PCA3 test was evaluated. The three available nomograms (Hansen’s and Chun’s nomograms, as well as the updated Prostate Cancer Prevention Trial risk calculator; PCPT) were applied to the cohort, and their predictive accuracies were assessed in terms of biopsy outcome: the presence of any prostate cancer (PCa) and high-grade prostate cancer (HGPCa). The PCA3 score provided significant predictive accuracy. While the PCPT risk calculator appeared less accurate; both Chun’s and Hansen’s nomograms provided good calibration and high net benefit on decision curve analyses. When applying nomogram-derived PCa probability thresholds ≤30%, ≤6% of HGPCa would have been missed, while avoiding up to 48% of unnecessary biopsies. The urinary PCA3 test and PCA3-incorporating nomograms can be considered as reliable tools to aid in the initial biopsy decision.

Purpose This study assessed the contribution of ahyaluronic acid (HA) injection between the rectum and the prostate to reducing the dose to the rectal wall in stereotactic body radiation therapy (SBRT). Methods and Materials As part of a phase 2 study of hypofractionated radiation therapy (62 Gy in 20 fractions), the patients received a transperineal injection of 10 cc HA between the rectum and the prostate. A dosimetric computed tomographic (CT) scan was systematically performed before (CT1) and after (CT2) the injection. Two 9-beam intensity modulated radiation therapy-SBRT plans were optimized for the first 10 patients on both CTs according to 2 dosage levels: 5 × 6.5 Gy (PlanA) and 5 × 8.5 Gy (PlanB). Rectal wall parameters were compared with a dose–volume histogram, and the prostate–rectum separation was measured at 7 levels of the prostate on the center line of the organ. Results For both plans, the average volume of the rectal wall receiving the 90% isodose line (V90%) was reduced up to 90% after injection. There was no significant difference ( P =.32) between doses received by the rectal wall on CT1 and CT2 at the base of the prostate. This variation became significant from the median plane to the apex of the prostate ( P =.002). No significant differences were found between PlanA without HA and PlanB with HA for each level of the prostate ( P =.77, at the isocenter of the prostate). Conclusions HA injection significantly reduced the dose to the rectal wall and allowed a dose escalation from 6.5 Gy to 8.5 Gy without increasing the dose to the rectum. A phase 2 study is under way in our department to assess the rate of acute and late rectal toxicities when SBRT (5 × 8.5 Gy) is combined with an injection of HA.

To compare postoperative outcomes of patients on oral anticoagulation (OA) treated with transurethral plasma vaporization of the prostate in saline water (TUVis) and transurethral resection of the prostate (TURP).Between January and December 2009, 111 patients on OA therapy were treated with either TURP or TUVis in eight centers. Types of OA and perioperative management were collected. Postoperative outcomes were statistically compared between the two groups.A total of 57 (51%) and 54 (49%) patients were treated with TURP and TUVis, respectively. Types of OA were not significantly different between the two groups, but bladder catheterization prior to surgery was more frequently observed in the TUVis group. Before surgery, 28 patients were treated with warfarin alone, 74 with a platelet aggregation inhibitor (PAI) alone, and 9 with a combination of both. PAI was withdrawn preoperatively in 50 patients. All treatments with warfarin were switched for heparin. Comparison of the two groups showed significantly less hemorrhagic complications after TUVis. Patients treated with TUVis experienced less bladder washouts (2% versus 18%, p = 0.008), less late hematuria (4% versus 19%, p = 0.02), and lower decrease of serum hemoglobin (mean decrease of 0.66 versus 1.47 g/dL, p = 0.02). Postoperative bladder catheterization and hospital stay were significantly shorter, whereas the rate of urinary retention was significantly higher. Three months after surgery, functional results were not significantly different between the two groups.In patients on OA, TUVis led to significantly less bleeding, as well as shorter bladder catheterization and hospital stay than TURP.

Background Dysregulation of many apoptotic related genes and androgens are critical in the development, progression, and treatment of prostate cancer. The differential sensitivity of tumour cells to TRAIL-induced apoptosis can be mediated by the modulation of surface TRAIL receptor expression related to androgen concentration. Our previous results led to the hypothesis that downregulation of TRAIL-decoy receptor DcR2 expression following androgen deprivation would leave hormone sensitive normal prostate cells vulnerable to the cell death signal generated by TRAIL via its pro-apoptotic receptors. We tested this hypothesis under pathological conditions by exploring the regulation of TRAIL-induced apoptosis related to their death and decoy receptor expression, as also to hormonal concentrations in androgen-sensitive human prostate cancer, LNCaP, cells. Results In contrast to androgen-insensitive PC3 cells, decoy (DcR2) and death (DR5) receptor protein expression was correlated with hormone concentrations and TRAIL-induced apoptosis in LNCaP cells. Silencing of androgen-sensitive DcR2 protein expression by siRNA led to a significant increase in TRAIL-mediated apoptosis related to androgen concentration in LNCaP cells. Conclusions The data support the hypothesis that hormone modulation of DcR2 expression regulates TRAIL-induced apoptosis in LNCaP cells, giving insight into cell death induction in apoptosis-resistant hormone-sensitive tumour cells from prostate cancer. TRAIL action and DcR2 expression modulation are potentially of clinical value in advanced tumour treatment.

La faible specificite de la strategie diagnostique du cancer de la prostate (toucher rectal et dosage serique de l’antigene prostatique PSA) conduit a la realisation de nombreuses biopsies inutiles et au diagnostic de cancers indolents, sans potentialite evolutive. Un test urinaire (Progensa PCA3 ®, Gen-Probe) mesurant l’expression du gene PCA3, specifique des cellules cancereuses prostatiques, a recemment ete propose pour orienter les indications de re-biopsies. Le but de notre etude, prospective, etait d’evaluer l’interet diagnostique du score PCA3 dans le cancer de la prostate. Dans les urines de 245 patients adresses pour biopsie prostatique, l’expression du gene PCA3 a ete determinee par une technique d’amplification et de detection de l’ARN et rapportee a celle du PSA. Les patients avec echantillon informatif (98 %) ont ete classes selon la presence (n = 126) ou l’absence (n = 114) de cancer sur les biopsies. Le score PCA3 median etait plus eleve dans le groupe avec biopsies positives (p < 0,0001). L’aire sous la courbe ROC pour le PCA3 etait de 0,70 versus 0,53 pour le PSA total et 0,65 pour le rapport PSA libre/total. Au meilleur seuil de 38, le test PCA3 avait une sensibilite de 59 %, une specificite de 72 % (respectivement : 66 %, 32 % pour le PSA total au seuil de 4 ng/mL et 81 %, 28 % pour le rapport PSA libre/total au seuil de 25 %). Ces performances etaient maintenues chez les patients ayant un PSA dans la zone grise (4-10 ng/mL) ou ayant des antecedents de biopsies prostatiques. Notre etude confirme l’interet du test urinaire PCA3 dans l’aide a la decision de biopsies prostatiques.

Background. In previous studies, the authors demonstrated the value of the monoclonal antibody (MoAb) BL2-10D1 in identifying malignant transitional cells. In this study, the authors evaluate the possible diagnostic value of a murine MoAb, BL2-10D1, raised against human bladder cancer in the determination of the urothelial origin of metastases in a series of 29 patients with metastatic bladder or prostatic carcinoma. Methods. Using an immunoperoxidase method, bl2-10d1 and anti-prostate-specific antigen (anti-psa) reactivity were studied, using histologic sections from 18 pelvic lymph nodes and 4 other anatomic sites invaded by transitional cell cancer, and from 7 pelvic lymph nodes containing prostatic cancer. Results. All lymph nodes containing metastases of transitional cell carcinoma were positive with BL2-10D1, whereas all metastases of prostatic cancer were negative; the four instances of distant urothelial metastases were positive with BL2-10D1 MoAb. Conversely, anti-PSA reacted only with prostatic metastases. Conclusion. Thus, MoAb BL2-10D1 and anti-PSA complement each other in the separation of cancers of prostatic and urothelial origin, and the BL2-10D1 MoAb has potential usefulness in differentiating between urothelial carcinoma and prostate adenocarcinoma. In patients with bladder tumors of uncertain origin, BL2-10D1 may be helpful in confirming that a tumor is a transitional cell carcinoma.

Study Type - Therapy (multi-centre cohort). Level of Evidence 2b.To evaluate the early functional outcomes of transurethral plasma vaporization of the prostate (TUVis) in a multicentre study.A prospective multicentre observational study was conducted in eight urology departments. The inclusion criterion was benign prostatic hyperplasia (BPH) requiring surgical treatment. Patients on anti-coagulant therapy were not excluded. The TUVis procedure was performed according to a classic transurethral resection of the prostate (TURP) scheme following the manufacturer's recommendations. We evaluated subjective functional outcome using self-questionnaires (International Prostate Symptom Score [IPSS] and five-item International Index of Erectile Function [IIEF-5]) and objective criteria (prostate volume, prostate-specific antigen [PSA], uroflowmetry, post residual volume) at baseline and at 1- and 3-month follow-ups. All types of complications were systematically recorded.Despite 52% of patients receiving anticoagulant therapy before surgery, we reported only 3% with haemorrhagic complications, no blood transfusion, a mean catheterization time of 44 h and a mean postoperative stay of 2.9 nights. No significant change in irrigation time, catheter time or hospital stay was observed in patients with or without anticoagulant therapy. The IPSS and bother scores significantly decreased after the 3-month follow-up (57% and 59%, respectively), but the average remaining prostate volume was 29 cc and the tissue ablation rate was only 0.5 cc/min. Three major complications occurred, consisting of two urinary fistulas and one partial bladder coagulation.The TUVis procedure has a proven fast postoperative recovery time, good short-term functional outcome and good haemostatic efficiency. However, the tissue ablation rate was lower than expected and we encountered three major complications, the mechanisms of which remain unclear. Considering the high energy level required to create the plasma effect, the generator, cable and resectoscope must be carefully checked before each procedure.

De novo tumors in renal allografts are rare and their prevalence is underestimated. We therefore analyzed renal cell carcinomas arising in renal allografts through a retrospective French renal transplant cohort. We performed a retrospective, multicentric survey by sending questionnaires to all French kidney transplantation centers. All graft tumors diagnosed after transplantation were considered as de novo tumors. Thirty-two centers participated in this study. Seventy-nine tumors were identified among 41 806 recipients (Incidence 0.19%). Patients were 54 men and 25 women with a mean age of 47 years old at the time of diagnosis. Mean tumor size was 27.8 mm. Seventy-four (93.6%), 53 (67%) and 44 tumors (55.6%) were organ confined (T1-2), low grade (G1-2) and papillary carcinomas, respectively. Four patients died of renal cell carcinomas (5%). The mean time lapse between transplantation and RCC diagnosis was 131.7 months. Thirty-five patients underwent conservative surgery by partial nephrectomy (n = 35, 44.3%) or radiofrequency (n = 5; 6.3%). The estimated 5 years cancer specific survival rate was 94%. Most of these tumors were small and incidental. Most tumors were papillary carcinoma, low stage and low grade carcinomas. Conservative treatment has been preferred each time it was feasible in order to avoid a return to dialysis.

Background/Aims: There are only a few surveys on the prevalence of lower urinary tract symptoms (LUTS) among the general population. The aim of this survey was to assess the prevalence of LUTS and their impact on discomfort in men. Methods: A questionnaire was mailed to 3,877 men aged 50–80 years, which included questions on their medical history, demographic and sociological status, and also the International Prostate Symptom Score (IPSS) with additional questions on discomfort related to urinary symptoms. Results: The response rate was 81.5%. Prevalence of mild and severe IPSS was 89.2%. Specific bother for each urinary symptom depended on symptom frequency: urgency, frequency, weak stream, nocturia, incomplete emptying, intermittency and straining 1 time out of 5 were responsible for discomfort in respectively 4.9, 6.1, 7.1, 7.5, 8.7 and 9.9%; the same symptoms more than half of the time were responsible for discomfort in respectively 32.8, 38, 45.3, 45.6, 53.2 and 58.7%. Urgency was much more deeply implicated in discomfort than frequency of nocturia. Conclusions: Urinary symptoms in men are very common. Nocturia is the most frequent but has a low impact on discomfort. Urgency has a higher impact on discomfort and should therefore be considered in treatment decision-making.

The urinary PCA3 gene test has proved helpful for deciding whether to (re)biopsy to diagnose prostate cancer. We searched for pathological features that influence the shedding of PCA3 producing prostate cancer cells in urine after digital rectal examination.Included in our study were 102 patients with an informative PCA3 score on the Progensa® PCA3 assay who underwent radical prostatectomy. Correlations were evaluated between PCA3 score and histopathological factors on prostatectomy, including tumor site in the prostate and the number of cancer foci.PCA3 score significantly correlated with total tumor volume in prostatectomy specimens (p0.001) but not with prostatectomy Gleason score or pathological stage. PCA3 score positively correlated with apical and basal invasion, and with bilaterality and multifocality. On multivariate analysis multifocality was an independent factor influencing PCA3 score (p = 0.012).Site in the prostate gland and the number of cancer foci may explain the observed PCA3 score variation in patients operated on for prostate cancer. The PCA3 test could be helpful in preoperatively selecting patients with unifocal and unilateral cancer who could benefit from active surveillance or focal therapy.

The authors studied microwave delivery by a flexible applicator providing simultaneous cooling for anesthesiafree outpatient single session treatment of benign prostatic hyperplasia (BPH) following preclinical trials in dogs and humans. The goal of transurethral microwave thermotherapy (TUMT) was to raise the temperature within the prostate to more than 45°C while maintaining the urethral temperature below 45°C. Histologically, the urethral mucosa and periurethral tissues were well preserved. There was a sharp transition (1-2 mm) to the microwave-treated area, where the normal cellular arrangement disappeared and small blood vessels were thrombosed. Smooth-muscle cells were seen to be more heat sensitive than glandular tissue. In 37 patients with BPH, the new device (Prostatron) produced significant improvements in the symptom score peak/low and post residual volume at 3 months. Seven patients required an indwelling catheter for 1 week after treatment, but four then voided satisfactorily. No infections oc...

International audience; OBJECTIVES: A population kinetic approach based on PSA clearance (CL(PSA)) may be a more rational strategy to characterize prostate-specific antigen (PSA) decrease profile after prostate surgery than the commonly used method (half-life from mono/bi-exponential models). METHODS: We used 182 post-adenomectomy PSA concentrations from 56 benign prostatic hyperplasia patients to build, with NONMEM software, a multi-exponential and a CL(PSA) model for comparison. RESULTS: The best multi-exponential model was PSA(t)=4.96e(-)(0.269t)+3.10e(-)(0.16t)+0.746e(+)(0.0002t) with a stable median residual PSA at 0.64 ng/mL. The best model parametrized with clearance was CL(PSA)=0.0229()(AGE/69)(3.78). Akaike information criteria and standard errors favored the CL(PSA) model. Median peripheral zone and transitional zone productions were 0.034 ng/mL/cm(3) and 0.136 ng/mL/g. A threshold at 2 ng/mL on day 90 allowed for a diagnostic of biochemical relapse diagnostic. CONCLUSIONS: The population CL(PSA) model was superior to the multi-exponential approach for investigating individual post-adenomectomy PSA decreases.

Sarcoidosis is a multisystemic, non-caseous, benign granulomatous disease of unknown etiology that is sometimes associated with testicular cancer. This association, which does not appear to be accidental, can give rise to diagnostic problems because adenopathies or parenchymatous pulmonary nodules related to sarcoidosis can lead to the presumption of metastatic testicular cancer. The objective of this article was to assess the clinical, histological, and radiological characteristics of the association between sarcoidosis and testicular cancer to help clinicians avoid potentially fatal diagnostic traps and management errors.Literature review.A total of 64 cases of sarcoidosis concomitant with testicular cancer were described in the literature. In more than 50% of the cases (35/64), testicular cancer was diagnosed before sarcoidosis or sarcoid-like reaction. Cancer was diagnosed concomitantly in 31% of cases (20/64). Every anatomopathological type of testicular tumor was described in association with sarcoidosis. Seminoma was the most frequent tumor, occuring in 62% (40/64) of patients. In 80% of the cases (51/64) sarcoidosis regressed spontaneously.Testis cancer may be accompanied by a sarcoid-like reaction or can be associated with real sarcoidosis. The association of testicular cancer with sarcoidosis did not change the therapeutic management of either of these two pathologies. The presence of sarcoidosis does not change the cancer prognosis. Sarcoidosis is a benign disease that resolved favorably and spontaneously in 80% of the cases.

New therapeutic approaches have recently been investigated in order to improve the voiding disorders of patient with lower urinary tract symptoms related to benign prostatic hyperplasia. The purpose of this article is to provide a review of these treatments: anti-inflammatory, antidiuretic, anticholinergic and botulinum toxin. Anticholinergic drugs associated with a risk of urinary retention, appear to be effective for irritative disorders in combination with an alpha-blocker. Antidiuretics can be proposed in patients younger than 65 with disabling polyuria confirmed by a voiding diary, related to BPH and refractory to conventional treatment of BPH. The interaction between inflammation and BPH has not yet been clarified, but anti-inflammatory drugs appear to improve symptoms and may have a place in short-term treatment of BPH, as their long-term use is not recommended and COX-2 inhibitors have been withdrawn from the market. Finally, botulinum toxin could have a place in the treatment of disorders related to BPH if clinical studies confirm the recently published promising results. These new approaches will probably be integrated into guidelines and flow-charts for the treatment of voiding disorders related to BPH.

Urothelial bladder tumours require regular surveillance: cystoscopy associated with urine cytology are reference examinations. Several new markers currently under evaluation or already validated have recently been proposed to replace cytology and potentially reduce or even replace unnecessary cystoscopies. The biological fluid studied for all of these markers is the same as that of urine cytology, i.e. urine. The authors review the results of recent studies on these new urinary markers. The results of these markers demonstrate a better global sensitivity than urine cytology, but often a lower specificity. In the majority of cases, these tests are performed during patient follow-up (NMP22, BTA, CYFRA 21-l., etc.), but do not replace cystoscopy, due to a large number of false-positives. Other techniques, such as FISH, uCyt+ or microsatellites appear to be more promising, especially for the diagnosis of low-grade tumours. The best solution in practice may consist of a combination of several markers to further improve sensitivity and to decrease the false-positive rate responsible for unnecessary cystoscopies.

Prostatic stents and microwave thermotherapy are minimally invasive techniques for the treatment of voiding disorders related to benign prostatic hyperplasia. A review of the literature evaluates the place of these treatments in 2006. Permanent prostatic stenting is rarely used, but remains a treatment option for patients with obstructive disorders and a formal anaesthetic contraindication. Temporary stenting can be used to predict the effect of resection in selected patients. Finally, microwave thermotherapy, not widely used in France, has a promising clinical efficacy and occupies a place between medical treatment and surgery.

To evaluate the functional results and morbidity of adjustable tension suburethral tape (REMEEX) in the treatment of urinary incontinence due to severe sphincter incompetence (MUCP40 cm H2O) in patients presenting a contraindication to artificial sphincter operated between December 2001 and May 2004. Twelve patients (66.7%) had already undergone incontinence surgery. Ten patients (55.5%) had mixed urinary incontinence. The efficacy of the tape was considered to be good when incontinence resolved completely, partial when incontinence was decreased by50% and/or PVR100 ml. All other cases were considered to be failures. In April 2005, after a mean follow-up of 26.3 months, retrospective evaluation of the functional results was performed by means of a pad-test and a questionnaire comprising an MHU (urinary disability) score and a Ditrovie score. Complications after each intercurrent event were recorded.The initial efficacy of the tape was considered to be good in 13 patients (72.2%) and partial in 4 patients (22.2%) with only one initial failure. Eight patients (44.4%) required secondary adjustment after a mean interval of 5.2 months, with a failure rate of 62.5%. In April 2005, 10 patients (55.5%) had a good result, 2 patients (11.1%) required self-catheterization (partial efficacy) and 6 patients (33.4%) were considered to be failures. In terms of morbidity, we observed 2 bladder injuries (11.1%), 6 superinfections of the device (33.3%), 2 (11.1%) of which required removal of the material. Fifteen patients (83.3%) answered the questionnaire: 6 patients (40%) had an MHU score greater than 3. The mean Ditrovie score was 2.1. 9 patients (60%) had a score less than 2 and 4 patients (26.6%) had a score greater than 3.The results of this series, in patients in whom artificial sphincter was contraindicated, are satisfactory at the price of acceptable morbidity. Before defining the place of this device in the range of treatment options for sphincter incompetence, our results must be confirmed by a longer series.

The authors report a case of well differentiated paratesticular liposarcoma in a 41-year-old patient. This is a rare tumour (about one hundred cases have been reported in the literature), which essentially arises from the spermatic cord. Clinical and radiological signs are nonspecific and the diagnosis is generally based on histological examination of the operative specimen. Due to the histological similarities, all specimens of benign lipoma must be examined for the presence of well differentiated liposarcoma. Treatment consists of transinguinal radical orchidectomy, sometimes with resection of adjacent structures. The prognosis is generally better than that of other paratesticular sarcomas. Adjuvant radiotherapy may be indicated in locally advanced masses or in the case of incomplete resection.

To assess 1) the value of fluorescence immunocytochemistry (uCyt+ test, DiagnoCure Inc., Quebec) in the detection of recurrent bladder tumour after transurethral resection (TUR) and 2) the predictive value of a positive uCyt+ test in patients with negative cystoscopy.This study was based on 132 patients with a mean follow-up of 21.9 weeks after TUR. The initial tumours were pTa G1-2 in 66.7% of cases, and G3 in 28.8% of cases. Cystoscopy, urine cytology (UC) and uCyt+ test data were collected on the day of the first control visit (D0), and the patients were then reviewed at 6 and 12 months. All lesions detected on cystoscopy were biopsed.The mean sensitivity of UC was 47.4% and the mean sensitivity of uCyt+ was 73.7% (84.2% in combination). In patients with negative cystoscopy on D0, a positive uCyt+ test has no predictive value at 6 months. At 12 months, 20.0% of patients with positive UC had relapsed, versus 16.7% of patients with negative UC (p = ns). On the other hand, at 12 months, 50.0% of patients with negative cystoscopy but positive uCyt+ test had relapsed, versus 16.4% of patients with a negative uCyt+ test (p0.01).The uCyt+ test allows assessment of the risk of recurrence at I year, while UC alone only has a diagnostic value. These results raise the possibility of combining the tests in order to decrease the frequency of follow-up cystoscopy.

Objectives To estimate the frequency and characteristics of prostatic lesions discovered incidentally in radical cystoprostatectomy specimens and to determine whether any factors would allow for the detection of prostate cancer preoperatively. Methods A total of 100 radical cystoprostatectomy specimens with orthotopic bladder reconstruction were performed for malignant bladder disease between 1990 and 2000. The mean patient age at surgery was 62 ± 8 years (range 32 to 75). Digital rectal examination and prostate-specific antigen (PSA) assay were done routinely before surgery. During the 10-year study period, the same pathologist examined the prostatic tissues from radical cystoprostatectomy specimens using McNeal’s technique on fine slices every 2.5 mm. Results The overall incidence of prostate cancer discovered incidentally in radical cystoprostatectomy specimens was 51%, of which 29% were microcancers (volume less than 0.5 cm 3 ) and 22% were significantly larger (volume 0.5 cm 3 or more). The mean Gleason score was 6. Of the tumors, 24% could be considered “clinically nonsignificant” (less than 0.5 cm 3 and Gleason score less than 7). The mean preoperative PSA level was 4.13 ± 1.36 ng/mL. Of 66 patients with a PSA level of less than 4 ng/mL (mean PSA 1.5 ± 0.8) and a normal digital rectal examination before surgery, 50% had prostate cancer, of which 69% were microcancers. Conclusions The prevalence of prostate cancer (51%) in our series is among the highest in published reports. Furthermore, our results stress that currently no factors are available to enable the detection of “clinically significant” prostate cancer preoperatively.

To evaluate the accuracy of four-channel multidetector CT for investigation of the proximal and distal renal arterial blood supply.Four-channel multidetector CT was performed in 51 patients prior to nephrectomy (3 bilateral nephrectomies). The anatomy of the renal pedicle was described intraoperatively and arteriography of the nephrectomy specimen was performed immediately postoperative. Preoperative CT data were compared to intraoperative anatomical findings and arteriography findings on 54 nephrectomy specimens. Concordance analysis (determination of the kappa coefficient) was based on 4 criteria: number of renal arteries, position of the artery with respect to the vein, the intra-sinus or extra-sinus situation of the division of the artery and the number of first order branches.The concordance between CT and intraoperative anatomical findings was good for number of renal arteries (kappa = 0.78) and moderate for the position of the artery with respect to the vein (kappa = 0.65). The concordance between CT and arteriography was poor for the intra-sinus or extra-sinus situation of the division of the renal artery (kappa = 0.5) and for the number of first order branches of the renal artery (kappa = 0.41).Four-channel multidetector CT precisely visualizes the proximal renal arterial blood supply, but remains less accurate than arteriography for investigation of the distal arterial blood supply.

The limitations of urinary cytology and the invasiveness of cystoscopy generate an increasing interest in noninvasive diagnostic tools for the management of transitional cell carcinoma. We assess the clinical performance of ImmunoCyt (DiagnoCure, Inc., Saint-Foy, Canada) in the detection of bladder cancer in a 10-center French trial.From October 2000 to April 2001, 694 patients undergoing cystoscopy were prospectively included in the study. Of the patients 458 (66%) had been previously treated for superficial transitional cell carcinoma and 236 (34%) were referred for symptoms suggestive of bladder cancer. All patients underwent ImmunoCyt test and standard urinary cytology from voided urine as well as a complete evaluation including cystoscopy and transurethral resection or biopsy of suspicious lesions. Sensitivity and specificity values of urinary cytology and ImmunoCyt whether or not combined were calculated using cystoscopy as the gold standard and histopathology when available.A total of 85 recurrent and 58 newly diagnosed bladder tumors were diagnosed by cystoscopy and histologicaly confirmed. Overall sensitivity of urinary cytology was 17.9%, 46.3% and 63.8% respectively, for G1, G2 and G3 transitional cell carcinoma, whereas that of ImmunoCyt was 60.7%, 75.6% and 76.8%. Sensitivity of the combined tests was 66.7%, 78% and 87%, respectively. Moreover, 10 of 55 (18.2%) new pT1 and pT2 or greater tumors were diagnosed by ImmunoCyt alone. Specificity of urinary cytology was 94.5%, whereas that of ImmunoCyt was 84.2%. Specificity of the combined tests was 80.7%. Marked variations in urinary cytology sensitivity were observed among the different centers (27.3% to 66.7%), whereas combined assays (urinary cytology and ImmunoCyt) enhanced the overall sensitivity in the 80% range at most centers.This prospective multicenter series confirmed a marked increase in sensitivity without significant loss in specificity when including ImmunoCyt in standard urinary cytology protocol. This increased sensitivity was observed in high grade lesions (with 100% sensitivity for carcinoma in situ) as well in low grade, low stage tumors.

This retrospective study was designed to determine the place of rigid ureteroscopy in the diagnosis of upper urinary tract tumours.63 patients (45 males and 18 females) with a mean age of 60 years, were investigated by rigid ureteroscopy for suspected upper urinary tract tumour. The Wolf 8-9.8 F ureteroscope was used in the case of suspected upper urinary tract tumour in a context of ureteric obstruction on the IVU in 29 cases, haematuria in 23 cases, a defect on retrograde ureteropyelography in 5 cases, suspicious CT scan in 5 cases and positive cytology with normal cystoscopy in 2 cases.The ureteroscope was able to be advanced as far as the suspicious zone in 89% of cases. The mean operating time was 48 minutes and the mean hospital stay was 3.2 days. Diagnostic rigid ureteroscopy has a Sensitivity of 58% (95% confidence interval CI95: +/- 28), a Specificity of 100%, a Positive Predictive Value of 100%, a Negative Predictive Value of 91% (+/- 7) and a low morbidity (3%).Rigid ureteroscopy does not appear to be the examination of choice for the diagnosis of upper urinary tract tumours, as it cannot investigate the renal pelvis or calices and the ureteroscope cannot always be advanced to the suspicious zone. The flexible ureteroscope now appears to be a more reliable diagnostic tool.

202 Background: Several studies are in favor of an α/β ratio of less than 3Gy for prostate (P) cancer, encouraging HFR. However, the development of such radiation patterns can only be done if the risk of rectal toxicity is well controlled. The objective of the present study was to evaluate the contribution of an injection of HA between the rectum and the P to reduce the risk of rectal toxicity in a HFR approach. Methods: A phase II study of HFR at 62Gy in 20 fractions (BED = 84Gy; α / β = 1.5Gy) is currently conducted. A transperineal injection of 10cc of HA (NASHA Spacer gel, Q-Med AB, Uppsala, Sweden) is systematically performed, between the rectum and the P, under local anesthesia and under ultrasound guidance. A dosimetric CT scan is performed before (CT1) and after injection (CT2). Patients are treated with a 7 beams IMRT plan, optimized on the CT2. For the first 10 patients included in the study, the same treatment plan was optimized on CT1. The rectum was empty on the 2 CTs and defined from 2cm above the seminal vesicles to 2 cm below the P. The rectal wall was defined by an internal expansion of 5 mm. The volumes of rectum irradiated, with and without HA, were compared on the following dosimetric parameters: maximum dose (D max), dose to 2.5cc (D2.5), 5cc (D5) and 10cc (D10) of rectal wall and volume of rectum receiving 90% (V90), 80% (V80) and 70% (V70) of the prescribed dose of 62Gy. To limit a potential impact of variation of rectal volume between the two CT, all results are given in cc and not in % of volume. Results: The mean P volume was 52.4cc (30cc - 93.8cc) on the CT1 and 52cc (32.5 - 92.7) on the CT2. The injection of HA reduced the mean D max value to the rectal wall of 4.5Gy (57.5Gy vs 62 Gy). The mean values of V90, V80, and V70 are reduced by 69% (1.9cc vs 6.1cc), 46% (4.5cc vs 8.4cc) and 32% (7.4cc vs 10.9cc). Same way, the average values of D2.5, D5 and D10 are reduced by 6.2 Gy (54.6Gy vs 60.8Gy) 9.3Gy (49.0Gy vs 58.3Gy) and 7.8Gy (39.7Gy vs 47.5Gy). Conclusions: In this study, the injection of HA limited the doses to the rectal wall. These results suggest that late toxicities could be significantly reduced. A phase II study is underway to assess the rate of late rectal toxicities when a HFR at 62Gy in 20 fractions is combined with an injection of HA.

For almost a decade, transurethral microwave thermotherapy has been a progressively viable minimally invasive treatment option for benign prostatic hyperplasia. Treatments have evolved from low-energy to high-energy protocols with increasingly better objective results, albeit at the cost of a somewhat increased morbidity. Nevertheless, symptomatic improvement remained highly satisfactorily, and long-term durability results also appeared to be better with high-energy protocols. Recent changes in treatment algorithms resulted in reduced treatment time at even higher energy levels without compromising the objective results. Morbidity with thermotherapy treatment mainly consists of prolonged urinary retention with the need for catheterization when applying the high-energy protocols. High-energy protocols also have a greater impact on sexual function compared with the low-energy protocols. It appeared that patients with higher grades of bladder outlet obstruction and patients with larger prostates were the best candidates for the high-energy protocols. Histological studies, in combination with ultrasound contrast agents in enhanced color Doppler studies, are aimed at clarification of the vascularization of the prostate to identify predictive intrinsic prostate parameters. Further advances in the technology itself are aimed at the development of treatment probes allowing intraprostatic temperature measurement, preferably with feedback mechanisms to regulate the amount and type of energy. The morbidity caused by prolonged catheterization might be reduced by the use of biodegradable and nonresorbable temporary urethral stents.

The monoclonal antibody (MoAb) BL2-10D1 directed against a tumor-associated antigen of human bladder cancer was used to identify tumor cells obtained by bladder washing or voided urine. The reactivity of BL2-10D1 MoAb was detected by an immunoperoxidase method and evaluated in ten healthy donors and in a series of 65 patients. The 65 patients studied were divided into three groups: ten with nontumor bladder disease (group A); 36 with bladder carcinoma (group B); and 19 with a history of bladder neoplasia but no visible tumor at the time of cytologic sampling (group C). The results were compared with the standard cytologic diagnosis on Papanicolaou-stained preparations. Conventional cytologic study showed a high false-negative rate in low-grade tumors (transitional cell carcinomas [TCC] Grades 1 and 2, 1/4 and 4/17, respectively). All urine from patients with a histologically proved TCC Grade 1 were stained with BL2-10D1 MoAb. Cytologic findings from patients with TCC Grade 2 (17 cases) contained positive cells in 14 cases and failed to react in three cases. Furthermore, whereas urine from patients with TCC Grade 2 or 3 was not always stained with BL2-10D1 MoAb, all patients with dysplastic lesions (three cases) or carcinoma in situ (5 cases) showed a positive reactivity. Such results suggest that BL2-10D1 MoAb may be considered as a valuable adjunct to the classical methods of early detection and follow-up of bladder cancer. However, a larger scale study is needed for MoAb BL2-10D1 to be proposed as an aid to improve the diagnostic sensitivity of urine cytologic investigation in the follow-up of patients treated for recurring bladder cancer, and for the screening of workers exposed to potent bladder carcinogens.