A multicenter comparative matched-pair analysis of percutaneous tumor ablation and robotic-assisted partial nephrectomy of T1b renal cell carcinoma (AblatT1b study-UroCCR 80).

OBJECTIVE: Renal cell carcinomas represent the sixth- and tenth-most frequently diagnosed cancer in men and women. Recently, percutaneous-guided thermal ablations have proved to be as effective as partial nephrectomy and safer for treating small renal masses (i.e., < 3 cm). This study compared the perioperative and recurrence outcomes of percutaneous thermal ablation (TA) and robotic-assisted partial nephrectomy (RAPN) for the treatment of T1b renal cell carcinomas (4.1-7 cm). METHODS: Retrospective data from 11 centers on the national database, between 2010 and 2020, included 81 patients treated with thermal ablation (TA) and 308 patients treated with RAPN for T1b renal cell carcinoma, collected retrospectively and matched for tumor size, histology results, and the RENAL score. TA included cryoablation and microwave ablation. Endpoints compared the rate between the two groups: local recurrence, metastases, complications, renal function decrease, and length of hospitalization. RESULTS: After matching, 75 patients were included in each group; mean age was 76.6 (± 9) in the TA group and 61.1 (± 12) in the RAPN group, including 69.3% and 76% men respectively. The local recurrence (LR) rate was significantly higher in the TA group than in the PN group (14.6% vs 4%; p = 0.02). The LR rate was 20% (1/5) after microwave ablation, 11.1% (1/9) after radiofrequency ablation, and 14.7% (9/61) after cryoablation. The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs 0%; p < 0.001). Metastases, eGFR decrease, and length of hospitalization did not differ significantly between the two groups. CONCLUSIONS: The local recurrence rate was significantly higher after thermal ablation; however, thermal ablation resulted in significantly lower rates of complications. Thermal ablation and robotic-assisted partial nephrectomy are effective treatments for T1b renal cancer; however, the local recurrence rate was higher after thermal ablation. KEY POINTS: • The local recurrence rate was significantly higher in the thermal ablation group than in the partial nephrectomy group. • The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs. 0%; p < 0.001).

Contemporary assessment of the correlation between Bosniak classification and histological characteristics of surgically removed atypical renal cysts (UroCCR-12 study).

PURPOSE: To evaluate and compare pathological characteristics of renal cysts Bosniak IIF, III and IV in light of recent histological classification. PATIENTS AND METHODS: The French research network for kidney cancer UroCCR conducted a multicentre study on patients treated surgically for a renal cyst between 2007 and 2016. Independent radiological and centralized pathological reviews were performed for every patient. Pathological characteristics were compared to the Bosniak classification. RESULTS: Of a total 216 patients included, 175 (81.0%) tumours (90.9% of Bosniak IV, 69.8% of Bosniak III) were malignant or had a low malignant potential, with 60% of clear cell renal cell carcinoma (CCRCC), 24% of papillary RCC (PRCC) and 6.9% of multilocular cystic renal tumour of low malignant potential (MCRTLMP). Malignancies were mostly of low pT stage (86.4% of pT1-2), and low ISUP grade (68.0% of 1-2). Bosniak III cysts had a lower rate of CCRCC (46.7 vs. 67.3%), higher rate of PRCC (30 vs. 20.9%) and MCRTLMP (18.3 vs. 0.9%) compared to Bosniak IV (p < 0.001). Low-malignant potential lesions were less likely Bosniak IV and pT3-4 stage was more frequent in Bosniak IV vs. III (15.7 vs. 3.5%; p = 0.04). There were two recurrences (1.1%) and no cancer-related death occurred during follow-up. CONCLUSION: These results confirmed that cystic renal malignancies have excellent prognosis. Bosniak III cysts had a low malignant potential, which suggests surveillance could be an option for these lesions.

How Did We Obtain Complete Remission in Patients Who Had Metastatic Renal Cancer in the Era of Targeted Therapies?

BACKGROUND: The management of metastatic renal cell carcinoma (mRCC) has been transformed by the use of targeted therapies, ablative therapies and improved surgical techniques. The objective of this study was to identify therapeutic strategies that resulted in complete remission (CR) and to assess survival of patients in CR. METHODS: In a prospective database, we included all patients treated for mRCC at a university hospital between 2007 and 2015. CR was defined as the absence of metastasis after a full-body computed tomographic scan. RESULTS: We treated 77 patients with mRCC and experienced a CR in 22 (29 %) patients. Patients in CR had, respectively, synchronous and metachronous metastases in 7 (32 %) and 15 (68 %) cases and unique and multiple metastases in 4 (18 %) and 18 (82 %) cases. All patients were treated with cytoreductive nephrectomy and 21 (96 %) had metastasectomy or percutaneous ablation of their metastases. One patient had a CR after systemic treatment with sunitinib. After a median (range) follow-up since metastatic diagnosis of 35 (1-89) months, 12 patients (55 %) had disease recurrence. The median (range) duration of CR before recurrence was 14 (1-39) months. After recurrence, a new CR was obtained in 7 patients (58 %). At the end of follow-up, 16 patients (73 %) were still in CR, 5 (23 %) were undergoing medical treatment, and 1 patient died during the postoperative course. CONCLUSIONS: In the era of targeted-therapies, CRs were obtained with multimodal treatment of metastatic kidney cancer. All patients in CR had a nephrectomy and almost all of them had multiple metastasectomies.

Posterior Spinal Cord Syndrome after Flexible Ureteroscopy for Kidney Stones.

A 49-year-old woman was treated for right kidney stones using flexible ureteroscopy and laser lithotripsy. She was readmitted 2 weeks after the treatment with complaints of walking difficulties. On neurologic examination, it was found that she had a bilateral proprioceptive dysfunction. Spinal MRI revealed an intramedullary lesion at the T10-T11 level consistent with an intramedullary cavernoma. The final diagnosis was a spinal compression consecutive to the cavernoma bleeding associated with the prolonged lithotomy position. Symptoms have not been reversible and the patient continued to have walking difficulties. We report for the first time a major complication that arises as a result of using flexible ureteroscopy for treating kidney stones.

Feasibility, safety, and efficacy of salvage radical prostatectomy after Tookad® Soluble focal treatment for localized prostate cancer.

PURPOSE: To investigate feasibility, safety, and efficacy of salvage radical prostatectomy (RP) for recurrent prostate cancer (PCa) after focal treatment with TOOKAD(®) Soluble vascular-targeted photodynamic therapy (VTP). METHODS: Nineteen patients underwent RP after biopsy-proven PCa post-focal VTP. We reported: operation time, blood loss, transfusion, complications, urethral catheterization time, functional outcomes, and short-term oncologic outcomes. RESULTS: Median age was 64 years (58-70). Median PSA before VTP was 6.30 ng/ml (3.20-9.80). Median delay between VTP and RP was 17 months (8-48). Median blood loss was 400 ml (100-1,000). Median operation time was 150 min (90-210), median urethral catheterization time was 7 days (5-18), and median hospital stay was 7 days (4-21). There was no perioperative mortality. Three patients had related per-operative complications: one pelvic hematoma (150 cc) (Clavien IIIa), one per-operative transfusion (900 cc hemorrhage) (Clavien II), and one superficial wound infection (Clavien I). After a median follow-up of 10 months (1-46), 13 were completely continent (68 %), five needed ≤1 pad/day, and one needed 3 pads/day (Clavien I). Severe erectile dysfunction was observed before and after RP (respectively 8 and 18). Ten patients regained potency with appropriate treatment. Median postoperative PSA was 0.02 ng/ml (<0.01-0.38) and remained undetectable for 16 patients (84 %). Nine patients had positive margins and six underwent complementary radiotherapy. Positive margins were significantly associated with bilateral VTP [risk ratio = 4.3, 95 % confidence interval (1.6-11.7), p = 0.003]. CONCLUSION: Salvage RP after VTP treatment was feasible, safe, and efficient to treat most of the locally recurrent PCa. Short-term oncologic and functional outcomes were promising, but further studies are required.

Successful medical treatment of glans ischemia after voluntary buprenorphine injection.

INTRODUCTION: The diverted use of synthetic opioid buprenorphine by drug addicts can be responsible for serious ischemic and infectious complications, particularly in the case of intravenous injection. AIM: We present a case of serious glans ischemia after buprenorphine injection directly into the deep dorsal vein of the penis. Analysis using new medical imaging techniques and treatments is detailed below. METHODS: A 26-year-old male drug addict presented with glans pain 4 days after self-injection of buprenorphine into the deep dorsal vein of the penis. The patient was apyretic and presented a urethral discharge. His glans was blue without discoloration on digital pressure. Additionally, his biologic and serologic tests were normal while bacteriology showed the presence of Enterobacter cloacae urethritis. RESULTS: After 48 hours of intravenous antibiotic treatment without improvement, a specific medical treatment using enoxaparin and ilomedin was initiated, with the assumption that there was an ischemic complication. Laser speckle contrast imaging allowed confirmation of the presence of distal penis ischemia and provided an accurate mapping of the ischemic zone. A 28-day treatment combining antibiotics, subcutaneous heparin at curative dose, antiplatelet drug, ilomedin, and hyperbaric oxygen therapy resulted in clinical improvement of the lesions with no functional complications. CONCLUSIONS: To date, no consensus exists on the proper diagnostic and treatment approach to severe glans ischemia due to buprenorphine injection into the deep dorsal vein of the penis. The results of laser speckle contrast imaging were of real interest during the process of diagnosis. In addition, the combination of ilomedin with hyperbaric oxygen therapy and anticoagulant and antiplatelet drugs appeared to be an effective therapy.

[Impact of delay before partial nephrectomy of a localized kidney tumor]. / Impact du délai avant prise en charge par néphrectomie partielle d'une tumeur du rein localisée.

INTRODUCTION: Partial nephrectomy is the treatment of choice for small localized renal tumors. In case of doubt, a biopsy can confirm the diagnosis. The aim of this study was to evaluate the impact of a delayed time to partial nephrectomy on cancer development. MATERIALS AND METHODS: Our single center study enrolled localized renal tumor patients who underwent a partial nephrectomy between 2015 and 2020; the collected data were included in the uroCCR prospective database. The histopathological stage of the tumors and the recurrence rate in patients treated with surgery >90 days after diagnosis were investigated. The impact a preoperative biopsy on was also explored. Statistical significance was tested using Student's t-test and Chi-squared test (SPSS software). RESULTS: The cohort consisted of 179 patients, among which 41 (23 %) received a preoperative biopsy. 89 patients (50 %) were treated surgically >3 months after diagnosis. The median time to nephrectomy was 86 days (13-1 037). A delayed time to surgery did not lead to significantly higher recurrence rates (P=0.66). Preoperative biopsy led to a doubling time to surgery (P<0.001) but was neither correlated to a more severe tumor stage (P=0.944) nor to a higher recurrence rate (P=0.08). Tumor growth was not significantly different with or without the presence of a biopsy (P=0.122). CONCLUSION: Our data evidence that a substantial delayed time to partial nephrectomy does not result in a negative impact on cancer prognosis in localized renal tumor patients.

Percutaneous tumor ablation versus image guided robotic-assisted partial nephrectomy for cT1b renal cell carcinoma: a comparative matched-pair analysis (UroCCR 80).

BACKGROUND: Partial nephrectomy (PN) is the gold standard treatment for cT1b renal tumors. Percutaneous guided thermal ablation (TA) has proven oncologic efficacy with low morbidity for the treatment of small renal masses (<3 cm). Recently, 3D image-guided robot-assisted PN (3D-IGRAPN) has been described, and decreased perioperative morbidity compared to standard RAPN has been reported. Our objective was to compare two minimally invasive image-guided nephron-sparing procedures (TA vs. 3D-IGRAPN) for the treatment of cT1b renal cell carcinomas (4.1-7 cm). METHODS: Patients treated with TA and 3D-IGRAPN for cT1b renal cell carcinoma, prospectively included in the UroCCR database (NCT03293563), were pair-matched for tumor size, pathology, and RENAL score. The primary endpoint was the local recurrence rate between the two groups. Secondary endpoints included metastatic evolution, perioperative complications, decrease in renal function, and length of hospitalization. RESULTS: A total of 198 patients were included and matched into two groups of 72 patients. The local recurrence rate was significantly higher in the TA group than that in the 3D-IGRAPN group (4.2% vs. 15.2%, P=0.04). Metastatic evolution and perioperative outcomes such as major complications, eGFR decrease, and length of hospitalization did not differ significantly between the two groups. CONCLUSIONS: 3D-IGRAPN resulted in a significantly lower local recurrence rate and comparable rates of complications and metastatic evolution compared with thermal ablation.

Percutaneous Ablation Versus Surgical Resection for Local Recurrence Following Partial Nephrectomy for Renal Cell Cancer: A Propensity Score Analysis (REPART Study-UroCCR 71).

BACKGROUND: Data comparing percutaneous ablation (PCA) and surgical resection (SR) for an isolated local recurrence (LR) following partial nephrectomy (PN) for renal cell carcinoma (RCC) are lacking. OBJECTIVE: To examine the outcomes between PCA and SR for an isolated LR following PN for RCC. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent PN for RCC and developed an LR between 2013 and 2019 were included. An LR was defined as the appearance of a mass in contact with the resection bed or the development of a tumor in the same region of the homolateral kidney as the original site. INTERVENTION: PCA or SR. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: To achieve balance in baseline characteristics, we used inverse probability of treatment weighting (IPTW) based on propensity to receive treatment. Oncological outcomes, complications, and renal function were evaluated between groups using logistic, linear, and Cox proportional hazard regression models. RESULTS AND LIMITATIONS: A total of 81 patients with an isolated LR were included (PCA: 42; SR: 39). The median follow-up was 23 mo. After adjustment, excellent balance was achieved for the majority of propensity score variables. In IPTW analysis, PCA was associated with a lower risk of postoperative complications (odds ratio=0.22; p=0.006) and a smaller change in eGFR (beta=-16.18; p=0.001). There were no significant differences in the risk of disease recurrence (hazard ratio [HR]=0.72; p=0.61), new LR (HR=1.51; p=0.59), and distant metastasis (HR=0.19; p=0.09). Limitations include the sample size and unmeasured confounding factors. CONCLUSIONS: Our results suggest that PCA provides comparable oncological outcomes to repeat surgery with fewer complications and better renal function preservation for the management of an LR after PN. PATIENT SUMMARY: This report shows that percutaneous ablation can be used for treating a local recurrence of renal cell carcinoma after partial nephrectomy, without significantly compromising cancer control.

Prostate cancer detection by targeted prostate biopsy using the 3D Navigo system: a prospective study.

PURPOSE: The 3D Navigo™ system is a magnetic resonance imaging (MRI) and transrectal ultrasound (TRUS) fusion device for prostate targeted biopsies (TB). Our aim was to evaluate the clinically significant prostate cancer (CSC) detection rate of TB using the 3D Navigo™ system. METHODS: Patients who underwent TB with the 3D Navigo™ system in our center between June 2014 and May 2018 were prospectively included, excluding those who have previously received treatment for prostate cancer. A 3-Tesla MRI imaging was performed before biopsies; findings were reported according to the Prostate Imaging Reporting and Data System version 2 (PIRADS). CSC was defined by an ISUP score ≥ 2. RESULTS: 304 patients underwent TB. Median age was 66 years (51-84). Median PSA was 7.75 ng/ml (0.6-70.0). Median prostate volume was 45.0 ml (15.9-221.7). PCa and CSC were found in 70.4% (214/304) and 47.7% (145/304) of the patients, respectively. The proportion of patients diagnosed with CSC among those with PCa was 67.8% (145/214). There was a significant risk of having a CSC in case of PIRADS score ≥ 4 and 5 (OR 5.0, 95% CI [2.7-9.2], P < 0.001; OR 3.2, 95% CI [1.8-5.5], P < 0.001). PIRADS score was an independent risk factor of having a CSC (OR 4.19, 95% CI [2.49-7.05], P < 0.001). There was no significant difference between pathological outcomes of TB and RP in paired analysis (P = 0.892). There was a correlation between TB and RP specimens for PCa detection (r = 0.60, P < 0.001). CONCLUSION: Detecting CSC with MRI-TRUS fusion targeted biopsies using the 3D Navigo™ system is feasible and safe. We found a positive correlation between TB and RP for ISUP scores.