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.

Selective Arterial Embolization with N-Butyl Cyanoacrylate Prior to CT-Guided Percutaneous Cryoablation of Kidney Malignancies: A Single-Center Experience.

The study's purpose was to assess the safety, feasibility and efficiency of selective arterial embolization (SAE) using N-butyl cyanoacrylate (NBCA) glue before percutaneous cryoablation (PCA) of renal malignancies in patients whose tumor characteristics and/or comorbidities resulted in an unacceptable risk of bleeding. In this single-center retrospective study of 19 consecutive high-risk patients (median age, 74 years) with renal malignancies managed in 2017-2020 by SAE with NBCA followed by PCA, data about patients, tumor and procedures characteristics, complications, renal function and hemoglobin concentration before and after treatment, as well as recurrence were collected. Charlson comorbidity index was ≥4 in 89.5% of patients. Ten patients were treated by antiplatelet and/or anticoagulant therapy. Median tumor largest diameter was 3.75 cm (range, 1-6.5 cm) and R.E.N.A.L. nephrometry score was ≥7 in 80%, indicating substantial tumor complexity. No major complications were recorded and minor complications occurred in 7 patients. No residual tumor was found at 6-week imaging follow-up in 18/19 patients. Tumor recurrence was visible in 1/16 patients at 6-month imaging follow-up. No significant difference was found for renal function after treatment (p = 0.07), whereas significant decrease in hemoglobin concentration was noted (p = 0.00004), although it was relevant for only one patient who required only blood transfusion and no further intervention. SAE prior to PCA is safe and effective for managing renal malignancies in high-risk patients.

Selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction.

BACKGROUND: Angiomyolipoma (AML) is the most common renal benign tumor. Treatment should be considered for symptomatic patients or for those at risk for complications, especially retroperitoneal bleeding which is correlated to tumor size, grade of the angiogenic component and to the presence of tuberous sclerosis complex (TSC). This study reports our single-center experience with the use of selective arterial embolization (SAE) in the management of symptomatic and asymptomatic renal AMLs. METHODS: In this retrospective mono-centric study, all demographic and imaging data, medical records, angiographic features, outpatient charts and follow-up visits of patients who underwent prophylactic or emergency SAE for AMLs between January 2005 and July 2016 were reviewed. Tumor size and treatment outcomes were assessed at baseline and after the procedure during follow-up. Computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography was used to evaluate AML shrinkage. Renal function was measured pre- and post-procedure. RESULTS: Twenty-three patients (18 females, 5 males; median age, 45 years; range, 19-85 years) who underwent SAE either to treat bleeding AML (n=6) or as a prophylactic treatment (n=17) were included. Overall, 34 AMLs were embolized. TSC status was confirmed for 6 patients. Immediate technical success rate was 96% and 4 patients benefitted from an additional procedure. Major complications occurred in 3 patients and minor post-embolization syndrome (PES) in 14 patients. The mean AML size reduction rate was 26.2% after a mean follow-up was 20.5 months (range, 0.5-56 months), and only non-TSC status was significantly associated with better shrinkage of tumor (P=0.022). Intralesional aneurysms were significantly more frequent in patients with hemorrhagic presentation (P=0.008). There was no change in mean creatinine level after SAE. CONCLUSIONS: SAE is a safe and effective technique to manage renal AMLs as a preventive treatment as well as in emergency setting, with significant reduction in tumor size during follow-up. A multidisciplinary approach remains fundamental, especially for TSC patients. In addition to size, the presence of intralesional aneurysms should be considered in any prophylactic treatment decision.

Management of Testicular Silicone Gel-Filled Prosthesis Rupture: Case Report of a Rare Event and a Review of the Literature.

Introduction. We report a case of spontaneous rupture of a single testicular prosthesis in a patient who had undergone bilateral orchiectomy and silicone gel-filled prosthesis insertion. The consequences of this rare event are discussed. There is no management algorithm. Case Presentation. A 55-year-old man presented to our outpatient department with altered consistency in his right testicular prosthesis and a painful right hemiscrotum with no systemic symptoms thirty-three years after the implantation of the prosthesis. We removed this implant without replacement, in accordance with the patient's wishes. Conclusion. The long time between the implantation and the spontaneous rupture is remarkable and was never before described. The removal of the prosthesis was straightforward and it would have been possible to implant a new prosthesis after taking into account the condition of the skin.

Image-guided percutaneous microwave ablation of small renal tumours: short- and mid-term outcomes.

BACKGROUND: The purpose is to assess the short- and mid-term outcomes of microwave ablation (MWA) of small renal tumours in selected patients. METHODS: From August 2012 to February 2015, 29 renal tumours in 23 patients (17 male, 6 female, mean age 75 years) were treated by percutaneous MWA under imaging guidance. The tumours were 1-4.7 cm in diameter (mean size, 2.7 cm). Therapeutic effects were assessed at follow-up with magnetic resonance imaging (MRI). All patients were followed up for 2-25 months (mean, 12.2 months) to observe the therapeutic effects and complications. Changes in renal function at day 1 after treatment were statistically analyzed using the Student paired t-test or the paired Wilcoxon test. RESULTS: Technical success was achieved in all cases. One severe bleeding complication post-procedure occurred leading to death. No other unexpected side effects were observed after the MWA procedures. Clinical effectiveness was 100%. None of the patients showed recurrence on MRI imaging follow-up. No significant changes in renal function were noted after treatment (P=0.57). CONCLUSIONS: Our preliminary study demonstrates that the use of MWA for the treatment of small renal tumours can be applied as safely and efficiently as other ablative techniques in selected patients not eligible for surgery.

Capsular incision in normal prostatic tissue during robot-assisted radical prostatectomy: a new concept or a waste of time?

PURPOSE: Because radical prostatectomy with robot-assisted surgery can lead to unwanted prostatic capsular incisions, capsular incision in normal prostatic tissue (CINPT) is not rare. To study the relationship between positive surgical margins (PSM) and CINPT after robot-assisted radical prostatectomy. METHODS: From September 2009 to January 2013, 203 consecutive robot-assisted prostatectomies were carried out by the same surgeon. A transperitoneal Montsouris technique was used for all cases, but modified to suit the use of the four-arm DaVinci device. The data were recorded prospectively in our database. Preoperative data were patient's age, body mass index, prostate-specific antigen level, prostate weight, percentage of positive biopsy, clinical stage, and Gleason score. Postoperative data were preservation of the bladder neck and neurovascular bundles (NVB), the presence of extended pelvic lymph-node dissection (ePLND), pathological stage, Gleason score, margin status, blood loss, and operative room times. The CINPT and no-CINPT groups were analysed and compared retrospectively. RESULTS: The CINPT rates were 23.2 versus 18.2 % for PSM. CINPT contrary to PSM seemed to be more frequent in low-risk prostate cancer. NVB preservation led to more CINPT (p = 0.01). At the multivariate analysis, only the absence of ePLND significantly affected the CINPT status (p = 0.03) and the absence of CINPT positively affected the PSM rate (p = 0.03). CONCLUSIONS: Capsular incision in normal prostatic tissue is not a predictive factor of PSM but reflected risk-taking during surgery especially when NVB preservation is indicated in low-risk prostate cancer. It can therefore only be considered a means to evaluate a surgical technique, but not a real predictor of PSM.

National prospective study on the use of local haemostatic agents during partial nephrectomy.

OBJECTIVE: To assess the use of local haemostatic agents (HAs) in a prospective multicentre large series of partial nephrectomies (PNs). PATIENTS AND METHODS: Prospective National Observational Registry on the Practices of Haemostasis in Partial Nephrectomy (NEPHRON): the study was conducted in 54 French urological centres from 1 June to 31 December 2010. In all, 570 consecutive patients undergoing a PN were enrolled in this study in a prospective manner. The data was collected prospectively via an electronic case-report form: five different sheets were included for preoperative, perioperative, postoperative and follow-up data respectively. Information related to haemostasis was analysed. RESULTS: The median patient age was 60 years and the mean (range) tumour size was 3.68 (0.19-15) cm. An HA was primarily used in 71.4% of patients, with a statistically significant difference among surgical approaches (P = 0.024). In 91.8% of cases, a single use of a HA was sufficient for achieving haemostasis. The HA was used either alone (13.9%) or in association with sutures (80.3%). One or more additional haemostatic action(s) was needed in 12.3% of the cases. When comparing patients who received a HA with those who did not receive a HA, there was no statistical difference between the groups for tumour size (P = 0.542), collecting system drainage (P = 0.538), hospital stay (P = 0.508), operation time (P = 0.169), blood loss (P = 0.387) or transfusion rate (P = 0.713). CONCLUSION: HAs are widely used by urologists during PN. Progress is needed for standardising HA application, especially for the timing of application. For the time being, the role of the HA in nephron-sparing surgery is still to be evaluated.

Robot-assisted or pure laparoscopic nerve-sparing radical prostatectomy: what is the optimal procedure for the surgical margins? A single center experience.

OBJECTIVES: To compare positive surgical margin rates after robot-assisted and pure laparoscopic radical prostatectomy when neurovascular bundles are preserved, and to identify parameters affecting surgical margin status. METHODS: From March 2004 to January 2009, 279 consecutive prostatectomies with preservation of neurovascular bundles were carried out by the same surgeon: 175 robot-assisted radical prostatectomies and 104 laparoscopic radical prostatectomies. An intraperitoneal Montsouris's technique was used for all cases. Patient's age, body mass index, prostate weight, prostate-specific antigen level, clinical stage, preoperative and postoperative Gleason score, percentage of positive biopsies, pathological stage, and positive surgical margin status were prospectively recorded in an institutional database. The two groups were retrospectively analyzed and compared. RESULTS: Positive surgical margin rates were 17% and 13% for the robot-assisted radical prostatectomy and laparoscopic radical prostatectomy group (P = 0.4), respectively. At multivariable analysis, only prostate-specific antigen level and prostate weight significantly affected the surgical margin status, where the type of procedure (robotic vs laparoscopic) did not have any effect. CONCLUSION: In our single-surgeon experience, prostate-specific antigen levels and prostate weight are predictive of positive surgical margin in patients undergoing nerve-sparing radical prostatectomy, whereas there seems to be no difference between the robot-assisted radical prostatectomy and the laparoscopic radical prostatectomy techniques.

Outcome and cost analysis of sacral nerve modulation for treating urinary and/or fecal incontinence.

BACKGROUND: Sacral nerve modulation (SNM) is an established treatment for urinary and fecal incontinence in patients for whom conservative management has failed. OBJECTIVE: This study assessed the outcome and cost analysis of SNM compared to alternative medical and surgical treatments. METHODS: Clinical outcome and cost-effectiveness analyses were performed in parallel with a prospective, multicenter cohort study that included 369 consecutive patients with urge urinary and/or fecal incontinence. The duration of follow-up was 24 months, and costs were estimated from the national health perspective. Cost-effectiveness outcomes were expressed as incremental costs per 50% of improved severity scores (incremental cost-effectiveness ratio). RESULTS: The SNM significantly improved the continence status (P < 0.005) and quality of life (P < 0.05) of patients with urge urinary and/or fecal incontinence compared to alternative treatments. The average cost of SNM for urge urinary incontinence was ∈8525 (95% confidence interval, ∈6686-∈10,364; P = 0.001) more for the first 2 years compared to alternative treatments. The corresponding increase in cost for subjects with fecal incontinence was ∈6581 (95% confidence interval, ∈2077-∈11,084; P = 0.006). When an improvement of more than 50% in the continence severity score was used as the unit of effectiveness, the incremental cost-effectiveness ratio for SNM was ∈94,204 and ∈185,160 at 24 months of follow-up for urinary and fecal incontinence, respectively. CONCLUSIONS: The SNM is a cost-effective treatment for urge urinary and/or fecal incontinence.

Visceral fat area as a new independent predictive factor of survival in patients with metastatic renal cell carcinoma treated with antiangiogenic agents.

Purpose. A better identification of patients who are more likely to benefit from vascular endothelial growth factor-targeted therapy is warranted in metastatic renal cell carcinoma (mRCC). As adipose tissue releases angiogenic factors, we determined whether parameters such as visceral fat area (VFA) were associated with outcome in these patients. Experimental Design. In 113 patients with mRCC who received antiangiogenic agents (bevacizumab, sunitinib, or sorafenib) (n = 64) or cytokines (n = 49) as first-line treatment, we used computed tomography to measure VFA and subcutaneous fat area (SFA). We evaluated associations linking body mass index (BMI), SFA, and VFA to time to progression (TTP) and overall survival (OS). Results. High SFA and VFA values were significantly associated with shorter TTP and OS. By multivariate analysis, high VFA was independently associated with shorter TTP and OS. These results were internally validated using bootstrap analysis. By contrast, VFA was not associated with survival in the cytokine group. In the whole population, interaction between VFA and treatment group was significant for TTP and OS, thereby confirming the results. Conclusion. Our study provides the first evidence that high VFA could be a predictive biomarker from shorter survival in patients given first-line antiangiogenic agents for mRCC.

Metronomic oral cyclophosphamide prednisolone chemotherapy is an effective treatment for metastatic hormone-refractory prostate cancer after docetaxel failure.

BACKGROUND: There is currently no standard of treatment for patients with hormone refractory prostate cancer (HRPC) after failure of docetaxel-based chemotherapy. The purpose of this study was to assess the anticancer activity and tolerance of metronomic cyclophosphamide prednisolone combination in this setting. PATIENTS AND METHODS: From 2005 to 2010, patients with HRPC who failed at least docetaxel-based chemotherapy were proposed metronomic cyclophosphamide-prednisolone regimen, and were prospectively registered. Twenty-three patients received 50 mg cyclophosphamide and 10 mg prednisolone per os daily until disease progression. Treatment tolerance and efficacy on PSA decrease and pain were studied. RESULTS: Metronomic cyclophosphamide prednisolone was safe, well tolerated, and demonstrated interesting clinical activity, yielding a prostate specific antigen decrease by ≥50% in 26% of patients and decrease by ≥30% in 48% of patients, but also favorable palliative effects on pain in 43% of patients. The median progression-free survival was 6 months (95% CI: 4-8 months) and the median overall survival was 11 months (95% CI: 7-19 months). CONCLUSION: For this patient population, low dose metronomic cyclophosphamide prednisolone might be a viable alternative. Its convenient oral administration, low cost, and lack of toxicity justify further studies alone, or in combination with other agents in HRPC patients.

Outcome of transcatheter arterial embolization for bladder and prostate hemorrhage.

PURPOSE: We evaluated the efficacy and outcomes of transcatheter arterial embolization for intractable bladder or prostate bleeding after failed conservative treatment. MATERIALS AND METHODS: We retrospectively studied the records of 2 women and 18 men with a mean +/- SD age of 73 +/- 17.2 years referred between 1999 and 2008 for selective pelvic angiography after failed conventional therapy. Embolization was feasible in 18 patients, including bilateral and unilateral embolization in 13 and 5, respectively. It consisted of superselective distal particulate or glue embolization of the vesical or prostatic arteries in 11 patients, selective proximal coil or gelatin sponge particle occlusion of the anterior division of the internal iliac artery in 2, the 2 techniques in 3 and coil blockade in 2. Clinical bleeding control and post-embolization angiography findings were used to assess outcomes. RESULTS: The technical success rate was 90% (18 of 20 cases). Bleeding was controlled after the first procedure in 15 of 18 patients (83.3%) and after a repeat procedure in the remaining 3. The periprocedural mortality rate was 20% (4 of 20 patients) and all deaths were related to underlying conditions. No major complications related to catheterization occurred. Late bleeding recurrence was reported in 4 of the 14 survivors (28.6%). Mean post-embolization followup was 16 months (range 15 days to 56 months). During followup 6 more patients died, including 2 of repeat bleeding. CONCLUSIONS: Selective angiographic embolization is safe and effective to control refractory, life threatening bladder or prostate bleeding. This procedure should be considered the treatment of choice since it usually obviates the need for emergency surgery in these severely ill patients.

Complete robotic-assistance during laparoscopic living donor nephrectomies: an evaluation of 38 procedures at a single site.

OBJECTIVE: To evaluate our initial experience with entirely robot-assisted laparoscopic live donor (RALD) nephrectomies. METHODS: From January 2002 to April 2006, we carried out 38 RALD nephrectomies at our institution, using four ports (three for the robotic arms and one for the assistant). The collateral veins were ligated, and the renal arteries and veins clipped, after completion of ureteral and renal dissection. The kidney was removed via a suprapubic Pfannenstiel incision. A complementary running suture was carried out on the arterial stump to secure the hemostasis. RESULTS: Mean donor age was 43 years. All nephrectomies were carried out entirely laparoscopically, without complications and with minimal blood loss. Mean surgery time was 181 min. Average warm ischemia and cold ischemia times were 5.84 min and 180 min, respectively. Average donor hospital stay was 5.5 days. None of the transplant recipients had delayed graft function. CONCLUSIONS: Robot-assisted laparoscopic live donor nephrectomy can be safely carried out. Robotics enhances the laparoscopist's skills, enables the surgeon to dissect meticulously and to prevent problematic bleeding more easily. Donor morbidity and hospitalization are reduced by the laparoscopic approach and the use of robotics allows the surgeon to work under better ergonomic conditions.

Robot-assisted laparoscopic and open live-donor nephrectomy: a comparison of donor morbidity and early renal allograft outcomes.

BACKGROUND: Robot-assisted laparoscopic donor (RALD) nephrectomy, a new procedure for the removal of a kidney from a living donor, was performed on 13 subjects at our centre. METHODS: The immediate post-operative courses for these donors, and their respective recipients, were compared with those of 13 previous open live-donor nephrectomies (OPEN), performed in our facility. RESULTS: We found no significant differences between these two donor groups with respect to age, gender, body mass index or renal vasculature. The average operative times and the warm ischaemia times were greater in the RALD group, 185.5'' vs 113.4'' (P = 0.0001) and 7'15'' vs 1'41'' (P = 0.0001), respectively. There was no conversion to the open procedure in the RALD group. The estimated blood loss was slight in both groups. Following nephrectomy, deep venous thrombosis occurred in one RALD patient and acute pyelonephritis in one OPEN patient. The average duration of hospitalization was shorter after the RALD procedure (5.84+/-1.8 days vs 9.69+/-2.2 days, P = 0.0001). The estimated creatinine clearance rate (eClcreat) was equivalent for all donors, at 5 days and 1 month after nephrectomy. All kidneys started functioning immediately after the transplantation. The mean recipient eClcreat (ml/min) was 58.16+/-26.7 for OPEN group kidneys and 62.23+/-17.59 for RALD group kidneys (P = 0.65), 5 days after transplantation. CONCLUSIONS: RALD nephrectomies were associated with very low morbidity among donors, in which both the operative and warm ischaemia times were of longer duration, but had no observable adverse effects upon short-term graft function.

[Cystomanometric study of bladder sensation during sacral neuromodulation test]. / Etude cystomanométrique de la sensation vésicale pendant le test de neuromodulation sacrée.

PURPOSE: Prospective clinical and urodynamic study evaluating modification of bladder sensation during sacral neuromodulation (SNM). MATERIALS AND METHODS: 24 consecutive patients with non-neurological hyperactive bladder underwent an SNM test. Questioned about their symptoms before and during the test by the urinary handicap assessment scale, patients were divided into two groups: A (improved) and B (not improved). Group A consisted of patients obtaining 50% improvement of their symptoms with SNM followed by return of symptoms at the end of the test, while the other patients constituted group B. We then compared the cystomanometric results according to their clinical response. RESULTS: The mean age was 53 years: 10 patients with a good response constituted group A (n=10, i.e. 42%) and 14 patients with a poor response constituted group B (n=14, i.e. 58%). Clinically, in patients with a good response, SNM decreased urge incontinence by 100%, day-time frequency by 89% and protections by 55%. Urodynamic assessment in group A during the test demonstrated a significant increase of +23% of bladder capacity (p<0.01), +57% of the volume of onset of the first unstable contraction (p<0.004), +83% of bladder volume to the first urge to urinate BI (p<0.001) and +46% to urgency B3 (p<0.04). During SNM, cystometry revealed that 1 or 2 bladder filling volumes were increased at B1 and/or B3 in 100% of improved subjects. In contrast, 1 or 2 volumes decreased at B1 and/or B3 in 58% of non-improved subjects. No significant difference of intensity of unstable contractions was observed between the 2 groups during SNM (p=0.31). CONCLUSION: A significant correlation was observed between the two methods of clinical and urodynamic assessment. Our results suggest the use of the cystomanometric increase of bladder volume at B1 and B3 as selection criterion for candidates for SNM with non-neurological hyperactive bladder.