Asymptomatic Bacteriuria and Urological Surgery: Risk Factor or Not? Results From the National and Multicenter TOCUS Database.

PURPOSE: Current guidelines recommend screening and treatment of asymptomatic bacteriuria prior to all urological surgeries breaching the mucosa. But little evidence supports this recommendation. At the least, risk stratification for postoperative UTI to support this strategy is lacking. The aim of this study was to define the associated factors for postoperative febrile infectious complications (UTI or surgical site infection) in urological surgery. MATERIALS AND METHODS: We conducted a retrospective, multicentric study including all consecutive patients undergoing any urological surgery with preoperative urine culture. The primary outcome was the occurrence of a UTI or surgical site infection occurring within 30 days after surgery. RESULTS: From 2016 to 2023, in 10 centers, 2389 patients were included with 838 (35%) positive urine cultures (mono-/bi-/polymicrobial). Postoperative infections occurred in 106 cases (4.4%), of which 44 had negative urine cultures (41%), 42 had positive mono-/bimicrobial urine cultures (40%), and 20 had polymicrobial urine cultures (19%). In multivariable analysis, UTI during the previous 12 months of surgery (odds ratio [OR] 3.43; 95% CI 2.07-5.66; P < .001), monomicrobial/bimicrobial preoperative urine culture (OR 3.68; 95% CI 1.57-8.42; P = .02), polymicrobial preoperative urine culture (OR 2.85; 95% CI 1.52-5.14; P < .001), and operative time (OR 1.09; 95% CI 1.04-1.15; P < .001) were independent associated factors for postoperative febrile infections. CONCLUSIONS: Positive urine culture, including preoperative polymicrobial urine culture, prior to urological surgery was associated with postoperative infection. Additionally, patients experiencing infectious complications also had a higher incidence of other complications. The effectiveness of systematic preventive antibiotic therapy for a positive urine culture has not been conclusively established.

Asymptomatic bacteriuria prior to partial and radical nephrectomy: To screen or not to screen? Results from the national and multicenter TOCUS database.

INTRODUCTION: In the era of increased bacterial resistance, the main strategy is to reduce the prescription of antibiotics when possible. Nowadays, it is highly recommended to screen for asymptomatic bacteriuria (ABU), prior to urological surgery with potential mucosal breach or urine exposure. Screening and treating urinary colonization is a strategy widely adopted before radical and partial nephrectomy but without any evidence. Our main end point in this study is to analyze the relationship between preoperative urine culture and the risk of postoperative febrile urinary tract infection (UTI) or surgical-site infection (SSI) in partial or radical nephrectomy patients. METHODS: We conducted a multicenter retrospective cohort study between January 2016 and January 2023 in 11 French tertiary referral hospitals (TOCUS database). We collected the data for 269 patients including several pre-, intra-, and post-operative variables that could potentially increase the risk of postoperative UTI and SSI including preoperative urinary culture results. RESULTS: The incidence rate of postoperative UTI and SSI was 8.9% in our study. After conducting a logistic multivariate analysis, a propensity score matching analysis, and a subgroup analysis, we found no significant correlation between the urine culture and the postoperative UTI risk [OR = 1.2 (0.5-2.7) (p = 0.7)]. Only the postoperative non-infectious complications were related to a higher risk of postoperative UTI [OR = 12 (4-37), p < 0.001)]. CONCLUSION: Our research shows that screening and treating for ABU prior to radical or partial nephrectomy seems to be unnecessary to prevent postoperative UTI and SSI.

Efficacy of hyperthermic intravesical chemotherapy (HIVEC) in patients with non-muscle invasive bladder cancer after BCG failure.

PURPOSE: To evaluate hyperthermic intravesical chemotherapy (HIVEC) efficacy regarding 1-year disease-free survival (RFS) rate and bladder preservation rate in patients with non-muscle invasive bladder cancer (NMIBC) who fail bacillus Calmette-Guérin (BCG) therapy. METHODS: This is a multicenter retrospective series from a national database (7 expert centers). Between January 2016 and October 2021, patients treated with HIVEC for NMIBC who failed BCG have been included in our study. These patients had a theoretical indication for cystectomy but were ineligible for surgery or refused it. RESULTS: A total of 116 patients treated with HIVEC and with a follow-up > 6 months were included in this study and retrospectively analyzed. The median follow-up was 20.6 months. The 12 month-RFS (recurrence-free survival) rate was 62.9%. The bladder preservation rate was 87.1%. Fifteen patients (12.9%) progressed to muscle infiltration, three of them having a metastatic disease at the time of progression. Predictive factors of progression were T1 stage, high grade and very high-risk tumors according to the EORTC classification. CONCLUSION: Chemohyperthermia using HIVEC achieved an RFS rate of 62.9% at 1 year and enabled a bladder preservation rate of 87.1%. However, the risk of progression to muscle-invasive disease is not negligible, particularly for patients with very high-risk tumors. In these patients who fail BCG, cystectomy should remain the standard of care and HIVEC may be discussed cautiously for patients who are not eligible for surgery and well informed of the risk of progression.

Expanding inclusion criteria for active surveillance in intermediate-risk prostate cancer: a machine learning approach.

PURPOSE: To develop new selection criteria for active surveillance (AS) in intermediate-risk (IR) prostate cancer (PCa) patients. METHODS: Retrospective study including patients from 14 referral centers who underwent pre-biopsy mpMRI, image-guided biopsies and radical prostatectomy. The cohort included biopsy-naive IR PCa patients who met the following inclusion criteria: Gleason Grade Group (GGG) 1-2, PSA < 20 ng/mL, and cT1-cT2 tumors. We relied on a recursive machine learning partitioning algorithm developed to predict adverse pathological features (i.e., ≥ pT3a and/or pN + and/or GGG ≥ 3). RESULTS: A total of 594 patients with IR PCa were included, of whom 220 (37%) had adverse features. PI-RADS score (weight:0.726), PSA density (weight:0.158), and clinical T stage (weight:0.116) were selected as the most informative risk factors to classify patients according to their risk of adverse features, leading to the creation of five risk clusters. The adverse feature rates for cluster #1 (PI-RADS ≤ 3 and PSA density < 0.15), cluster #2 (PI-RADS 4 and PSA density < 0.15), cluster #3 (PI-RADS 1-4 and PSA density ≥ 0.15), cluster #4 (normal DRE and PI-RADS 5), and cluster #5 (abnormal DRE and PI-RADS 5) were 11.8, 27.9, 37.3, 42.7, and 65.1%, respectively. Compared with the current inclusion criteria, extending the AS criteria to clusters #1 + #2 or #1 + #2 + #3 would increase the number of eligible patients (+ 60 and + 253%, respectively) without increasing the risk of adverse pathological features. CONCLUSIONS: The newly developed model has the potential to expand the number of patients eligible for AS without compromising oncologic outcomes. Prospective validation is warranted.

HoSAGE: sarcopenia in older patient with intermediate / high-risk prostate cancer, prevalence and incidence after androgen deprivation therapy: study protocol for a cohort trial.

BACKGROUND: Sarcopenia is defined by a loss of muscle strength associated to a decrease in skeletal muscle mass. Ageing greatly contributes to sarcopenia as may many other factors such as cancer or androgen deprivation therapies (ADT). This cohort study aims to evaluate (1) the prevalence of muscle disorders and sarcopenia in older patients before initiation of intermediate to high risk prostate cancer treatment with ADT and radiotherapy, and (2) the occurrence and/or aggravation of muscle disorders and sarcopenia at the end of cancer treatment. METHODS: This cohort study is monocentric and prospective. The primary objectives are to determine the risk factor of sarcopenia prevalence and to study the relationship between ADT and sarcopenia incidence, in patients 70 years and older with histologically proven localized or locally advanced prostate cancer, addressed to a geriatrician (G8 score ≤14) for comprehensive geriatric assessment (CGA) in Marseille University Hospital. Secondary objectives encompass, measurement of sarcopenia clinical criteria along prostate oncological treatment; evaluation of the quality of life of patients with sarcopenia; evaluation of the impact of socio-behavioral and anthropological factors on sarcopenia evolution and incidence; finally the evaluation of the impact of ADT exposure on sarcopenia. Sarcopenia prevalence was estimated to be between 20 and 30%, therefore the study will enroll 200 patients. DISCUSSION: The current guidelines for older patients with prostate cancer recommend a pelvic radiotherapy treatment associated to variable duration (6 to 36 months) of ADT. However ADT impacts muscle mass and could exacerbate the risks of sarcopenia. Our study intends to assess the specific effect of ADT on sarcopenia incidence and/or worsening as well as to estimate sarcopenia prevalence in this population. The results of this cohort trial will lead to a better understanding of sarcopenia prevalence and incidence necessary to further elaborate a prevention plan. TRIAL REGISTRATION: The protocol was registered to the French drug and device regulation agency under the number 2019-A02319-48, before beginning the study (11/12/2019). The ClinicalTrials.gov identifier is NCT04484246, registration on the ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT04484246 ).

Epidemiology and care pathway of vesicovaginal fistulas managed in France between 2010 and 2018.

PURPOSE: To evaluate the incidence of vesicovaginal fistula (VVF) in France. METHODS: We conducted a retrospective analysis of prospectively and systematically collected data from January 2010 to December 2018 in the French Hospital Discharge Database. We used ICD-10 code "N820" to identify new VVF diagnoses. VVF incidence was calculated using estimations of the French population. We compared age on diagnosis, medical history of pelvic tumoral disease, radiotherapy, hysterectomy and childbirth, according to three subgroups: surgical repair attempt (SRA), long-term catheter and/or nephrostomies (LTC) or immediate surgical urinary diversion (ISUD). We focused on the patients diagnosed in 2017 to better analyse VVF aetiologies and outcomes (7-year hindsight and 1 year of follow-up). Chi-squared and Kruskal-Wallis tests were, respectively, used for qualitative and quantitative data comparisons. RESULTS: Of the 196 million hospital stays out of 50 million French citizens hospitalised from 2010 to 2018, 5499 women were hospitalised for VVF. The estimated incidence of VVF was 2.3/100,000 women-year. Approximately half of the patients underwent SRA (48.4%); 39.8% had LTC and 11.9% had ISUD. Patients were younger in the SRA subgroup (53.4 ± 14.7 years p < 0.001) with a lower rate of pelvic cancer (p < 0.001) or radiotherapy (p < 0.001) and a higher rate of hysterectomies (p > 0.001). In 2017, two-thirds of the VVF diagnosed were secondary to pelvic surgery. Mean management time was 9.2 ± 10.6 months. After SRA, 5.4% underwent incontinence surgery and 5.0% underwent secondary surgical urinary diversion. CONCLUSIONS: VVF is not a rare pathology in France, mainly due to pelvic surgery. Its management is complex and not well defined.

Long-term results of endoscopic treatment in vesicoureteral reflux after kidney transplantation.

OBJECTIVES: To assess the long-term clinical outcomes and identify factors predicting success of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) after kidney transplantation. PATIENTS AND METHODS: A retrospective chart review of all patients who had a symptomatic VUR after renal transplantation at our centre between January 2000 and December 2020 was performed. VUR was documented by retrograde cystography and was determined by at least one episode of acute graft pyelonephritis (AGPN). Endoscopic injections of polydimethylsiloxane (MacroPlastique™) or dextranomer/hyaluronic acid copolymer (Deflux™) were performed by expert urologists via rigid cystoscopy with a bevelled needle system. The results of endoscopic treatment were evaluated by cystography at three months. The primary endpoint was clinical efficacy as defined by the absence of AGPN during follow-up. Radiological success was defined by the absence of VUR at the three months follow-up cystography. RESULTS: Out of 2135 kidney transplantations, a total of 117 (5.5%) patients had symptomatic VUR: 100 (85.5%) underwent Deflux™ and 17 (14.5%) MacroPlastique™. Preoperative high-grade VUR was recorded in 71% of patients. One postoperative complication was observed, Clavien > II. After a median follow-up of 11.2 years (IQR 6.5-14.4), clinical success was achieved in 73 patients (62.4%). Radiological success was obtained in 42 patients (36%). Multivariable analysis failed to identify predictors of endoscopic treatment success, which was independent of the preoperative grade of VUR and the type of bulking agent used. CONCLUSION: Endoscopic treatment of VUR is a simple and well-tolerated procedure with long-term clinical efficacy.

Ureteral reimplantation after deflux failure for vesicoureteral reflux in renal transplant.

PURPOSE: To evaluate the outcomes of ureteral reimplantation (UR) after failure of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) in renal transplant recipients. METHODS: We conducted a monocentric retrospective study that included all renal transplant recipients with failure of Deflux™ as first-line treatment of VUR from January 2007 to December 2020. Failure of Deflux™ was defined by: VUR on retrograde cystography and at least one acute pyelonephritis of the renal graft. The preferred surgical treatment was native ureteropyelostomy (NPUS) in the recent years. If the native ureter could not be used, ureteroneocystostomy (UNC) was performed. The primary outcome was the clinical efficacy of UR defined as the absence of acute graft pyelonephritis during follow-up. RESULTS: Out of 1565 kidney transplantations, 119 (7.6%) had symptomatic VUR treated with bulking agent. 35 (29.4%) had Deflux™ failure and were addressed to UR: 21/35 (60%) NPUS and 14/35 (40%) UNC. The median estimated blood loss, operative time, and length of stay were 120 mL, 90 min, and 7 days, respectively. After a median follow-up of 7.1 (IQR 4.1-9.8) years, UR was clinically successful in a total of 32 patients (91.4%): 20 (95.2%) and 12 (85.7%) patients in the NPUS and UNC groups, respectively (p = 0.55). Three (8.5%) high-grade complications have been reported. No nephrectomy of native kidney was required in the NPUS group. CONCLUSIONS: After failure of Deflux™ for VUR of renal graft, surgical treatment with native ureteropyelostomy or ureteroneocystostomy is associated to a high success rate and few high-grade complications.

Radical nephroureterectomy for UTUC conferred survival benefits irrespective of age and comorbidities.

PURPOSE: We investigated the effects of age, American Society of Anesthesiologists Physical Status Classification (ASA) grading and Charlson Comorbidity Index (CCI) on the survival outcomes of upper tract urothelial carcinoma (UTUC). METHODS: The CROES-UTUC registry was an international, multicenter study on patients with UTUC. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Kaplan-Meier and multivariate Cox regression analyses were performed by stratifying patients according to their age (≤ 70 and > 70 years old) and ASA grade (I-II and III-V)/CCI (0-1 and ≥ 2). RESULTS: A total of 2352 patients were included in this study. Patients aged ≤ 70 years with ASA grading of I-II (p = 0.002), and patients aged ≤ 70 years with a CCI of 0-1 (p = 0.002) had the best OS. Upon multivariate analysis, both in patients aged ≤ 70 and > 70 years, ASA grading and CCI were not significantly associated with OS. Patients aged ≤ 70 years with ASA grading of III-IV (p = 0.024) had the best DFS. When stratified according to age and CCI, no significant difference in DFS was noted. Upon multivariate analysis, radical nephroureterectomy (RNU) was significantly associated with better DFS in patients aged ≤ 70 and > 70 years; CCI of ≥ 3 was significantly associated with worse DFS in patients ≤ 70 years; ASA grading was not associated with DFS in patients aged ≤ 70 and > 70 years. CONCLUSIONS: A high ASA grading and CCI should not be considered contraindications for RNU. RNU should be considered even in elderly patients when it is deemed feasible and achievable after a geriatric assessment.

Knowledge, professional attitudes, and training among health professionals regarding male contraceptive methods.

OBJECTIVES: Health professionals are at the forefront of information and acceptability regarding contraceptive methods, however only one study evaluated their knowledge of male contraception (MC) including hormonal MC (HMC) and thermal MC (TMC). Our objective was to evaluate the knowledge, professional attitudes, and training of French practitioners regarding the management of couple contraception by male contraception (MC). STUDY DESIGN: We designed a descriptive, cross-sectional, multicentre study in 2,396 French practitioners belonging to national or regional institutions involved in contraception. We solicited practitioners by e-mail to complete an anonymous questionnaire; we analysed their knowledge, professional attitudes, and training regarding the management of couple contraception by MC. RESULTS: The overall participation rate was 18% (427/2,396). Condoms, withdrawal, and vasectomy were known by 98%, 89%, and 76% of the population, respectively. Hormonal MC and Thermal (TMC) were known by 10% and 24% of the population, respectively. Fifty-five percent of the population never or infrequently offered MC during a couple's contraceptive request consultation. Only 14% of the population had ever participated in training on MC; 96% wanted to be better trained on MC, and 87% expressed a willingness to participate in training on the subject. CONCLUSIONS: Health professionals involved in contraception have unsatisfactory knowledge about MC methods based on spermatogenesis inhibition and are eager to have more information about them. To advance the acceptability and dissemination of MC methods, it seems imperative to enhance research in the field and to provide health professionals with an adapted training programme.

[Pedagogical impact of a MOOC on surgical technique of kidney transplantation]. / Impact pédagogique d'un MOOC de technique chirurgicale de transplantation rénale.

OBJECTIVE: To evaluate the educational impact of a pilot MOOC (Massive Open Online Course), validated by the French College of Urology Teachers (FCUT), on the surgical technique of kidney transplantation. MATERIALS AND METHODS: We developed a MOOC on the surgical technique of kidney transplantation, based on a video of a surgical procedure, performed by an expert surgeon. The MOOC has been validated by the FCUT. We have created 2 student groups: 1) MOOC-pre-QCM group: visualization of the MOOC then answer to the MCQs and satisfaction questions; 2) MOOC-post-QCM group: answer to the MCQs then visualization of the MOOC then answers to the satisfaction questions. In total, 20 MCQs on the kidney transplantation technique were completed by the 2 groups. The answers were anonymous. RESULTS: A total of 142 people answered the MCQs (MOOC-pre-QCM group (n=66) and MOOC-post-QCM group (n=76)). Twenty-nine percent (41/142) of the participants were fellows and 71 % (101/142) were residents. The proportion of fellows and residents was identical between the 2 groups. The rate of correct answers to the 20 MCQs was statistically higher in the MOOC-pre-QCM group, compared to the MOOC-post-QCM group (88.6 % versus 73.3 %, P<0.0001). Ninety-one percent of students found the MOOC "Very Useful" or "Useful". The median MOOC rating, given by students, was 8/10. CONCLUSION: This study showed a positive impact of the MOOC on theoretical knowledge of kidney transplantation surgical technique. This MOOC could serve as a pilot project for the development of other MOOCs on urological surgery. LEVEL: 3.

Sunitinib Alone or after Nephrectomy in Metastatic Renal-Cell Carcinoma.

BACKGROUND: Cytoreductive nephrectomy has been the standard of care in metastatic renal-cell carcinoma for 20 years, supported by randomized trials and large, retrospective studies. However, the efficacy of targeted therapies has challenged this standard. We assessed the role of nephrectomy in patients with metastatic renal-cell carcinoma who were receiving targeted therapies. METHODS: In this phase 3 trial, we randomly assigned, in a 1:1 ratio, patients with confirmed metastatic clear-cell renal-cell carcinoma at presentation who were suitable candidates for nephrectomy to undergo nephrectomy and then receive sunitinib (standard therapy) or to receive sunitinib alone. Randomization was stratified according to prognostic risk (intermediate or poor) in the Memorial Sloan Kettering Cancer Center prognostic model. Patients received sunitinib at a dose of 50 mg daily in cycles of 28 days on and 14 days off every 6 weeks. The primary end point was overall survival. RESULTS: A total of 450 patients were enrolled from September 2009 to September 2017. At this planned interim analysis, the median follow-up was 50.9 months, with 326 deaths observed. The results in the sunitinib-alone group were noninferior to those in the nephrectomy-sunitinib group with regard to overall survival (stratified hazard ratio for death, 0.89; 95% confidence interval, 0.71 to 1.10; upper boundary of the 95% confidence interval for noninferiority, ≤1.20). The median overall survival was 18.4 months in the sunitinib-alone group and 13.9 months in the nephrectomy-sunitinib group. No significant differences in response rate or progression-free survival were observed. Adverse events were as anticipated in each group. CONCLUSIONS: Sunitinib alone was not inferior to nephrectomy followed by sunitinib in patients with metastatic renal-cell carcinoma who were classified as having intermediate-risk or poor-risk disease. (Funded by Assistance Publique-Hôpitaux de Paris and others; CARMENA ClinicalTrials.gov number, NCT00930033 .).

The prognostic value of serum procalcitonin in acute obstructive pyelonephritis.

PURPOSE: To evaluate the prognostic value of procalcitonin (PCT) in the occurrence of infectious complications in the management of acute obstructive pyelonephritis (AOP) compared with other biological parameters (leucocyte count, C-reactive protein [CRP]). METHODS: We conducted a retrospective study including patients who were treated for AOP and performed serum PCT tests in our center between January 1, 2017 and December 31, 2017. Upper urinary tract obstruction was confirmed by either ultrasound or CT urography. Clinical examinations and laboratory tests including leukocyte count, CRP, urine and blood cultures, and serum PCT measurements were performed in the emergency unit. Treatment included early renal decompression using indwelling ureteral stents or nephrostomy and empiric antibiotic therapy. The primary endpoint was occurrence of severe sepsis (SS), a composite criterion including urosepsis and/or septic shock and/or admission to the intensive care unit (ICU) and/or death. RESULTS: A total of 110 patients (median age: 61 years) were included, of whom 56.3% were female. SS occurred in 39 cases (35.4%). Multivariate regression analysis showed that serum PCT (OR 1.08; 95% CI 1.03-1.17; p = 0.01), CRP (OR 1.007; 95% CI 1.001-1.015; p = 0.03), and diabetes mellitus (OR 5.1; 95% CI 1.27-27.24; p = 0.04) were independent predictors for SS. Serum PCT was the biological marker associated with the highest accuracy to predict SS (ROC 0.912 (95% CI 0.861-0.962) and was superior to CRP (p < 0.001): the sensitivity and specificity of PCT to predict SS were 95% and 77%, respectively, with a serum PCT cutoff value of 1.12 µg/L. CONCLUSIONS: PCT levels > 1.12 µg/L could help physicians to identify high-risk patients who could benefit from early and aggressive management in collaboration with intensive care specialists.

Efficacy of HIVEC in patients with high-risk non-muscle invasive bladder cancer who are contraindicated to BCG and in patients who fail BCG therapy.

PURPOSE: To evaluate Hyperthermic-Intra-Vesical Chemotherapy (HIVEC) efficacy regarding 1-year disease-free survival (RFS) rate and bladder preservation rate in patients with High-risk Non-Muscle Invasive Bladder Cancer (NMIBC) who fail BCG therapy or are contraindicated to BCG. METHODS: Between June 2016 and October 2019, patients treated with HIVEC for mostly high-risk NMIBC who failed BCG or BCG-naive if BCG contraindicated have been included in our study. These patients had a theoretical indication for cystectomy but were ineligible for surgery or refused it. RESULTS: Fifty-three patients, median age 72 [39-93] years, were included in this study (n = 29 BCG-failure and n = 24 BCG-naive). The median follow-up was 18 months. The bladder preservation rate was 92.4%. The 12 months-RFS rate was 60.5%. The RFS rates for BCG-naive and BCG-failure groups were respectively 70% and 52.2% at 12 months. Three patients progressed to muscle infiltration, all in the BCG-failure group and all in the very high-risk EORTC group. Two of them developed metastatic disease and died from bladder cancer. CONCLUSION: Chemohyperthermia using HIVEC achieved a RFS rate of 60% at 1 year and enabled a bladder preservation rate of 92%. Given the low risk of progression in the BCG-naive group, HIVEC could be a good alternative. Conversely, for patients with very high-risk tumors that fail BCG, cystectomy should remain the standard of care and HIVEC may be discussed cautiously for patients who are not eligible for surgery and well informed of the risk of progression to muscle-invasive disease.

Micro-percutaneous nephrolithotomy (Microperc) for renal stones, outcomes and learning curve.

OBJECTIVE: To report the effectiveness, reliability and learning curve of Microperc, a minimal invasive percutaneous technique using a 4.85-Ch (16-gauge) sheath, in the treatment of nephrolithiasis. MATERIAL AND METHODS: 31 consecutive Micropercs for nephrolithiasis<2.5cm were performed by 2 operators in 2 different institutions from the 1st of May 2015 to 31st of December 2017. RESULTS: The mean size of stones was 19mm±11mm, and mean density was 1048±249UH. Stones were located in lower calyx in 21/31(68%), medium calyx in 3/31(10%), pelvis in 4/31(12%) and were multi-caliceal in 3/31(10%). Five patients (16%) had urinary diversion (4 ileal conduits, 1 enterocystoplasty with Mitrofanoff+bladder neck closure) all of those having neurological disease (2 multiple sclerosis, 3 spinal cord injury). Mean operating time was 83±35min and decreased after short period for both operators. 9/31(29%) patients had complication: 8 (26%) had fever (Clavien II) and 1 (3%) had renal colic pain (Clavien III) (required JJ stent). Stone-free was obtained in 13/31(42%) and 11/31(36%) had residual microfragments<3mm which did not require further treatment, corresponding to a technical success of 78% (24/31). Success rate was similar in patients with urinary diversion and patients with normal anatomy. CONCLUSIONS: This study showed that Microperc was an effective technic for kidney stone treatment with low complication rate, acceptable operating time and short learning curve. Microperc was useful for stones in the lower calyx and/or urinary diversion where retrograde ureteroscopy could reach its limits. LEVEL OF EVIDENCE: 3.

[Single use versus reusable flexible ureteroscopy for the treatment of urolithiasis: a comparative study of perioperative complications].

OBJECTIVE: To compare the perioperative complications of patients who underwent flexible ureteroscopy (fURS) for the treatment of urolithiasis according to the type of ureteroscope used, single-use (suURS) or reusable (rURS) flexible ureteroscope. PATIENTS AND METHODS: A retrospective and single-center study was conducted between January 2017 and May 2019, including all fURS performed for nephrolithiasis management. During the study period, 5rURS and 1suURS (UscopePU3022) were available. The primary endpoint was the occurrence of 30-days postoperative complications, especially infectious complications, classified according to Clavien-Dindo grading system. RESULTS: Overall, 322 consecutive fURS were included corresponding to 186 rURS (57.8%) and 136 suURS (42.2%). Respectively in rURS and suURS groups, the median (IQR) age was 57 (45-65) vs 57 (44-66) years (p=0.75), 83 (44.6%) vs 63 (46.3%) female were included (p=0.82), and median (IQR) Charlson score was 2 (1-3) vs 2 (0-3) (p=0.15). Fifty-one patients (15.8%) developed postoperative complications, 28 patients (15%) in rURS group and 23 patients (17.6%) in suURS group (p=0.64). Most of them (n=47, 92.1% of overall complications) were minor (Clavien I-II). Occurrence of urinary tract infection in suURS group (n=13; 9.5%) was equally comparable with rURS group (n=10; 5.4%), p=0.15. CONCLUSIONS: Our data suggests that suURS represents a safe alternative to rURS. Compared to reusable devices, UscopePU3022 use was associated with a similar complication rates, however, did not decrease the occurrence of infectious events.

Predictive risk factors of urinary tract infection following flexible ureteroscopy despite preoperative precautions to avoid infectious complications.

PURPOSE: Urinary tract infection (UTI) is a common complication after flexible ureteroscopy (fURS) despite technical precautions to avoid infectious complications. The aim was to investigate incidence and predictive risk factors of UTI following fURS procedure. PATIENTS AND METHODS: We conducted a retrospective study including consecutive fURS performed in our center from January 2015 to March 2019. The indications were: nephrolithiasis management and diagnosis and conservative treatment of upper urinary tract urothelial carcinomas (UTUC). Since 2015, we had technical precautions to avoid postoperative infectious complications: centralized collection of preoperative urine cultures which are examined daily by an urologist and a service provider, systematic use of ureteral access sheath and application of standardized antibiotic prophylaxis measures. The primary endpoint was occurrence of UTI within 15 days following fURS. RESULTS: Six hundred and four fURS were included for nephrolithiasis (n = 462) and UTUC management (n = 142). The median (IQR) age in the study cohort was 61(48-68) years, 268 female patients were included (44.4%), the median (IQR) Charlson score was 2(1-4) and single-use fURS were used in 186 cases (30.8%). Postoperative UTI occurred in 41 cases (6.7%). In multivariate analysis, female gender (OR 2.20 [1.02-5.02], p = 0.04), UTI within the last 6 months (OR 2.34 [1.12-5.11], p = 0.02), preoperative polymicrobial urine culture (OR 4.53 [1.99-10.56], p < 0.001) and increased operative time (OR 1.02 [1.002-1.031], p = 0.02) remain associated with postoperative UTI. CONCLUSIONS: In a large cohort study, female gender, prior UTI, increased operative time and preoperative polymicrobial urine culture were associated with the occurrence of postoperative UTI. Limiting operative time and improving our knowledge of polymicrobial urine cultures could reduce the infectious risk.

Diagnostic ureteroscopy prior to nephroureterectomy for urothelial carcinoma is associated with a high risk of bladder recurrence despite technical precautions to avoid tumor spillage.

PURPOSE: There have recent reports in the literature of increased rates of bladder recurrence (BR) after radical nephroureterectomy (RNU) when diagnostic flexible ureteroscopy (DFU) was performed before RNU. The technical heterogeneity of DFU was a major bias in these studies. Our purpose was to evaluate the impact of a standardized DFU technique before RNU on the risk of BR. METHODS: A retrospective monocenter study including patients who underwent RNU for upper tract urothelial carcinoma (UTUC) between 2005 and 2017. 171 patients were identified. 78 patients were excluded owing to a history of bladder cancer before RNU or neo-adjuvant/adjuvant chemotherapy. 93 included patients were stratified according to pre-RNU ureteroscopy (DFU + 70 patients) or no pre-RNU ureteroscopy (DFU-23 patients). The standardized DFU technique consisted of systematic ureteral sheath (ch9-10), flexible ureteroscopy, biopsy, and drainage with a mono-J/bladder catheter to avoid contact of contaminated urine of the upper tract with the bladder. RESULTS: Epidemiological, initial staging, and postoperative tumoral characteristics were similar in both groups. Mean follow-up was 35 months [2-166], 47(50%) BR occurred with 41(87%) in the DFU + group, and pre-RNU-DFU was an independent predictive factor of BR (OR = 4[1.4-11.9], P = 0.01) (Cox regression model). The characteristics of BR were similar in both groups, although BR occurred earlier in DFU + (427 days vs. 226 days (P = 0.07)). CONCLUSION: Bladder recurrence after diagnostic ureteroscopy + nephroureterectomy was high despite technical precautions to avoid contact of bladder mucosa with contaminated urine from the upper urinary tract. Post-DFU endovesical instillation should be investigated.

Pelvic Surgery in the Transplant Recipient: Important Considerations for the Non-transplant Surgeon.

PURPOSE OF REVIEW: Classically, kidney transplantation (KT) consists of heterotopic implantation of the renal graft in the iliac fossa with vascular anastomosis on the iliac vessel and reimplantation of the graft ureter in the bladder of the recipient. However, a wide range of variations exist in both vascular anastomosis and urinary diversion that the non-transplant surgeon should know. RECENT FINDINGS: For any pelvic surgery in a KT patient, the non-transplant surgeon should preoperatively evaluate the anatomy of the graft, its vascularization and its urinary tract. The transplant ureter should be identified and secured by preoperative JJ stenting whenever needed. For any surgery, maintenance and control of both immunosuppressive treatment and renal function is crucial. The advice or even the assistance of a transplant surgeon should be required because any damage to vascularization or urinary drainage of the renal graft could have dramatic and definitive consequences on graft function.

Robot-assisted implantation of an artificial urinary sphincter, the AMS-800, via a posterior approach to the bladder neck in women with intrinsic sphincter deficiency.

OBJECTIVES: To describe a new technique for robot-assisted AMS-800 artificial urinary sphincter (AUS) bladder neck implantation in women. PATIENTS AND METHODS: We reviewed the medical files of patients who underwent robot-assisted AUS implantation between March 2017 and November 2018 at our centre. All of the implantations were performed using a posterior approach to the bladder neck in order to avoid blind dissection and the risk of vaginal and/or bladder injury. This strategy was viewed as an alternative to the anterior robot-assisted implantation recently described. The AUSs were activated 5 weeks after implantation. Patients were followed up at 3, 6 and 12 months, then annually. RESULTS: Eight patients, with a median age of 64 years, underwent robot-assisted AUS implantation via a posterior approach to the bladder neck. The median preoperative pad weight was 300 g/24 h. The median operating time was 244 min. No peri-operative vaginal and or bladder injuries were observed. At a median of 12 months of follow-up, all the AUSs were functional. Five patients required no protection (62.5%), three had day protection (37.5%), and all said they were satisfied except for one patient (12.5%) who requested treatment for persistent urge incontinence. CONCLUSION: Robot-assisted AUS implantation in women via a posterior approach to the bladder neck is a procedure that is simple, reproducible and safe. The short-term functional results are satisfactory and comparable to those obtained via an open approach. A more long-term comparison of the efficacy and longevity of AUSs implanted using this posterior approach is needed to confirm its benefit compared with the anterior robot-assisted approach and the classic open technique.