[Do postoperative drainage types modify outcomes after retrograde intrarenal surgery?]. / Le type de drainage postopératoire modifie-t-il les résultats de l'urétérorénoscopie souple pour la fragmentation laser des calculs rénaux?

INTRODUCTION: The aim of the current study was to evaluate if the postoperative drainage type modified the outcomes after retrograde flexible ureteroscopy (f-URS) and intracorporeal lithotripsy f-URS for intrarenal stones. MATERIAL AND METHODS: We retrospectively analyzed 162 procedures of f-URS for intrarenal stones between January 2010 and January 2013 at a single institute. Independent-sample t-tests and chi-square tests were used for comparisons of means and proportions between patients with ureteral stent or double pigtail stents. RESULTS: There were 86 males (52.8%) and 77 females (47.3%) with a mean age of 52.8 ± 17 years. Double pigtail stents and ureteral stents were used in 117 (72.2%) and 45 (27.8%) cases, respectively. Cases with postoperative double pigtail stents had a longer operative time (96.2 ± 35 min vs 81.2 ± 5 min; P = 0.018) and were less often operated by an experienced surgeon (P = 0.001). Length of hospital staying (P = 0.804), postoperative complication (P = 0.148) and stone free status (P = 0.116) were not different between postoperative drainage by double pigtail and ureteral stents. CONCLUSION: Postoperative drainage by double pigtail stent was used more often by surgeons in the beginning of their RIRS experience and was associated with longer operation time. Nevertheless, the postoperative drainage type did not modify the outcomes regarding the postoperative complication rate, the length of hospital staying and the stones free rate.

[Evaluation of the management of metastatic renal cell carcinoma in the era of targeted therapies. retrospective clinical study over six years]. / Évaluation de la prise en charge du cancer du rein métastatique à l'ère des thérapies ciblées. Étude clinique rétrospective sur six ans.

OBJECTIVE: To evaluate the outcomes following targeted therapies in the management of metastatic renal cell carcinoma (mRCC), through the study of overall survival (OS) and progression-free (PFS). PATIENTS AND METHODS: We retrospectively included 78 patients treated with targeted therapies for mRCC at the Paul Papin Cancer Institute from 2004 to 2009. Overall survival (OS), progression free survival (PFS), response to treatment, occurrence of grade III and IV side effects, were analyzed following first and second line treatments. RESULTS: Median follow-up was 33 months [5-236], and 41 patients died (52.6%). Median OS was 36 months [95% CI 29-43]. The median PFS was 14 months [95% CI 6.71-21.29] for sunitinib, 38 months [95% CI 11.41-64.59] for bevacizumab with interferon (IFN), and 8 months [95% CI 0-17.03] for IFN alone. A partial reduction, stabilization or increase in tumor size was observed for 19.2%, 47.4% and 25.6% of cases. A second line treatment was given for 53 patients. They received either sunitinib (n=20, 37.8%), bevacizumab with IFN (n=7, 13.2%), sorafenib (n=17, 32.2%), temsirolimus (n=3, 5.6%) or other molecules (n=6 11.2%). Grade III or IV side effects were observed for 14.1%, 28.3% and 18.2% of the patients following first, second and third line treatment, respectively. CONCLUSION: Outcomes of targeted therapies in our center upheld the literature data. These therapies allow a benefit survival versus immunotherapy, with sometimes large side-effect.

[Evidence-based medicine and French medical students: an appraisal]. / Evidence-based medicine et étudiants en médecine français : état des lieux.

INTRODUCTION: Nowadays, evidence-based medicine (EBM) is essential to learn and to practice medicine. The aim of the current study was to investigate the baseline level of knowledge of French students regarding EBM. MATERIALS AND METHODS: Between April and May2008, a questionnaire was sent by e-mail to 900students in their last year of medical study. RESULTS: On 327 answers, 297 (91%), 94 (29%) and 85 (26%) students declared they read, write and speak medical English. Ninety (28%) read an article of a French medical review once a month and 43 (13%) read an article of an international medical review once a month. Three hundred and eleven (95%) knew the bases of medical research on the Internet and 219 (67%) used them. Twenty-four (7%) had already participated in a editorial staff of a medical article, 7 (2%) had been co-authors. Two hundred and seventy-two (83%) had made an oral presentation during a medical staff and 3 (1%) during a congress. Finally, 237 (73%) understood the interest of the critical analysis of an article at the ECN and 70 (21%) thought they were prepared. CONCLUSION: The incapacity of learning EBM is one of the limits of the French medical training system. The introduction of the reading critical of an article at the ECN is the concrete beginning of an answer to this problem.

[Tuna: clinical retrospective study addressing mid-term outcomes]. / Tuna: étude rétrospective à propos de 28 patients, résultats et évaluation du retraitement à 20 mois.

PURPOSE: To estimate the efficiency and morbidity of the radiofrequency (Tuna) for treatment of symptomatic benign prostatic hyperplasia (BPH) in patients with medical treatment failure. MATERIAL AND METHODS: Between September 2003 and July 2007, 31 patients, mean age 59,5 years (50-76), were treated for BPH with Tuna. Patients had initially received medical treatment, which happened to fail and Tuna was offered as surgical treatment. Available clinical data of 28 patients was retrospectively analyzed. Mictionnel status was estimated with International Prostatic Symptoms Score (IPSS), urinary peak flow (UPF) and post void residual urine (PVR). Quality of life issues were also addressed. Efficiency of treatment was estimated on the evolution of these parameters after an average follow-up of 20 months (5-47). To estimate morbidity of treatment, peroperative and late complications were assessed. RESULTS: Twenty-eight patients were included in the study. At a mean follow-up of 20 months, a significant improvement of the mictionnel status was found for the IPSS, the quality of life, the Qmax (p<0,001) and the PVR (p<0,005) and quality of life. Morbidity was verified as minimal in the series. At a follow-up period of 20 months, 15 patients (53,6%) had stopped medical treatment, 10 patients (35,7%) pursued medical treatment and three patients (10,7%) had undergone another type of surgical treatment for BPH. The rate of re-treatment in the series was 46,4%. Among the group of patients without any medical treatment (15 patients), 10 patients reported satisfactory quality of life. CONCLUSION: Tuna is a technique with significant good results for the treatment of LUTS-BPH. The main advantage of this technique is its low morbidity, however, the rate of retreatment was observed as high. Series of patients with long-term follow-up should provide evidence to objectively define the role of Tuna in BPH surgical treatment.

[Evaluation of the practical skills of final year medical students: example of bladder catheterization]. / Evaluation des compétences pratiques en fin de deuxième cycle des études médicales: exemple du drainage du bas appareil urinaire.

INTRODUCTION: When performed incorrectly, bladder catheterization can cause iatrogenic complications, especially urinary tract infections and trauma. The objective of this study was to determine the capacity of final year medical students to perform the various bladder catheterization techniques. MATERIAL AND METHODS: Between January and March 2007, a catheterization self-administered questionnaire was sent by e-mail to a representative sample of final year medical students, two months before the national classifying examination. RESULTS: Two hundred and seventy-seven questionnaires were returned and analysed. Seventy-two students (26%) considered that they were able to perform bladder catheterization in males and 106 (38.3%) in females at the end of their medical training. Seventy-one out of 277 (25.5%) students had completed an urology term during their training and 53.5% of them considered that they had acquired the indwelling catheter technique in males (p<0.001) versus 39 (54.9%) in females (p<0.001). Seventy-three students (26.4%) considered that they were able to perform intermittent catheterization in males or females and only one student was able to perform suprapubic catheterization. CONCLUSION: Teaching of catheterization procedures is inappropriate during medical training and young doctors consider themselves unable to perform these techniques at the end of their training. This is unfortunate, as all doctors should be able to perform catheterization as part of their daily practice, especially in hospital. This study indicates the need for improved teaching of essential medical procedures during undergraduate medical training.

Effect of nonsteroidal anti-inflammatory agents and finasteride on prostate cancer risk.

PURPOSE: We examine the relationship of nonsteroidal anti-inflammatory drugs and finasteride on the risk of prostate cancer. MATERIALS AND METHODS: Participants in this case control study using a prospective collection of data were drawn from consecutive patients who underwent prostate biopsy at 12 different departments of urology from January 1999 to June 2000. Medication use was assessed by self-questionnaire as well as questions about dietary and lifestyle factors that might be relevant for prostate cancer risk. RESULTS: The study included 639 patients with prostate cancer and 659 cancer-free controls. Univariate analysis showed no significant impact of aspirin and finasteride on prostate cancer risk while the nonaspirin nonsteroidal anti-inflammatory drug users had a lower risk (OR 0.80, 95% CI 0.64-0.99). After adjusting for potential confounders, the protective effect of nonaspirin nonsteroidal anti-inflammatory drugs was no longer significant (OR, 0.84, 95% CI 0.66-1.07), while finasteride showed a significant protective effect (OR 0.58, 95% CI 0.37-0.92). CONCLUSIONS: The results suggest that finasteride could have a chemopreventive role in prostate cancer. While aspirin did not show any impact on prostate cancer risk, the role of nonaspirin nonsteroidal anti-inflammatory drugs warrants further studies.

Differential diagnosis of prostate cancer and benign prostate hyperplasia using two-dimensional electrophoresis.

Prostate specific antigen (PSA) is a protease which is characteristic of the prostate. It is widely used as a serum marker for the early diagnosis of prostate cancer (PCa). Nevertheless, for concentrations between 4 and 10 ng/mL, PSA does not enable PCa to be distinguished from benign diseases, such as benign prostate hyperplasia (BPH). In sera, the use of a ratio between free PSA (PSA uncomplexed with protease inhibitor) and total PSA (free PSA and PSA bound to alpha-1 anti-chymotrypsin) enables the "gray zone" to be reduced, but an important proportion of patients are still wrongly classed. Using two-dimensional electrophoresis, we demonstrated using 52 PCa and 40 BPH well-documented clinical cases that BPH sera show a significantly greater percentage of low-molecular-weight free PSA elements (IwPSA) than PCa sera. In our study, the use of a ratio between IwPSA and standard free PSA enables the correct diagnosis of 100% of PCa and 82.5% of BPH cases as against when 73.1% and 42.5% respectively were correctly diagnozed using the total PSA and the free/total PSA ratio. This important finding may be related to differences in the mechanism secreting PSA from the prostate into the bloodstream. We have shown how a tissue marker may be turned into a powerful tumor marker by events probably unrelated to its expression.

[Palliative treatment of rectal carcinoma using a urologic resectoscope]. / Traitement palliatif du cancer du rectum à l'aide d'un résecteur urologique à prostate.

OBJECTIVE: The aim of this study was to report our experience with endoscopic transanal resection (ETAR) using a urologic resectoscope for palliative treatment of rectal carcinoma. METHODS: Outcome in patients who underwent ETAR with a urologic resectoscope between October 1992 and March 1999 are reported. RESULTS: The 60 ETAR procedures were performed in 37 patients (19 men and 18 women, median age 82 years). Morbidity was 10% (6 patients) and mortality was 2.7% (1 patient). Median hospital stay for the procedure was 5 days. Symptom control was achieved in 86% of the patients (40% partial control, 46% complete control). Colostomy was performed in 8 patients 7 months after ETAR. At study end, 4 patients were alive. Median survival was 14 months (range 0 - 62). The 1-, 2-, and 5-year survival rates were 54, 32 and 5%, respectively. CONCLUSION: ETAR is a simple, minimally invasive and economical method for palliative treatment of patients with rectal carcinoma. ETAR is a useful addition to the surgeon's armamentarium.

Comparison of the Bard Trak test with voided urine cytology in the diagnosis and follow-up of bladder tumors.

OBJECTIVES: To compare the results of the BTA Trak test with voided urine cytology (VUC) in the diagnosis and follow-up of bladder tumors. PATIENTS AND METHODS: Urine samples were obtained from 53 patients with bladder tumor (77 samples) and 53 patients treated for bladder tumor with no evidence of disease on the basis of cystoscopic evaluation (88 samples). Urine samples were collected prior to cystoscopy. The BTA assay was performed by the BTA Trak test according to the manufacturer's recommendations. A value >14 U/ml was considered abnormal. RESULTS: There was a statistically significant increase in median BTA value with increasing stage of tumor: 11.9, 57.9 and 391.0 U/ml respectively for stages pTa, pT1 and pT2/3 (p<0.0001, Kruskal-Wallis test). There was also a correlation between increasing grade and median BTA values measured at 6.9, 13.1 and 235.0 U/ml in grades 1, 2 and 3 tumors respectively (p<0.0001, Kruskall-Wallis test). The overall sensitivity of the BTA Trak test was 58.4% compared to 46.7% for VUC, a difference of 11.7%, which was statistically significant (McNemar test, p<0.005). The sensitivity of both tests combined was 63.6%. The specificity of the VUC (94.3%) was significantly higher than that of the BTA Traktrade mark (75.0%) (p<0.005, McNemar test). The accuracy of the Bard Trak test (67.3%) was similar to that of VUC (66.9%). CONCLUSION: The BTA Trak test is more sensitive than urinary cytology in the detection of bladder tumors but the improvement involved is insufficient to consider decreasing the frequency of endoscopic examinations in the follow-up of superficial bladder tumor.

[Is it possible to define a threshold for free PSA index that is useful in the daily practice of urology?]. / Est-il possible de définir un seuil de l'index de PSA libre utile en pratique urologique quotidienne?

OBJECTIVES: Retrospective evaluation of the use of the free PSA index before prostatic biopsies. MATERIAL AND METHODS: The authors retrospectively studied the values for total PSA, free PSA, and free PSA index (ratio of free PSA over total PSA expressed as a %) in men with a total PSA between 2 and 10 ng/ml, from a population of 391 men prior to prostatic biopsies. They also isolated a subgroup of patients in whom the free PSA index could have been used as a first-line marker to decide whether or not to perform prostatic biopsies. RESULTS: The mean values for total PSA, free PSA, and free PSA index were compared as a function of the diagnosis, age, and ultrasound prostatic volume. The yields of the various cut-off values for the free PSA index for PSA between 2 and 4 ng/ml, 4 and 10 ng/ml, and 2 and 10 ng/ml with a normal digital rectal examination are reported. Between 2 to 10 ng/ml, at a cut-off value of 30%, 94.1% of cancers would have been detected (sensitivity) and 22% of biopsies would have been avoided, 10 of which would have been useless, i.e. a 30.3% economy of useless biopsies not performed (specificity). At the cut-off value of 15%, less than half of cancers would have been detected (47.1%) and 90.9% of useless biopsies would have been avoided. Biases creating difficulties of interpretation were the assay kits, the reference population, age, storage of sera, and prostatic volume. CONCLUSION: The free PSA index would be a useful first-line parameter in only 12.7% of candidates for prostatic biopsies. The cut-off value of 30%, validated for our assay method, would be able to detect the majority of cancers in men aged 50 to 65 years, while avoiding biopsies in the third of men with no detectable cancer.

[Free PSA: its routine use is premature in the screening of prostatic cancer]. / PSA libre: l'utilisation en routine est prématurée pour le dépistage du cancer de prostate.

The free form of PSA represents an average of 30% of total PSA. The free PSA level, in relation to total PSA, is expressed as a percentage (of free PSA). The percentage of free PSA appears to be relatively independent of benign prostatic hypertrophy, but it is markedly and significantly decreased in the case of prostate cancer and acute prostatitis. A cut-off value for the percentage of free PSA combined with a cut-off value for total PSA can decrease the number of biopsies indicated for the detection of prostate cancer. This approach avoids 20 to 30% of useless biopsies (specificity), but is accompanied by a 5 to 10% reduction of the number of cancers detected (sensitivity of 90 to 95%) compared to the use of total PSA alone. This 5 to 10% risk of missing a cancer of significant volume in a man under the age of 65 years explains why the use of free PSA to guide prostatic biopsies is not routinely recommended. Despite the promising performance of the percentage of free PSA to improve the indication for prostatic biopsies, the methodology of the studies performed to evaluate this test is not sufficient to validate their conclusions. The percentage of free PSA can be prescribed as a second-line test by the urologist, following a first series of negative biopsies in a man with a high clinical and laboratory suspicion of prostatic cancer, in order to propose a second series of biopsies after three months or to define the frequency of clinical and laboratory surveillance. While waiting for the results of prospective studies in the screening setting, recommendations concerning the use of PSA by general practitioners, who are the first to order this test in the context of screening, can be formulated as follows: The value of free PSA assay for first-line cancer screening has not been validated. A consensus has not been reached concerning the use of free PSA as an indication for biopsies and the frequency of assays. Total PSA assay (cut-off value: 4 ng/ml) remains the reference laboratory test for screening and indication of biopsies. A lower normal cut-off value (between 2 and 4 ng/ml) is currently under evaluation.

Values for the free to total prostate-specific antigen ratio as a function of age: necessity of reference range validation.

OBJECTIVE: To measure the levels of free prostate-specific antigen (PSA), total PSA, and free to total PSA ratio in a population of men with no known prostate pathology aged from 20 to 70 years. PATIENTS AND METHODS: Serum total PSA and free PSA values were determined in 1,502 patients due for a systematic health examination. The digital rectal examination was only proposed for those over 50 years of age. The assays were determined on the AsXYM apparatus, from Abbott laboratories, by MEIA technology with monoclonal antibodies. RESULTS: 1,274 men were available for study. The mean age was 43.6 +/- 11 years (range 20-69 years). The total PSA level was stable up to 40 years. Beyond that, it increased with age. There was a linear regression between the age and the logarithm of the total PSA rate (r = 0.26, p < 0.0001) from 40 to 70 years. The upper limit of the normal value (95th percentile) increased from 1.07 for the 20- to 30-year age range to 2.82 for the 60- to 70-year range. The free PSA level was stable up to 50 years of age. It then significantly increased. The upper limit of the normal value was measured as 0.42 in the range of 20-30 years and as 0.53 in the range of 60-70 years with an annual average increase rate of roughly 0.5%. Overall there was a linear regression between age and the free PSA rate (r = 0.12, p < 0.0001). The upper limit of the free to total PSA ratio, measured as being 0.68 in the range of 20-29 years, dropped towards 60-69 years with an upper limit of the normal of 0.48. The average annual reduction rate was around 0.70%. There was a linear regression between the age and the free to total PSA ratio (r = 0.17, p < 0.0001). CONCLUSION: These total PSA levels are lower than the ones measured in other studies with other assay methods. These variations stress the importance of validating reference values of total PSA and free PSA as a function of the assay method and the population to which they are applied before using them as an aid in the diagnosis of prostate cancer.

Results of duodenopancreatectomy for solitary pancreatic metastasis from renal cell carcinoma.

The pancreas is an uncommon site of metastasis from renal cell carcinoma. We present five patients with solitary pancreatic metastasis from renal cell carcinoma located in the head of the pancreas, treated by duodenopancreatectomy. There were no perioperative deaths. Mean survival was 48 months; three patients were alive at the end of the study (at 27, 46, and 88 months, respectively) and two patients died, at 13 and 70 months. The 3- and 5-year survival rates of our patients together with 22 previously reported patients were 86% and 68%, respectively. We advocate aggressive surgical treatment when the metastatic disease is limited to the pancreas.

[Flow cytometry in cancer of the bladder]. / Cytométrie en flux dans les cancers de la vessie.

We reassessed the use of DNA flow cytometry in bladder cancers on the basis of our research and already published findings. We discuss technical aspects underlying the validity of the results. Currently, the validity of DNA flow cytometry is established by parametric analysis of the DNA content of tumor cells found in the course of multiple biopsies of the tumor. In addition, we examine the results obtained with bladder washings and, in some cases, the results of biopsies of the bladder mucosa which may appear normal under cystoscopy. The complementarity of these examinations appears to be essential. Our experience confirms the results already published, suggesting that the frequency of DNA aneuploidy increases significantly according to the grade and the tumor stage. However, clinical interpretation of DNA flow cytometry results calls for some caution. There is a general consensus not to use these results in the screening of bladder cancers. However, DNA flow cytometry is particularly useful in the follow-up of carcinoma in situ since DNA aneuploidy is almost always present. DNA flow cytometry is also useful in the stratification of superficial grade 2 tumors. Finally, during the follow-up of invasive tumors, the persistence or appearance of DNA aneuploidy may be attributed to therapeutic resistance.

[Prognostic value of Fürhman's grade in renal cell carcinoma. A study of 170 cases]. / Valeur pronostique du grade de Führman dans le carcinome à cellules rénales.

In order to evaluate the prognostic value of the anatomical stage (pTNM 1992) and of the histological factors (Führman's grade, cellular and architectural types), 170 renal cell carcinoma diagnosed between 1971 and 1991 were reviewed. In univariate analysis, the prognosis was correlated with the anatomical stage and Führman's grade: for the 125 patients without metastasis, grades 1 and 2 had a good prognosis, whereas grades 3 and 4 did poorly. The cellular type was not related to survival. Among architectural types, only the pseudo-sarcomatous type was correlated with prognosis. Multivariate analysis revealed that grade and metastasis at diagnosis were two independent predictors of survival; the grade was prognostically superior to metastasis. Führman's grade is essential in determining prognosis; its statistical value is superior to anatomical stage in multivariate analysis.

Expression of oxidative phosphorylation genes in renal tumors and tumoral cell lines.

To investigate the regulation of genes encoding the proteins involved in energy metabolism in cancer cells, we studied the expression of several mitochondrial and nuclear genes involved in ATP production. Northern blot analysis was performed on renal tumors of different types: a clear cell carcinoma, an oncocytoma, and urothelial tumors at two different stages. The steady-state transcript patterns were compared with those observed in cell lines derived from renal tumors and in transformed cell lines. Striking differences were revealed among the three types of tumors, their respective controls, and the cultured renal cells. The levels of all mitochondrial transcripts were lower in tumor biopsies and tumoral cell lines than in the normal cell types. Moreover, a higher transcript level of nuclear genes involved in oxidative phosphorylation was observed in the oncocytomas and in the more malignant urothelial tumor. Different transcript patterns were observed in each of the tumoral and transformed cell lines, explaining the difference in metabolism between the different tumors and the tumoral or transformed cell lines. In particular, a high transcript level for the adenine nucleotide translocator isoform 2(ANT2) gene, which is usually not expressed in differentiated cells, was observed in oncocytoma and malignant urothelial renal tumor. This phenomenon was also observed in renal carcinoma cell lines and transformed cells. These data provide the first argument for the involvement of the ANT2 protein in glycolytic ATP uptake in cancer cell mitochondria and suggest a possible ANT2 antisense strategy for cancer therapy.

[Clinical assessment of free serum prostate specific antigen (PSA)]. / Evaluation clinique de la mesure de l'antigène spécifique de la prostate (PSA) sous sa forme libre sérique.

The prostate specific antigen (PSA) level represents all of the immunoreactive serum PSA, either free or bound to alpha-1-anti-chymotrypsin. Isolated assay of free PSA has demonstrated a higher free PSA/total PSA ratio in cases of benign prostatic hyperplasia (BPH) than in cases of cancer, suggesting the possible use of this ratio in the detection of prostatic cancer when the PSA level is between 4 and 10 ng/mL. We retrospectively assayed free PSA in 64 cases of localized prostate cancer, 90 cases of BPH before transurethral resection and 59 healthy controls. By comparing the mean values of the 3 populations and the ROC curves, we confirmed the superiority of the free PSA/total PSA ratio over total PSA in the detection of prostatic cancer, but these results, established in a retrospectively constituted population, need to be confirmed by prospective epidemiological studies. Nevertheless, in routine urological practice, we propose that free PSA assay be performed in all men with a PSA level between 4 and 10 ng/mL and a normal prostate on digital rectal examination.

[Palliative treatment of rectal cancer by the trans-anal approach using a urologic prostatectomy device]. / Traitement palliatif des cancers du rectum par voie trans-anale à l'aide du résecteur urologique à prostate.

Palliative treatment for patients with rectal carcinoma affect more than 10% of the 8000 cases diagnosed each year in France. Twenty-four patients underwent endoscopic trans-anal resection using a urological resectoscope. The morbidity rate was 18,5% and there were no postoperative deaths. The median hospital stay for the procedure alone was 4 days. Good palliation was obtained in 89% of cases. This simple, minimally invasive and economic method should join palliative treatment for patients with rectal carcinoma beside laser destruction and external beam radiotherapy.