Prognostic significance of PI-RADS 5 lesions in patients treated by radical prostatectomy.

PURPOSE: To analyse the pathological features and survival of patients with a PI-RADS 5 lesion on pre-biopsy MRI. METHODS: We extracted from a European multicentre prospectively gathered database the data of patients with a PI-RADS 5 lesion on pre-biopsy MRI, diagnosed using both systematic and targeted biopsies and subsequently treated by radical prostatectomy. The Kaplan-Meier model was used to assess the biochemical-free survival of the whole cohort and univariable and multivariable Cox models were set up to study factors associated with survival. RESULTS: Between 2013 and 2019, 539 consecutive patients with a PI-RADS 5 lesion on pre-biopsy MRI were treated by radical prostatectomy and included in the analysis. Follow-up data were available for 448 patients. Radical prostatectomy and lymph node dissection specimens showed non-organ confined disease in 297/539 (55%), (including 2 patients with a locally staged pT2 lesion and lymph node involvement (LNI)). With a median follow-up of 25 months (12-39), the median biochemical recurrence-free survival was 54% at 2 years (95% CI 45-61) and 28% at 5 years (95% CI 18-39). Among the factors studied, MRI T stage [T3a vs T2 HR 3.57 (95%CI 1.78-7.16); T3b vs T2 HR 6.17 (95% CI 2.99-12.72)] and PSA density (HR 4.47 95% CI 1.55-12.89) were significantly associated with a higher risk of biochemical recurrence in multivariable analysis. CONCLUSION: Patients with a PI-RADS 5 lesion on pre-biopsy MRI have a high risk of early biochemical recurrence after radical prostatectomy. MRI T stage and PSA density can be used to improve patient selection and counselling.

Radical Nephroureterectomy Tetrafecta: A Proposal Reporting Surgical Strategy Quality at Surgery.

Background: Standardized methods for reporting surgical quality have been described for all the major urological procedures apart from radical nephroureterectomy (RNU). Objective: To propose a tetrafecta criterion for assessing the quality of RNU based on a consensus panel within the Young Association of Urology (YAU) Urothelial Group, and to test the impact of this tetrafecta in a multicenter, large contemporary cohort of patients treated with RNU for upper tract urothelial carcinoma (UTUC). Design setting and participants: This was a retrospective analysis of 1765 patients with UTUC treated between 2000 and 2021. Outcome measurements and statistical analysis: We interviewed the YAU Urothelial Group to propose and score a list of items to be included in the "RNU-fecta." A ranking was generated for the criteria with the highest sum score. These criteria were applied to a large multicenter cohort of patients. Kaplan-Meier curves were built to evaluate differences in overall survival (OS) rates between groups, and a multivariable logistic regression model was used to find the predictors of achieving the RNU tetrafecta. Results and limitations: The criteria with the highest score included three surgical items such as negative soft tissue surgical margins, bladder cuff excision, lymph node dissection according to guideline recommendations, and one oncological item defined by the absence of any recurrence in ≤12 mo. These items formed the RNU tetrafecta. Within a median follow-up of 30 mo, 52.6% of patients achieved the RNU tetrafecta. The 5-yr OS rates were significantly higher for patients achieving tetrafecta than for their counterparts (76% vs 51%). Younger age, lower body mass index, and robotic approach were found to be independent predictors of tetrafecta achievement. Conversely, a higher Eastern Cooperative Oncology Group score, higher clinical stage, and bladder cancer history were inversely associated with tetrafecta. Conclusions: Herein, we present a "tetrafecta" composite endpoint that may serve as a potential tool to assess the overall quality of the RNU procedure. Pending external validation, this tool could allow a comparison between surgical series and may be useful for assessing the learning curve of the procedure as well as for evaluating the impact of new technologies in the field. Patient summary: In this study, a tetrafecta criterion was developed for assessing the surgical quality of radical nephroureterectomy in patients with upper tract urothelial carcinoma. Patients who achieved tetrafecta had higher 5-yr overall survival rates than those who did not.

Magnetic Resonance Imaging-Targeted Biopsy and Pretherapeutic Prostate Cancer Risk Assessment: a Systematic Review: Biopsie ciblée par Imagerie par résonance magnétique et évaluation pré-thérapeutique du risque de cancer de la prostate : revue systématique.

INTRODUCTION: Multiparametric magnetic resonance imaging (MRI) has been included in prostate cancer (PCa) diagnostic pathway and may improve disease characterization. The aim of this systematic review is to assess the added value of MRI-targeted biopsy (TB) in pre-therapeutic risk assessment models over existing tools based on systematic biopsy (SB) for localized PCa. EVIDENCE ACQUISITION: A systematic search was conducted using Pubmed (Medline), Scopus and ScienceDirect databases according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We included studies through October 2021 reporting on TB in pretherapeutic risk assessment models. EVIDENCE SYNTHESIS: We identified 24 eligible studies including 24'237 patients for the systematic review. All included studies were retrospective and conducted in patients undergoing radical prostatectomy. Nine studies reported on the risk of extraprostatic extension, seven on the risk of lymph node invasion, three on the risk of biochemical recurrence and nine on the improvement of PCa risk stratification. Overall, the combination of TB with imaging, clinical and biochemical parameters outperformed current pretherapeutic risk assessment models. External validation studies are lacking for certain endpoints and the absence of standardization among TB protocols, including number of TB cores and fusion systems, may limit the generalizability of the results. CONCLUSION: TB should be incorporated in pretherapeutic risk assessment models to improve clinical decision making. Further high-quality studies are required to determine models' generalizability while there is an urgent need to reach consensus on a standardized TB protocol. Long-term outcomes after treatment are also awaited to confirm the superiority of such models over classical risk classifications only based on SB. © 2022 Elsevier Masson SAS. All rights reserved.

Focal therapy for prostate cancer: Making the punishment fit the crime.

BACKGROUND: Focal therapy is recently gaining popularity as an intermediate option between active surveillance and whole-gland treatment for localized prostate cancer. OBJECTIVE: This comprehensive review aims to present the different focal therapy technologies available to date while tackling the rationale for focal treatment, its indications, principles and outcomes of each technique. EVIDENCE ACQUISITION: A comprehensive review of the PubMed, Embase, and Web of Science was done. Keywords used for research were: "prostate cancer"; "focal therapy"; "focal treatment"; "High-Intensity Focal Ultrasound"; "cryotherapy"; "photodynamic therapy"; "focal laser ablation"; "irreversible electroporation"; "focal brachytherapy" and "gold nanoparticle directed therapy". Accepted languages were English and French. EVIDENCE SYNTHESIS: Choosing the best candidate for focal therapy is crucial (localized small to medium sized Gleason≤7 lesions). Focal high-intensity focal ultrasound has shown excellent survival rates at 5 years, while maintaining good functional outcomes (urinary continence and erectile function). Focal cryotherapy, one of the oldest focal treatments for prostate cancer, has shown good oncologic outcomes, with good continence rates and fair erectile function rates. Focal laser ablation seems a safe and feasible technique, with promising results. Irreversible electroporation has demonstrated good survival outcomes with no biochemical recurrence or disease relapse in the preliminary studies. Focal brachytherapy has a good toxicity profile, a good biochemical outcome, and gives a sustained quality of life. Finally, gold nanoparticle directed therapy is safe and is being studied in current trials. CONCLUSION: While proven to be safe in terms of continence and sexual aspects, the challenge remains to better assess oncological outcomes of these techniques in randomized longer follow-up studies.

COVID-19 and the male susceptibility: the role of ACE2, TMPRSS2 and the androgen receptor.

COVID-19 is the pandemic that hit the world starting December 2019. Recent studies and international statistics have shown an increased prevalence, morbidity as well as mortality of this disease in male patients compared to female patients. The aim of this brief communication is to describe the pathophysiology of this sex-discrepancy, based on the infectivity mechanism of the coronavirus including the Angiotensin-Converting Enzyme 2 (ACE2), the Type II transmembrane Serine Protease (TMPRSS2), and the androgen receptor. This could help understand the susceptibility of urological patients, especially those receiving androgen deprivation therapy for prostate cancer, and testosterone replacement therapy.

Management of chronic testicular pain due to thoracolumbar junction syndrome: A pilot study.

INTRODUCTION: Thoracolumbar dysfunction (TLD) had been evoked as a possible etiology of chronic testicular pain. Our study investigated the efficacy of osteopathic diagnosis and treatment of TLD in men with chronic testicular pain. METHODS: Patients suffering from testicular pain were examined for thoracolumbar dysfunction and enrolled in a prospective trial if they have both conditions. Following standardized examination, all patients were prescribed 1 to 3 osteopathic treatment sessions, usually at weekly interval. Treatment success was evaluated using the Visual Analog scale and durability was assessed by regular follow-up. Patient satisfaction was also assessed. Comparison of pain improvement was done using Wilcoxon matched-pairs signed-ranks test. Logistic regression was used to assess for risk factors of success. A P<0.001 was used for significance. RESULT: Out of 62 patients enrolled, 41 patients (median age 32 years, IQR 24-37) were suffering from chronic testicular pain and TLD. 37 of the 41 participants completed the treatment and follow-up according to the plan. Patients underwent a median of 2 osteopathic treatment sessions (range 1-3). Overall, pain disappeared completely in 25 patients (67.5%) and improvement was noted in 7 patients (18.9%). After initial improvement, two patients experienced relapse at their last visit (5.4%). Five patients (13.5%) had no improvement of their symptoms after osteopathic treatment. Statistically, improvement was significant with a P<0.001 and on logistic regression, site of pain and duration of pain were the sole predictors of failure. CONCLUSION: TLD is a pathology that should be considered in the differential diagnosis in patients with chronic testicular pain and osteopathic manipulation of the spine appears to be an effective treatment option.

Elastic fusion biopsy versus systematic biopsy for prostate cancer detection: Results of a multicentric study on 1,119 patients. / Evaluación de la biopsia de fusión elástica vs. biopsia sistemática para la detección del cáncer de próstata: resultados de un estudio multicéntrico en 1.119 pacientes.

OBJECTIVES: To assess the accuracy of targeted and systematic biopsies for the detection of prostate cancer (PCa) and clinically significant PCa (csPCa) in the everyday practice, evaluating the need for additional systematic biopsies at the time of targeted biopsy. PATIENTS AND METHODS: From our multicentric database gathering data on 2,115 patients who underwent fusion biopsy with Koelis™ system between 2010 and 2017, we selected 1,119 patients who received targeted biopsies (a median of 3 for each target), followed by systematic sampling of the prostate (12 to 14 cores). Overall and clinically significant cancer detection rate (CDR) of Koelis™ fusion biopsies were assessed, comparing target and systematic biopsies. Secondary endpoint was the identification of predictors of PCa detection. RESULTS: The CDR of targeted biopsies only was 48% for all cancers and 33% for csPCa. The performance of additional, systematic prostate sampling improved the CDR of 15% for all cancers and of 12% for csPCa. PCa was detected in 35%, 69%, and 92% of patients with lesions scored as PI-RADS 3, 4 and 5, respectively. Elevated PI-RADS score and positive digital rectal examination were predictors of PCa, whereas biopsy-naïve status was associated with csPCa. CONCLUSION: In the everyday practice target biopsy with Koelis™ achieves a good CDR for all PCa and csPCa, which is significantly improved by subsequent systematic sampling of the prostate. The outstanding outcomes of fusion biopsy are confirmed also in biopsy-naïve patients. Elevated PI-RADS score and positive digital rectal examination are strongly associated with presence of PCa.

The impact of neutrophil-to-lymphocyte, platelet-to-lymphocyte and haemoglobin-to-platelet ratio on localised renal cell carcinoma oncologic outcomes.

INTRODUCTION: The neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR) are established markers of systemic inflammation. Moreover, anemia is a known adverse prognostic factor and reduced haemoglobin to platelet ratio (HPR) seems associate to poor outcomes in urothelial cancer. Aim of the current study was to explore the prognostic value of NLR, HPR and PLR in patients harboring localized RCC. Materials and Methods 184 patients undergoing partial and radical nephrectomy for renal mass in a single hospital were retrospectively analyzed. Uni- and multivariate logistic regressions were performed to assess associations between various risk factors, including NLR, PLR and HPR and locally advanced disease (≤pT2 vs.≥pT3) and tumor grade. Kaplan Meier curves and Cox regressions were constructed to assess the association of NLR, PLR and HPR to recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). To determine thresholds for variables, we considered the 75th percentile of our distribution of values, which was computed at 3.45 for NLR, 189 for PLR and 0.48 for HPR. A two-sided P<0.05 defined statistical significance. RESULTS: Patients with an elevated NLR (>3.45) were more likely to present with≥pT3 stage (p=0.046). RFS was significantly different according to NLR value, with patients having an NLR>3.45 experiencing significantly worst RFS (P=0.019); similarly, an increased PLR was significantly associated to a reduced RFS (P=0.012). Restricting the Cox regression to patients with locally advanced disease (≥pT3), NLR was even more associated to recurrence (HR 3.22; 95%CI: 1.06-9.81, P=0.039). Patients exhibiting an NLR>3.45 (p=0.03) or a PLR>189 (P=0.005) did have a significantly worse CSS, while a HPR<0.48 did not predict CSS (P=0.12) on Kaplan Meier curves. Finally, an increased NLR (P=0.047), increased PLR (P=0.0006) and decreased HPR (P=0.05) were all associated to a poor overall survival on univariate analysis. On multivariate analysis, only HPR remained significantly predictive of OS (HR 0.077; 95%CI: 0.02-0.37, P=0.001). CONCLUSIONS: In this single-center study analyzing non-metastatic RCC, an increased NLR was significantly associated to a reduced RFS, CSS and OS on univariate analyses and to RFS on multivariate analysis. Larger prospective studies are needed to validate our findings. LEVEL OF EVIDENCE: 4.

The impact of postoperative inflammatory biomarkers on oncologic outcomes of bladder cancer.

INTRODUCTION: The clinical impact of inflammatory biomarkers has been evaluated in urothelial bladder cancer. However, data are limited to preoperative values and there is paucity of evidence of the role of postoperative measurement of those biomarkers. The aim of the current study was to determine the association of inflammatory biomarkers as neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), hemoglobin to platelet ratio (HPR) and C-reactive protein (CRP), before and after radical cystectomy, with recurrence and survival of bladder cancer. MATERIAL AND METHODS: We prospectively evaluated 134 patients undergoing radical cystectomy for invasive bladder cancer between January 2013 and January 2018. The inflammatory biomarkers were measured 10days before surgery and at 1, 6 and 12months postoperatively. Kaplan-Meier curves and Cox proportional hazards and logistic regression models were used to evaluate the association between the different inflammatory biomarkers and recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). RESULTS: The median follow-up time was 21.1months (5-37 mo). On multivariate analysis, preoperative NLR>3.88 was associated to locally-advanced disease (>pT3) and NLR>3.88 and HPR<0.039 were significantly associated to node positive disease. Postoperative NLR at 3months>4.68 (HR: 2.37, 95% CI: 1.08-4.47, P=0.03) was associated with a reduced RFS. A postoperative NLR at 3months>4.68 (P=0.04) and a postoperative HPR at 3months<0.029 (P=0.001) were associated with a significant reduction in CSS and OS. CONCLUSION: Postoperative NLR and HPR at 3months appear to be closely associated with RFS, CSS and OS. Further studies are needed on these postoperative markers to establish the potential impact of these inflammatory biomarkers on a tailored therapeutic approach for each patient. LEVEL OF EVIDENCE: 3.

68Ga-PSMA PET/CT-based metastasis-directed radiotherapy for oligometastatic prostate cancer recurrence after radical prostatectomy.

PURPOSE: The aim of this communication was to assess the efficacy of directed oligometastatic radiotherapy (RT) based on 68Ga-PSMA PET/CT in patients with prostate cancer (PCa) biochemical relapse (BCR) after primary treatment with curative intent. METHODS: This is a retrospective analysis of a monocentric cohort of PCa patients diagnosed with oligometastatic disease on 68Ga-PSMA PET/CT and treated with metastasis-directed RT. Inclusion criteria were: histologically proven PCa, BCR after primary treatment with curative intent, oligometastatic disease defined as ≤ 3 metastatic lesions. To evaluate the efficacy of the therapy, biochemical response defined as a decrease of > 50% of PSA (PSA50) was measured at 1 and 4 months. Patients were followed up until progression and start of androgen deprivation therapy (ADT). BCR-free survival and ADT-free survival were calculated. RESULTS: 20 patients met the inclusion criteria. Median PSA value: 1.4 ng/ml (IQR, 0.3-2.3 ng/ml). A total of 30 PSMA-positive lesions were treated: 18 lymph nodes (60%), nine bone (30%) and three visceral lesions (10%). Median follow-up was 15 months (range 4-33 months). Biochemical response at 1 and 4 months was found in 3/20 patients (15%) and 14/20 (70%), respectively. BCR-free survival rate at 1 year was 79% and 53% at 2 years. ADT-free survival at 2 years was 74%. CONCLUSION: This retrospective study suggests that metastasis-directed RT based on 68Ga-PSMA PET/CT may be a valuable treatment in patients with PCa oligometastatic disease, providing promising BCR-free survival rates and potentially postponing ADT for at least 2 years in 74% of the patients. Response assessment should not be measured before 4 months after treatment.

A systematic review of contemporary management of oligometastatic prostate cancer: fighting a challenge or tilting at windmills?

PURPOSE: Amongst the unanswered questions regarding prostate cancer (PCa), the optimal management of oligometastatic disease remains one of the major concerns of the scientific community. The very existence of this category is still subject to controversy. Aim of this systematic review is to summarize current available data on the most appropriate management of oligometastatic PCa. EVIDENCE ACQUISITION: All relevant studies published in English up to November the 1st were identified through systematic searches in PubMed, EMBASE, Cochrane Library, CINAHL, Google Scholar and Ovid database. A search was performed including the combination of following words: (prostate cancer) and (metastatic) and [(oligo) or (PSMA) or (cytoreductive) or (stereotaxic radiotherapy) or (prostatectomy)]. 3335 articles were reviewed. After title screening and abstract reading, 118 papers were considered for full reading, leaving a total of 36 articles for the systematic review. EVIDENCE SYNTHESIS: There is still no consensus on the definition of oligometastatic disease, nor on the imaging modalities used for its detection. While retrospective studies suggest an added benefit with the treatment the primitive tumor by cytoreductive prostatectomy (55% survival rate vs 21%, p < 0.001), prospective studies do not validate the same outcome. Nonetheless, most studies have reported a reduction in local complications after cytoreductive prostatectomy (< 10%) compared to the best systemic treatment (25-30%). Concerning radiotherapy, an overall survival benefit for patients with a low metastatic burden was found in STAMPEDE (HR 0.68, 95% CI 0.52-0.90; p = 0.007) and suggested in subgroup analysis of the HORRAD trial. Regarding the impact of metastases-directed therapy (MDT), the STOMP and ORIOLE trials suggested that metastatic disease control might improve androgen deprivation therapy-free survival (in STOMP: 21 vs 13 months for MDT vs standard of care). Nonetheless, the impact of MDT on long-term oncologic results remains unclear. Finally, oligometastatic disease appears to be a biologically different entity compared to high-burden metastatic disease. New findings on exosomes appear to make them intriguing biomarkers in the early phases of oligometastatic PCa. CONCLUSION: Oligometastatic PCa is today a poorly understood disease. The implementation of new imaging techniques as whole-body MRI and PSMA PET/CT has increased exponentially the number of oligometastatic patients detected. Data of available trials suggest a benefit from cytoreductive prostatectomy to reduce local complication, though its impact on survival remains unknown. Radiotherapy may be beneficial for patients with low-burden metastatic PCa, while MDT may delay the need for androgen deprivation therapy. Results from ongoing trials data are eagerly awaited to draw reliable recommendations.

A multicentric study on accurate grading of prostate cancer with systematic and MRI/US fusion targeted biopsies: comparison with final histopathology after radical prostatectomy.

OBJECTIVE: To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both (SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens. MATERIALS AND METHODS: Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation® and Trinity®) prior to radical prostatectomy between 2010 and 2017. Cochran's Q test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies. RESULTS: Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (p < 0.001). Total number of cores and previous biopsies were significant independent predictive factors for concordance with TB technique. CONCLUSION: In this retrospective study, combination of SB and TB significantly increased concordance with final histopathology despite a limited additional number of cores needed.

Comparing laparoscopic and percutaneous renal biopsy for diagnosing native kidney disease: A matched pair analysis.

BACKGROUND: Percutaneous renal biopsy is a well-established diagnostic procedure in patients with underlying medical renal disease. Aim of this study is to compare the adequacy of the biopsy material, the diagnostic yield, and the complication rates of the trans-peritoneal laparoscopic approach and the image-guided percutaneous approach to renal biopsy in the diagnosis of native kidney disease. METHODS: We performed a matched-pair analysis matching 1:3 40 patients who underwent trans-peritoneal laparoscopic renal biopsy to 120 patients who underwent percutaneous renal biopsy in the same years. Patients were retrospectively analyzed. Differences in adequacy of biopsy material (i.e. number of glomeruli, continuous), diagnostic yield (categorical) and postoperative complications across the two groups were assessed using Wilcoxon Rank sum or χ2 test. RESULTS: Laparoscopic biopsy was associated with a higher number of harbored glomeruli (median 50, IQR 20-77) compared to the percutaneous approach (median 10, IQR 7-15), P<0.001. Adequate biopsies containing at least ten glomeruli were obtained in a significantly higher percentage of patients in the laparoscopic group versus the percutaneous group (92.5% vs. 57.1%, P<0.001). The laparoscopic approach was also associated with a significantly higher diagnostic yield than the percutaneous approach (82.5% vs. 63.5%, P=0.027). Patients who underwent laparoscopic biopsy had no perioperative or postoperative complications, resulting in a significantly lower complication rate than percutaneous biopsy (0% vs. 4%, P<0.001), particularly in the need for transfusion for post-procedure bleeding (0% vs. 1.8%, P<0.001). CONCLUSIONS: In this retrospective matched-pair analysis comparing patients undergoing renal biopsy for medical kidney disease, trans-peritoneal laparoscopic renal biopsy was safer and more effective for the diagnosis of medical renal diseases compared to percutaneous renal biopsy. Prospective trials with a good follow-up are needed to define the best candidate for each approach. LEVEL OF EVIDENCE: 4.

[New strategies in specific care for benign prostatic hypertrophy in older men]. / Nouvelles stratégies dans la prise en charge de l'hypertrophie bénigne de la prostate chez le sujet âgé.

Beyond its scientific and ethical competencies, a good doctor is characterized by his communication skills. The ability to listen is fundamental. During an interview, the physician must keep in mind a bio-psycho-social approach while being able to hear the unspeakable and inaudible. Knowledge of patients and their relatives, which seems to be a specific knowledge for general practitioners, offers a lot of information. Among the main sensitive topics that the clinician must identify are: intrafamily violence, domestic violence, substance abuse and anxiety-depressive disorders. In order to improve, the practitioner can use tools such as the Calgary-Cambridge guide and techniques used in Motivational Maintenance.

Au-delà de ses compétences scientifiques et déontologiques, un bon médecin se caractérise par ses compétences communicationnelles. La capacité d'écoute est fondamentale. Durant un entretien, le médecin doit garder à l'esprit une approche bio-psycho-sociale tout en étant capable d'entendre l'indicible et l'inaudible. La connaissance des patients et de leurs proches, qui semble être une connaissance spécifique aux médecins généralistes, offre énormément d'informations. Parmi les principaux sujets sensibles que doit repérer le clinicien, se trouvent : la violence intrafamiliale, la violence conjugale, les abus de substances et les pathologies anxio-dépressives. Afin de s'améliorer, le praticien peut s'aider d'outils tels que le guide de Calgary-Cambridge ainsi que des techniques utilisées en Entretien Motivationnel.

Exploring positive surgical margins after minimally invasive radical prostatectomy: Does body habitus really make a difference ?

BACKGROUND: Positive surgical margins (PSMs) at radical prostatectomy (RP) are generally recognized as a surrogate of poor or difficult dissection of the prostatic gland. In open RP cohorts, obesity seems to be associated to an increased risk of PSMs, probably due to the technical challenge that obese men pose to surgical access. Minimally invasive RP has been claimed to possibly reduce PSM rate. Aim of the study was to explore the impact of obesity and body habitus on PSM risk and their localisation during laparoscopic and robotic-assisted RP. MATERIALS AND METHODS: We reviewed 539 prospectively enrolled patients undergoing laparoscopic and robotic-assisted RP with pT2 prostate cancer. The outcome measured was rate of PSM according to the BMI and surgical approach (laparoscopic vs robotic-assisted). Patients were categorized in BMI<25kg/m2, BMI 25-29.9kg/m2 and BMI >30kg/m2 groups respectively and compared using Kruskall-Wallis or χ2 test, as appropriate. Uni- and multivariate logistic regression models were constructed to assess the impact of BMI and surgical technique on PSM risk. RESULTS: Overall, 127 (24%) of men had PSMs detected at final specimen evaluation. Mean PSM length was 3.9±3.4mm, and 30 (6%) men presented significant margins ≥4mm. Analysing the rate of PSMs across BMI categories, no significant association between increased BMI and PSM was detected (all P>0.48). On uni- and multivariate logistic regression BMI was not a statistically significant risk factor for PSM (P=0.14), nor was the minimally invasive technique (laparoscopic vs robotic-assisted) (P=0.54). CONCLUSIONS: In this study obese men do not appear to have a significant increase in risk of PSMs at RP compared to lean and overweight men when operated by a minimally invasive approach. The magnified vision and increased access to the pelvis allowed by a laparoscopic and robotic-assisted approach may be accountable for our findings. Larger studies are needed to validate our results. LEVEL OF PROOF: 4.

Interest of next-generation sequencing in BCG-treated high-risk bladder cancer.

OBJECTIVES: There are only few predictive factors for response of non-musculo-invasive bladder cancer (NMIBC) to Bacillus Calmette-Guérin (BCG) therapy. Our study analyzed the results of the sequencing of new generation (NGS) targeted on 50 genes of oncological interest obtained on bladder resection parts in high-risk NMIBC patients treated with BCG, to describe this population from a molecular point of view and try to correlate these results in patients who present or not recurrence after BCG. METHODS: We reviewed 63 patients with high grade NMIBC treated between 2014 and 2016 with BCG after endoscopic resection. Each one had NGS analysis. Association tests between mutations detected by NGS and recurrence or progression were realized. RESULTS: The 45 remaining patients were fully analysed. For 73% of cases a mutation has been found, most frequent one's being FGFR3, TP53 and PIK3CA. With a median follow-up of 24 months (4-40), recurrence was present in 15 patients (33.3%), with 10 NMIBC (22.2%) and 5 progressions to muscular-invasive cancer (11.1%). If some mutations were more frequent in different prognostic groups no significant association has been found. No patient presenting CIS had FGFR3 mutation (P<0.0001). CONCLUSION: Next generation sequencing in NMIBC could be a supplementary aid in treatment decision making in the future. In an area where personalized medicine is rapidly growing in importance we need larger studies to define molecular characteristics in tumours to detect genomic associations between clinical phenotypes and recurrence or progression of the disease. LEVEL OF EVIDENCE: 3.

Are concurrent systematic cores needed at the time of targeted biopsy in patients with prior negative prostate biopsies?

INTRODUCTION AND OBJECTIVES: MRI-guided targeted biopsies are advised in patients who have undergone an initial series of negative systematic biopsies, in whom prostate cancer (PCa) suspicion remains elevated. The aim of the study was to evaluate whether, in men with prior negative prostate biopsies, systematic cores are also warranted at the time of an MRI-targeted repeat biopsy. MATERIAL AND METHODS: We enrolled patients with prior negative biopsy undergoing real time MRI/TRUS fusion guided prostate biopsy at our institute between 2014 and 2016. Patients with at least one index lesion on multiparametric MRI were included. All eligible patients underwent both systematic random biopsies (12-14 cores) and targeted biopsies (2-4 cores). RESULTS: The study included 74 men with a median age of 65 years, PSA level of 9.27ng/mL, and prostatic volume of 45ml. The overall PCa detection rate and the clinically significant cancer detection rate were 56.7% and 39.2%, respectively. Targeted cores demonstrated similar clinically significant PCa detection rate compared to systematic cores (33.8% vs. 28.4%, P=0.38) with significantly less tissue sampling. Indeed, a combination approach was significantly superior to a targeted-only in overall PCa detection (+16.7% overall detection rate, P=0.007). Although differences in clinically significant PCa detection were statistically non-significant (P=0.13), a combination approach did allow detecting 7 extra clinically significant PCas (+13.8%). CONCLUSIONS: In patients with elevated PSA and prior negative biopsies, concurrent systematic sampling may be needed at the time of targeted biopsy in order to maximize PCa detection rate. Larger studies are needed to validate our findings. LEVEL OF EVIDENCE: 4.

[Update on laparoscopic electrosurgical devices and their use in complex urologic procedures]. / Actualités en électrochirurgie laparoscopique et ses applications en chirurgie urologique.

INTRODUCTION: Laparoscopy is the standard of care for many urologic procedures and witnesses nowadays technological advancements. Hemostasis is highly important in laparoscopy since bleeding could rapidly alter the operative conditions. The objective of this review is to expose the different electrosurgical techniques, their history and their applications in urology. MATERIAL AND METHODS: A literature review was overdone using the following terms "laparoscopic electrosurgery" and/or "nephrectomy" and/or "prostatectomy". Two hundred and forty articles were found through Pubmed. After reviewing the title and the content of these articles, 18 were eligible for the following review. RESULTS: The different electrosurgical techniques and their technological evolution are exposed. Physical properties of each system are exposed as well. Advantages and limitations of each system are also reviewed and analyzed. CONCLUSION: Bipolar electrosurgery with thermofusion and ultrasound technology can achieve good results in terms of nerve sparing for radical laparoscopic prostatectomies. They can both be used in partial nephrectomies. However, they can compromise the surgical resection margins. Hybrid systems seem to have an important role in urological laparoscopic procedures despite the scarce number of available studies. LEVEL OF EVIDENCE: 3.

[Quality of life after robotic prostatectomy: Impact of BMI and age on urinary incontinence]. / Qualité de vie après prostatectomie robotique : impact des indices de masse corporelle et âge sur l'incontinence urinaire.

INTRODUCTION: Data evaluating risk factors for urinary incontinence (UI) and quality of life (QoL) after robotic-assisted radical prostatectomy are scarce. The objective of our study was to explore the impact of age and body mass index (BMI) on postoperative incontinence, and the impact of such incontinence and urinary symptoms on QoL. MATERIAL AND METHODS: Two hundred and seventy two patients undergoing robotic-assisted radical prostatectomy answered the questionnaires ICIQ-UI short-form (evaluating UI) and EORTC QoL PR25 (evaluating QoL) in the preoperative setting, then at 1, 3, 12 et 24 months after surgery. Data regarding bother due to UI and urinary symptoms were extrapolated and calculated from the EORT PR25 questionnaire. The modification of ICIQ, of the bother from UI and of urinary symptoms was compared between the preoperative and the early (1-3 months) and late postoperative period (12-24 months). Differences of these scores were explored across non-obese and obese patients, as well as across different age groups. Chi-squared and logistic regression models were performed to test the association between BMI, age and ICIQ score, the bother from UI and urinary symptom score. RESULTS: Median age was 64 years and median BMI was 26.4kg/m2. After surgery, all scores (ICIQ, bother from UI and urinary symptoms) were significantly modified and worsened compared to preoperative values; in particular, median ICIQ passed from 1 to 10, 20% of patients were highly bothered by their urinary symptoms (compared to 2% in the preoperative setting) and the urinary score symptom passed from 8% to 33%. We observed a progressive amelioration of all scores of late controls (12-24 months), with a significantly improved QoL. Across BMI groups, we did not observe any significant difference in terms of modification of ICIQ, of the bother from UI or of urinary symptoms. Moreover, on multivariate logistic regression, BMI was not a risk factor for UI at neither 1 month (P>0.35) nor 12 months (P=0.35). On the other hand, age was significantly associated to an increased risk of UI in the immediate postoperative period on multivariate analysis (P<0.001). Indeed, the rate of patients with an ICIQ≥1 in the immediate postoperative period was higher in men>60 years old compared to younger men<60 years (96% vs 78%, P<0.001). When exploring the QoL scores, we did not observe any significant association between age and QoL, with the exception of an inversion correlation between age and urinary symptoms at 1 month after surgery (P=0.01). CONCLUSION: In this study, after robotic-assisted radical prostatectomy, older men appear to be at increased risk of immediate postoperative incontinence when compared to their younger counterparts, although their QoL is less likely to be bothered. BMI instead was not significantly associated to either urinary incontinence nor to QoL scores as bother form UI and urinary symptoms. LEVEL OF EVIDENCE: 4.

[Can preoperative prostate MRI before radical prostatectomy predict extracapsular extension and the side of the index lesion?]. / L'IRM de la prostate préopératoire avant prostatectomie radicale peut-elle prédire l'extension extracapsulaire et le côté de la lésion de référence?

AIM: To evaluate the role of preoperative multi-parametric magnetic resonance imaging (MP-MRI) in patients undergoing radical prostatectomy. Specifically, the accuracy of MP-MRI in detecting extracapsular extension (ECE) and individuating the side of the index lesion have been explored. METHODS: Thirty-five consecutive patients undergoing radical prostatectomy have been retrospectively analyzed. The MRI exam incorporated T2-weighted imaging, diffusion-weighted imaging and dynamic contrast enhancement in all patients. χ(2) test was performed to assess an association between an MP-MRI suggestive of ECE and pathologic ECE; similar tests were performed to study the association between the MRI-detected side of the index lesion and its true localization on final pathology. Univariate logistic regression models were constructed to evaluate possible predictors of ECE, including MP-MRI suspected ECE. RESULTS: Seventeen percent (6/35) of men presented ECE on final pathology. MP-MRI was predictive of pathologic ECE with a negative predictive value and specificity of 93% and 90%, respectively. Global accuracy of MP-MRI in predicting ECE was 86%. MRI-detected ECE was significantly predictive of pathologic ECE on logistic regression (OR: 17.3, 95% CI: 2.2-138.2, P=0.007). Moreover, MRI significantly predicted the side of the index lesion (P=0.012). CONCLUSIONS: In this single center cohort, preoperative MP-MRI was significantly predictive of ECE and side of the index lesion. Further studies are necessary to individuate patients who can benefit from preoperative MP-MRI. LEVEL OF EVIDENCE: 5.