How the diagnosis and the management of genetic renal phosphate leak impact the life of kidney stone formers?

Genetic renal phosphate leak is one of the rare disorders in recurrent stone formers with absorptive hypercalciuria. Diagnosis and appropriate management may change the life of patients. To provide answers on how and when to make the diagnosis of genetic renal phosphate leak and how medical management prevents the recurrences and changes patients' life, we conducted a retrospective study including nine patients with recurrent nephrolithiasis and a confirmed genetic mutation of a phosphate transporter between 2008 and 2019 in our multidisciplinary center at the Pitié Salpetriere Hospital, Paris, France. We compared the number and the annual rate of urological intervention before and after the diagnosis and management using the Wilcoxon test. A qualitative survey was done to evaluate the quality of life of patients. A total of 9 patients were included in this study. Patient baseline characteristics and elements supporting the diagnosis are described. We showed an effective decrease in urological intervention number (p = 0.0078) and annual rate (p = 0.0117) after the diagnosis and the appropriate management, and an improvement in the patients' quality of life. The diagnosis and the appropriate management of genetic renal phosphate leak disorder improve the quality of life by preventing stone recurrence and decreasing the number of surgical intervention.

Fluoroless endourological surgery for high burden renal and proximal ureteric stones: A safe technique for experienced surgeons.

Objective: To describe the feasibility of treating proximal ureteric and renal stones using flexible ureteroscopy (fURS) or a double approach (mini-percutaneous nephrolithotomy [PCNL] + fURS) without any use of radiation. Patients and methods: We retrospectively reviewed the data of all patients operated by one surgeon for retrograde endoscopic removal of renal and ureteric lithiasis performed between June 2015 and January 2019 in our institution. Patients with anatomical complexities, high-burden stone disease (diameter >20 mm), and medical comorbidities (anti-platelet drug administration) were included in our study. Outcomes analysed included complication rate, stone-free rate (SFR, defined as no residual stone >1 mm), and repeat procedure rate. Results: In all, 183 consecutive URS for proximal ureteric and renal lithiasis were conducted. C-arm fluoroscope guidance was not required, not even in the complex cases. Simultaneous ultrasonography and fURS guidance was used in patients where the mini-PCNL approach was indicated. Lead aprons were not needed by the operating room staff in any of the operations. The SFR was 91.8% after the first procedure, with no Clavien-Dindo Grade III or IV complications. Conclusion: Our present series shows clearly that the fURS and mini-PCNL approach under fURS control is a feasible and safe technique for experienced surgeons. Patients had a high SFR and no technique-related complications, with no additional risk of X-ray exposure. However, a prospective study is required to test the reproducibility of this technique. Abbreviations: GMSV: Galdakao-modified supine Valdivia; ICRP: International Commission on Radiological Protection; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; OR: operating room; PCNL: percutaneous nephrolithotomy; SFR: stone-free rate; UAS: ureteric access sheath; (f)URS: (flexible) ureteroscopy; US: ultrasonography.

Adverse events associated with currently used medical treatments for cystinuria and treatment goals: results from a series of 442 patients in France.

OBJECTIVE: To evaluate medical treatments, in terms of adverse events (AEs) and therapeutic goals, in a large series of patients with cystinuria. PATIENTS AND METHODS: Data from 442 patients with cystinuria were recorded retrospectively. Crystalluria was studied in 89 patients. A mixed-effects logistic regression model was used to estimate how urine pH, specific gravity and cysteine-binding thiols (CBT) correlate with risk of cystine crystalluria. RESULTS: Alkalizing agents and CBT agents were given to 88.8% (n = 381) and 55.3% (n = 238) of patients, respectively. Gastrointestinal AEs were reported in 12.3%, 10.4% and 2.6% of patients treated with potassium bicarbonate, potassium citrate and sodium bicarbonate, respectively (P = 0.008). The percentages of patients who experienced at least one AE with tiopronin (24.6%) and with D-penicillamine (29.5%) were similar (P = 0.45). Increasing urine pH and decreasing urine specific gravity significantly reduced the risk of cystine crystalluria, whereas D-penicillamine and tiopronin treatments did not reduce this risk (odds ratio [OR] 1 for pH ≤6.5; OR 0.52 [95% confidence interval {95% CI} 0.28-0.95] for 7.0 8.0, P <0.001). CONCLUSION: Adverse events were frequent with D-penicillamine and tiopronin. Alkaline hyperdiuresis was well tolerated and reduced cystine crystalluria. Urine specific gravity ≤1.005 and urine pH >7.5, while warning about calcium-phosphate crystallization, should be the goals of medical therapy.

Multiparametric MRI for Suspected Recurrent Prostate Cancer after HIFU:Is DCE still needed?

PURPOSE: To assess the added value of the dynamic contrast-enhanced sequence (DCE) to combination T2-weighted imaging (T2w) + diffusion-weighted imaging (DWI) in detecting prostate cancer (PCa) recurrence after HIFU (high-intensity focused ultrasound). METHODS: Forty-five males with clinical and biological suspected PCa recurrence were retrospectively selected. All underwent multi-parametric MRI (mpMRI) before biopsies. Two readers independently assigned a Likert score of cancer likelihood on T2w + DWI + DCE and T2w + DWI images. Prostatic biopsies were taken as the gold standard. RESULTS: Recurrent PCa was identified at biopsy for 37 patients (82%). Areas under the receiver-operating curve of T2w + DWI and T2w + DWI + DCE imaging were not significantly different for both readers. Using a Likert score ≥ 3 for the PCa diagnosis threshold, sensitivity at the lobe level for the (1) senior and (2) junior reader for T2w +DWI +DCE sensitivity was (1) 0.97 and (2) 0.94 vs. (1) 0.94 and (2) 0.97 for T2w + DWI. CONCLUSION: Accuracy of mpMRI was not significantly improved by adding DCE to T2w + DWI. Sensitivity was high for T2w + DWI + DCE and T2w + DWI with no significant difference for either the junior or senior reader. KEY POINTS: • MpMRI has the capability to detect PCa recurrence in post-HIFU monitoring. • The sensitivity of T2w and DWI for detecting PCa recurrence was not improved by DCE. • Readers with different degrees of experience did not improve their performance with DCE.

Dynamic contrast-enhanced imaging in localizing local recurrence of prostate cancer after radiotherapy: Limited added value for readers of varying level of experience.

BACKGROUND: The incremental value of dynamic contrast-enhanced (DCE) imaging in localizing radiorecurrent prostate cancer is uncertain. PURPOSE: To assess the added-value of DCE imaging to the combination T2 -weighted imaging (T2 W)+diffusion-weighted imaging (DWI) in detecting locally radiorecurrent prostate cancer (PCa), by radiologists with different levels of experience. STUDY TYPE: Analytic retrospective study. POPULATION: In all, 52 men with biological suspected PCa recurrence after radiotherapy were retrospectively included. FIELD STRENGTH/SEQUENCE: All men underwent prostatic MRI (1.5T or 3T), including T2 W, DWI, and DCE imagings, before biopsies. ASSESSMENT: Two junior (6 months' experience) and two senior readers (more than 3 years' experience) independently assigned a Likert score for each prostatic sextant on T2 W+DW+DCE imagings, then on T2 W+DW imagings, 4 weeks later. STATISTICAL TESTS: The reference standard was prostatic biopsies. For two levels of positivity of Likert score, 3/5 and 4/5, sensitivity, specificity, area under the receiver operating curve (AUC), and interreader agreement were compared. RESULTS: T2 W+DWI+DCE and T2 W+DWI imaging had similar AUC at lobe and sextant level (0.853-0.946 vs. 0.819-0.955, P from 0.071-0.534). Using a Likert score ≥4/5, T2 W+DWI+DCE significantly improved the sensitivity for junior readers at the patient, lobe, and sextant level (40-80% vs. 22-66%, P < 0.0001-0.041). Sensitivity was not significantly modified with DCE imaging for senior readers (54-95% vs. 50-91%, P from 0.074-1). Specificity was not modified for all readers (50-100% vs. 50%-100%, P from 0.134-1). DCE imaging improved interreader agreement for a Likert score ≥4/5 (kappa from 0.6-0.73 vs. 0.38-0.73). DATA CONCLUSION: The addition of DCE imaging did not significantly improve accuracy in recurrent PCa detection after radiotherapy, whatever the level of experience of the readers. However, the addition of DCE imaging slightly improved the sensitivity for less-experienced readers and increased their diagnostic confidence. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1012-1023.

HOXB13 a useful marker in pleomorphic giant cell adenocarcinoma of the prostate: a case report and review of the literature.

We report the case of an 81-year-old patient with a pleomorphic giant cell adenocarcinoma of the prostate. After diagnosis, he rapidly developed bone metastasis and died within 1 year. This variant of acinar adenocarcinoma is extremely rare and prognosis is poor. This entity has been included into the 2016 WHO classification. The principal differential diagnosis is urothelial carcinoma. To assess the prostatic origin, routine immunohistochemistry can be problematic. Loss of epitopes in this poorly differentiated entity can occur, such as loss of expression of PSA and p504s. We recently described a very sensitive and specific marker of prostate cancer, HOXB13, which once again has proven to be highly specific and sensitive. This is the first description of a pleomorphic giant cell prostate cancer expressing HOXB13.

Comparing Image Perception of Bladder Tumors in Four Different Storz Professional Image Enhancement System Modalities Using the íSPIES App.

OBJECTIVES: To evaluate the variation of interpretation of the same bladder urothelium image in different Storz Professional Image Enhancement System (SPIES) modalities. SPIES contains a White light (WL), Spectra A (SA), Spectra B (SB), and Clara and Chroma combined (CC) modality. MATERIALS AND METHODS: An App for the iPAD retina was developed to study evaluation of images. A total of 80 images from 20 bladder areas acquired in four modalities were included. Seventy-three participants completed the study. Images were analyzed on differences in delineated tumor margin variation, perceived quality of the image, and delineation time. RESULTS: A separation between high agreement (n = 14) and low agreement (n = 6) images was found. In high agreement images, no difference in root mean square (RMS) was found between modalities. In low agreement images, WL (26.5 pixels) and SA (33.4 pixels) had a higher RMS than CC (18 pixels) and SB (21.4 pixels). The quality of SPIES modalities images was rated significantly higher. Delineation time was similar. CONCLUSION: In low agreement cases, images in CC and SB have less variation in interpretation than WL and SA. The image quality in SPIES modalities is graded significantly higher than WL. There is no difference in delineation time between modalities.

CKD and Its Risk Factors among Patients with Cystinuria.

BACKGROUND AND OBJECTIVES: Cystinuria is an autosomal recessive disorder affecting renal cystine reabsorption; it causes 1% and 8% of stones in adults and children, respectively. This study aimed to determine epidemiologic and clinical characteristics as well as comorbidities among cystinuric patients, focusing on CKD and high BP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective study was conducted in France, and involved 47 adult and pediatric nephrology and urology centers from April 2010 to January 2012. Data were collected from 442 cystinuric patients. RESULTS: Median age at onset of symptoms was 16.7 (minimum to maximum, 0.3-72.1) years and median diagnosis delay was 1.3 (0-45.7) years. Urinary alkalinization and cystine-binding thiol were prescribed for 88.8% and 52.2% of patients, respectively, and 81.8% had at least one urological procedure. Five patients (1.1%, n=4 men) had to be treated by dialysis at a median age of 35.0 years (11.8-70.7). Among the 314 patients aged ≥16 years, using the last available plasma creatinine, 22.5% had an eGFR≥90 ml/min per 1.73 m(2) (calculated by the Modification of Diet in Renal Disease equation), whereas 50.6%, 15.6%, 7.6%, 2.9%, and 0.6% had an eGFR of 60-89, 45-59, 30-44, 15-29, and <15, respectively. Among these 314 patients, 28.6% had high BP. In multivariate analysis, CKD was associated with age (odds ratio, 1.05 [95% confidence interval, 1.03 to 1.07]; P<0.001), hypertension (3.30 [1.54 to 7.10]; P=0.002), and severe damage of renal parenchyma defined as a past history of partial or total nephrectomy, a solitary congenital kidney, or at least one kidney with a size <10 cm in patients aged ≥16 years (4.39 [2.00 to 9.62]; P<0.001), whereas hypertension was associated with age (1.06 [1.04 to 1.08]; P<0.001), male sex (2.3 [1.3 to 4.1]; P=0.003), and an eGFR<60 ml/min per 1.73 m(2) (2.7 [1.5 to 5.1]; P=0.001). CONCLUSIONS: CKD and high BP occur frequently in patients with cystinuria and should be routinely screened.

Kidney stones and imaging: what can your radiologist do for you?

OBJECTIVES: We discuss in this review, urologists' expectations of imaging in terms of detection, characterization, pre-planning treatment and follow-up of urinary stones. MATERIALS AND METHODS: Data acquisition regarding kidney stones and imaging was performed using MEDLINE searches with combinations of the following keywords: urinary stones, CT Urography, low dose CT, MRI urography, renal stones ultrasound, conventional radiography, surgery. RESULTS: CT has become the gold standard for the evaluation of urinary stones. Scanning provides information regarding stone (composition, size, burden, location), collecting system and renal parenchyma. Those findings are crucial in determining appropriate treatment strategies. Because CT exposes the patient to substantial ionizing radiation, efforts have already been made to decrease the CT radiation dose for CT examination (low dose CT) and optimize image quality. Efforts also are being made to use non ionizing modalities such as ultrasound in combination with radiography particularly for the follow up of renal stones. CONCLUSION: CT is the preferred method for the evaluation and treatment planning of urolithiasis. CT radiation dose reduction can be achieved with low dose CT. However, conventional radiography and ultrasound are still recommended in the follow up of renal stones.

Current evidence for transurethral en bloc resection of non-muscle-invasive bladder cancer.

INTRODUCTION: Despite today's standard procedure for staging and treating non-muscle-invasive bladder cancer by transurethral resection via a wire loop (TURBT), several other publications have dealt with a different concept of en bloc resection of bladder tumors using different energy sources. MATERIAL AND METHODS: MEDLINE and the Cochrane central register were searched for the following terms: en bloc, mucosectomy, laser, resection, ablation, Neodym, Holmium, Thulium, transitional cell carcinoma. RESULTS: Fourteen research articles dealing with en bloc resection of non-muscle-invasive bladder cancer could be identified (modified resection loops: six, laser: six, waterjet hydrodissection: two). CONCLUSION: En bloc resection of bladder tumors >1 cm can be performed safely with very low complication rates independent of the power source. By using laser, complication rates might even be decreased, based on their good hemostatic effect and by avoiding the obturator nerve reflex. A further advantage seems to be accurate pathologic staging of en bloc tumors. Randomized controlled trials are still needed to support the assumed advantages of en bloc resection over the standard TURBT with regard to primary targets: First-time clearance of disease, accurate staging and recurrence rates.

HOXB13 is a sensitive and specific marker of prostate cells, useful in distinguishing between carcinomas of prostatic and urothelial origin.

The origin of a primary or metastatic carcinoma in the pelvic area is sometimes difficult to establish, in particular the distinction between those originating in the bladder and the prostate. A candidate marker is the HOXB13 gene, essential for prostate development. Some studies have shown expression of HOXB13 protein by immunohistochemistry in the nuclear compartment of benign prostate luminal epithelium and prostate carcinoma. Forty-two cases of biopsies and resection specimens of the prostate and urinary bladder, metastatic lymph nodes, and pelvic masses were retrieved from our databases. In all cases, doubt persisted regarding prostatic versus urothelial origin. All cases were stained for CK7, p63, p504s, PSA, CK20, and HOXB13. Chromogranin A, CD56, and synaptophysin were used when neuroendocrine differentiation was suspected. HOXB13 staining was negative or only weakly positive in all carcinomas of urothelial origin. Three of four carcinomas with neuroendocrine differentiation did not express HOXB13. The fourth carcinoma, in a patient with a history of prostate carcinoma, was positive. In two cases with a synchronous prostatic and urothelial carcinoma, HOXB13 was exclusively expressed in the prostatic carcinoma. Our results demonstrate that HOXB13 expression identifies prostatic origin of a carcinoma with good sensitivity (89 %) and very good specificity (100 %). HOXB13 is a specific and sensitive marker for prostate cells and a valuable diagnostic tool, especially when poorly differentiated or neuroendocrine tumors are encountered. These results justify testing of HOXB13 as a prostate-specific carcinoma marker in larger cohorts for a more thorough evaluation of its sensitivity and specificity.

Different subtypes of carcinoma in situ of the bladder do not have a different prognosis.

Urothelial carcinoma in situ (CIS) is a high-grade lesion with different subtypes (large cell pleomorphic (LCP), large cell nonpleomorphic (LC), small cell and clinging (CL)). We explored the frequency of different subtypes in primary CIS and compared different patterns with outcome. We explored whether subtyping of CIS leads to a change in therapy and/or follow-up and should be formally reported. We included 39 patients with a primary CIS and divided them into two groups: one with LPC/LG and one with CL elements. Other subtypes did not exist or occurred only as a mixture. Patient age ranged from 36 to 80 years (mean, 63 years). Twenty had a primary CIS with one single subtype. LCP was predominant with 16 (41 %) cases; the second most important subtype was the CL with four (10 %) cases. Mean follow-up was 26.4 months, (range, 4-100 months). Thirteen patients developed a ≥ pT2 carcinoma. When progression of the different subtypes was examined, no statistical significance was found between mixed forms (p = 0.9437) nor between pure forms (p = 0.744 and p = 0.5955, respectively). Pathologists need not include different subtypes of primary CIS in their report as there is no difference in patient outcomes. It is important to recognize all different subtypes as CIS for best patient treatment.

[Urinary stone management at the time of its discovery]. / Conduite a tenir lors de la découverte d'un calcul urinaire.

Circumstances of diagnosis of urinary stones vary. Medical management is performed either in emergency for acute or serious symptoms, or delayed. Renal colic is the most typical clinical form. The emergency analgesic treatment is well established. After sedation of the pain, radiological study (plain film and ultrasound of the abdomen) may be supplemented by abdominal computerized tomography which is the best exam for the diagnosis of urinary stone and its impact. In complicated cases urological drainage is performed in emergency. If needed the urological treatment of the urinary stone is performed secondarily according to the French recommendations. A metabolic evaluation and dietary survey are required for each patient to identify and avoid the risk of recurrence. Some stone formers or complex patients must be followed in nephrology.

Estimation of urinary stone composition by automated processing of CT images.

The objective of this article was developing an automated tool for routine clinical practice to estimate urinary stone composition from CT images based on the density of all constituent voxels. A total of 118 stones for which the composition had been determined by infrared spectroscopy were placed in a helical CT scanner. A standard acquisition, low-dose and high-dose acquisitions were performed. All voxels constituting each stone were automatically selected. A dissimilarity index evaluating variations of density around each voxel was created in order to minimize partial volume effects: stone composition was established on the basis of voxel density of homogeneous zones. Stone composition was determined in 52% of cases. Sensitivities for each compound were: uric acid: 65%, struvite: 19%, cystine: 78%, carbapatite: 33.5%, calcium oxalate dihydrate: 57%, calcium oxalate monohydrate: 66.5%, brushite: 75%. Low-dose acquisition did not lower the performances (P < 0.05). This entirely automated approach eliminates manual intervention on the images by the radiologist while providing identical performances including for low-dose protocols.

Promising functional outcomes obtained with robot-assisted laparoscopic pyeloplasty: a single-center experience.

PURPOSE: To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS: We retrospectively reviewed our database for all patients who were treated for UPJO by a single surgeon using a robot-assisted procedure between 2005 and 2007. We collected the following: Patient age, clinical presentation, perioperative data, complications, length of hospital stay, and outcome. Preoperative evaluation of UPJO always included an injected renal CT scan and furosemide-mercaptoacetyltriglycine (MAG-3) renal scintigraphy. Patients were seen at 3 and 6 months after surgery and once a year thereafter. Postoperative success was defined as symptomatic response and radiographic evidence of no further obstruction. RESULTS: Twenty patients with a mean age of 36.8 +/- 16 years (range 15-69 yr) were included. Six (30%) patients had previously undergone endoscopic treatment. The mean operative time was 150.3 +/- 36.22 minutes (range 150-240 min). The mean follow-up was 19.9 +/- 10.03 months (range 3-37 mos). Two (10%) procedures necessitated conversion to laparoscopic procedures, and there was no conversion to laparotomy. Four (20%) patients experienced minor complications: Two urinary tract infections and two urinomas. Repeated early surgery was needed in one patient for temporary (ie, 8 days) stent placement in the case of urinoma. There was no recurrence of the UPJO, and no repeated surgery was deemed necessary during the follow-up period. The success rate was estimated to be 95%. CONCLUSIONS: Functional outcomes after robot-assisted procedures for alleviation of UPJO are very promising. Our data showed that the robot-assisted procedure was safe and featured negligible morbidity. Therefore, we conclude that our approach is a viable alternative to open surgery.

Aurora-A/STK-15 is differentially expressed in the micropapillary variant of bladder cancer.

INTRODUCTION: Micropapillary carcinoma (MPC) of the bladder is a rare and aggressive histologic variant of urothelial carcinoma (UC). At the time of presentation, most MPC are muscle invasive with frequent vascular invasion (VI). Our series explores protein expression of markers known to be indicators of poor clinical outcome and progression, trying to explain aggressiveness of MPC. PATIENTS AND METHODS: 18 patients with MPC were reviewed. We explored protein expression of p53, MIB-1, Aurora-A and survivin in MPC and compared their expression to conventional urothelial carcinoma (CUC) of the same grade and stage. RESULTS: Patients, aged 46-85 years, underwent transurethral resection or cystoprostatectomy for UC. MPC was either pure (39%) or only partially present (61%). 55% of the patients died. VI was seen in 95%. MPC displayed overexpression of p53 and MIB-1, Aurora-A and survivin. No statistically significant difference could be made with CUC except for Aurora-A (p = 0.03). CONCLUSIONS: This is the first study to explore different markers of bad clinical outcome in MPC. We suggest that Aurora-A via mechanisms implied into early steps of mitosis might play a role in aggressive clinical behavior of MPC.

Fluorescence diagnosis and flat lesions of urothelium: new challenges for pathologists and urologists (Review).

Bladder cancer is a common malignancy. Recurrence rate and progression vary greatly depending on factors such as tumor multiplicity, size, previous recurrence rates, tumor stage, tumor grade and the presence of carcinoma in situ. Treatment is expensive, recent studies demonstrated that superficial bladder cancer is a major economic burden. It is necessary to establish new kinds of techniques to improve diagnosis, therapy and follow-up, such as fluorescence diagnosis, without adding significant risk of complications. As urologists have a better sight of bladder lesions with fluorescence diagnosis, pathologists will be asked in the future to evaluate more frequently flat lesions, which up to now would not have been a matter of concern. For several reasons it is very important to have accurate and precise definitions of these flat lesions. First to permit uniform treatment of large groups of patients and second to see in large cohorts the evolution and natural history of several flat lesions, not always well known up to now. The aim of the study was to review the most important flat lesions, to demonstrate the difficulty of classifying several lesions, to introduce to urologists the new problems linked to FD and to suggest new models for accurate analysis. How far can we go in our answer as pathologists and how will it change the patient management?

Mapping of transrectal ultrasonographic prostate biopsies: quality control and learning curve assessment by image processing.

OBJECTIVE: Mapping of transrectal ultrasonographic (TRUS) prostate biopsies is of fundamental importance for either diagnostic purposes or the management and treatment of prostate cancer, but the localization of the cores seems inaccurate. Our objective was to evaluate the capacities of an operator to plan transrectal prostate biopsies under 2-dimensional TRUS guidance using a registration algorithm to represent the localization of biopsies in a reference 3-dimensional ultrasonographic volume. METHODS: Thirty-two patients underwent a series of 12 prostate biopsies under local anesthesia performed by 1 operator using a TRUS probe combined with specific third-party software to verify that the biopsies were indeed conducted within the planned targets. RESULTS: The operator reached 71% of the planned targets with substantial variability that depended on their localization (100% success rate for targets in the middle and right parasagittal parts versus 53% for targets in the left lateral base). Feedback from this system after each series of biopsies enabled the operator to significantly improve his dexterity over the course of time (first 16 patients: median score, 7 of 10 and cumulated median biopsy length in targets of 90 mm; last 16 patients, median score, 9 of 10 and a cumulated median length of 121 mm; P = .046). CONCLUSIONS: In addition to being a useful tool to improve the distribution of prostate biopsies, the potential of this system is above all the preparation of a detailed "map" of each patient showing biopsy zones without substantial changes in routine clinical practices.

Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm.

PURPOSE: We determined the cancer control provided by nephron sparing surgery for renal cell carcinoma greater than 4 cm. MATERIALS AND METHODS: We performed a retrospective review of data on patients treated between 1980 and 2005. The case characteristics analyzed were patient age, surgical procedure, intraoperative parameters, complications, tumor size, Fuhrman grade, TNM stage, pathological data and outcome. Kaplan-Meier survival curves were generated. RESULTS: Median age of the 61 patients was 64 years (range 40 to 83). Mean +/- SD intraoperative blood loss was 622 ml +/- 691 (range 50 to 4,800) and mean operative time was 155.7 +/- 82 minutes (range 52 to 360). Mean creatinine preoperatively and immediately postoperatively was 1.16 and 1.25 mg/dl, respectively. Mean renal cell carcinoma size was 56.3 +/- 18 mm (range 41 to 100). Margin status was positive in 11 cases (18%). Median followup was 70.7 months. The 5 and 10-year cancer specific survival rate was 81% and 78%, respectively. The tumor-free survival rate was 92% at 5 years and 88% at 10 years. On univariate analysis tumor size more than 7 cm (p = 0.002), pathological stage (p = 0.001) and Fuhrman grade (p = 0.004) were associated with survival. On multivariate analysis only pathological stage and Fuhrman grade were significant (p <0.0001 and 0.007, respectively). CONCLUSIONS: Our results support the fact that nephron sparing surgery is a useful and acceptable approach to renal cell carcinoma greater than 4 cm. When technically possible, nephron sparing surgery provides acceptable long-term cancer specific survival rates. However, oncological safety is less evident in cases of renal cell carcinoma greater than 7 cm. To date in such cases nephron sparing surgery should only be considered for absolute indications.

Oncologic control provided by HIFU therapy as single treatment in men with clinically localized prostate cancer.

OBJECTIVE: To assess the long term oncologic results of high-intensity focused ultrasound therapy (HIFU) as a primary and single treatment for clinically localized prostate cancer. METHODS: A total of 119 patients with clinically localized prostate cancer underwent HIFU (Ablatherm((R)), EDAP, France) as first-line treatment and were retrospectively reviewed. They were stratified according to risk groups proposed by D'Amico. No patient had undergone previous hormonal therapy. PSA level was monitored at 3, 6, 12, 18, 24 months and then yearly. According to the latest ASTRO criteria, failure was defined by a PSA rise of 2 ng/ml or more above the PSA nadir. The biochemical-free survival rate (BFSR) was calculated. RESULTS: Mean patient age was 68 +/- 7.8 years (46-83). Mean follow-up was 3.9 years (1-6.8). Overall 52 patients (43.7%) experienced a biochemical recurrence which included 26, 23 and 3 patients in the low, intermediate and high-risk groups, respectively. In univariate and multivariate analyses, there was a statistical association between preoperative PSA value > 10, a nadir PSA value > 1 and the risk of biochemical recurrence (P < 0.05). The 5-year BFSR rate was 30% with no statistical difference between low- and intermediate-risk patients. None of the 119 patients died of prostate cancer. CONCLUSION: High-intensity focused ultrasound therapy provides efficient oncologic control only in patients with low-risk prostate cancer. However, our data could be used to improve the selection of patients who are potential candidates for HIFU therapy.