[Long-term follow-up of renal cell carcinomas T1a treated by percutaneous radiofrequency]. / Suivi à long terme des carcinomes à cellules rénales T1a traités par radiofréquence percutanée.

OBJECTIVE: To evaluate the long-term oncological and functional results of the ablative treatment of T1a kidney malignancies by percutaneous radiofrequency (RF). MATERIALS AND METHODS: Monocentric retrospective study including all patients treated for renal cell carcinoma (RCC) T1a by radiofrequency, in our center, from 2005 to 2009. All patients had a tumor biopsy before treatment. The primary endpoint was local recurrence. A total of 44 RCCs in 41 consecutive patients were treated (1 patient had 3 synchronous tumors and 1 patient had 2 tumors). There were 26 clear cell RCCs, 13 papillary RCCs and 5 chromophobe RCCs. The median age at diagnosis was 70 years [48-82]. The median American Society of Anesthesiologists (ASA) score was 2 [1-3] and the median glomerular filtration rate (GFR) was 64mL/min [26-109]. Furhman grade was defined for 39 tumors (Clear cell RCC and papillary RCC), of which 82% were grade 1-2. The median tumor size was 20mm [11-40], and the median RENAL score was 4 [4-6]. Complications were assessed according to the Clavien-Dindo classification. Overall survival, recurrence-free survival and metastasis-free survival were calculated using the Kaplan-Meier method. RESULTS: Median follow-up was 90.5 months [17.8-145.3]. Three (7%) local recurrences were reported within a median of 26 months [12-93]. All were treated by a 2nd RF. The overall 10-year survival was 70% (95% CI [56-85]). The 10-year recurrence-free survival was 72% (95% CI [57-88]). The 10-year metastasis-free survival was 87% (95% CI [74-97]). The median GFR on the date of the last news was 51mL/min [16-98] (P=0.05). Post-RFA complications consisted in 5 (11.3%) Clavien-Dindo 1-2 complications. No high grade (Clavien ≥3). CONCLUSION: Percutaneous radiofrequency for RCC T1a is an alternative. It appears to be safe with low morbidity, satisfaying long-term oncological and functional results, but a risk of reprocessing of 7%. LEVEL OF EVIDENCE: 3.

[Treatment by radiofrequency ablation for a renin-secreting juxtaglomerular tumour: a case report]. / Traitement par radiofréquence d'une tumeur de l'appareil juxta-glomérulaire sécrétant de la rénine. À propos d'un cas.

Juxtaglomerular cell tumors are rare and benign tumors, occurring in young patients. The standard treatment is partial nephrectomy. We report the case of a young 22-year-old patient with a renin-secreting tumor diagnosed during an exploration of severe hypertension associated with hypokalemia that we treated by radiofrequency ablation.

[Initial results of adjustable periurethral balloons (ACT™ and pro ACT™) in the treatment of adult stress urinary incontinence with intrinsic sphincter deficiency]. / Résultats initiaux de l'utilisation des ballons périurétraux ajustables (ACT™ et pro ACT™) dans le traitement de l'incontinence urinaire d'effort par insuffisance sphinctérienne de l'adulte.

OBJECTIVE: To report efficacy and morbidity of periurethral adjustable balloons (PUAB) in the treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). PATIENTS AND METHODS: Retrospective descriptive and analytic patients cohort study was performed from July 2010 to June 2012. We reviewed data from 43 patients (19 women and 24 men). The patients were categorized into 3 groups: i) women, ii) men after prostatectomy, iii) men with neurogenic SUI (prostate in position). Sandvick score and the average of 3 days 24 h Pad test evaluated the efficacy of the device. The patients impression of improvement was assessed in three degrees: completely improved, partially improved, not improved. RESULTS: After a median follow-up of 67 weeks (min. 40, max. 91) a significant improvement of the score of Sandvik was observed (8 to 4, P<0.005). The proportion of dry patients or with one security protection in the three groups was 57.9%, 64.3% and 50% respectively for women, men after prostatectomy, and men with neurological SUI. About 27.9% (12/43) of the patients had post-operative complications. These complications required an explantation of the PUAB in 11/12 patients among whom 7/11 (63.6%) had a delayed re-implantation of the device. CONCLUSION: In this series, the overall efficacy observed was 67.4% with a post-operative complication rate of 27.9%. The device adjustment was done in consultation as well as the complications management and the explantation when necessary. LEVEL OF EVIDENCE: 4.

[Comparative study of radical prostatectomy versus external beam radiotherapy (75.6 Gy) combined with hormone therapy for prostate cancer of intermediate D'Amico risk classification]. / Étude comparative des résultats carcinologiques après prostatectomie et radiothérapie externe (75,6Gy) avec hormonothérapie concomitante pour cancer de prostate à risque intermédiaire de D'Amico.

INTRODUCTION: Thirty-three percent of the localized cancers belongs initially to the group of intermediate risk of D'Amico. The standard treatments validated by the French Association of Urology are the radical prostatectomy and the external beam radiotherapy. OBJECTIVES: We retrospectively compared the carcinologic results of the radical prostatectomy±adjuvant treatment (RP) and the external beam radiotherapy combining high dose (75.6 Gy) and short hormonotherapy (RH), in the treatment of intermediate risk prostate cancer. The series consisted of 143 patients treated between 2000 and 2006 in the department of Urology and Kidney transplantation of the Conception Hospital, Marseilles. The main assessment criteria was the survival without biological recurrence (SBR). RESULTS: The median follow-up was 90 months [59-51]. The 5 years and 8 years SBR were 85% and 73% in the RH group, versus 74% and 65% with RP (P=0.196). There was a significant difference between the series: on the age of diagnosis (63.9 versus 73.3 years, P<0.001), the Charlson score of comorbidity (2 versus 3, P<0.001) and the number of intermediate criteria per patients (one intermediate criteria: RP 74% versus 57%, P<0.01). CONCLUSION: According to our study, there was no superiority of the radical prostatectomy±adjuvant treatment or the external radiotherapy combining high dose and concomitant short hormonotherapy on the survival without biological recurrence at 5 and 8 years. Many studies confirm that a concomitant hormonotherapy increases the carcinologic control, even with a high rate external beam radiotherapy.

[Economic and organizational impact of the use of a disposable sheath with a flexible cystoscope]. / Cystoscope flexible à gaine stérile à usage unique: impact organisationnel et économique et sécurité bactériologique.

PURPOSE: To assess both economical and organizational impact as well as bacteriologic safety of a flexible cystoscope with sterile disposable sheath (FCSDS) compared to standard flexible cystoscopy (SFC) in two French urologic academic units. PATIENTS: Two-center prospective study, comparing the use of the FCSDS to the SFC on two consecutive periods of time. Two hundred and five patients were included and divided into each group. Duration procedures and costs were analysed in the two techniques. The urinary tract infection rate was also described. A dedicated sheaths leaks test after use was performed systematically. RESULTS: The preparation time of the fibroscope was longer for the sheathed cystoscopy group: 16.2 minutes versus 10.9 minutes for the standard group. The mean duration of disinfection was significantly shorter for the sheathed cystoscopy group: 53.8 minutes saved compared to the standard group; 99.01% of the tested sheaths, after their use, had no breaches. Urinary tract infections rate were similar in the two groups. The average cost of a sheathed cystoscopy compared to the standard was significantly cheaper in Lyon and almost equivalent in Marseille. CONCLUSION: The FCSDS allows significant saving over the disinfection duration, consumable costs and staff costs, while ensuring patient bacteriologic safety similar to SFC.

[Female stress incontinence treatment: urethral slings]. / Traitement de l'incontinence urinaire d'effort féminine : les bandelettes sous-urétrales.

Female stress incontinence is often the consequences of obstetrical traumatisms. They are responsible of a weakness of perineal musculoaponevrotic structures. Until 1996, the reference treatment of this pathology was the "Burch" colposuspension, by laparotomy, then laparoscopic way. After 1996, a new procedure was developped by Ulmten, reproducible, easy, safe and mini-invasive: the tension free-vaginal-tape (TVT) followed by the trans-obturator-tape (TOT). This therapeutic tool has become the reference for the treatment of the female stress incontinence. There are now 15 years from the beginning of this procedure and still 80% of the patients are improved.

[Treatment of detrusor-striated sphincter dyssynergia with permanent nitinol urethral stent: results after a minimum follow-up of 2 years]. / Résultats à moyen terme du traitement de la dyssynergie vésicosphinctérienne par sphinctérotomie prothétique permanente.

OBJECTIVES: The aim of this study was to assess the outcomes of nitinol permanent urethral stents used in detrusor-striated sphincter dyssynergia (DSD) treatment on male patients with a spinal cord injury. MATERIALS: We investigated retrospectively all patients treated from 2004 to 2012. A total of 22 patients were included, with an age ranging from 22 to 76 years old. The DSD syndrome was due to spinal cord injury (18) or various spinal cord diseases (four) and treated with a nitinol urethral stent (11 Ultraflex(®) and 11 Mémotherm(®)). Every patient had an urodynamical study. The follow-up reached at least 2 years. RESULTS: The mean follow-up was 56 months (± 14). Complementary procedures after stenting included: five stent prolongation or displacement (mean interval 7.6 months), six bladder neck incisions (12.2 months), three urethrotomy (42 months), ten obstruction treated by laser (47.3 months). Eight patients had a change of their urinary pattern: four underwent ileal conduit diversion, one had a continent urinary diversion, one chose self intermittent catheterization, two were under indwelling catheterization waiting for another treatment. Stent retrieval was either harmful or impossible for four of them. Three patients were free of complementary procedures. CONCLUSIONS: Nitinol urethral stent was an effective treatment initially. However, by the third year, urethral stenosis and hypertrophic growth of the urethral mucosa usually require iterative endoscopic procedures (0.31 per patient per year). Patients treated with permanent uretral stent deserve a yearly endoscopic follow-up. Safety and effectiveness of permanent uretral stent compared to surgical sphincterotomy to treat DSD are discussed.

[Partial nephrectomy for cancer and percutaneous biopsy: Oncologic results]. / Néphrectomie partielle pour cancer et biopsie percutanée : résultats oncologiques.

OBJECTIVES: To evaluate the results of partial nephrectomy (NP) for cancer in 60 patients selected by the biopsy of the tumor by analyzing the information, oncologic follow-up. PATIENTS: It was a cohort study unicenter retrospective from 1994 to 2006. The biopsy was systematically done for patients who were candidates for elective NP. The criteria for elective indications NP tumors were less than 4cm, low grade Fuhrman (I and II). The tubulopapillary tumors (TBP) on biopsy were excluded from the elective indications. The parameters studied were the biopsy data, overall survival, disease-free survival. RESULTS: The median age was 59 years (32-79 years) and 69% of tumor were fortuitous discovery. Indications of need accounted for 30% of cases (single kidney, bilateral tumors and chronic renal failure [CRF]). Biopsy allowed a diagnosis in 89% of cases. There was one death in specific postoperative immediately. A final histology was 75% of clear cell carcinoma, 13.3% of chromophobe and 11.7% of TBP, 96.6% of T1a including 86.6% of low grade and no surgical margin. The median follow-up was 49 months with 98.5% of specific survival at 5 years, one local recurrence and no general recurrence. CONCLUSION: The study has shown that the selection of patients by biopsy gives satisfactory carcinologic results with 98.5% specific survival at the end of follow-up; it is between 89 and 100% in the literature.

[Renal angiomyolipomas without fat component: tomodensitometric and histologic characteristics, clinical course]. / Angiomyolipomes rénaux sans composante graisseuse : caractéristiques tomodensitométriques, histologiques et évolutives.

INTRODUCTION: Angiomyolipoma is the most frequent benign renal solid tumor. Because of the lack of fat component on the CT scan, diagnosis of this tumor is hard and can require percutaneous biopsy of unknown renal tumor. The follow-up of the poor fat CT scan component AML (PFCT AML) is uncertain. METHODS: Five hundred percutaneous renal biopsy under tomodenstitometry have been realised between 1998 and 2008. There was 41 PFCT AML on the 500 biopsy. By definition, a PFCT AML is an AML where the diagnosis is done on a percutaneous biopsy but where there was no fat component on the first CT scan. We studied and compared clinical, tomodensitometric and histologic parameters of these 41 patients (mean age: 56, 9±11.04; sexe rate M/F: 6/35) where renal AML was diagnosed on percutaneous renal biopsy but without fat component on CT scan. Average size was 26.44±14.68mm. We phone-called 16 patients for the long-term follow-up. Average follow-up was 41±28.3 months. For four patients on 16, initial diagnosis was done in front of local symptoms, for one of the 16 diagnosis was done in front of general symptoms, for one of the diagnosis was done during Bourneville tuberous sclerosis evolution and 10 of the 16 was done fortuitously. RESULTS: After review of the initial CT scan, fat density was found on 24% of them. Ten percent was epithelioid angiomyolipoma. Four renal biopsy on 41 (10%) was epithelioid AML. No epithelioid AML had fat component after the second look of the CT scan. Among the 16 patients who were phone-called, three (19%) underwent a complication. Two had abdominal pain and was treated medically. Initial sizes were 26 and 30mm. Only one patient must be operated by radical nephrectomy for acute hemorrhage. Initial size was 45mm. No neoplasic degeneration was identified for those 16 patients. CONCLUSION: In our study, the PFCT AML rate was 8.2%. In 25% cases, CT scan read-through shown a fat component and could help for the diagnosis. PFCT AML evolution seems to be the same as a classic AML. Conservative treatment had a good covering because there was no death and no malignant evolution. However, we found 10% of epithelioid angiomyolipoma in which malignant risk is high. PFCT AML diagnosed on renal percutaneous biopsy of unknown renal tumor requires the same management than the classic AML.

[3D conformal radiation therapy and hormonal therapy for localized prostate cancer: is age a limiting factor?]. / La radiothérapie conformationnelle associée à l'hormonothérapie du cancer de prostate localisé: l'âge est-il un facteur limitant ?

No study on side effects had showed that conformal radiation therapy for prostate cancer is more harmful in patients older than 70 years to patients younger. The aim of this study was to evaluate acute and late toxicities of conformal radiotherapy, with high dose for localized prostate cancer in patients older than 70 years and compared to patients younger than 70 years. Between 1996 and 2009, 104 patients were treated with radiation therapy and hormonal therapy for localized cancer prostate. Median follow-up was 105 months (9-300). Acute (occurred at ≤ three months) and late side effects of 55 patients older than 70 years (median age: 75 [71-92]) were graded according to the CTCAE 3.0 criteria and compared to the younger population. Median dose to the prostate was 75.6 Gy (67-80) in both groups. There were no significant differences in acute and late side effects between age groups. For patients above 70 years, the incidence of grade II or higher acute and late side effects were respectively 27 and 22% for urologic symptoms and 13 and 16% for rectal symptoms. The frequency of grade III late symptoms was low and ranged between 0 and 6% for the evaluated symptoms, irrespective of age group. Older patients had a better biochemical recurrence-free survival than younger patients (86 versus 77% at four years, P=ns). High dose 3D conformal radiotherapy for localized prostate cancer was well tolerated in patients older than 70 years. Age is not a limiting factor for conformal radiation therapy and hormonotherapy for older patients.

[Local recurrence of renal carcinoma after laparoscopic partial nephrectomy]. / Récidive locale après néphrectomie partielle laparoscopique (NPL) pour cancer du rein.

We report the case of an early local recurrence after a laparoscopic partial nephrectomy (LPN) for a Furhman grade 1-2 clear cell renal carcinoma (CCRC). CT scan at 6 months revealed a local recurrence. An open total nephrectomy was performed. There were six nodules in the perirenal fat from a grade 3 CCRC. Twenty-six months after the LPN, the patient had a wound recurrence, which was surgically removed. Four months after the wound recurrence, the patient had pulmonary, liver and adrenal glands metastasis. He received an oral treatment with sunitinib. At 4 months after the initiation of the sunitinib, he had a total response.

[Pelvic kystic schwannoma evoking a tumor of the right seminal vesicle]. / Schwannome kystique pelvien évoquant une tumeur de la vésicule séminale droite.

We present the case of a pelvic schwannoma in a 36 year old man. It was discovered by chance during the medical assessment of a prostatitis. A computed tomography scan and magnetic resonance imaging revealed a 8 centimeters cystic pelvic tumor, closed to the right seminal vesicle. The patient underwent a transrectal ultrasound-guided biopsy, which showed a proliferation of neural peripheric cells with nuclear abnormalities. A tumorectomy was performed by laparotomy. The histological study diagnosed a benign cystic schwannoma. The patient was free of disease 12 months postoperatively.

[PSA and spironolactone]. / PSA et spironolactone.

The spironolactone is a diuretic of potassium savings. It is also used in the treatment of the hirsutism for its antiandrogenic action. Its use and its effects on the patients affected by a prostate cancer are less known. We report the case of a 72-year-old man having a cancer of prostate which normalized its PSA after institution of a treatment by spironolactone for ascites. This patient had a biological recurrence of a prostate cancer, arisen 7 years later after a treatment by hormonal radiotherapy. Nine months after the implementation of the treatment by spironolactone, there were no clinical and biological signs of disease progress.

[New perspectives in prostate cancer management]. / Les nouvelles perspectives de prise en charge du cancer de la prostate.

The treatment of prostate cancer is experiencing important innovations. Hormone therapy includes a new class of drugs: LHRH antagonists, which induce a rapid, fast and sustained reduction of testosterone levels. Active surveillance enables to avoid an aggressive treatment without decreasing survival, provided that strict eligibility and follow-up criteria are applied. New imaging techniques and laboratory assays lead to early diagnosis of small size tumors. Lastly, focal therapy has the potential to target localized cancers without deterioration of surrounding structures. These concomitant improvements offer the clinician and the patient attractive options for prostate cancer management. However, they are not devoid of limitations and constraints. Thus, it is crucial to define the most appropriate patient's profile for each therapeutic option, taking into account the objective characteristics of the tumor and the psychological features of the patient.

[First line indications for hormonal therapy in prostate cancer]. / Cancer de la prostate et hormonothérapie: indications thérapeutiques de première ligne.

The utilization of androgen deprivation therapy in prostate cancer has evolved over time. Unquestionably considered first line treatment in metastatic cancers or in case of lymph node involvement, it is increasingly used in locally advanced and high-risk cancers, combined with radiation therapy. However, the practical modalities of treatment are still controversial (neoadjuvant, concomitant/adjuvant) and should be discussed on a case-by-case basis, taking into account tumor stage and risk level, which depends mainly on Gleason score and PSA levels and kinetics. Hormone therapy is also indicated in case of systemic relapse, especially if PSA doubling time is less than 12 months. LHRH agonists have become the standard care; antiandrogens can be added at the beginning of the LHRH agonist therapy to obtain a complete androgen blockade. Intermittent androgen deprivation therapy has recently proved efficacious and might be more widely used in the future, provided that strict prescription and follow-up recommendations are clearly established.

[Critical analysis of prognostic factors for metastatic renal cell carcinoma]. / Analyse critique des classifications pronostiques du cancer du rein métastatique.

A prognostic factor is a statistically associated variable with an event in a certain context. In the case of metastatic renal cell carcinoma, the variables are the clinical, biological and histological features of the cancer and its host, the event is the deaths linked to the cancer and context is the treatment suffered by the patient. Several prognostic classifications have permitted to predict the response to the different treatment of metastatic renal cell carcinoma. This review has aimed to put the main prognostic classifications in context of applicability so that the clinician uses them wisely. The classification of the French Group of Immunotherapy allows the clinician to determine the indications of treatment with IL-2 and IFN and Motzer classification of 2002 must be reviewed to determine the indications targeted therapies.

[Renal epithelioid angiomyolipoma]. / Angiomyolipome épithélioïde rénal.

Renal epithelioid angiomyolipomas (ReAML) are rare tumors (identified in less than 0,1 per thousand in general population) and represent 8% of operated angiomolipomas (AML). The diagnostic is histological, with an epithelioid cell component among the typical AML cells. ReAML are tumors derived from perivascular epithelioid cells (PEComa). There are benign PEComas, potentially aggressive PEComas and malignant PEComas. Most malignant PEComas are ReAML. There are two ReAML clinical entities, sporadic or associated to Tuberous Sclerosis Complex (TSC). ReAML are unique, localized and sporadic solid tumors of the kidney of variable size that can be revealed as classical AML with local symptoms or a complication (hemorrhage). Revelation mode is mostly radiologic. ReAML are fat-poor on CT-scan. They can be misdiagnosed with renal cell carcinoma (RCC). (One third of ReAML are malignant with a locoregional, nodal or metastatic evolution that can lead to death. ReAML treatments are multimodal depending of histology, clinical-radiological entity, evolution and the patient. Partial nephrectomy or follow-up are the benign entity treatment. Radical nephrectomy eventually followed by doxorubicine or rapamycine treatments are recommended for potentially aggressive and malignant entities.

[Retrograde endopyelotomy using Holmium-Yag laser for uretero-pelvic junction obstruction]. / Traitement des sténoses de la jonction pyélo-urétérale par endopyélotomie rétrograde au laser Holmium-Yag.

OBJECTIVE: To evaluate our results of retrograde laser endopyelotomy for uretero-pelvic junction obstruction. MATERIAL AND METHODS: Retrospective study of 27 consecutive retrograde laser endopyelotomies performed on 24 patients over a six years period (June 1999 to July 2005). Sixteen stenoses were primary. The level of obstruction was severe in 13 patients and moderate in 14 patients. A polar pedicle was diagnosed by pre-operative CT-angiography in seven cases. Balloon dilatation was performed in 17 procedures. A double J ureteral stent remained in place for six weeks mean. We evaluated results by a clinical examination and an excretory urography (at 1 and 6 months then annually). Mean follow-up was 35+/-22.7 months. RESULTS: Mean operating time and mean length of hospital stay were 49.8+/-17.9min and four days (range: 2-10 days). Two cases of pyelonephritis were observed. The overall success was 70%. In the eight unresolved cases, the failure appeared at 2.7+/-1 month mean. Success criteria were moderate level of obstruction and primary junction. Here, patients so selected have 100% of success. CONCLUSION: Study confirmed retrograde laser endopyelotomy was safety with a short length of hospital stay. This minimally invasive procedure should be reserved to primary moderate stenoses without polar pedicle.

[Anaesthesia without anaesthetist?]. / L'anesthésie sans anesthésiste?

The continuing decline in the number of anaesthetists-intensive care physicians means that certain operations need to be performed under the responsibility of urologists alone. These procedures can be performed perfectly safely in selected patients, provided the urologist is aware of the inherent risks of each local and regional anaesthesia or sedation technique.

[Economic evaluation of deflexible ureteroscopy with laser]. / Evaluation économique de l'urétéroscopie souple laser.

PURPOSE: The purpose of our study was to make an evaluation of the effective cost of a session of deflexible ureteroscopy with laser to cure kidney stones and kidney urothelials tumors. MATERIAL: This cost was calculated based on 103 sessions (83 kidney stones, 18 urothelials tumors, one cyst and one endopyelotomy) carried out on 73 patients and was including (1) staff expenses in the operation room (based on work time stated on the anesthesia sheet); (2) material expenses: technically specific or not. Reusable or single use; (3) amortisement of medical supply calculated on a seven year basis; (4) hospital stay. In this study medical logistic expenses and administrative expenses were not taken into account as well as structural expenses which were considered apart of this activity. RESULTS: Cost of a laser deflexible ureteroscopy was estimated by more or less 4237.3euro, including 1677.6euro for hospital charges. The cost of a session was 4490.5euro for a tumor and 4141.4euro for a stone, however the difference was not significant. Cost without hospital charges was estimated by 1196.5euro. CONCLUSION: The main part of a laser deflexible ureteroscopy session cost was the consequence of hospital expenses. It could only be obtained in a structure running a sufficient activity level depend on amortisement of medical supply.