Ureteropelvic junction obstruction and renal calculi: Simultaneous treatment by robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy. Technique description and early outcomes.

BACKGROUND: Ureteropelvic junction obstruction (UPJO) and renal calculi are associated in 20 to 30% of cases and treatment is mandatory. The simultaneous surgical management is a therapeutic challenge that is still a source of controversy. We describe our technique combining robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy (fURS), assessing the feasibility of simultaneous treatment through an original technique. METHODS: This single centre series reports our initial experience with 12 patients. From January 2014 to September 2018, 12 patients underwent robot-assisted laparoscopic pyeloplasty with simultaneous fURS for UPJO and renal calculi. Mean age was 46 years (24-68). 92% had multiple renal stones and the mean cumulative stone diameter was 31,3mm. Robot-assisted pyeloplasty was performed with peroperative transcutaneous retrograde fURS through a ureteral access sheath introduced in an incision on the bassinet through a subcostal trocar. Stone extraction was performed using a basket. RESULTS: All patients underwent surgery successfully, achieving UPJ repair and complete stone extraction. Mean operating time was 92,5min (85-110). All reported Clavien-Dindo complications were grade 1. Non-contrast enhanced abdominal CT performed 1 month after surgery confirmed the absence of residual stones in all patients. Mean follow-up time was 10 months with no recurrence of UPJO. CONCLUSION: This small series confirms the feasibility with good surgical results of concomitant robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde fURS stone extraction. No major complications were observed. This technique is easily reproducible but requires 2 experienced urologists to be achieved in a contained operative time.

[Pathological pelvic lymph node involvement in muscle-invasive bladder cancer patients treated with radical cystectomy: A narrative review]. / Envahissement ganglionnaire pelvien anatomopathologique après cystectomie totale pour le traitement des tumeurs de vessie infiltrant le muscle : une revue narrative de la littérature.

OBJECTIVE: To perform a narrative review of the contemporary literature on the diagnosis, prognosis and adjuvant management of muscle-invasive bladder cancer (MIBC) patients with pathological pelvic lymph node involvement (pN+) at radical cystectomy. METHOD: A narrative review of the contemporary literature available on Medline was conducted to report studies evaluating the diagnosis, prognosis and/or adjuvant treatments for MIBC patients with pN+ disease at radical cystectomy. RESULTS: Open or robotic extended pelvic lymph node dissection up to the crossing of the ureter with common iliac vessels can enhance the diagnosis of pN+ MIBC, especially using separate packages for the submission of a maximum number of lymph nodes. The main prognosis factors for pN+ patients are the number of positive and retrieved lymph nodes, lymph node density, extranodal extension as well as lymph node metastasis diameter. Adjuvant chemotherapy is likely to prolong overall survival in pN+ patients treated with radical cystectomy alone while adjuvant immunotherapy using nivolumab has been shown to decrease the risk of recurrence in all pN+ patients, especially those with ypN+ disease after neoadjuvant chemotherapy followed by radical cystectomy. However, few data are currently available on the role of adjuvant radiation therapy, which remains currently experimental for these patients. CONCLUSION: Multiple parameters have been reported to impact the diagnosis and prognosis of patients with pN+ MIBC at radical cystectomy. Adjuvant management is currently based on chemotherapy and immunotherapy with preliminary data on radiation therapy.

Positive environmental impact of remote teleconsultation in urology during the COVID-19 pandemic in a highly populated area.

INTRODUCTION: Greenhouse gas (GHG) emissions are a serious environmental issue. The healthcare sector is an important emitter of GHGs. Our aim was to assess the environmental cost of teleconsultations in urology compared to face-to-face consultations. MATERIALS AND METHODS: Prospective study of all patients who had a remote teleconsultation over a 2-week period during COVID-19 pandemic. Main outcome was the reduction in CO2e emissions related to teleconsultation compared to face-to-face consultation and was calculated as: total teleconsultation CO2e emissions-total face-to-face consultation CO2e emissions. Secondary outcome measures were the reduction in travel distance and travel time related to teleconsultation. RESULTS: Eighty patients were included. Face-to-face consultations would have resulted in 6699km (4162 miles) of travel (83.7km (52 miles) per patient). Cars were the usual means of transport. CO2e avoided due to lack of travel was calculated at 1.1 tonnes. Teleconsultation was responsible for 1.1kg CO2e while face-to-face consultation emitted 0.5kg of CO2e. Overall, the total reduction in GHGs with teleconsultation was 1141kg CO2e, representing a 99% decrease in emissions. Total savings on transport were 974 € and savings on travel time were 112h (1.4h/patient). CONCLUSIONS: Teleconsultation reduces the environmental impact of face-to-face consultations. The use of teleconsultation in our urology departments resulted in the avoidance of more than 6000km of travel, equivalent to a reduction of 1.1 tonnes of CO2e. Teleconsultation should be considered for specific indications as the healthcare system attempts to become greener. LEVEL OF EVIDENCE: 3.

Proof of concept: could snake venoms be a potential source of bioactive compounds for control of mould growth and mycotoxin production.

The objective was to screen 10 snake venoms for their efficacy to control growth and mycotoxin production by important mycotoxigenic fungi including Aspergillus flavus, Aspergillus westerdijkiae, Penicillium verrucosum, Fusarium graminearum and F. langsethiae. The Bioscreen C rapid assay system was used. The venoms from the Viperidae snake family delayed growth of some of the test fungi, especially F. graminearum and F. langsethiae and sometimes A. flavus. Some were also able to reduce mycotoxin production. The two most potent crude snake venoms (Naja nigricollis and N. siamensis; 41 and 43 fractions, respectively) were further fractionated and 83/84 of these fractions were able to reduce mycotoxin production by >90% in two of the mycotoxigenic fungi examined. This study suggests that there may be significant potential for the identification of novel fungistatic/fungicidal bioactive compounds as preservatives of raw and processed food commodities post-harvest from such snake venoms.

Is there a volume-outcome relationship for partial nephrectomy?

OBJECTIVE: To investigate the impact of hospital volume on partial nephrectomy indications and outcomes. MATERIALS AND METHODS: Data were extracted from the National Observational Registry on the Practice and Hemostasis in Partial Nephrectomy registry. Four groups were created according to the number of partial nephrectomy (PN) performed: very high (VH, ≥ 19 PN), high (H, 10-18 PN), moderate (M, 4-9 PN) and low (L, <4 PN) PN activity. Indications and surgical outcomes were compared among all groups. The effect of hospital volume on postoperative complications and positive margin rate was examined by a multivariable analysis. RESULTS: Fifty-three centers included a total of 570 PN. There were 9 VH, 13 H, 12 M and 19 L volume centers which performed 270 (47.4 %), 179 (31.4 %), 74 (13 %) and 47 (8.2 %) PN, respectively. Patients in higher volume centers were significantly younger (p = 0.008), had a lower BMI (p = 0.002) and decreased ASA score (p < 0.001). PN was more frequently performed in higher volume centers (p = 0.006) particularly in case of renal masses <4 cm (p = 0.005). Open surgery was the most common approach in all groups, but laparoscopic PN was more frequent in M volume hospitals (p < 0.001). Positive margin (p = 0.06) and complications (p = 0.022) rates were higher in M group. In multivariable analysis, renal chronic disease was an independent predictor of positive margin rate (p < 0.001, OR 3.91). CONCLUSIONS: PN is more frequently performed in high volume institutions particularly for small renal masses. We observed increase positive margin and complication rates in moderate volume centers that might be explained by an increased use of laparoscopy.

Comparison of functional outcomes with purely laparoscopic sacrocolpopexy and robot-assisted sacrocolpopexy in obese women.

OBJECTIVE: To compare the functional outcomes and complication rates following laparoscopic sacrocolpopexy (LS) with those occurring in robot-assisted laparoscopic sacrocolpopexy (RALSCP) in obese women. PATIENTS AND METHODS: A comparative retrospective multicentre study was made, involving 39 obese women (BMI≥30 kg/m2) who underwent LS, and 17 obese women who underwent RASCLP. The operative parameters (length of operation, associated procedures, complication rate and length of hospitalization) and the objective and subjective results were evaluated at 12 months follow-up. RESULTS: The median (IQR) BMI was 30.5 kg/m2 (30-32) in the LS group vs 31.6 kg/m2 (30-34) in the RALSCP group (P=0.402). The anatomical results were comparable in both groups (LS vs RALSCP): post-operative stage of prolapse (POP-Q-ICS): stage 0-1: 34/39 (88%) vs 16/17 (94.1%), P=0.7; stage 2: 4/39 (10%) vs 0/17 (0%), P=0.7; stage 3-4: 1/39 (2%) vs 1/17 (5.9%), P=0.7. The complication rate was similar in both groups (LS vs RALSCP): bladder injury 2.5% (1/39) vs 0% (0/17), P=0.6, laparoconversion 5.1% (2/39) vs 5.9% (1/17), P=0.5. The overall reoperation rate was (LS vs RALSCP): 18% (7/39) vs 5.9% (1/17), P=0.4. CONCLUSION: Laparoscopic sacrocolpopexy and robot-assisted laparoscopic sacrocolpopexy have equal results in obese women. The complication rates and outcomes appear to be similar in both groups of obese women. LEVEL OF EVIDENCE: 3.

[Prognostic influence of prostate gland invasion by bladder tumour and/or prostate cancer in cystoprostatectomy specimen: a review]. / Influence pronostique de l'envahissement tumoral de la glande prostatique par la tumeur de vessie et/ou du cancer de la prostate découvert après cystoprostatectomie : analyse de la littérature.

INTRODUCTION: Cystoprostatectomy (CPT) is the gold standard surgical treatment for muscle invasive bladder cancer (MIBC). In certain cases, MIBC can invade the prostate gland and/or a prostate cancer (PCa) can be discovered fortuitously on the pathologic specimen. The aim of the current study was to report the prognostic influence of PCa in patients who underwent a CPT for MIBC. MATERIALS AND METHODS: A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: prostatic neoplasm; urinary bladder neoplasm; cystectomy; surgery; recurrence; prognosis; survival. Clinical cases and series of less than five cases were deliberately excluded herein. RESULTS: Overall, ten studies published between 2004 and 2011 and involving 2196 patients were selected. Only retrospective studies of low level of evidence (NP 4) were available. The incidence of neoplastic invasion of the prostate gland by MIBC ranged from 25 to 48%. Preoperative predictors were multiple BC, recurrent, location in the trigone and existence of CIS. Overall survival at 3 years was significantly affected by the invasion of the prostate gland (pT4a) in these patients. The incidence of PCa discovered incidentally pathologic specimen CPT ranged from 14 to 49%. Only age was found as a positive predictor. The diagnosis of PCa did not influence survival of patients with MIBC and no specific PCa adjuvant treatment was systematically advocated. CONCLUSION: Fortuitous diagnosis of PCa and/or neoplastic invasion of the prostatic gland by BC on CPT specimen is not uncommon but this is variable across studies, depending on the quality of the pathological analysis. The invasion of the prostate gland by MIBC is a serious situation (pT4a) and linked with a poor prognosis. In case of concomitant PCa and MIBC, the prognosis is much more related to the natural history of the bladder tumour.

[Results obtained after robotic-assisted laparoscopic sacral colpopexy for the management of urogenital prolapse: a review]. / Résultats de la promontofixation par voie laparoscopique robot-assistée pour la prise en charge des prolapsus urogénitaux : analyse de la littérature.

INTRODUCTION: Laparoscopic sacral colpopexy (LSCP) is one of the gold standard surgical treatment for the management of urogenital prolapse. Robot-assisted laparoscopic sacrocolpopexy (RALSCP) is an alternative surgical access which has been recently proposed. The aim of the current study was to report the functional results obtained after RALSCP. MATERIAL AND METHODS: [corrected] A systematic review of the scientific literature was achieved in the Pubmed database, using the following keywords: robotic; robot; sacrocolpopexy; sacralcolpopexy. Clinical cases and series of less than five cases were spontaneously not selected herein. RESULTS: Overall, 12 series in published between September 2004 and September 2011 which included 350 female patients were selected. The mean age was 63 years old with a pelvic organ prolapse of stage 3 to 4 in the Baden Walker classification. The mean operative time of the RALSCP was 207 minutes with a conversion rate of 3,4% and an intraoperative complication rate of 4,6%. The mean length of hospital stay was 3 days and the perioperative complication rate of 7,1%. The success rate of the RALSCP was 97% and the vaginal erosion rate was 2,5% with a median follow-up of 13,5 months. CONCLUSION: The mid-term functional results obtained after RALSCP were equivalent to those obtained with the LSCP approach. However, there is no prospective randomized comparison available between the two access so far. In addition, the experience with RALSCP remains limited due to the important cost that the robotic access generates.

[Prevention of complications of general anesthesia linked with laparoscopic access and with robot-assisted radical prostatectomy]. / Complications de l'anesthésie générale inhérentes à la voie laparoscopique et à la prostatectomie totale robot-assistée.

INTRODUCTION: The aim of our work was to present a review of technical features and complications of general anesthesia during robot-assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS: Data on RALRP and general anesthesia were explored on Medline using the following MeSH terms: radical prostatectomy; morbidity; anesthesia complications; laparoscopy; robotics; Trendeleburg. Publications were considered on the following criteria: methodology, relevance and date of publication. RESULTS: There was no data of level of evidence 1 available. The first RALRP was reported in 2000. Technological innovation brought by the robot with its 3-D vision, the acquisition of degrees of mobility and a more ergonomic position for the surgeon, have led to a growing interest from new teams in the western world. However, the RALRP generates constraints for the anesthesia team who need to incorporate the rules of laparoscopy and the patient's specific installation to guarantee maximum safety. There are inherent complications with the installation of the patient himself in the Trendelenburg position (ocular, neurological, hemodynamic, respiratory) and respiratory complications related to the specific procedure in gaseous atmosphere due to pneumoperitoneum. One of the criteria of the quality of publications in the field of surgery is related to the objective evaluation of complications by appropriate scale systems and the complications of general anesthesia must also be absolutely recorded. CONCLUSION: RALRP had deeply modified the anatomical landmarks of the surgical removal of prostate cancer. However, the perioperative environment has also been completely altered and the installation of RALRP in the daily routine of a service requires from the anesthesia team to adapt their behavior to this sophisticated surgical access.

[Should temperature be monitorized during kidney allograft preservation?]. / Faut-il monitorer la température pendant la phase de préservation en transplantation rénale ?

GOAL: It is generally considered that kidney grafts should be preserved at 4 degrees C during cold storage. However, actual temperature conditions are not known. We decided to study the temperature levels during preservation with the Biotainer storage can and Vitalpack transport pack. MATERIAL: Temperature was monitored using the Thermobouton probe during preservation of pig kidneys, in the same conditions used with human grafts. The probe recorded the temperature level every 10 minutes during four days. We compared the results found with the new storage can with results obtained in the same conditions with the storage can formerly used by our team. We also studied the best position of the probe for temperature monitoring and the influence of the amount of ice within the transport pack on the temperature level. We then monitored the temperature during the conservation of actual human kidney grafts harvested at our institution from August 2007 to May 2008. RESULTS: The temperature levels were the same regardless of the position of the probe within the transport pack. The lowest temperature was maintained during 15 hours, and the temperature level stayed below 5 degrees C for 57 hours with the new storage can. The former storage can maintained the lowest temperature level for 80 minutes, and temperature reached 5 degrees C after 10 hours 40 minutes. Temperature levels were similar when 2 or 4 kg of crushed ice were used. We observed similar results when monitoring the conservation of human grafts. CONCLUSION: The new storage can affords more stable temperature levels when compared to the formerly used can. Since temperature is stable during conservation, continuous monitoring in everyday practice does not seem warranted.

[Erectile dysfunction after radical prostatectomy: pathophysiology, evaluation and treatment]. / Dysfonction érectile après prostatectomie totale : physiopathologie, évaluation et traitement.

Radical prostatectomy (RP) is the gold standard treatment for localized prostate cancer; yet erectile dysfunction (ED) in selected series is still reported as high as 80% after this surgery. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of postoperative ED. Pharmacological treatment of postoperative ED, using either oral or local approaches, is effective and safe. Thus, most men need adjuvant treatments to be sexually active following RP. These include intracorporeal injections of vasoactive drugs, vacuum constriction devices and transurethral dilators, all of which have reported response rates of 50 to 70%. Unfortunately, long-term compliance is sub-optimal, with a discontinuation rate of nearly 50% at 1year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy (IPDE5) since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections is the gold standard for partients over 60years old and those who underwent non-sparing surgery. In younger patients and/or when preservation of nerve tissue was feasible, oral IPDE5 may be effective in promoting an earlier return of erectile function. Recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in cases of properly selected young patients treated with a bilateral nerve-sparing approach by experienced urologists.

Carbon dioxide production as an indicator of Aspergillus flavus colonisation and aflatoxins/cyclopiazonic acid contamination in shelled peanuts stored under different interacting abiotic factors.

Aspergillus flavus is the main xerophylic species colonising stored peanuts resulting in contamination with aflatoxins (AFs) and cyclopiazonic acid (CPA). This study evaluated the relationship between storage of shelled peanuts under interacting abiotic conditions on (a) temporal respiration (R) and cumulative CO2 production, (b) dry matter losses (DMLs) and (c) aflatoxin B1 (AFB1) and CPA accumulation. Both naturally contaminated peanuts and those inoculated with A. flavus were stored for 7-days under different water activities (aw; 0.77-0.95) and temperatures (20-35°C). There was an increase in the temporal CO2 production rates in wetter and warmer conditions, with the highest respiration at 0.95 aw + A. flavus inoculum at 30°C (2474 mg CO2kg-1h-1). The DMLs were modelled to produce contour maps of the environmental conditions resulting in maximum/minimum losses. Maximum mycotoxin contamination was always at 0.95 aw although optimal temperatures were 25-30°C for AFs and 30-35°C for CPA. These results showed a correlation between CO2 production and mycotoxin accumulation. They also provide valuable information for the creation of a database focused on the development of a post-harvest decision support system to determine the relative risks of contamination with these mycotoxins in stored shelled peanuts.

Laparoscopic radical prostatectomy in kidney transplant patient: our first experience-a case report.

The association between prostate cancer and kidney transplantation has an unknown incidence despite an increased screening in that population. Radical prostatectomy remains the gold standard in treating localized tumors. Retropubic or perineal approaches are usually considered. The surgical aspects and successful outcome of laparoscopic radical prostatectomy in a kidney transplant recipient are reviewed.