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Resume Objectif Proposer des recommandations pour la prise en charge du carcinome urothelial du patient transplante renal et du candidat a la transplantation renale. Methode Une revue de la litterature (Medline) d’approche systematique a ete conduite par le CTAFU concernant l’epidemiologie, le depistage, le diagnostic et le traitement du carcinome urothelial du patient transplante renal et du candidat a la transplantation renale en evaluant les references et leur niveau de preuve. Resultats L’incidence des carcinomes urotheliaux du patient transplante renal est 3 fois plus elevee que l’incidence des carcinomes urotheliaux de la population generale. Les principaux facteurs de risque de carcinomes urotheliaux du patient transplante renal sont identiques a ceux de la population generale. La nephropathie a l’acide aristolochique et l’infection a BK virus sont des facteurs de risques plus frequents du patient transplante renal. En comparaison avec la population generale, a stade equivalent, les TVNIM du patient transplante renal sont associees a un taux de recidive plus eleve et a une recidive plus precoce, La tolerance et l’efficacite des traitements adjuvants intra-vesicaux (Mitomycine C et BCG) ont ete rapportees par des series retrospectives. Le traitement de reference des TVIM localisees du patient transplante renal est la chirurgie d’exerese carcinologique. Chez le candidat a une transplantation renale avec antecedent de tumeur urotheliale, il est recommande de realiser imperativement les cystoscopies de suivi selon la frequence recommandee en fonction du risque de recidive et de progression de la TVNIM et de maintenir ce suivi a une frequence au moins semestrielle jusqu’a la transplantation quel que soit le niveau de risque de recidive et de progression. Les donnees actuelles permettent de proposer des delais de contre-indication temporaire apres traitement d’une tumeur urotheliale, selon un avis d’expert. Conclusion Ces recommandations francaises doivent contribuer a ameliorer la prise en charge du carcinome urothelial du patient transplante renal et du candidat a la transplantation renale en integrant les objectifs oncologiques avec l’acces a la transplantation.

OBJECTIVE To propose recommendations for the management of renal cell carcinomas (RCC) of the renal transplant. METHOD Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to evaluate prevalence, diagnosis and management of RCC arousing in the renal transplant. References were assessed according to a predefined process to propose recommendations with levels of evidence. RESULTS Renal cell carcinomas of the renal transplant affect approximately 0.2% of recipients. Mostly asymptomatic, these tumors are mainly diagnosed on a routine imaging of the renal transplant. Predominant pathology is clear cell carcinomas but papillary carcinomas are more frequent than in general population (up to 40-50%). RCC of the renal transplant is often localized, of low stage and low grade. According to tumor characteristics and renal function, preferred treatment is radical (transplantectomy) or nephron sparing through partial nephrectomy (open or minimally invasive approach) or thermoablation after percutaneous biopsy. Although no robust data support a switch of immunosuppressive regimen, some authors suggest to favor the use of mTOR inhibitors. CTAFU does not recommend a mandatory waiting time after transplantectomy for RCC in candidates for a subsequent renal tranplantation when tumor stage

Resume Objectif Le but du Comite de transplantation de l’association francaise d’urologie est de proposer des recommandations pour la prise en charge du carcinome a cellules renales du rein natif (CCRN) chez le receveur d’un transplant renal et du carcinome a cellules renales (CCR) du patient malade renal chronique terminal (MRCT) candidat a une transplantation renale (TR). Methode Une revue d’approche systematique de la litterature (Medline) a ete conduite par le CTAFU concernant l’epidemiologie, le diagnostic et le traitement du CCRN chez le receveur d’un transplant renal et du CCR chez le MRCT en evaluant les references et leur niveau de preuve. Resultats L’incidence standardisee du CCR chez le MRCT est 4,5 fois superieure a la population generale. Le CCRN concernerait 1 a 3 % des patients transplantes avec un risque 10 a 15 fois plus eleve que la population generale. Ce risque est majore en cas de maladie renale multi-kystique acquise. Les differentes series s’accordent sur l’interet d’une imagerie annuelle de l’appareil urinaire natif par echographie. Le traitement du CCR chez le MRCT et du CCRN chez le transplante renale repose sur une prise en charge chirurgicale par nephrectomie elargie par voie ouverte ou cœlioscopie. La surveillance est une option valide pour les tumeurs kystiques ou de petite taille. La prise en charge des formes localisees ne necessite aucune modification dans le traitement de fond immunosuppresseur sauf pour les patients sous inhibiteurs de mTOR compte tenu des donnees montrant un taux plus eleve de complications chirurgicales. Le CTAFU ne recommande pas de delai de carence apres traitement d’un CCR localise chez un patient MRCT et candidat a une transplantation renale si la tumeur est de stade Conclusion Ces recommandations francaises doivent contribuer a ameliorer la prise en charge du CCRN chez le patient transplante renal et CCR chez le candidat a une transplantation renale en integrant les objectifs oncologiques dans le contexte de transplantation renale.

Resume Objectif Le but du Comite de transplantation de l’Association francaise d’urologie est de proposer des recommandations pour la prise en charge du cancer de la prostate localise (CaP) chez le candidat ou le receveur d’un transplant renal. Methode Une revue de la litterature d’approche systematique (Medline) a ete conduite par le CTAFU concernant l’epidemiologie, le depistage, le diagnostic et le traitement du CaP chez le candidat ou le receveur d’un transplant renal en evaluant les references et leurs niveaux de preuve. Resultats L’incidence du CaP chez le transplante renal est similaire a la population generale. Le depistage dans cette population doit suivre les recommandations du CCAFU. Le depistage est systematique chez le candidat a un transplant renal de plus de 50 ans. Le diagnostic repose sur les biopsies de la prostate realisees apres IRM multiparametrique et sans specificite de l’antibioprophylaxie. Les recommandations therapeutiques du CaP proposees par le CCAFU restent applicables a la population des patients transplantes avec certaines specificites en particulier pour le traitement des aires ganglionnaires. Pour les candidats a la transplantation renale, la problematique de l’acces a la transplantation doit etre prise en compte. Les donnees actuelles permettent de proposer des delais de carence apres traitement du CaP avec un faible niveau de preuve. Conclusion Ces recommandations francaises doivent contribuer a ameliorer la prise en charge du CaP chez le patient candidat ou receveur d’un transplant renal en integrant objectifs oncologiques et acces a la transplantation.

Resume Objectif Proposer des recommandations chirurgicales pour la nephrectomie dans le cadre d’un don de rein pour transplantation. Methode Une revue de la litterature (Medline) avec approche systematique a ete conduite par le CTAFU concernant les elements d’evaluation fonctionnelle et anatomique du candidat au don, les options dans le choix du rein a prelever et des differentes techniques chirurgicales, en evaluant les references et leur niveau de preuve. Resultats Les recommandations precisent le cadre legal et reglementaire du don de rein. Une evaluation de qualite du candidat au don est un des prerequis indispensable a la securite du donneur qui est une priorite absolue. L’impact de la nephrectomie sur la fonction renale doit etre evalue. En cas de vascularisation modale des deux reins sans difference relative de fonction ni anomalie urologique, le rein gauche doit etre preleve afin d’avoir une veine plus longue. Les techniques chirurgicales de nephrectomie mini-invasives ont pour avantages une recuperation plus rapide, une hospitalisation plus courte et une diminution des douleurs pour le donneur. Ces techniques mini-invasives doivent etre proposees a la place d’une voie incisionnelle ouverte. Conclusion Ces recommandations francaises doivent contribuer a ameliorer la prise en charge chirurgicale des patients candidats a un don de rein.

To propose recommendations for the management of renal cell carcinomas (RCC) of the renal transplant.Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to evaluate prevalence, diagnosis and management of RCC arousing in the renal transplant. References were assessed according to a predefined process to propose recommendations with levels of evidence.Renal cell carcinomas of the renal transplant affect approximately 0.2% of recipients. Mostly asymptomatic, these tumors are mainly diagnosed on a routine imaging of the renal transplant. Predominant pathology is clear cell carcinomas but papillary carcinomas are more frequent than in general population (up to 40-50%). RCC of the renal transplant is often localized, of low stage and low grade. According to tumor characteristics and renal function, preferred treatment is radical (transplantectomy) or nephron sparing through partial nephrectomy (open or minimally invasive approach) or thermoablation after percutaneous biopsy. Although no robust data support a switch of immunosuppressive regimen, some authors suggest to favor the use of mTOR inhibitors. CTAFU does not recommend a mandatory waiting time after transplantectomy for RCC in candidates for a subsequent renal tranplantation when tumor stageT3 and low ISUP grade.These French recommendations should contribute to improving the oncological and functional prognosis of renal transplant recipients by improving the management of RCC of the renal transplant.

To define guidelines for the management of renal cell carcinoma of the native kidney (NKRCC) in kidney transplant (KTx) recipients and renal cell carcinoma (RCC) in end-stage renal disease (ESRD) patients candidates for renal transplantation.A review of the literature following a systematic approach (Medline) was conducted by the CTAFU to report renal cell carcinoma epidemiology, screening, diagnosis and management in KTx candidates and recipients. References were assessed according to a predefined process to propose recommendations with the corresponding levels of evidence.ESRD patients are at higher risk of RCC with a standardized incidence ratio of approximately 4,5 as compared with general population. NKRCC tumors occur in 1 to 3 % of KTx recipients with a 10 to 15-fold increased risk as compared with general population, especially in patients with acquired multicystic kidney disease. Most authors suggest yearly monitoring of the native kidneys using ultrasound imaging. Radical nephrectomy (either open or laparoscopic approach) is the preferred treatment of NKRCC in KTx recipients and RCC in ESRD. Surveillance in a valid option in small or cystic renal masses. In the localized setting, change in immunosuppressive therapy is not recommended besides perioperative avoidance of mTOR inhibitor to limit morbidity. CTAFU does not recommend a mandatory waiting time after nephrectomy for RCC in ESRD patients candidates for renal tranplantation when tumor stageT3 and low ISUP grade. Follow-up modalities should follow recommendations in general population.The French recommendations should contribute to improve management of NKRCC in KTx recipients and RCC in ESRD candidates for KTx, integrating oncological objectives in the context of kidney transplantation.

To define guidelines for the management of localized prostate cancer (PCa) in kidney transplant (KTx) candidates and recipients.A systematic review (Medline) of the literature was conducted by the CTAFU to report prostate cancer epidemiology, screening, diagnosis and management in KTx candidates and recipients with the corresponding level of evidence.KTx recipients are at similar risk for PCa as general population. Thus, PCa screening in this setting is defined according to global French guidelines from CCAFU. Systematic screening is proposed in candidates for renal transplant over 50 y-o. PCa diagnosis is based on prostate biopsies performed after multiparametric MRI and preventive antibiotics. CCAFU guidelines remain applicable for PCa treatment in KTx recipients with some specificities, especially regarding lymph nodes management. Treatment options in candidates for KTx need to integrate waiting time and access to transplantation. Current data allows the CTAFU to propose mandatory waiting times after PCa treatment in KTx candidates with a weak level of evidence.These French recommendations should contribute to improve PCa management in KTx recipients and candidates, integrating oncological objectives with access to transplantation.

To define guidelines for the management of kidney stones in kidney transplant (KTx) donor or recipients.Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU to report kidney stone epidemiology, diagnosis and management in KTx donors and recipients with the corresponding level of evidence.Prevalence of kidney stones in deceased donor is unknown but reaches 9.3% in living donors in industrialized countries. Except in Maastrich 2 donors, diagnosis is done on systematic pre-donation CT scan according to standard french procedure. No prospective study has compared therapeutic strategies available for the management of kidney stones in KTx donor: ureteroscopy or an extra corporeal lithotripsy in case of living donor prior to donation, ex vivo approach (pyelotomy or ureteroscopy), ureterocopy in the KTx recipient or surveillance. De novo kidney stones result from a lithogenesis process to be identified and treated in order to avoid recurrences. The context of solitary functional kidney renders the prevention of recurrence of great importance. Diagnosis is suspected when identification of a renal graft dysfunction, hematuria or urinary tract infection with renal pelvis dilatation. Stone size and location are determined by computed tomography. There are no prospective, controlled studies on kidney stone management in the KTx. The therapeutic strategies are similar to standard management in general population.These French recommendations should contribute to improve kidney stones management in KTx donor and recipients.

To propose surgical recommendations for living donor nephrectomy.Following a systematic approach, a review of the literature (Medline) was conducted by the CTAFU regarding functional and anatomical assessment of kidney donors, including which side the kidney should be harvested from. Distinct surgical techniques and approaches were evaluated. References were considered with a predefined process to propose recommendations with the corresponding levels of evidence.The recommendations clarify the legal and regulatory framework for kidney donation in France. A rigorous assessment of the donor is one of the essential prerequisites for donor safety. The impact of nephrectomy on kidney function needs to be anticipated. In case of modal vascularization of both kidneys without a relative difference in function or urologic abnormality, removal of the left kidney is the preferred choice to favor a longer vein. Mini-invasive approaches for nephrectomy provide faster donor recovery, less donor pain and shorter hospital stay than open surgery.These French recommendations must contribute to improving surgical management of candidates for kidney donation.

La ureterolisis tiene como finalidad liberar el ureter de una compresion extrinseca, cuyo origen es, en la mayoria de las ocasiones, una fibrosis retroperitoneal idiopatica. Sin embargo, tambien puede deberse a una fibrosis secundaria o a otras causas de compresion. En la fase diagnostica, el objetivo prioritario es descartar el diagnostico diferencial de un obstaculo de origen endoluminal o parietal, lo que requiere una exploracion con contraste ureteral. Cuando se confirma la compresion extrinseca, conviene descartar las causas secundarias, sobre todo oncologicas, evaluar su grado de repercusion renal y buscar una afectacion contralateral. Los principios de la ureterolisis quirurgica son preservar la vascularizacion ureteral, aislar el ureter de la fibrosis mediante transposicion ureteral o por interposicion de tejidos sanos y asegurar el drenaje de las cavidades excretoras renales. Se da prioridad a las vias de acceso laparoscopico, porque son menos invasivas que las vias incisionales y tienen la misma eficacia. En el seguimiento, hay que detectar una reaparicion de la compresion, que puede ser uni o bilateral, y producirse de forma precoz o tardia.

Urinary complications after kidney transplantation are common and can compromise renal function. While they are mainly attributed to ischemic lesions of the ureter, there is no existing method to evaluate its vascularization during surgery. The aim of the study was to evaluate if indocyanine green, revealed by infra-red light andused to visualize tissue perfusion, could provide an appreciation of the ureter's vascularization during kidney transplantation.This feasibility study was conducted over one month, on eleven consecutive kidney transplants. During transplantation, an injection of indocyanine green enabled the surgeon to visualize in real time with an infra-red camera the ureter fluorescence. Its intensity was reported on a qualitative and semi-quantitative scale. Occurrence of urinary complications such as stenosis or ureteral fistula were collected during 6 months.In all of the 11 cases (100%), the last centimeters of the ureters were not fluorescent. Three (27%) ureters were poorly or partiallly fluorescent. Out of these three cases, only one case of urinary fistula occurred, followed by ureteric stenosis. In the series, two fistulas (18%) and two ureteric stenoses (18%) occurred. No side effects were observed. The low number of events did not allow statistical analysis.Infra-red fluorescence of indocyanine green could be a simple and innovative way to appreciate the transplant's ureteric vascularization during kidney transplantation. It could help surgeons to identify the level of ureter section and to decide the anastomosis technique, in order to limit urinary complications.3.

Sarcopenia evaluated from the measurement of skeletal muscle index (SMI) has been evaluated as a predictive factor of morbidity and mortality after surgery. The objective of this study was to evaluate whether it was predictive of morbidity and mortality in patients managed by cystectomy or tri-modality therapy (TMT), combining radiotherapy and chemotherapy after endoscopic resection of the tumour, for localized muscle-invasive bladder cancer.In all, 146 consecutive patients from 2 university hospital centres treated by cystectomy between January 2012 and April 2017 or TMT between October 2008 and October 2014 were included. The SMI was measured on axial computed-tomography at the level of the transverse process of L3, before treatment. Sarcopenia was assessed in two ways: either by SMI without muscle mass adjustment or according to the definition by Martin and al. based on gender and patient BMI, then called "adjusted sarcopenia". The primary endpoint was overall survival (OS) for sarcopenia. The secondary endpoints were OS, progression-free survival (PFS) and survival without re-admission (SRH) for the total population and for each treatment group. Survival analyses were performed using the Cox model. The association between sarcopenia and complications has been investigated by the ChiThe characteristics of sarcopenic (n=67) and non-sarcopenic (n=79) patients were comparable except for 2 criteria: older patients in the sarcopenic group and a higher proportion of neo-adjuvant chemotherapy in non-sarcopenic patients. Sarcopenia was not significantly associated with any type of survival. Sarcopenia was not associated with the proportion or severity of complications.Unlike unadjusted SMI, sarcopenia was not associated with survival or complications.3.

To assess the value of systematic urine culture before ureteric double j removal.This prospective audit was performed to assess the validity of our current clinical practice. A cohort of informed patients without clinical signs of urinary tract infection and without predefined risk factors were programmed for ureteral double j stent removal in an outpatient setting. Urine was sampled for culture immediately before the procedure. Patients had to complete a self-questionnaire 15 days following stent removal, inquiring about tolerance and complications which were to be analyzed according to the culture results. The primary endpoint was the occurrence of febrile urinary tract infection.Among the 56 participants, immediate preoperative urine culture revealed colonization in 9 patients (16.1%) and contamination in 6 patients (10.7%). A significant association was found between bacteriuria and double j placement following surgery with urinary tract injury (P0.02) and diabetes (P0.009). Two patients had fever including a man with sterile urine and a woman with Staphylococcus Aureus infection. No hospitalization was necessary. Twelve patients reported functional signs with lumbar pain being the most common. There was no significant association between functional signs and patients' clinical characteristics.This evaluation was not in favor of modifying our protocol of care i.e. the lack of performing neither antibiotic prophylaxis nor systematic urine culture before JJ ureteral stent removal in a selected population.4.

Resume Introduction Apres le developpement de la nephrectomie laparoscopique de donneur vivant en 1995, puis l’evolution vers la laparoscopie robot-assistee en 1999, certaines equipes ont evalue l’apport de ces techniques en transplantation renale. Methodes Une revue de la litterature a ete menee colligeant les etudes cliniques evaluant la chirurgie laporoscopique robot-assistee pour le prelevement renal a donneur vivant et pour la transplantation renale. Resultats Le prelevement renal donneur vivant robot-assiste a une tres faible morbidite et de bons resultats a long terme concernant donneurs et receveurs. Elle permet notamment une amelioration des douleurs postoperatoire. L’apport de la chirurgie robotique en transplantation renale semble plus limite. Les differentes series semblent mettre en lumiere un interet chez les patients obeses et/ou sous anticoagulants en diminuant la morbidite parietale.

To assess the influence of vascular clamping and ischemia time on long-term post-operative renal function following partial nephrectomy (PN) for cancer in a solitary kidney. This is a retrospective study including 259 patients managed by PN between 1979 and 2010 in 13 centers. Clamping use, technique choice (pedicular or parenchymal clamping), ischemia time, and peri-operative data were collected. Pre-operative and last follow-up glomerular filtration rates were compared. A multivariate analysis using a Cox model was performed to assess the impact of ischemia on post-operative chronic renal failure risk. Mean tumor size was 4.0±2.3cm and mean pre-operative glomerular filtration rate was 60.8±18.9mL/min. One hundred and six patients were managed with warm ischemia (40.9%) and 53 patients with cold ischemia (20.5%). Thirty patients (11.6%) have had a chronic kidney disease. In multivariate analysis, neither vascular clamping (P=0.44) nor warm ischemia time (P=0.1) were associated with a pejorative evolution of renal function. Pre-operative glomerular filtration rate (P

Resume But Evaluer, par la pratique systematique d’une deuxieme resection, le taux de tumeur residuelle chez les patients pTa haut grade versus pT1 haut grade. Materiel et methodes Entre janvier 2010 et juillet 2013, 53 patients ayant une tumeur de vessie n’infiltrant pas le muscle vesical (TVNIM) a risque eleve de recidive et de progression ont eu une re-resection systematique, selon les recommandations actuelles du CCAFU. Resultats Parmi les 53 patients ayant une TVNIM a risque eleve, l’examen anatomopathologique de la resection initiale a identifie : 17 lesions pTa haut grade (32,1 %) et 36 lesions pT1 haut grade (67,9 %). Il existait une difference significative entre les 2 groupes de patients (Ta haut grade versus T1 haut grade) concernant le taux de tumeur residuelle a la seconde resection (11,8 % versus 66,7 % ; p = 0,0002). Les facteurs predictifs de tumeur residuelle a la seconde resection etaient le stade T1 ( p = 0,0002), la multifocalite tumorale ( p = 0,02) et le Cis associe ( p = 0,0005). Conclusion Le taux eleve de tumeur residuelle dans notre serie a souligne l’interet d’une re-resection systematique pour les TVNIM a risque eleve. Cependant, pour les tumeurs de stade initial pTa sans Cis associe, l’interet de cette re-resection a semble moindre. Niveau de preuve 5.

Resume Introduction L’objectif de ce travail a ete de preciser la place actuelle des traitements adjuvants et neoadjuvants dans la prise en charge des cancers du rein. Materiel et methodes Les donnees ont ete explorees dans Medline ( http://www.ncbi.nlm.nih.gov ) en utilisant les mots cles MeSH suivants ou une combinaison de ces mots cles : « cancer », « rein », « kidney », « adjuvant », « neoadjuvant », « anti-angiogenique », « anti-angiogenic » ; et en selectionnant les articles obtenus sur leur methodologie, leur pertinence par rapport au theme explore et leur date de publication. Resultats Trente-deux articles anglophones et francais publies entre 2001 et 2011 ont ete selectionnes : cinq etudes de niveau de preuve 1, neuf etudes de niveau 2, neuf etudes de niveau 4, cinq etudes de niveau 5 et quatre revues de la litterature. La place de la nephrectomie de reduction tumorale dans la prise en charge des cancers du rein localement avances ou metastatiques est desormais controversee a l’ere des nouvelles therapies ciblees anti-angiogeniques. En situation neoadjuvante, ces traitements ont montre un impact modere sur la reduction de volume tumoral avec une moindre amelioration de la resecabilite en dehors de quelques cas rapportes. En situation adjuvante, les donnees de la litterature sont encore limitees et plusieurs essais cliniques sont actuellement en cours. Conclusion Les anti-angiogeniques ont bouleverse les strategies therapeutiques actuelles. Le developpement d’essais cliniques et de protocoles de recherche nous permettra dans un avenir proche de determiner les sequences therapeutiques optimales.

Despite advances in the diagnosis of prostate cancer over the past century, it remains a leading cause of cancer related death. A recent recommendation against screening has further complicated the diagnosis and management of this condition. It remains to be demonstrated if newer diagnostic modalities will have an impact on mortality rates. Most certainly, not all prostate cancers need to be diagnosed, and methods of accurately diagnosing those cancers that lead to death needs more work. In this review article, we describe the different techniques, approaches and diagnostic accuracies of the currently used biopsy methods.

Resume Objectif Notre objectif etait d’evaluer si en comparaison de la nephrectomie elargie (NE), le benefice de la nephrectomie partielle (NP) pour la preservation de fonction renale se maintient au-dela du seuil des 4 cm de taille tumorale. Methodes Les donnees de 888 patients operes dans huit centres universitaires francais ont ete analysees de maniere retrospective. Le debit de filtration glomerulaire (DFG) a ete estime avant et apres chirurgie par l’equation du MDRD (Modification of Diet in Renal Disease). Les patients ayant une indication de NP imperative ou un DFG inferieur a 30 mL/min par 1,73 m 2 etaient exclus de l’etude. Le passage dans un groupe de DFG moins favorable apres chirurgie etait considere comme significatif. Resultats Sept cent-trente patients ont ete inclus dans cette etude. L’âge median au diagnostic etait de 60 ans (19–88). Parmi les tumeurs, 359 (49,2 %) mesuraient plus de 4 cm. La NP et la NE etaient effectues respectivement chez 384 (52,6 %) et 346 (47,4 %) patients. En analyse univariee, les patients operes par NP avaient moins de risque que ceux operes par NE d’avoir une diminution du DFG : pour les tumeurs inferieures ou egales a 4 cm ( p = 0,0001) et les tumeurs superieures a 4 cm ( p = 0,018). En analyse multivariee, les facteurs predictifs independants de diminution du DGF en postoperatoire etaient : la realisation d’une NE ( p = 0,001), le DFG preoperatoire faible ( p = 0,006), l’âge eleve au diagnostic ( p = 0,001) et le score ASA eleve ( p = 0,004). Conclusion Le benefice de la NP elective sur la NE pour preserver la fonction renale persiste lorsque l’on elargit ses indications a des tumeurs mesurant plus de 4 cm dans des cas selectionnes.

Background The advanced renal cell carcinoma (RCC) affects patients mainly ∼60 years of age and who may have an active sex life. The objective of the study was to investigate possible sexual disorders in a male population with advanced RCC treated with a molecular targeted therapy (MTT). Patients and methods Thirty-eight male patients with a stabilized advanced RCC on MTT were proposed a personal interview about their sexual life, filled in the International Index of Erectile Function (IIEF) auto-questionnaire, and were reassessed if the treatment was modified. Results This is the first evaluation of sexual life while on MTT. For 64% of the patients (median age 59 years, treatment duration 12 months), the quality of their sexual life was considered important. The scores of the IIEF were reduced from 30% to 60% in erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction. The erectile dysfunction was more severe in the MTT population compared with age-stratified general or urological populations. The disorders were reversible in a few cases after treatment interruption. Conclusions Patients on MTT for an advanced RCC experience a decline of sexual activity. Onco-urologists should systematically inform, screen, initiate management, and refer patients to sexual medicine physicians.

Deep pelvic endometriosis surgery may need substantial excisions, which in turn expose to risks of injury to the pelvic nerves. To limit functional complications, nerve-sparing surgical techniques have been developed but should be adapted to the specific multifocal character of endometriotic lesions. The objective was to identify the anatomical areas where the pelvic nerves are most at risk of injury during endometriotic excisions.The Medline and Embase databases have been searched for available literature using the keywords "hypogastric nerve or hypogastric plexus [Mesh] or autonomic pathway [Mesh], anatomy, endometriosis, surgery [Mesh]". All relevant French and English publications, selected based on their available abstracts, have been reviewed. Five female adult fresh cadavers have been dissected to localize the key anatomical areas where the pelvic nerves are most at risk of injury.Six anatomical areas of high risk for pelvic nerves have been identified, analysed and described. Pelvic nerves can be damaged during the dissection of retrorectal space and the anterolateral rectal excision. Furthermore, before an uterosacral ligament excision, a parametrial excision, a colpectomy or a dissection of the vesico-uterine ligament, the hypogastric nerves, splanchnic nerves, inferior hypogastric plexus and its efferent pathways must be mapped out to avoid injury. The distance between the deep uterin vein and the pelvic splanchnic nerves were measured on four cadavers and varied from 2.5cm to 4cm.Six key anatomical pitfalls must be known in order to limit the functional complications of the endometriotic surgical excision. Applying nerve-sparing surgical techniques for endometriosis would lead to less urinary functional complications and a better short-term postoperative satisfaction.

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery.

Quantify the rate of residual bladder tumor following systematic second look resection of pTa high-grade versus pT1 high-grade patients.From January 2010 to July 2013, 53 patients with a non-muscle-invasive bladder cancer with high-risk of recurrence and progression underwent a second systematic resection in accordance with the current guidelines of the French Association of Urology (AFU).Among the 53 patients with a high-risk non-muscle-invasive bladder cancer, histological examination of the initial resection identified: 17 pTa high-grade (32.1%) and 36 pT1 high-grade (67.9%). There was a significant difference between the 2 groups of patients (Ta high-grade versus T1 high-grade) concerning the rate of residual tumor on second look resection (11.8% versus 66.7%, P=0.0002). The predictive factors of residual tumor after second resection were the pT1 stage (P=0.0002), tumor multifocality (P=0.02) and presence of associated Cis (P=0.0005).The high rate of residual tumor in our series confirmed the importance of a systematic second look resection for high-risk non-muscle-invasive bladder cancers. However, for the pTa tumors without associated Cis, the interest of this second look seemed of less concern.5.

To assess the workload of an on-call urology resident at a French University Hospital.A prospective study was performed during 15 days in February 2012. The data recorded in our database regarded the resident (sex, age, time to go to work), the call (emergency, type and reason) and the person who called (grade, department).Seven centres including 18 residents participated. On average five calls were received per day [0-17]. After midnight, the resident was called less than twice (1.6). There was an actual emergency in 64% of cases [0-13]. The urology-related call motives (73%) mainly consisted in acute urine retention (AUR) and catheter problems (73), renal colic (RC) (49), acute pyelonephritis (23), and hematuria (22). Residents had to go to the hospital in 55% of AUR and catheter problems, 30% of acute pyelonephritis, 17% of RC and 14% of hematuria. The emergency department (ED) called the urology resident in 39% of cases but only 18% required the presence of the resident. A call made by a senior was more likely to be an emergency (67%) than by a resident or a nurse (51%, P=0.02).The urology resident when on-call is mainly asked for an advice by the ED. Among urology-related advice, bladder catheterization problems were the most frequent. RC was the second call motive but most of the time was not an actual emergency.

The aim of this study was to clarify the current role of adjuvant and neo-adjuvant in the treatment of kidney cancer.The data were explored in Medline (http://www.ncbi.nlm.nih.gov) using the following MeSH terms or combinations of these keywords: "cancer", "rein", "kidney", "adjuvant", "neoadjuvant", "antiangiogenique", "antiangiogenic" and selecting the items produced in their methodology, their relevance to the theme explored and their date of publication.Thirty-two English and French items published between 2001 and 2011 were selected: five studies of evidence level 1, nine level 2 studies, nine level 4 studies, five studies at level 5 and four literature reviews. The cytoreductive nephrectomy as first-line treatment of locally advanced or metastatic kidney cancer is now controversial with the advent of new targeted anti-angiogenic therapies. In neoadjuvant setting, these treatments showed a moderate decrease in tumor volume and rarely improved resectability. In adjuvant setting, their place has yet to be specified and several trials are currently underway.Recent years have seen the anti-angiogenic therapeutic strategies upset in locally advanced and metastatic renal cancer. The development of clinical trials and research protocols will allow us to determine in the near future the optimal therapeutic sequences.

The objective of our study was to assess the frequency, circumstances of diagnosis and treatment of anastomotic arterial aneurysms and compare them to the literature.A single-center series of 3000 kidney transplants and 126 pancreas transplants between 1974 and 2010 was studied retrospectively. Ten patients had anastomotic arterial aneurysms: eight after kidney transplantation and two after pancreas-kidney transplantation. Diagnosis was based on the association Doppler ultrasonography-angioscanner.Ten arterial anastomotic aneurysms were identified. The circumstances of discovery were clinical in eight cases, half of them by hemodynamic collapsus. A majority of our patients (60%) were diagnosed in the year following the transplantation and two cases were discovered after transplantectomy. Pancreas-kidney transplantation had a high risk for arterial anastomotic aneurysm. Candida albicans was isolated in preoperative samples in four cases. The management consisted to transplantectomy in seven patients, revascularization of the lower limb in six patients and one renal transplant preservation. We found two lower limb ischemia and two deaths by a fatal intraoperative haemorrhage and vascular cerebral haemorrhage. No recurrence was identified after in the follow-up ranged from 20 months to 12 years.Arterial anastomotic aneurysm was in our study a serious complication that requires emergency surgery. The transplantectomy followed by revascularization of the limb is the treatment of choice associated to an appropriate antifungal or antibiotic treatment.

To assess the frequency, circumstances, and possible medico-legal consequences of the pT0 prostate cancer, defined by the absence of tumor in a radical prostatectomy specimen.Six centers retrospectively identified all cases of pT0 and selectionned those that occurred without prior hormone therapy or prostate resection. Preoperative data, histological report and clinical and biological outcome were analyzed. The lawsuits' registry in pathology were consulted at insurance companies.Thirty cases of pT0 prostate cancer (0.4%) were reported on 7693 patients. The median age was 63years, PSA 7.4ng/mL. The number of positive preoperative biopsies ranged from one to four for a median tumor length of 1mm (0.3 to 18mm). The biopsy Gleason score was 3+3 for 23 patients, less than 5 for six others and included a contingent of grade 4 in two patients. With a median follow-up of 82months, no clinical or biochemical recurrence was observed. One patient complaint for pT0 prostate was found in the insurances registry.The occurrence of a prostate pT0 called into question all the diagnostic procedures and surgical indication. To avoid a forensic procedure, urologists should inform patients of the possibility of this situation before radical prostatectomy.

Pyelonephritis is a bacterial infection of the upper urinary tract and renal parenchyma. Infection occurs primarily by urinary contamination upward and backward from the intestinal flora, and genital skin, explaining that the seeds are most commonly encountered Gram-Negative bacilli (GNB), Escherichia coli in mind. The peak incidence is among women aged 15 to 65, but pyelonephritis may include subjects of all ages and both sexes. The diagnosis is usually straightforward and based on a combination of fever, unilateral flank pain and a positive urine culture. Biology and imaging aim to seek any form of pyelonephritis complicated, especially due to the obstructive form a barrier (usually a calculation) of the urinary tract and is a surgical emergency. Support depends on the existence of signs of severity or complications. Treatment consists of antibiotics, to begin immediately, initially probabilistic and secondarily adapted to the antibiogram. Patients hospitalized in the urology will be those with complicated pyelonephritis (urinary obstruction, abscess, sepsis, renal insufficiency, solitary kidney, comorbidity).

To evaluate the accessibility of the fellowship for the residents of Urology expecting to accomplish their residentship between November 2010 and 2013.Between November 2010 and January 2011, all the residents ongoing for the residentship of Urology in France were reached by an electronic mailing using the AFUF register. A questionnaire reported all the residents expecting to accomplish their residentship between November 2010 and 2013, and the number and the expected availability of fellow and specialist assistant posts during the same period.Our study counted 306 urologists on training (190 residents, 76 fellows, 30 assistants, 10 on other posts). On November 2010, 56 residents accomplished their residentship, while 68 and 79 residents expected to accomplish their residentship on November 2011 and 2012, respectively. One hundred and six posts validated the fellowship of Urology on November 2010 (76 fellows, 30 assistants), among 54 posts were available. Over the residents expecting to accomplish their residentship on November 2011 and 2012, 22 and 54 residents may not find a fellow post available.The number of residents expecting to accomplish the residentship of Urology between November 2010 and 2013 was increasing, showing a greater interest for this speciality and a lack of regulation for its accessibility. By reason of a discrepancy of fellow and specialist assistant posts, only 67.6 and 31.6% of the residents expecting to accomplish their residentship on November 2011 and 2012 may be able to find a post available.

The bone loss and the fracture risk are enhanced in patients with hormonal deprivation for prostate cancer. The demineralisation can be quantified by BMD (Bone Mineral Density) and prevented by lifestyle and diet therapeutics or new therapeutic agents. These agents may have a preventive effect on metastasis occurrence, but it has to be confirmed. An intra-venous biphosphonate or a sub-cutaneous RANK-inhibitor administration prevent from bone metastasis-related events.

Biomarkers of prostate cancer can assess a presence risk or an evolution risk of the disease. The integration of temporal and clinical data during the interpretation of a PSA dosage improves its performance. Trough a performing algorithm, the Phi index (Prostate Health Index) combines the results of total PSA, free PSA, and pro-PSA. The ration of urinary PCA3 and urinary PSA determines a powerful marker to be used in difficult diagnostic situations. Gene fusions in prostate cancer are promising biomarkers and eventual therapeutic targets. The cost of these new biomarkers is limiting their current use to individual situations.

The treatment of a castration-resistant prostate cancer can be immediate or delayed according to the circumstances and the time of its occurrence. New therapeutic targets have been determined with basic tumor biology studies. Treatments available or on development are various and range from estrogens to new anti-androgens. Endothelin inhibitors, abiraterone, MDV3100 or RD162 are the most promising examples but they require to enroll patients in therapeutic trials.

The main news in kidney oncourology are PET CaIX as potential new diagnostic and monitoring tool, the lack of progress in terms of drug combination therapy, the sequential approach remains the standard, lack of progress also in selecting good candidates for immunotherapy, the possible benefit of nephrectomy, that only the CARMENA study will determine, and the emergence of determining the risk of recurrence after nephrectomy using genomic study. Concerning non muscle invasive bladder cancer, endoscopic diagnosis seems improved by the NBI and immunofluorescence. The staging of pT1 tumors may evolve. The poor prognosis of Cis was stressed. The indication of cystectomy for BCG failure has been clarified. For muscle invasive bladder cancer, the prognostic impact of lympho-vascular invasion was reported. The importance of an extended lymphadenectomy has been demonstrated. In cases of symptomatic bone metastases, zoledronic acid increased overall survival. An analysis of performance and drawbacks of radio-hormonotherapy was performed. The denosumab and zoledronic acid were compared in prevention of bone loss during androgen deprivation. The antagonists of LH-RH, the cabazitaxel and immunotherapies could be part of the therapies for advanced prostate cancer. For penile cancer treatment, in case of suspicious nodes, ultrasound guided cytopuncture is useful. For testis cancer, the recurrence rate for stage I seminoma has been estimated, at 15%. The PET-scan is also helpful to assess the nodal tumoral spread during the staging and the follow-up of patients treated by chemotherapy.

To assess the burn-out syndrome in the population of urologists in training.A trans-sectional study was carried out among the French urologists in training association (AFUF) members. A questionnaire including the Maslach Burnout Inventory and questions on the age, gender, professional and familial status, working time and hobbies was emailed.The response rate was 65.5 %. Mean burn-out, emotional exhaustion and depersonalization scores were 15.57 ± 8.55 (low burn-out), 8.56 ± 5.52 (moderate burn-out) and 37.19 ± 6.21 (moderate burn-out), respectively. Forty-five (24 %) had a severe burn-out syndrome, 11 an emotional exhaustion and 41 a depersonalization. Urologists in couple had a significant lower emotional exhaustion level than single. Depersonalization and low personal accomplishment scores were related to the age and working time. Having at least one hobby prevented emotional exhaustion and improved personal accomplishment levels. Gender had no impact on burn-out syndrome.Quarter of French urologists in training had a burn-out syndrome. Factors preventing it were working time reduction, being in couple and having at least one hobby. burn-out syndrome severity decreased with age and senior status.

The objective of the present study was to analyse whether nephron-sparing surgery (NSS) was superior to radical nephrectomy (RN) in preserving renal function outcome in tumors larger than 4cm.The data from 888 patients who had been operated upon at eight french university hospitals were retrospectively analyzed. Glomerular filtration rate (GFR) pre- and post-surgery was calculated with the abbreviated Modification of Diet in Renal Disease (MDRD) equation. For a fair comparison between the two techniques, all imperative indications for NSS and all GFR30 mL/min/1.73 m(2) were excluded from analysis. A shift to a less favorable DFG group following surgery was considered clinically significant.Seven hundred and thirty patients were suitable for comparison. Median age at diagnosis was 60 years (19-88). Tumors measuring more than 4cm represented 359 (49.2%) cases. NSS and RN were performed in 384 (52.6%) and 346 (47.4%) patients, respectively. In univariate analysis, patients undergoing NSS had a smaller risk than RN of developing significant GFR change following surgery. This was true for tumors≤4cm (P=0.0001) and for tumors4cm (P=0.018). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P=0.001), decreased preoperative DFG (P=0.006), increased age at diagnosis (P=0.001) and increased ASA score (P=0.004).The renal function benefit offered by elective NSS over RN persists even when expanding NSS indications beyond the traditional 4 cm cut-off.

Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk.The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis.The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve.In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

To evaluate the interest borne towards neuro-urology within the community of the urology residents.Between January and May 2009, all urology residents received an anonymous questionnaire by e-mail estimating their interest for neuro-urology. The analyzed data were: epidemiologic data; participation in theoretical learning and training courses practices; interest and investment in the speciality; opinion on the current formation. The qualitative variables were compared by the chi-2 test. P values0,05 were considered significant.The rate of answer was 45,3 %. The middle age was 28,7+/-2,3 years. Ninety-two (70,7 %) of the 130 urologist residents questioned wished to exert full-time or divided in a hospital structure. They were 40 % to have a multidisciplinary neuro-urology staff, and 80 % were in a service which dealt with suffering patients of neurological bladder. The percentage of urologist residents interested by neuro-urology was 69,2 %, and 61,5 % of them wished to practice this activity in their future exercise. This wish was significantly higher for those resulting from the ENC (p0,05), for those wishing to exert at the hospital (p0,01) and for those who practice urology at a level of expertise in neuro-urology (p0,01). The theoretical and practical teaching of neuro-urology were considered as being insufficient for respectively 73,9 % and 64,2 % of the urologist residents. In contrast, the average note allotted to the neuro-urology module of the ECU was of 7,47 out of 10.Neuro-urology seems to be particularly attractive for the urologist residents, and many wished to integrate it in their future exercise. The motivation was more important for those who wished to carry out a career in hospital. Even if the quality of the teaching was very noted, their modalities were considered to be insufficient by most of them.