Practice patterns and survival outcomes for muscle-invasive bladder cancer: real-life experience in a general population setting.

Bladder cancer (BC) is a common malignancy in Europe and North America. Among BCs, muscle-invasive BCs (MIBCs) are distinguished, as they require aggressive treatment due to their spreading potential and poor prognosis. Despite its clinical relevance, little information on MIBC in a general population setting is available. This study aims to report practice patterns and survival outcomes for MIBC patients in a general population setting. MIBCs among BC incidence in 2011 and 2012 recorded in a French population-based cancer registry (810 000 inhabitants) were included in the study. Data were extracted from the medical files. Individual, tumour-related characteristics and initial management including diagnostic tools, multidisciplinary team meeting (MDT) assessment, and treatment delivered were described. Cystectomy, chemoradiation, radiotherapy, and chemotherapy were considered as specific treatments. Matching between MDT decision and the treatment provided was detailed. Management practices were discussed according to the guideline's recommendations. Overall survival (using the Kaplan-Meier method) and net survival (using the Pohar-Perme estimator) were calculated. Among 538 incident BC cases, 147 (27.3%) were MIBCs. Diagnostic practices displayed a relevant locoregional assessment of BC. Almost all cases (n = 136, 92.5%) were assessed during an uro-oncological MDT with a median time from diagnosis of 18 days (first quartile:12-third quartile:32). Discrepancies appeared between MDT decisions and treatments delivered: 71 out of 86 subjects received the recommended cystectomy or chemoradiation (with or without neoadjuvant chemotherapy); 6 out of 11 had the recommended radio- or chemotherapy; and 9 patients did not undergo any specific treatment despite the MDT decision. Cystectomy was the most common treatment performed; the time to surgery appeared consistent with the guideline's recommendations. Forty people only received supportive care. Still, the 5-year overall and net survival was poor, with 19% (13-26) and 22% (14-31), respectively. The 5-year net survival was 35% (23-48) for people who underwent curative-intent treatments. MIBC management remains challenging even for cases assessed during an MDT. Many people did not undergo any specific treatment. Prognosis was poor even when curative-intent therapies were delivered. Efforts to reduce exposure to risk factors such as tobacco smoking and occupational exposures must be maintained.

Laparoscopic Radical Prostatectomy with a Remote Controlled Robot.

PURPOSE: Robotics in surgery is a recent innovation. This technology offers a number of attractive features in laparoscopy. It overcomes the difficulties with fixed port sites by restoring all 6 degrees of freedom at the instrument tips, provides new possibilities for miniaturization of surgical tasks and allows remote controlled surgery. We investigated the applicability of remote controlled robotic surgery to laparoscopic radical prostatectomy. MATERIALS AND METHODS: Our previous experience with laparoscopic prostatectomy served as a basis for adapting robotic surgery to this procedure. A surgeon at a different location who activated the tele-manipulators of the da Vinci∗ robotic system performed all steps of the intervention. A scrub nurse and second surgeon who stood at patient side had limited roles to port and instrument placement, exposure of the operative field, assistance in hemostasis and removal of the operative specimen. Our patient was a 63-year-old man presenting with a T1c tumor discovered on 1 positive sextant biopsy with a 3+3 Gleason score and 7 ng./ml. preoperative serum prostate specific antigen. RESULTS: The robot provided an ergonomic surgical environment and remarkable dexterity enhancement. Operating time was 420 minutes, and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively, and 1 week later the patient was fully continent. Pathological examination showed a pT3a tumor with negative margins. CONCLUSIONS: Robotically assisted laparoscopic radical prostatectomy is feasible. This new technology enhances surgical dexterity. Further developments in this field may have new applications in laparoscopic tele-surgery.

Final results of the phase III URO-BCG 4 multicenter study: efficacy and tolerance of one-third dose BCG maintenance in nonmuscle invasive bladder cancer.

The objective of this study was to assess at 3 years bacillus Calmette-Guerin (BCG) maintenance treatment for NMIBC using one-third dose schedule and fewer instillations every 3 or 6 months. This was a phase III randomized study including patients with intermediate-risk or high-risk NMIBC, who received, after a full-dose induction schedule, three-weekly instillations of one-third dose BCG every 6 months (group I) and two-weekly instillations every 3 months (group II) during 3 years. We assessed oncological efficacy, BCG side effects, leukocyturia, and prostate-specific antigen. No tumor recurrence was reported at 36 months for 55 (82.09%) patients in group I versus 64 (90.14%) patients in group II (P=0.241). Muscle invasion was observed in six patients at 36 months (P=0.942). In terms of BCG toxicity, grade II and III local or systemic side effects were, respectively, reported in 8.7 and 23.9% of patients during the first year. Nevertheless, the adverse events (AEs) score at 36 months underlined a lower median value of 0.8 in group I versus 1.1 in group II (P=0.037). Furthermore, 9.9% major AEs occurred in group II versus 3% in group I (P=0.031). Leukocyturia and prostate-specific antigen level were not associated significantly with either tumor recurrence or muscle progression. We observed a significant difference in the AEs score at 36 months, suggesting less toxicity in patients who were treated with one-third dose of BCG for 3 consecutive weeks every 6 months.

Efficacy and tolerance of one-third full dose bacillus Calmette-Guérin maintenance therapy every 3 months or 6 months: two-year results of URO-BCG-4 multicenter study.

OBJECTIVES: To assess bacillus Calmette-Guérin maintenance treatment schedule for non-muscle invasive bladder cancer at 2 years, using one-third of the full dose and fewer instillations every 3 months or 6 months. METHODS: This was a prospective, randomized, multicenter study. All patients had an intermediate- or high-risk non-muscle invasive bladder cancer. They received three weekly instillations of one-third dose bacillus Calmette-Guérin every 6 months (group I) and two weekly instillations every 3 months (group II) during 3 years. In the two schedules we assessed efficacy, tolerance, leukocyturia and prostate-specific antigen. RESULTS: No significant difference was observed between the two groups for recurrence at 6, 12 or 18 months. At 2 years, tumor recurrence was observed in 10.9% and muscle invasion in 2.9% of cases. Bacillus Calmette-Guérin tolerance was comparable - the adverse events score was 0.8 in group I and 1 in group II (P = 0.242). No statistical correlation was observed between the adverse events score over 2 years, either for leukocyturia (P = 0.8891) or prostate-specific antigen level (P = 0.7155). Leukocyturia level was not significantly associated with tumor recurrence or progression. CONCLUSION: One-third dose maintenance bacillus Calmette-Guérin is effective with no impact on tumor recurrence or muscle invasion. Furthermore, there seems to be no difference in tumor response or side-effects between patients receiving two or three maintenance instillations every 3 months or 6 months. In clinical practice, the use of leukocyturia or total prostate-specific antigen levels do not appear to be useful in predicting bacillus Calmette-Guérin toxicity.

Clinical outcomes after salvage radiotherapy without androgen deprivation therapy in patients with persistently detectable PSA after radical prostatectomy: results from a national multicentre study.

PURPOSE: To assess oncologic outcomes after salvage radiotherapy (SRT) without androgen deprivation therapy (ADT) in patients with persistently detectable PSA after radical prostatectomy (RT). METHODS: Two hundred and one patients who failed to achieve an undetectable PSA received SRT without ADT. The primary endpoint was failure to SRT that was defined by clinical progression or use of second-line ADT. Clinicopathological parameters, 6-week PSA level, PSAV and pre-SRT PSA levels were assessed using time-dependent analyses. RESULTS: Median postoperative 6-week PSA and pre-SRT PSA levels were 0.25 and 0.48 ng/mL, respectively. Median time between surgery and SRT was 7 months. Failure to SRT was reported in 42.8 % of cases with the need for second-line ADT in 26.9 % of cases. Pre-SRT PSA was strongly correlated with postoperative 6-week PSA (p < 0.001) but not with PSAV. The risk of SRT failure was increased by threefold in case of Gleason score 8-10 (p = 0.036) or pT3b cancer (p = 0.006). Risk group classification based on these prognostic factors improved SRT failure prediction. Survival curves confirmed that 5-year ADT-free survival rates were significantly influenced by PSAV (p = 0.002) and pre-SRT PSA (p = 0.030). CONCLUSIONS: In patients with persistently detectable PSA after RP and selected for local salvage treatment, SRT offers good oncologic clinical outcomes. The most powerful pathologic predictive factors of SRT failure include a pT3b stage, a Gleason score 8 or more cancer and high PSAV and pre-SRT PSA levels. Patients having a high PSAV >0.04 ng/mL/mo would be potentially better candidates for a systemic therapy due to a high SRT failure rate.

The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy.

PURPOSE: Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU. METHODS: In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis. RESULTS: Median age was 70 years [interquartile range (IQR), 60-75] with median follow-up of 27 months (IQR, 10-50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73-88 %] for pN0 patients, 85 % (95 % CI, 80-90 %) for pNx patients and 47 % (95 % CI, 24-69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation. CONCLUSION: LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.

Influence of positive surgical margin status after radical nephroureterectomy on upper urinary tract urothelial carcinoma survival.

BACKGROUND: The influence of a positive surgical margin (PSM) on survival outcome of post radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UUT-UC) is unclear. The objectives of this study were to determine the significance of PSM on cancer-specific survival (CSS), recurrence-free survival (RFS), and metastasis-free survival (MFS) post RNU. METHODS: From a multicenter collaborative database, data on SM status, stage, grade, lymph node status, lymphovascular invasion (LVI), tumor location, follow-up, and survival was retrieved for 472 patients. Patients underwent open RNU with bladder cuff excision. Clinicopathological features were compared using χ(2) or Fisher exact test and unpaired t test for categorical and continuous variables, respectively. Survival was estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards regression models were calculated. RESULTS: Median follow-up was 27.5 months (12.1-49.3 months). PSM was identified in 44 patients (9.3%) and correlated with pT stage (p = 0.002), grade (p < 0.001), LVI (p < 0.001), and location (p < 0.001). Univariate analyses revealed that PSM was a poor prognostic factor for CSS, RFS, and MFS (p = 0.003, 0.04, and <0.001, respectively). The 5-yr CSS and MFS for PSM was 59.1 and 51.6%, respectively, compared with 83.3 and 79.3% for patients with negative SM. Multivariate analyses revealed that SM status was an independent predictor of MFS [hazard ratio 2.7; p = 0.001). CONCLUSIONS: PSM after RNU is an important prognostic factor for developing UUT-UC metastases. The status of the surgical margin should be systematically reported on the pathological report and may be a useful variable to include in nomogram risk prediction tools.

Assessment of oncologic control obtained after open versus laparoscopic nephroureterectomy for upper urinary tract urothelial carcinomas (UUT-UCs): results from a large French multicenter collaborative study.

BACKGROUND: The purpose of this study was to compare the postsurgical survival of UUT-UC patients treated with ONU and LNU. METHODS: Using a multi-institutional, national, retrospective database, we identified patients with UUT-UC who underwent radical nephroureterectomy by open access (ONU) or by the minimally invasive alternative (LNU). Survival curves were estimated using Kaplan-Meier method. A multivariate Cox model was used to evaluate the association between surgical approach and disease recurrence. RESULTS: Overall, 609 patients were included (ONU = 459 and LNU = 150). The median age was 69.8 years (range 61.9-76), and the male-to-female ratio was 2:1. Postoperative complications occurred in 80 patients, with no significant difference between ONU and LNU on the whole (P = 0.64). The median follow-up was 27 months. There was no difference between the 2 procedures in the 5-year CSS or 5-year RFS. Moreover, the 5-year CSS (P = 0.053) and 5-year RFS (P = 0.9) for cases with locally advanced disease (pT3/pT4) were similar between ONU and LNU. In the multivariate analysis, the surgical procedure used was not found to be associated with survival. The main limitation of the study is its retrospective design, which is the result of the rarity of the disease. CONCLUSIONS: There is no evidence that oncological outcomes for LNU are inferior to those for open surgery, provided that the appropriate precautionary measures are taken.

Comparison of oncological outcomes after segmental ureterectomy or radical nephroureterectomy in urothelial carcinomas of the upper urinary tract: results from a large French multicentre study.

UNLABELLED: What's known on the subject? and What does the study add? Upper urinary tract urothelial carcinomas (UUT-UCs) are rare tumours. Because of the aggressive pattern of UC, radical nephroureterectomy (RNU) with bladder cuff removal remains the 'gold-standard' treatment. However, conservative strategies, such as segmental ureterectomy (SU) or endourological management, have also been developed in patients with imperative indications. Some teams are now advocating the use of conservative management more commonly in cases of elective indications of UUT-UCs. Due to the paucity of cases of UUT-UC, only limited data are available on the oncological outcomes afforded by conservative management. We retrospectively investigated the oncological outcomes after SU and RNU in a large multi-institutional database. Overall, 52 patients were treated with SU and 416 with RNU. There was no statistical difference between the RNU and SU groups for the 5-year probability of cancer-specific survival, recurrence-free survival and metastasis-free survival. The type of surgery was not a significant prognostic factor in univariate analysis. The results were the same in a subgroup analysis of only unifocal tumours of the distal ureter with a diameter of <2 cm and of low stage (≤T2). Our results suggest that oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases. OBJECTIVE: To compare recurrence-free survival (RFS), metastasis-free survival (MFS) and cancer-specific survival (CSS) after segmental ureterectomy (SU) vs radical nephroureterectomy (RNU) for urothelial carcinoma (UC) of the upper urinary tract (UUT-UC) located in the ureter. PATIENTS AND METHODS: We performed a multi-institutional retrospective review of patients with UUT-UC who had undergone RNU or SU between 1995 and 2010. Type of surgery, Tumour-Node-Metastasis status, tumour grade, lymphovascular invasion and positive surgical margin were tested as prognostic factors for survival. RESULTS: In all, 52 patients were treated with SU and 416 with RNU. The median (range) follow-up was 26 (10-48) months. The 5-year probability of CSS, RFS and MFS for SU and RNU were 87.9% and 86.3%, respectively (P = 0.99); 37% and 47.9%, respectively (P = 0.48); 81.9% and 85.4%, respectively (P = 0.51). In univariable analysis, type of surgery (SU vs RNU) failed to affect CSS, RFS and MFS (P = 0.94, 0.42 and 0.53, respectively). In multivariable analyses, pT stage and pN stage achieved independent predictor status for CSS (P = 0.005 and 0.007, respectively); the positive surgical margin and pT stage were independent prognostic factors of RFS and MFS (P = 0.001, 0.04, 0.009 and 0.001, respectively). The main limitation of the study is its retrospective design, which is due to the rarity of the disease. CONCLUSIONS: Short-term oncological outcomes after conservative treatment with SU are comparable to RNU for the management of UUT-UC in select cases and should be considered an option. In every other case, RNU still represents the 'gold standard' for the treatment of UUT-UC.

A proportion of hereditary upper urinary tract urothelial carcinomas are misclassified as sporadic according to a multi-institutional database analysis: proposal of patient-specific risk identification tool.

UNLABELLED: What's known on the subject? and What does the study add? Hereditary non-polyposis colorectal cancer (HNPCC), also known as Lynch syndrome, is an autosomal dominant multi-organ cancer syndrome. Upper urinary tract urothelial carcinomas belong to HNPCC-related tumours and rank third within this group after colorectal and endometrial cancer. However, many urologists are not aware of this association and it is presumed that some hereditary cancers are misclassified as sporadic and that their incidence is underestimated. Consequently, family members of patients with upper urinary tract urothelial carcinomas secondary to HNPCC may be denied appropriate surveillance and early detection. A significant proportion of patients (21.3%) with newly diagnosed upper urinary tract urothelial carcinomas may have underlying HNPCC. Demographic and epidemiological characteristics suggest different mechanisms of carcinogenesis among this population. Recognition of such potential is essential for appropriate clinical and genetic management of patients and family. In order to help to identify these patients, we propose a patient-specific checklist. OBJECTIVE: • To identify, based on previously described clinical criteria, hereditary upper urinary tract urothelial carcinomas (UUT-UCs) that are likely to be misclassified as sporadic although they may belong to the spectrum of hereditary non-polyposis colorectal cancer (HNPCC) associated cancers. PATIENTS AND METHODS: • We identified, using established clinical criteria, suspected hereditary UUT-UC among 1122 patients included in the French national database for UUT-UC. • Patients were considered at risk for hereditary status in the following situations: age at diagnosis <60 years with no previous history of bladder cancer; previous history of HNPCC-related cancer regardless of age; one first-degree relative with HNPCC-related cancer diagnosed before 50 years of age or two first-degree relatives diagnosed regardless of age. RESULTS: • Overall, 239 patients (21.3%) were considered to be at risk of hereditary UUT-UC. • Compared with sporadic cases, hereditary cases are more likely to be female (P= 0.047) with less exposure to tobacco (P= 0.012) and occupational carcinogens (P= 0.037). A greater proportion of tumours were located in the renal pelvis (54.5% vs 48.4%; P= 0.026) and were lower grade (40% vs 30.1%; P= 0.015) in the hereditary cohort. • The overall, cancer-specific and recurrence-free survival rates were similar in both cohorts. • We propose a patient-specific risk identification tool. CONCLUSIONS: • A significant proportion (21.3%) of patients with newly diagnosed UUT-UC may have underlying HNPCC as a cause. • Recognition of such potential and application of a patient-specific checklist upon diagnosis will allow identification and appropriate clinical and genetic management for patient and family.

Potentially Inappropriate Prescribing for Prostatic Hyperplasia in Older Persons.

OBJECTIVES: In the context of improved medication management of older patients, we wished to evaluate the overprescription of potentially inappropriate drugs [α1-blockers and 5α-reductase inhibitors (5-ARI)] for benign prostate hyperplasia (BPH). These drugs are considered by geriatricians to increase the risk of falls and pharmacodynamic interactions, but these properties have not yet been proven. DESIGN: This was a descriptive study of drug prescriptions in a geriatric academic center. SETTING AND PARTICIPANTS: We included all patients older than 75 years who received a prescription for α1-blockers or 5-ARIs for 2 weeks in our hospital. METHODS: We evaluated the prevalence of the potentially inappropriate prescription of α1-blockers and 5-ARI in older people during hospitalization using a new tool consisting of an 8-item list of explicit indicators developed using the most recent summary of product characteristics (SmPC) and latest European Association of Urology (EAU) guidelines. RESULTS: A population of 117 patients (≥75 years) was included in the study. The median age was 84.5 (±6.3) years. The average time since urological medication prescription was 1.2 ± 1.6 years. According to explicit criteria, 84 patients (71.8%) received at least 1 potentially inappropriate urologic medication, 77 (91.7%) related to α1-blockers. Patients with a potentially inappropriate prescription for α1-blockers and/or 5-ARIs more frequently had urological assessments (P = .026), more frequently showed pharmacological interactions, with the risk of orthostatic hypotension (P = .005) or arrhythmia (P = .028), and experienced more falls in their history (P = .043). The misuse group was associated with an increased risk of falls, with an odds ratio of 3.22 (P = .039, 95% confidence interval 1.08-10.2). CONCLUSIONS AND IMPLICATIONS: In our study, potentially inappropriate prescriptions for older individuals for BPH was close to 72% and mainly involved α1-blockers. Potentially inappropriate prescriptions for BPH were associated with a threefold higher frequency of falls.

ARCHITECT® urine-neutrophil gelatinase-associated lipocalin (u-NGAL) assay as new prognostic marker for clear cell Renal Cell Carcinoma (ccRCC) (preliminary results).

INTRODUCTION: Biomarkers for the diagnosis and monitoring treatment response of kidney cancer are urgently needed. Neutrophil gelatinase-associated lipocalin (NGAL) is a relevant urinary biomarker for the diagnosis of a wide variety of acute and chronic kidney diseases. Its potential utility as a prognostic marker of kidney cancer is largely unknown and, therefore, was the subject of this investigation. MATERIALS AND METHODS: A retrospective study was done on 50 kidney tumor patients (urine samples prospectively collected before nephrectomy between 2004 and 2012, stored at Biobank Resource Center). The specificity, sensitivity and the predictive value of NGAL were determined for progression-free and disease-specific survival after nephrectomy in renal cell carcinoma (particularly, the clear cell renal cell carcinoma (ccRCC)). Urinary NGAL concentration (u-NGAL) was determined by CMIA technique (ARCHITECT® urine NGAL essay/ABBOTT®). RESULTS: Out of the 50 kidney tumor patients, 40 had clear cell carcinoma with a median u-NGAL excretion of 1.4 (IQR: 5.76) ng/mg urinary creatinine (Ucr). u-NGAL was correlated to tumor stage (p = 0.005), and Fuhrman grade (p = 0.0002). Multivariate Cox regression analysis showed a significant association between u-NGAL excretion and clear cell renal cell carcinoma progression free survival and disease specific survival (p = 0.002; p = 0.0001). CONCLUSIONS: Urinary NGAL was significantly associated with the stage and the grade of kidney cancer. u-NGAL excretion could be considered as a potential biomarker to identify ccRCC patients with the more pejorative outcomes.

Oncological risk of laparoscopic surgery in urothelial carcinomas.

OBJECTIVE: To assess the oncological safety of laparoscopic procedures for the management of urothelial carcinomas of the urinary tract. METHODS: Data on laparoscopic management of urothelial carcinomas in the literature were analysed using MEDLINE and by matching the following keywords: urological malignancies, upper tract tumours, bladder carcinomas, laparoscopic approach, recurrence, follow-up and metastasis site. RESULTS: Minimally invasive techniques are being used increasingly in the management of these tumours and successfully achieving the benefits of lower blood loss and more rapid patient recovery. To date, no evidence level 1 information is available and published series of these technically challenging cases are small and follow-up limited. Short to medium term follow-up appears encouraging in terms of recurrence and survival rates, but long-term data are immature compared to the established open techniques these procedures seek to duplicate. Specific concerns in terms of the oncologic safety of laparoscopy, especially with regard to the pneumoperitoneum, tumour manipulation and specimen extraction are addressed. Port-site metastases and tumour seeding are rare events and appear to be mainly related to the grade and stage of the tumour. Specific precautions are required to minimise these risks. CONCLUSION: Oncological results of the laparoscopic approach are difficult to compare with those of open surgery. However, recent series have not reported unusual tumour dissemination or a higher rate of recurrence with this approach. Laparoscopic techniques are not yet standard of care in invasive urothelial carcinomas. Long-term assessment is ongoing and awaited.

Which efficiency index for urinary stones treatment?

Clinical results in urinary stones management are often reported using the stone-free (SF) rate, which is simple, reproducible and useful to compare techniques or centers. But this index does not take into account costs or patients' quality of life. In a way, SF "pursuit", which cannot be considered as a universal therapeutic goal could increase costs and decrease patients' comfort. We retrospectively reviewed files of stone management to describe costs according to several items and we emphasize the need for a true efficiency index.

[Bacillus of Calmette-Guérin immunotherapy: which protocol?]. / Immunothérapie par Bacille de Calmette-Guérin: quel protocole?

Several meta-analyses have reviewed the efficacy of bacille Calmette-Guérin (BCG) immunotherapy in treating nonmuscle-invasive bladder cancer (NMIBC). First, it was shown that BCG therapy was better than endoscopic resection alone in reducing the tumor progression rate, as long as a maintenance protocol was used. Moreover, BCG seems to be superior to mitomycin C in preventing recurrence. BCG has also proven its superiority over mitomycin C in terms of the risk for tumor progression when maintenance treatment is used. BCG maintenance treatment therefore seems to be the choice option to reduce the risk of both recurrence and tumor progression. The modalities for this treatment have not been clearly defined. Several protocols have been tested. Since its efficacy has been proven on a large cohort with randomized analysis, the SWOG protocol is currently the most widely used. It comprises six weekly instillations for the induction treatment, followed by three weekly instillations at 3, 6, 12, 18, 24, 30 and 36 months. It has been shown that BCG therapy toxicity was frequently the reason for interrupting maintenance therapy. In these patients with poor tolerance to the standard BCG dose, reducing the dose seems to be a useful option to improve BCG tolerance while preserving it efficacy. Finally, recent studies have shown that it would be preferable to adapt the dose and frequency of instillations of maintenance BCG to each patient. This individualized approach is undoubtedly BCG therapy's future.

[Place of serum HCG assay in the follow-up of non-HCG-secreting testicular seminomas]. / Place du dosage sérique de l'HCG dans la surveillance des tumeurs testiculaires séminomateuses non sécrétantes.

OBJECTIVE: Human chorionic gonadotrophin (HCG) is secreted by 10 to 20% of seminomas. The authors evaluated variations of serum total HCG levels in patients with normal baseline levels for the surveillance of treated testicular seminomas in order to determine the value of assay of this tumour marker in the follow-up of testicular seminoma. PATIENTS AND METHODS: Retrospective study from January 1988 to March 2007, including 95 cases of operated testicular cancer, including 28 seminomas, 25 of which did not secrete HCG (baseline total HCG less than 15 IU/L). Patients were reviewed periodically: every three months for one year, every six months during the second year, then annually, comprising of clinical examination, CT examination and assay of tumour markers (HCG, LDH and AFP). RESULTS: Mean follow-up was 77.5 months (range: 6-120). Twenty-five patients had a total HCG level less than 15 IU/L three months after orchidectomy. Serum HCG remained stable at less than 15 IU/L in all patients with a follow-up of more than three years. Two patients developed non-regional lymph node recurrence with no modification of the serum HCG level. CONCLUSION: All treated non-HCG-secreting seminomas with or without recurrence had stable and normal HCG levels throughout follow-up, which raises the question of the value of HCG assay in the follow-up of these patients following histological confirmation of the diagnosis.

[Proportion of surgical workload related to chronic renal failure in an urology and transplantation operating room]. / Importance de l'activité chirurgicale liée à l'insuffisance renale chronique dans un bloc opératoire d'urologie et de transplantation.

OBJECTIVE: To evaluate the proportion of surgical workload, in terms of time and number of procedures, devoted to chronic renal failure surgery in an urology and transplantation operating room. MATERIAL AND METHODS: Analysis of the operative activity of the urology and transplantation operating room of Amiens Hospital over a period of one year (2003), by evaluating the number of procedures and the operating room occupation time (time between entry and exit from the operating room) recorded on ecology forms completed for each operation. Procedures performed in this operating room comprise conventional adult urological surgery and chronic renal failure procedures (from creation of venous access sites for haemodialysis to treatment of complications of renal transplantation). RESULTS: Surgical management of chronic renal failure in the operating room represents 22.6% of all procedures and 30.1% of the operating room occupation time. 69% of the renal transplantation operating time and 95% of kidney harvesting operating time are performed on an oncall basis. CONCLUSION: Operative activity related to chronic renal failure represents almost one third of the total surgical workload of a department managing this disease. These data justify the allocation of additional surgical resources adapted to this activity that is growing in parallel to the number of patients with chronic renal failure.

Predictive factors for final pathologic ureteral sections on 700 radical cystectomy specimens: Implications for intraoperative frozen section decision-making.

PURPOSE: To identify preoperative predictive factors for final ureteral section invasion after radical cystectomy (RC) and to validate significant factors on an external independent cohort. MATERIAL AND METHODS: We retrospectively reviewed data of all consecutive RC performed for bladder cancer in 2 high-volume institutions. Clinical, pathological, and follow-up data were collected prospectively and reviewed retrospectively. Pathological evaluation was performed by 2 well-trained uropathologists in each center. Logistic regression analyses were performed to identify predictive factors for final ureteral sections involvement. Significant factors in cohort A were validated in cohort B. Receiver operating curve and area under curve were modeled to evaluate predictive accuracy of the markers. RESULTS: A total of 441 RC were performed in center A and 307 RC were performed in center B. Mean follow-ups were 36.2 and 38.1 months, respectively. Invasion of the final ureteral section was observed on 5.5% of patients in cohort A and 4.8% of patients in cohort B. In cohort A, multivariable logistic regression identified preoperative hydronephrosis on computed tomography scan (odds ratio [OR] = 4.9, P = 0.004) and presence of Carcinoma in situ (CIS, OR = 3.9, P = 0.01) as the only factors associated with ureteral sections positivity. In cohort B, hydronephrosis and CIS were both associated with ureteral sections positivity in univariable analysis. In multivariable analysis, only hydronephrosis remained significant (OR = 5.9, P = 0.01). Predictive accuracy of hydronephrosis and CIS combined in 1 variable was 0.72. CONCLUSION: Hydronephrosis and bladder CIS have good accuracy in predicting ureteral sections positivity after RC. In the presence of those factors, ureteral frozen sections should be performed.

[Urodynamic changes after transobturator suburethral tape]. / Modifications urodynamiques après pose d'une bandelette sous-urétrale trans-obturatrice.

INTRODUCTION: Prospective study of urodynamic changes induced by transobturator insertion of suburethral tape a dip-stick under-urethral. MATERIALS AND METHODS: 25 women with pure (12) or mixed (13) stress urinary incontinence were operated by this technique, allowing urodynamic assessment and completion of the MHU urinary disability questionnaire. Three operators performed these 25 tape insertions in 2 centres (Amiens and St Quentin hospitals) according to a standardized technique. Six months after the operation, patients were reviewed by clinical examination, MHU questionnaire and urodynamic assessment. RESULTS: The cure rate at 6 months was 80% (20 patients) and the improvement rate was 20% (5 patients). The maximum flow rate decreased from 23.6 ml/s to 18.9 ml/s (p = 0.02) and the post-voiding residual volume increased from 26.8 ml to 66.8 ml (p = 0.01). Urethral resistance increased from 0.16 to. 0.25 (p = 0.03) and maximum closure pressure increased from 43.8 to 47.5 cm H2O (p = 0.02). These results demonstrate the obstructive nature of this suburethral tape. The results of the MHU questionnaire showed accentuation of dysuria (p = 0.04) and improvement of stress urinary incontinence (p < 0.001). CONCLUSION: This prospective study confirms the efficacy of this technique, but analysis of the urodynamic studies and the MHU questionnaire demonstrates obstruction. Long-term surveillance of these patients by uroflowmetry and residual urine appears to be useful to detect possible progression to chronic urinary retention.