[Impact of neoadjuvant chemotherapy on the peri-operative morbidity of radical cystectomy for muscle invasive bladder cancer]. / Impact de la chimiothérapie néoadjuvante sur la morbidité péri-opératoire de la cystectomie pour tumeur de vessie infiltrant le muscle.

INTRODUCTION: Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone. METHODS: Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications. RESULTS: We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001). CONCLUSION: NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.

Risk factors of severe incisional hernia after renal transplantation: a retrospective multicentric case-control study on 225 patients.

PURPOSE: The aim of this study was to analyze the incidence of severe incisional hernias and find their specific risk factors in renal transplant patients. METHODS: This retrospective multicentric case-control study focused on 225 kidney transplant patients among 4348 patients transplanted during this period within two French university hospitals (Saint-Louis/Lariboisière in Paris and Tours, Loire Valley) from 2000 to 2014 and from 1995 to 2014, respectively. Forty-five patients developed a severe incisional hernia after renal transplantation. The primary outcome measure was the development of a severe incisional hernia after surgery. Statistical analysis included an univariate analysis and a multivariate analysis using a logistic regression according to the Cox model. RESULTS: Forty-five patients (1.03%) had a severe incisional hernia surgery after renal transplantation. The median follow-up was 55.5 months. In univariate analysis, smoking, the occurrence of a lymphocele and parietal closure in a single musculo-fascial layer was significantly associated with the occurrence of incisional hernia after renal transplantation. Former or active smoking (OR 2.32, p = 0.0370), lymphocele (OR 4.3903, p = 0.0018) and parietal musculo-fascial closure in one single layer (OR 3.37, p = 0.0088) significantly increased the risk of incisional hernia after kidney transplant in multivariate analysis. CONCLUSIONS: We report in this study one of the largest series of patients who had incisional hernia after renal transplantation. Former or active smoking, lymphocele and parietal closure in one single musculo-fascial layer were independent risk factors for incisional hernia following kidney transplant.

[Total pancreas sampling and transplantation]. / Prélévement et transplantation de pancréas total.

Pancreas removal and transplantation consists in three main steps: sampling, preparation of the transplant with reconstruction of vessels and finally transplantation. Sampling requires good anatomical knowledge and perfect synchronization between hepatic surgeons so as to ensure adequate dissection of liver and pancreas vessels: portal vein, splenic, upper mesenteric and hepatic arteries. Washing and conservation of organs require the use of University of Wisconsin solution. The preparation of the pancreatic graft consists in reconstructing the unique arterial axis using an iliac arterial fork sutured with upper mesenteric and splenic arteries. The portal vein is lengthened step by step, avoiding venous patch source of thrombosis. The transplantation is realized in the right flank, on the aorta and the vena cava near the iliac crossroads. The digestive anastomosis is performed between duodenum of the transplant and first bowel hail of the recipient. It must be done carefully to avoid any risk of pancreas fistula.

A new prostatic stent for the treatment of benign prostatic hyperplasia in high-risk patients.

OBJECTIVES: The objective of this study was to evaluate the efficacy and safety of a new prostatic stent (Trestle((R)), Boston Scientific Microvasive) for the treatment of BPH in patients with complete urinary retention and considered to be inoperable. METHODS: The efficacy of the stent was evaluated in terms of return of micturition, level of patient satisfaction, uroflowmetry and residual urine. Any stents removed were examined by infrared spectrophotometry for the presence of crystalline encrustations. RESULTS: From December 1997 to April 1999, 20 stents were inserted under local anaesthesia in 17 patients aged 54-90 years. Stents remained in place for an average of 3.5 months. Two migrations were reported. The mean maximum flow rate was 13.7 ml/s and the mean residual urine was 110 ml. The infrared spectrophotometry study revealed a glycoprotein film on stents in place for 1-6 months, accompanied by uric acid crystals on stents in place for 9 months. CONCLUSION: The Trestle prostatic stent is effective and constitutes a good alternative to surgical treatment in patients with a high operative risk.

Low-dose BCG instillations in the treatment of stage T1 grade 3 bladder tumours: recurrence, progression and success.

The aim of this retrospective study was to evaluate the effects and results of low-dose bacillus Calmette-Guérin (BCG) therapy on a selective high-risk population of stage T1, grade 3 (G3) bladder tumours. Recurrence and progression were also analysed. Thirty-five consecutive patients presenting with T1 G3 tumours were treated with intravesical BCG. All patients underwent complete transurethral tumour resection. A course of BCG 75 mg Pasteur strain was begun 4 weeks after the first resection of the diagnosed tumour and continued for a 6-week period. At the end of treatment, a complete urological evaluation was routinely carried out: urine cytology test, cystoscopy with bladder biopsies randomly performed, and any recurrences were resected. In cases of abnormal cytology and/or recurrence an additional course of BCG was initiated, followed by the same tests. Follow-up examination and cystoscopy or fibroscopy were conducted every 3 months for 1 year, semiannually and annually thereafter. Median follow-up was 45 months (range 10-120); 7 patients (20%) did not respond to BCG instillations. Of these patients, 5 underwent cystectomy and in 2 patients the bladder was left in place in spite of recurrence because of age (+80 years). Twenty-eight patients (80%) responded positively, 24 after one single course of BCG, and 4 patients after two courses. During follow-up, recurrence was observed in 8 cases: stage T1 G3 in 4 patients, T1 CIS (carcinoma in situ) in 2 patients, Ta G2 and Ta G1 in 2 patients. Three of these patients were treated by cystectomy and the remaining patients with transurethral resection alone or combined with additional courses of BCG. Overall, 25 patients (71%) were considered free of tumour occurrence after low-dose BCG therapy. Ten patients underwent cystectomy (29%) or remained in occurrence and 2 patients died of the disease. These results can be closely compared to the results of other trials conducted on stage T1 G3 and BCG treatment, using a different dosage and BCG protocol therapy. BCG is an effective prophylactic and therapeutic agent for T1 G3 carcinoma of the bladder responders. The identification of these responders before beginning instillations still remains a challenge.

Urethral recurrence of transitional cell carcinoma of the bladder. Predictive value of preoperative latero-montanal biopsies and urethral frozen sections during prostatocystectomy.

OBJECTIVE: The management of the male urethra after cystectomy for bladder cancer continues to be a dilemma. Patients who undergo a cystectomy require either urinary diversion or bladder substitution. Therefore, the use of the urethra to ensure voiding is important. On the other hand, the probable risk of urethral carcinoma recurrence is generally estimated at approximately 10%. The aim of this study was to assess the predictive value of preoperative urethral biopsies, and of frozen sections during cystoprostatectomy, in patients with invasive bladder cancer. METHODS: From 1982 to 1986, 118 male patients underwent a cystoprostatectomy for transitional cell carcinoma of the bladder. All patients underwent endoscopic latero-montanal biopsies 2 weeks preoperatively and urethral frozen cut section during radical prostatocystectomy. RESULTS: Carcinoma was observed in 12 patients on both examinations. All patients underwent en bloc urethrectomy during cystectomy. In the remaining 106 patients, the frozen cut margin was negative (including 9 with positive latero-montanal biopsies), and these patients had the urethra preserved. After a 10-year minimum follow-up, no recurrence was observed in these patients with negative frozen cut-section. No significant risk factors for urethral recurrence were found. Latero-montanal biopsies did not reveal a positive specificity, and this procedure was later abandoned in our institution (in 1986). CONCLUSIONS: The urethral frozen section was the only guideline used for simultaneously performing the urethrectomy. All male patients with negative frozen cut sections should be considered candidates for bladder substitution. A prophylactic urethrectomy is only indicated in patients with carcinoma (minimum carcinoma in situ) in the frozen urethral margin section during cystectomy.

Correlation between p53 over expression and response to bacillus Calmette-Guerin therapy in a high risk select population of patients with T1G3 bladder cancer.

PURPOSE: The aim of this study was to determine if p53 status, assessed before intravesical bacillus Calmette-Guerin (BCG) therapy, can predict clinical outcome in a high risk population of patients with stage T1, grade G3 bladder cancer and if it can be used to select patients responsive to therapy. MATERIAL AND METHODS: After complete transurethral resection 35 patients with T1G3 bladder carcinoma received 6 weekly instillations of BCG and nonresponsive patients received a second course. After treatment cystoscopy and randomized biopsies of the bladder mucosa were performed. Pathologists had sufficient material to perform immunomarking in 25 cases using the peroxidase-antiperoxidase technique with antiprotein monoclonal antibody p53. The results were expressed in percentage of marked nuclei. We established 5% increment thresholds from 0 to 60%. Contingent tables were established, and chi-square and Fisher's exact test were performed for each 5% threshold. RESULTS: Median followup was 51.3 months (range 25 to 144). Of the 25 patients 8 (32%) did not respond to BCG therapy and 17 (68%) did. Immunomarkings were not statistically different between BCG responsive and nonresponsive patients for 0, 5, 10, 20, 35, 40, 45, 55 and 65 thresholds. Chi-square and Fisher's exact test were 0.91 and 0.83, 0.40 and 0.20, 0.58 and 0.29, 0.96 and 0.81, 0.80 and 0.88, 0.67 and 0.73, 0.91 and 0.83, 0.80 and 0.38, 0.69 and 0.32, respectively. CONCLUSIONS: Our results indicate that the percentage of p53 immunomarked cell cannot currently be used to predict clinical response to BCG therapy and, therefore, p53 over expression is not a viable indicator of T1G3 recurrence when using this treatment.

[Infectious risks of outpatient cystoscopy in men with sterile urine]. / Risques infectieux de la fibroscopie urétro-vésicale en ambulatoire chez l'homme à urines stériles.

OBJECTIVE: To prospectively assess the inherent risk of infection associated with outpatient cystoscopy performed in men with sterile urine without antibiotic prophylaxis. MATERIAL AND METHODS: 298 cystoscopies were performed in men corresponding to these criteria, with the exclusion of patients at risk of bacterial endocarditis. The equipment consisted of three cystoscopes prepared according to the recommendations of the Société Française d'Hygiène Hospitalière. The disease justifying the examination was specified for each patient. The sterility of the urine was verified during the week preceding the examination and 48 hours later by urine culture. RESULTS: Out of 281 evaluable patients, an infection was observed in 22 cases (7.8%), and was symptomatic in only one case. Escherichia coli was the organism most frequently isolated (50%) and no multiresistant bacteria were detected. A particularly high infection rate was observed in enterocystoplasty patients (21.7%). CONCLUSION: The infectious risk of cystoscopy in the presence of sterile urine, performed according to recommendations, appears to be higher than previously reported. This risk appears to be significantly higher in the case of enterocystoplasty than for other diseases.

[Value of nephron preservation in conservative surgery of renal tumors]. / Intérêt de la préservation néphronique dans la chirurgie conservatrice des tumeurs rénales.

The increasing use of abdominal ultrasonography and computed tomography results in the increasingly early diagnosis of subclinical renal tumours. These asymptomatic tumours can sometimes be treated conservatively. This technique raises the problem of the multifocal nature of renal tumours In order to assess the real benefit of nephron-sparing surgery in relation to the risk of recurrence, this study evaluates the repercussions of exclusive tumour resection on the nephron number. From 1990 to 1995, 28 patients underwent partial nephrectomy for suspected renal cell carcinoma. Computed tomography was use to estimate the volume and therefore the weight of the kidney and the tumour: weight (g) = volume (mL) = length x width x height/2. The mean age of the patients was 59.1 years. The contralateral kidney was normal in 20 patients (group 1) and the tumour affected a solitary kidney in 8 patients (group 2). The initial serum creatinine level was normal (between 78 and 96) in all patients. The mean weight of the tumour was 16.1 g (13.6 g for group 1 and 22.3 g for group 2), and corresponded to 3.84% of the total kidney weight in group 1 and 9.73% in group 2. 1,400,000 nephrons were preserved in group 1 versus 900,000 nephrons in group 2, equivalent to a glomerular filtration rate of 89 mL/min and 58 mL/min, respectively. Partial nephrectomy therefore constitutes a real nephron-sparing technique. It allows sparing of a sufficient number of nephrons to ensure normal renal function and, most importantly, allows the possibility of subsequent partial surgery in view of the potential risk of multifocal tumours.

[Mixed secretory and obstructive azoospermia. Transseptal vasovasostomy by vas deferens transposition: a case report and review of the literature]. / Azoospermie mixte sécrétoire et obstructive. Vasovasostomie trans-septale par transposition des déférents: à propos d'un cas et revue de la littérature.

The authors report a case of complex azoospermia in a 35-year-old man, due to a combination of right testicular atrophy and an iatrogenic lesion of the contralateral vas deferens. Vasovasostomy with transseptal transposition of the vasa deferens restored fertile ejaculation.

[Vital prognosis in acute pancreatitis. Study of 5 clinicobiological indices]. / Pronostic vital dans la pancréatite aiguë. Etude de 5 indices clinico-biologiques.

The values of the Acute Physiology and Chronic Health Enquiry (Apache II) and the Simplified Acute Physiology Scores (SAPS) were compared with Ranson and Imrie scores to predict death after acute pancreatitis. Fifty-five (ten deaths) patients were evaluated. Patients who died had a mean score greater than those who survived. The accuracy of all scores was similar after 48 hours. The ICU (Intensive Care Unit) available at the time of admission may facilitate the early selection of patients for appropriate management.