Transversal European survey on testosterone deficiency diagnosis.

BACKGROUND: Despite being one of the relevant public health threats among ageing men, testosterone deficiency syndrome (TDS) is under-recognized and under-diagnosed. OBJECTIVE: To assess current clinical practices of European physicians regarding diagnosis and management of TDS compared with current guidelines. METHODS: Postal survey conducted June-November 2008 in France, Germany, Italy and Spain among urologists, endocrinologists and general practitioners to collect information regarding knowledge of TDS. RESULTS: Among 801 respondents, the majority of endocrinologists and urologists had received training on TDS, either initially or as part of continuous medical education. TDS was recognized by 86.5% of physicians as a true clinical entity, and estimated the prevalence at 10-15% of the male population; 73.5% considered that symptoms and a low level of testosterone were required for diagnosis. Treatment preferences were quarterly intramuscular injections (26.3% of physicians), percutaneous gels (23.9%), matrix patch (21.2%), semi-monthly injections (15.4%) and oral therapy (13.4%). Adverse effects of testosterone replacement therapy, such as benign prostatic hyperplasia and prostate cancer, were a concern for physicians. CONCLUSIONS: TDS management appeared to be close to that recommended in international guidelines. Signs and symptoms of testosterone deficiency were fairly well known, but some diagnostic and treatment variations were observed.

Urinary collecting system invasion is an independent prognostic factor of organ confined renal cell carcinoma.

PURPOSE: We evaluated urinary collecting system invasion as a prognostic parameter of renal cell carcinoma. MATERIALS AND METHODS: A total of 1,124 patients who underwent nephrectomy for a renal tumor at 5 European centers were included in this retrospective study. Several variables were analyzed including urinary collecting system invasion, age, sex, TNM stage, Fuhrman grade, histological subtype, Eastern Cooperative Oncology Group performance status and cancer specific survival. RESULTS: There were 771 males (68.6%) and 353 females (31.4%) in this study, and median age was 61 years (range 14 to 88). Median tumor size was 6 cm (range 1 to 24). Tumors were organ confined and Fuhrman grade was recorded as 1 or 2 in 67.1% and 62.3% of cases, respectively. Symptoms were present at diagnosis, and Eastern Cooperative Oncology Group performance status was 1 or more in 50.3% and 16.1% of the cases, respectively. Median followup was 43 months (range 1 to 299). At the end of followup 246 patients (21.9%) died of cancer. In 132 cases (11.7%) urinary collecting system invasion was noted. Urinary collecting system invasion was associated with symptoms, TNM stage, Fuhrman grade, tumor size (p <0.001) and Eastern Cooperative Oncology Group performance status (p = 0.003), but not with histological subtype (p = 0.7). On univariate analysis TNM stage, Fuhrman grade, symptoms, Eastern Cooperative Oncology Group performance status, tumor size and urinary collecting system invasion (p = 0.0001) were significant predictors of cancer specific survival. Urinary collecting system invasion was an independent prognostic parameter only in the setting of pT1-T2 tumors. When the urinary collecting system was invaded the 5 and 10-year probabilities of survival were 43% and 41%, respectively. CONCLUSIONS: Urinary collecting system invasion appears to be an independent prognostic parameter of organ confined renal cell carcinoma. Our data support the need to integrate this parameter in further TNM revisions.

Can renal mass biopsy assessment of tumor grade be safely substituted for by a predictive model?

PURPOSE: Fuhrman grade represents a key determinant of the natural history of small renal masses that represent renal cell carcinoma. We tested whether renal mass biopsy prediction of Fuhrman grade in the nephrectomy specimen could be safely substituted for by an accurate statistical model. To date the best available model has shown poor accuracy (55.6%), which is close to flipping a coin (50%) and clearly inadequate for use in clinical practice. MATERIALS AND METHODS: We identified 1,139 patients with T1aN0M0 renal cell carcinoma treated with partial or radical nephrectomy at 11 participating institutions from 1989 to 2004. This cohort was used in univariate and multivariate logistic regression models predicting high Fuhrman grade (III-IV) at nephrectomy. Predictors included age at diagnosis, gender, tumor size and symptom classification. Multivariate logistic regression coefficients were used to generate a nomogram. RESULTS: The rate of Fuhrman grade III-IV in patients with T1aN0M0 renal cell carcinoma was 12.3%. Stratifying patients with Fuhrman grade III-IV by age, gender, histological subtypes and sample size failed to reveal statistically significant differences. On univariate analysis predicting Fuhrman grade III-IV at nephrectomy only tumor size was a statistically significant predictor (p = 0.05). The most accurate multivariate nomogram for Fuhrman grade III-IV prediction was 58.3% (95% CI 57.8-58.9) accurate. Of all tested predictors only tumor size achieved independent predictor status (p = 0.009). CONCLUSIONS: Our analysis derived in European patients shows that statistical models cannot safely replace renal mass biopsy based prediction of Fuhrman grade III-IV at nephrectomy. Our findings corroborate a report from the United States in which a similar model had 55.6% accuracy. Jointly the studies indicate that statistical models are unreliable and cannot safely be substituted for renal mass biopsy in North American or European patients.

Conditional survival predictions after nephrectomy for renal cell carcinoma.

PURPOSE: Conditional survival implies that on average long-term cancer survivors have a better prognosis than do newly diagnosed individuals. We explored the effect of conditional survival in renal cell carcinoma. MATERIALS AND METHODS: We studied 3,560 patients with renal cell carcinoma of all stages treated with nephrectomy. We applied conditional survival methodology to a previously reported posttreatment nomogram predicting survival after nephrectomy for patients with renal cell carcinoma stage I to IV. We used the same predictor variables that were integrated in the original multivariable Cox regression models, namely TNM stage, Fuhrman grade, tumor size and symptom classification. To validate the conditional survival nomogram we used an independent cohort of 3,560 patients from 15 institutions. RESULTS: The 5-year survival of patients immediately after nephrectomy was 74.2%, which increased to 80.4%, 85.1%, 90.6% and 89.6% at 1, 2, 5 and 10 years after nephrectomy, respectively. The predicted probabilities varied by as much as 50% when, for example, predictions of renal cell carcinoma specific mortality at 10 years were made after nephrectomy vs 5 years later. Within the external validation cohort the accuracy of the conditional nomogram was 89.5%, 90.5%, 88.5% and 86.7% at 1, 2, 5 and 10 years after nephrectomy. CONCLUSIONS: We developed (2,530) and externally validated (3,560) a conditional nomogram for predicting renal cell carcinoma specific mortality that allows consideration of the length of survivorship. Our tool provides the most realistic prognosis estimates with high accuracy.

CA9 level in renal cyst fluid: a possible molecular diagnosis of malignant tumours.

AIMS: The preoperative differentiation of malignant renal cystic tumours from benign lesions is critical, and it remains a common diagnostic problem. The aim was to examine if the Carbonic anhydrase 9 (CA9) level in cyst fluid can provide a molecular diagnosis of malignant cyst. METHODS AND RESULTS: Twenty-eight patients with a cystic renal mass were included. Fine-needle aspiration was performed to obtain the fluid. Postoperative pathology confirmed that there were 16 cystic renal cell carcinomas. Twelve benign cystic tumours were used as controls. One hundred microlitres of supernatant of cyst fluid was used to measure the CA9 protein level, which was measured by an enzyme-linked immunosorbent assay technique. CA9 was strongly detected and considered as positive in the cyst fluid of all 16 cystic malignant tumours (>1000 pg/ml), whereas its expression was negative in 11/12 benign cystic tumours (<300 pg/ml). The difference in percentages of positive CA9 between malignant and benign renal cystic tumours was significant (P < 0.001). CONCLUSION: The fluid of malignant cystic renal tumours contains a high level of CA9 protein. The measurement of CA9 level in cyst fluid may be used as a molecular diagnosis for differentiation between malignant and benign renal cystic masses.

Cancer-specific and non-cancer-related mortality rates in European patients with T1a and T1b renal cell carcinoma.

OBJECTIVE: To examine cancer-specific and non-cancer-related mortality rates in 451 patients with T1a-bN0M0 renal cell carcinoma (RCC) treated with either radical or partial nephrectomy (RN or PN) in Europe. PATIENTS AND METHODS: Between 1987 and 2007, 451 patients with T1a-bN0M0 RCC were treated for histologically confirmed RCC with RN or PN at one of seven participating European institutions. The preoperative American Society of Anesthesiology (ASA) score was available for all patients and was used to control for baseline comorbidities. The preoperative glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease study group equation. We used univariate and multivariate competing-risks regression analyses to test the effect of the ASA score, GFR, T stage (T1a vs T1b) and nephrectomy type (RN or PN) on RCC-specific mortality and non-RCC-related mortality. RESULTS: In patients with T1a-b RCC cancer- specific mortality was unaffected by stage, nephrectomy type or GFR. Conversely, non-RCC-related mortality was strongly affected by the ASA score and GFR. Unlike in a previous report, nephrectomy type did not affect non-RCC-related mortality. This lack of significance relative to RN may stem from the relatively high rate of PN use in the present series. CONCLUSION: PN or RN virtually eliminate the risk of cancer-specific mortality in patients with T1a-b RCC. Poor preoperative ASA score and impaired renal function appear to represent relative contra-indications to surgical management of T1a-b lesions.

Baseline renal function, ischaemia time and blood loss predict the rate of renal failure after partial nephrectomy.

OBJECTIVE: To identify independent predictors of renal failure after partial nephrectomy (PN) in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: Data were available for 166 patients with pathological T1-3 N0M0 RCC treated with PN. Renal failure after PN was defined as a decrease in glomerular filtration rate (GFR) of >25% (RIFLE criteria). The GFR before and after PN was estimated using the Modification of Diet in Renal Disease study group equation. Univariable and multivariable logistic regression models were used to assess a decrease of >25% in GFR from the preoperative level. Candidate predictor variables were age, gender, PN indication (absolute vs relative), preoperative GFR, tumour size, perioperative blood loss, surgery duration and clamping time. RESULTS: After PN, 22 (13.3%) patients had a decrease in GFR of >25%. The perioperative blood loss (P = 0.02), clamping time (P = 0.04) and preoperative GFR (P = 0.002) were independent predictors of a decrease in GFR of >25%. CONCLUSIONS: We identified two important potentially modifiable variables that should be considered in the planning of PN, i.e. the clamping time and blood loss. It is possible that selective referral to experienced surgeons who can perform PN within short surgical and clamping times, and with minimal blood loss, could minimize the rate of renal failure, especially in patients with an underlying renal function impairment.

Stage-specific effect of nodal metastases on survival in patients with non-metastatic renal cell carcinoma.

OBJECTIVE: To quantify the survival disadvantage related to the presence of exclusive nodal metastases (eNM) in patients with otherwise non-metastatic (M0) renal cell carcinoma (RCC). PATIENTS AND METHODS: Data were retrieved from 12 institutional databases and yielded 3507 patients with T1-3N1-2M0 RCC treated with partial or radical nephrectomy. Cox regression analyses relied on T stage, Fuhrman grade and presence of eNM. Data were analysed using univariable, multivariable and stratified analyses. RESULTS: Overall 165 (4.7%) patients had eNM; of 2023 patients of stage T1, 23 (1.1%) had eNM, vs 20 of 448 (4.5%) for T2 and 122 of 993 (12.3%) for T3. In univariable analyses the presence of eNM increased the rate of cancer specific mortality (CSM) by 7.1 times. After adjusting for T stage and Fuhrman grade, in all patients eNM increased the rate of CSM by 3.2 times. In stratified analyses adjusted for Fuhrman grade, the increase in CSM related to the presence of eNM was 28.9, 4.3 and 2.5 times (all P < 0.001) for stages T1, T2 and T3, respectively. CONCLUSIONS: From the prognostic perspective, staging lymphadenectomy appears of most value in patients with T1-2 RCC, but the low prevalence of eNM questions the practical applicability of nodal staging in those patients. Conversely, in patients with T3 RCC, the prevalence and the prognostic impact of eNM might make a staging lymphadenectomy worthwhile.

Serum carbonic anhydrase 9 level is associated with postoperative recurrence of conventional renal cell cancer.

PURPOSE: We explored the clinical usefulness of serum carbonic anhydrase 9 as a potential biomarker for conventional renal cell cancer. MATERIALS AND METHODS: This study included 91 patients with conventional renal cell cancer and 32 healthy individuals. Enzyme linked immunosorbent assay was used to measure the carbonic anhydrase 9 level. A followup (median 38 months) was performed to track early recurrence after surgery for patients with localized disease. Recurrence-free survival curves were calculated by the Kaplan-Meier method and compared using the log rank test. RESULTS: The mean serum carbonic anhydrase 9 level in patients with metastatic conventional renal cell cancer (216.68 +/- 67.02 pg/ml) or localized conventional renal cell cancer (91.65 +/- 13.29 pg/ml) was significantly higher than in healthy individuals (14.59 +/- 6.22 pg/ml, p <0.001 and p = 0.001, respectively). The mean serum carbonic anhydrase 9 level in patients with metastatic conventional renal cell cancer was significantly higher than in those with localized disease (p = 0.004). Of patients with localized disease those with recurrence had a significantly higher serum carbonic anhydrase 9 than those without recurrence (p = 0.001). On univariate analysis serum carbonic anhydrase 9, tumor stage, tumor grade and tumor size were associated with recurrence. The recurrence-free survival curve indicates that patients with a high serum carbonic anhydrase 9 level had a significantly higher recurrence rate than those with a low serum carbonic anhydrase 9 (p = 0.001). CONCLUSIONS: Our data suggest that serum carbonic anhydrase 9 is increased as the tumor progression occurs. A high carbonic anhydrase 9 level is associated with postoperative recurrence.

Differential expression of prognostic markers in histological subtypes of papillary renal cell carcinoma.

OBJECTIVE: To assess the expression of the tumour markers stromelysin 3, MUC1, p53 and cytokeratin-7 in papillary renal cell carcinoma (pRCC, for which two histological subtypes are distinguished, i.e. type 1 and type 2, the latter appearing to be associated with a poorer prognosis) and to determine whether any of these markers might be of prognostic value. PATIENTS AND METHODS: In a retrospective study of 50 patients, the type and nuclear grade of tumours was determined by histological analyses, the presence of microvascular emboli detected, and the markers assessed by immunohistochemical analysis using anti-stromelysin 3, anti-MUC1, anti-p53 and anti-cytokeratin-7 antibodies. RESULTS: Twenty-five patients each had a type 1 or type 2 tumour. MUC1 and cytokeratin-7 were principally expressed in type 1 tumours, being detected in 76% and 84%, respectively. By contrast, p53 accumulated principally in type 2 tumours (36%); the accumulation of p53 was also associated with poorer survival. In patients with type 2 tumours with a more unfavourable development, stromelysin-3 expression was associated with a more advanced stage and a higher risk of metastases. CONCLUSION: Subtyping pRCC according to the recommended morphological criteria appears to be worthwhile, and can be reinforced by immunohistochemical tests capable of detecting cytokeratin-7 and MUC1 expression. Immunohistochemical detection of p53 is of prognostic value, as accumulation of this factor is associated with poorer survival.

Patients with distant metastases from renal cell carcinoma can be accurately identified: external validation of a new nomogram.

OBJECTIVE: To identify clinical variables that can accurately predict the presence of distant metastases in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: Age, symptom classification, tumour size and the prevalence of distant metastases at diagnosis before nephrectomy were available for 5376 patients with pathologically confirmed RCC. The data of 2660 (49.5%) patients from 11 centres were used to develop a multivariable logistic regression model-based nomogram predicting the individual probability of distant metastases. The remaining data from 2716 (50.5%) patients from three institutions were used for external validation. RESULTS: In the development cohort, 269/2660 (10.1%) had distant metastases, vs 285/2716 (10.5%) in the external validation cohort. Symptom classification and tumour size were independent predictors of distant metastases in the development cohort; age was not an independent predictor. A nomogram based on symptom classification and tumour size was 85.2% accurate in predicting the individual probability of distant metastases in the external validation cohort. CONCLUSION: Although distant metastases might be easily identifiable in some patients, their diagnosis might be a challenge in others. The current nomogram provides a simple, user-friendly and, most importantly, an accurate tool aimed at predicting the probability of distant metastases in patients with RCC.

Prognostic variables to predict cancer-related death in incidental renal tumours.

OBJECTIVE: To identify, in a large multicentre series of incidental renal tumours, the key factors that could predict cancer-related deaths, as such tumours have a better outcome than symptomatic tumours and selected patients are increasingly being included in watchful-waiting protocols. PATIENTS AND METHODS: Data from 3912 patients were extracted from three international kidney-cancer databases. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status (PS), Tumour-Node-Metastasis (TNM) stage, tumour size, Fuhrman grade, and final pathology were recorded. Benign tumours and malignant lesions with incomplete information were excluded from final analysis. RESULTS: The mean (SD) age of the patients was 60.6 (12.2) years and the mean tumour size 5.5 (3.5) cm. Most tumours were malignant (90.2%) and of low stage (T1-T2, 71.7%) and low grade (G1-G2, 72.4%). There were nodal and distant metastases in 5.7% and 13% of the patients. In all, 525 (14.4%) patients died from cancer; in this group, tumours were >4 cm in 88.2% and had nodal or distant metastases in 20.2% and 49.3%, respectively. Multivariable analysis showed that tumour size >4 cm, ECOG PS >or=1, TNM stage and Fuhrman grade were independent predictors of cancer-related death. CONCLUSION: A significant proportion of incidental renal tumours can lead to the death of the patient. Standard prognostic variables for renal cell carcinoma appear to remain valid for this subset of patients. A watchful-waiting strategy should not be recommended if the tumour diameter is >4 cm, if biopsy confirms high-grade tumours, or if there is an impaired ECOG PS, or computed tomography findings suggest the presence of advanced T stage.

Elevated serum-circulating RNA in patients with conventional renal cell cancer.

BACKGROUND: Reliable serum biomarkers for differential diagnosis of conventional renal cell carcinoma (RCC) are highly desirable. Recent studies have confirmed the stability of circulating RNA in serum of cancer patients. The purpose of our study was to evaluate whether the amounts of circulating RNA could discriminate between conventional renal cancer patients and healthy individuals as a tumor marker. PATIENTS AND METHODS: A total of 71 patients with conventional RCC, 12 with renal oncocytomas and 44 healthy individuals entered into this study. Serum samples were taken and subjected to RNA extraction. The amount of RNA was quantified spectrophotometrically. Additionally, 9 serum samples from conventional RCC were also studied one week after nephrectomy. Diagnostic performance of RNA concentration was calculated through the receiver operating characteristic (ROC) curve to distinguish between conventional RCC and healthy individuals. RESULTS: The mean level of RNA in conventional RCC (1414.19 +/- 91.95 ng/ml) was significantly higher than that in healthy individuals (520.49 +/- 39.75 ng/ml, p<0.0001) and these with renal oncocytomas (560.71 +/- 69.54 ng/ml, p<0.0001). Among the conventional RCC, there was no significant difference in circulating RNA levels in terms of tumor stage, grade or size. The area under the ROC curve was 0.956 (95% confidence interval, 0.923 to 0.989), indicating an acceptable sensitivity and specificity as a tumor marker. For conventional RCC, the RNA level was reduced significantly (p<0.0001) one week after nephrectomy. CONCLUSION: The data suggest that elevated circulating RNA may be a valuable diagnostic tool for discriminating conventional RCC patients from normal individuals or from these with renal oncocytoma. Elevated serum circulating RNA provides a new research area as biomarker for the diagnosis of conventional RCC.

Testosterone deficiency: a common, unrecognized syndrome.

Testosterone deficiency syndrome (TDS) refers to the clinical signs and symptoms that result from an abnormally low testosterone level. Men with 'classic' hypogonadism can have unequivocally low testosterone levels and typical symptoms and signs. By contrast, the age-related decline of testosterone levels can be responsible for ambiguous clinical pictures, which can potentially be misinterpreted as part of the aging process or depression. Nevertheless, this decline can have detrimental effects on quality of life and on the function of multiple organ systems. TDS is underdiagnosed-its overall prevalence varies from 6% to 9.5% in community-dwelling men aged 40-70 years, and rises to 15-30% in diabetic or obese men-and undertreated; less than 10% of men with TDS receive treatment. This Review highlights potential pitfalls in the diagnosis of both clinical and biochemical components of TDS.

Patients with renal cell carcinoma nodal metastases can be accurately identified: external validation of a new nomogram.

Outcome of patients with renal cell carcinoma nodal metastases (NM) is substantially worse than that of patients with localized disease. This justifies more thorough staging and possibly more aggressive treatment in those at risk of or with established NM. We developed and externally validated a nomogram capable of highly accurately predicting renal cell carcinoma NM in patients without radiographic evidence of distant metastases. Age, symptom classification, tumour size and the pathological nodal stage were available for 4,658 individuals. The data of 2,522 (54.1%) individuals from 7 centers were used to develop a multivariable logistic regression model-based nomogram predicting the individual probability of NM. The remaining data from 2,136 (45.9%) patients from 5 institutions were used for external validation. In the development cohort, 107/2,522 (4.2%) had lymph node metastases vs. 100/2,136 (4.7%) in the external validation cohort. Symptom classification and tumour size were independent predictors of NM in the development cohort. Age failed to reach independent predictor status, but added to discriminant properties of the model. A nomogram based on age, symptom classification and tumour size was 78.4% accurate in predicting the individual probability of NM in the external validation cohort. Our nomogram can contribute to the identification of patients at low risk of NM. This tool can help to risk adjust the need and the extent of nodal staging in patients without known distant metastases. More thorough staging can hopefully better select those in whom adjuvant treatment is necessary. (c) 2007 Wiley-Liss, Inc.

CA9 gene expression in conventional renal cell carcinoma: a potential marker for prediction of early metastasis after nephrectomy.

About 30-40% of patients with renal cell carcinoma (RCC) will develop metastasis after curative nephrectomy. There is a strong need to identify the early metastasis with conventional and molecular risk factors. The present study aimed to test if analysis of the CA9 gene can provide useful information to predict early metastasis after nephrectomy. This study included 63 patients with a conventional RCC. Ten tumors were N+ or/and M+ at diagnosis. The mean follow-up was 43 months (range, 4-67 months). About 11 M0N0 patients were found to have a metastasis during the follow-up. Quantitative RT-PCR of CA9 gene expression was performed. The metastasis-free survival curve was established according to the Kaplan-Meier method with comparison by the Log-Rank test. At diagnosis, the average of CA9 gene expression was significantly lower (p = 0.004) in metastatic tumors (N+ or/and M+) than in non-metastatic tumors (N0M0). For the follow-up of M0N0 patients, the metastasis-free survival rate was significantly higher (p = 0.005) in the high CA9 group than in the low-CA9 group. When combined with CA9, the metastasis-free survival rates, in terms of stage (p = 0.015) or grade (p = 0.010) were significantly different. When the stage, grade, and CA9 were combined, there was a significant difference (p = 0.004) in metastasis-free survival rates (T1T2 + G1G2 + high expression of CA9 versus T3 + G3G4 + low expression of CA9). Finally, the multivariate regression analysis identified CA9 expression (p = 0.036) as an independent predictor of early metastasis. Our study confirms that the expression level of CA9 gene in conventional RCC is related to metastasis. CA9 may be a potential marker for the prediction of early metastasis after nephrectomy and to guide post-operative follow-up and treatment.

ECOG performance status 0 or 1 and symptom classification do not improve the ability to predict renal cell carcinoma-specific survival.

OBJECTIVES: We tested and compared the improvement in prognostic ability related to the consideration of either ECOG performance status (ECOGPS) and/or symptom classification (S-CLASS) in renal cell carcinoma specific mortality (RCC-SM) predictions. METHODS: Univariate and multivariate Cox regression analyses targeted RCC-SM in 2570 RCC patients treated with either partial or radical nephrectomy. The increment in predictive accuracy related to the addition of either ECOGPS, S-CLASS or both was quantified using Harrell's concordance index. RESULTS: Follow-up ranged from 0.1 to 23 years (median 3.2) and 610 patients (23.7%) died of RCC. In multivariable analyses, ECOGPS and S-CLASS represented independent predictors of RCC-SM. The addition of ECOGPS to established RCC-SM predictors increased the predictive accuracy by 0.3% (p=0.8) versus 0.6% (p=0.5) for S-CLASS versus 0.6% (p=0.5) for both. CONCLUSIONS: Neither ECOGPS nor S-CLASS improves the ability to predict RCC-SM. Therefore, these variables may be safely omitted when RCC-SM risk is quantified.

[Varicocele and male infertility: AFU 2006 guidelines]. / Varicocèle et infertilitè masculine: recommandations Comité Andrologie--AFU 2006.

The routine assessment of an infertile man with varicocele must comprise complete clinical interview including the patient's medical and reproductive history, physical examination and at least two sperm counts. Imaging examinations are not indicated to characterize the varicocele, except when physical examination is inconclusive. However; scrotal ultrasound can be useful in infertile men to detect concomitant diseases, especially testicular tumours. Treatment of varicocele must be proposed when all of the following conditions are present: 1) the varicocele is palpable; 2) the couple's infertility is documented; 3) there is no female infertility problem or this problem is potentially curable; 4) there is at least one abnormality of spermatic parameters on the sperm count. Treatment can also be proposed in men with palpable varicocele and spermatic abnormalities on the sperm count, even when they do not have any immediate plans to have a child. Young men with varicocele and a normal sperm count must be followed by sperm counts every one or two years. Treatment of varicocele must also be proposed to adolescents with varicocele and ipsilateral a reduction of testicular volume. Adolescents with varicocele associated with a normal-sized testis must be reviewed annually to measure testicular volume and/or sperm count when it can be performed. Surgery or percutaneous embolization are two possible treatment options for varicocele provided they are performed by a well trained and experienced operator. The treatment of varicocele can be considered to be first-line treatment in a patient with moderate oligo-astheno-teratospermia with no associated female infertility factor. IVF with or without ICSI can be considered to be first-line treatment in the presence of an independent female infertility factor requiring the use of these techniques. Concomitant treatment of varicocele can be considered to improve semen fertility. Persistence or relapse of varicocele can be treated by surgery or percutaneous embolization provided spermatic venography is performed to identify the site of persistent venous reflux. After treatment of varicocele, a sperm count must be performed approximately every three months for one year or until pregnancy is achieved.

[Comparison of open and laparoscopic partial nephrectomy: a French multicentre experience]. / Comparaison de la néphrectomie partielle par voie laparoscopique et par voie ouverte: une expérience multicentrique française.

OBJECTIVES: To compare open (OPN) and laparoscopic (LPN) partial nephrectomy (PN) techniques in the light of a French multicentre series. MATERIAL AND METHODS: Data corresponding to 741 PN (91 laparoscopic and 650 open procedures) were compared in terms of the indications, tumour diameter, operative data, complication rates and length of hospital stay. RESULTS: Tumours were smaller in the LPN group (2.7 vs 3.4 cm, p = 0.001). There were fewer malignant tumours (71.1% vs 80% p = 0.05) and fewer NP by necessity (20.9% vs 31.4%. p = 0.04) in the LPN group than in the OPN group. There were fewer hilar tumours in the LPN group than in the OPN group (LPN: 4% vs OPN: 14.8%, p = 0.03). Pedicle clamping was performed less frequently in the LPN group (33% vs 50.2%, p = 0.002) but for a significantly longer mean duration (35 minutes vs 19 minutes, p = 0.0001). The mean operating time was longer in the LPN group (163 vs 150 minutes, p = 0.02). The surgical complication rate (17.6% vs 14.3%), transfusion rate (6.6% vs 10.5%) and mean blood loss (363 vs 434 ml) were not significantly different between the 2 groups. There were significantly more urinary fistulas (12.1% vs 2.5%, p < 0.001) and medical complications (24.2% vs 14%, p = 0.01) in the laparoscopy group, but, in the longer-term, urinarvfistula rates were comparable in the 2 groups. The length of hospital stay was shorter for LPN (9.1 vs 11.2 days, p = 0.009). CONCLUSION: This comparative series, reflecting initial experience, shows that laparoscopic partial nephrectomy achieves similar operative and perioperative results to those of open partial nephrectomy. However, the indications for laparoscopic partial nephrectomy remain selective, as the pedicle clamping time and medical complication rates are higher with laparoscopic surgery. Experience and technical progress in laparoscopic partial nephrectomy should make the operative technique comparable to that of open surgery.

Prognostic value of histologic subtypes in renal cell carcinoma: a multicenter experience.

PURPOSE: To analyze to what extent histologic subtype is of prognostic importance in renal cell carcinoma based on a large, international, multicenter experience. PATIENTS AND METHODS: Four thousand sixty-three patients from eight international centers were included in this retrospective study. Histologic subtype (1997 International Union Against Cancer [UICC] criteria of tumor response), age, sex, TNM stage, Fuhrman grade, tumor size, Eastern Cooperative Oncology Goup performance status (ECOG PS), and overall survival were determined in all cases. The prognostic values of clear cell, papillary, and chromophobe histologic features were assessed by uni- and multivariate analysis using the Kaplan-Meier method and Cox model, respectively. RESULTS: Clear cell, papillary, and chromophobe carcinomas accounted for 3,564 (87.7%), 396 (9.7%) and 103 (2.5%) cases, respectively. In univariate analysis, a trend toward a better survival was observed when clear cell, papillary, and chromophobe histologies were considered prognostic categories (log-rank P = .0007). However, in multivariate analysis, TNM stage, Fuhrman grade and ECOG PS, but not histology, were retained as independent prognostic variables (P < .001). CONCLUSION: The stratification in three main renal cell carcinoma histologic subtypes as defined by the 1997 UICC-American Joint Committee on Cancer consensus should not be considered a major prognostic variable comparable to TNM stage, Fuhrman grade and ECOG PS.