[Interest of surgical companionship during the training period of robot-assisted radical prostatectomy]. / Intérêt du compagnonnage chirurgical durant la période d'apprentissage de la prostatectomie radicale robot-assistée.

OBJECTIVE: Study of the learning curve of robot-assisted radical prostatectomy, evaluating intraoperative difficulties and postoperative complications according to Clavien-Dindo classification. PATIENTS AND METHODS: Retrospective study of our first 157 consecutive patients treated with robot-assisted prostatectomy for localized prostate cancer between September 2011 and December 2014. Comparison of learning for each group of 50 procedures and then comparison between patients operated on by a pair of two seniors specially trained for robotic surgery and patients operated on by one mixed pair including a surgeon junior coached by one senior of the first group. RESULTS: Only postoperative complications decreased significantly from the 51st patient (P=0.04). The curves showing the evolution of the operative time decreased with a parallel trend between the two pairs, but with more variability in the mixed pair. There was no significant difference in terms of intraoperative difficulties (P=0.59), nor postoperative complications (P=0.56) mainly of grade 2. The blood loss, transfusion rate, duration of hospitalization and readmission rates did not differ. Lymph node dissection did not affect outcomes. For oncological results, the overall rate of positive surgical margins (R+) was 30.6 % in the initial pair against 24.2 % in the mixed group with no significant difference. Nevertheless, the subpopulation study objectified a R+ rate of 12.86 % for pT2 against 42.85 % for pT3. CONCLUSION: The early involvement of a junior surgeon who did not receive specific training, but benefiting from the guidance of a senior surgeon, did not compromise the results while allowing a faster learning curve with a rate of operative complications close to the one observed by the senior pair. LEVEL OF EVIDENCE: 4.

[Treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff]. / Traitement de l'incontinence urinaire masculine par sphincter urinaire artificiel avec manchette intracaverneuse.

OBJECTIVE: The aims of this study are to describe the implantation technique of an artificial urinary sphincter (AUS) with intracavernous cuff, define the indications and report the preliminary results of this technique. MATERIAL AND METHOD: A single-centre retrospective study was carried out in 10 patients with a median age of 66 years. The aetiology of urinary incontinence was radical prostatectomy alone in four cases, combined with radiotherapy in four cases and transurethral resection of the prostate in two cases. The initial treatment consisted of AUS in seven cases and suburethral tape in two cases and the last patient had not been previously treated. Failure of AUS was due to atrophy in three cases and urethral erosion in four cases. Six patients needed to use more than three pads per day. Erections were absent in all patients. All patients were treated by insertion of an intracavernous cuff according to the same technique: perineoscrotal incision on the median raphe, dissection of the bulbar urethra and inferior aspect of the corpora cavernosa, vertical incision of the tunica albuginea on either side of the urethra, passage of the cuff from one incision to the other behind the tunica albuginea and leaving the tunica albuginea against the urethra, and closure of the tunica albuginea by interrupted sutures leaving a passage for the cuff. The median follow-up was 15.5 months. RESULTS: The median operating time was 90 min. No intraoperative complication was observed. Two patients had to be explanted because of infection of the material. Seven of the remaining eight patients were satisfied and six of them needed less than one pad per day. A history pelvic irradiation did not appear to have any impact on the results. CONCLUSION: The treatment of male urinary incontinence by artificial urinary sphincter with intracavernous cuff is a simple technique that improves the trophicity and calibre of the urethra underneath the cuff. This technique achieved good results in patients with a history of pelvic irradiation.

[Elevation of total PSA after intravesical BCG instillations: granulomatous prostatitis or prostatic adenocarcinoma?]. / Elévation du PSA total après instillations endovesicales de BCG: prostatite granulomateuse ou adénocarcinome prostatique?

OBJECTIVE: The objective of this study was to evaluate the incidence of prostatic carcinoma in patients treated by intravesical BCG-therapy for superficial bladder cancer and presenting granulomatous prostatitis. The authors discuss the problems of interpretation of total PSA and the potential indications for prostatic biopsies in this population. MATERIAL AND METHODS: A retrospective study was performed on the cases of symptomatic granulomatous prostatitis observed among patients treated with intravesical BCG instillations between January 1997 and December 2006. A total of 153 men were treated for high-risk or intermediate-risk superficial bladder cancer according to the usual recommendations. The attenuated Connaught strain of BCG was used at a dose of 81 mg. Induction treatment consisted of six weekly instillations and was followed by maintenance treatment for a period of three years. RESULTS: Six patients developed symptomatic granulomatous prostatitis (4% of cases). On average, this complication occurred after about the 10th intravesical instillation (6-13) of maintenance treatment. The mean total PSA at three months was 8 ng/ml (range: 5-11.6). Ultrasound-guided biopsies were indicated in view of the persistently elevated PSA level and confirmed the tuberculoid granulomatous lesion of the prostate in each case and revealed prostatic adenocarcinoma in two patients. CONCLUSION: Prostatic carcinoma must be systematically excluded by ultrasound-guided biopsies in all patients with clinical granulomatous prostatitis and persistently elevated PSA three months after intravesical BCG instillations.

Risk factors of arterial hypertension after renal transplantation.

Arterial hypertension often present after kidney transplantation is of multifactorial origin. The aim of this study was to determine the role of donor and recipient factors in the development of hypertension after renal transplantation. We retrospectively analyzed the data of 280 patients transplanted between 1985 and 2005, who still had functioning grafts at 1 year after transplantation. We recorded donor and recipient parameters. One hundred eighty-seven patients (66.8%) were hypertensive. Upon multivariate analysis of recipient factors, pretransplant hypertension (odds ratio) [OR]: 8.5, 95% confidence interval [CI]: 4.5 to 16.1); serum creatinine level > 130 micromol/L at 6 months (OR: 2.5, 95% CI: 1.3 to 4,7), male gender (OR: 2.02, 95% CI: 1.2 to 3.4), and chronic rejection (OR: 2.4, 95% CI: 1.2 to 4.7) were independent predisposing factors. Among donor factors, age was significantly associated with arterial hypertension upon univariate analysis. In conclusion, recipient factors, especially pretransplant hypertension, contribute to the disorder in renal transplant patients.

[Bladder herniation]. / Hernie Vésicale.

Inguinal hernia of the bladder is uncommon. The diagnosis is frequently done during surgery. It can be evoked before surgery when the patient presents with irritative and obstructive lower urinary tract symptoms. Retrograde urethrocystography or computerized tomography confirm the diagnosis. We report a case of bilateral inguinal hernia involving the bladder at the right side in a 87 years old man who had a surgical history of transvesical adenomectomy of the prostate. The diagnosis was done on the retrograde urethrocystography. We performed bilateral herniorrhaphy with herniated bladder reduction. The postoperative history was uneventful.