Effect of Treatment of Residual Disease After Immunotherapy-Based Combinations on Complete Response Rate of Patients With Metastatic Renal Cell Carcinomas.

INTRODUCTION: Immune checkpoint inhibitor (ICI)-based combinations have revolutionized the management of first-line metastatic renal cell carcinoma (mRCC) by improving patient survival. Large phase 3 randomized trials assessing ICI-based combinations have reported complete response (CR) rates of 10% to 18% in the first-line setting. However, there is a scarcity of data about the effect of treatment of residual disease regarding CR rates improvement. MATERIALS AND METHODS: We included retrospectively all consecutive mRCC patients treated in first-line setting at the Institut de Cancérologie Strasbourg Europe with an ICI-based combination involving ICI or TKI, either alone or with added local treatment of residual disease. Patients were characterized according to IMDC risk. Radiologic response was defined according to RECIST v1.1. RESULTS: We enrolled 80 mRCC patients treated with ICI-based combinations between May 2015 and May 2022. The median age was 63 years. Regarding IMDC risk, there were 12 favourable (15%), 50 intermediate (63%), and 18 poor-risk (22%) patients. Forty-seven patients (59%) received ICI + ICI, 24 (30%) received ICI + TKI, and 9 (11%) received another ICI-based therapy. In total, 8 achieved CR (10%), 36 patients (45%) achieved partial response, 23 (29%) achieved stable disease and 12 achieved progressive disease (15%) as the best response with systemic therapy alone. By adding local treatment of residual disease, 11 additional patients (14%) achieved radiological NED. Residual disease resected sites included kidney (n = 6), lymph nodes (n = 5), lung metastases (n = 2) and liver metastases (n = 1). CONCLUSIONS: The resection of residual disease after first-line ICI-based therapy is associated with improved CR rate (CR + NED) in patients with mRCC. These results need to be validated in prospective trial. PATIENT SUMMARY: In recent years, the advent of immunotherapy has radically changed the management of patients with metastatic kidney cancer. Approximately 10% to 18% of these patients using immune checkpoint inhibitor (ICI)-based combinations no longer have detectable disease on CT scans (complete response). There are currently few data on the use of treatment of residual disease to increase the number of patients in complete response. In this retrospective study, the complete response rate with ICI-based treatment was 10%. When local treatment was added, the number of patients with a complete response increased to 24%. This strategy could increase the number of patients with a prolonged complete response in the future.

Analysing the learning curve of prostate enucleation with the Holmium laser: A retrospective, single-center experience.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is a proven surgical technique for the treatment of benign prostatic hyperplasia (BPH). However, its challenging learning curve prevents its widespread adoption by urologists. The aim of this study was to analyse the learning curve of HoLEP and to determine the factors accelerating it. METHODS: This was a retrospective, monocentric cohort study of the first 60 cases of HoLEP performed by three operators. The primary outcome measure was operative efficiency, defined as the ratio of preoperative prostate volume estimated by trans-abdominal ultrasound (TAUS)to total surgical time in minutes. The studied learning curve parameters included the number of previously performed cases (NPPCs) and monthly case density (CD) (number of monthly performed cases before the studied one). RESULTS: Overall, 180 patients with a mean age of 71 (±9) years and a mean prostate volume (g) of 80.4 (±41) were included. The mean operative efficiency in the population was 0.74 (±0.37) g/min. Operative efficiency was increased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 0.66 (±0.27) g/min vs. CD ≥3: 0.79 (±0.43) g/min; P=0.012). At 3months, 46 patients (29%) developed stress urinary incontinence (SUI). Early SUI was significantly decreased in patients who had been operated on by surgeons with a CD ≥3 (CD ≤2: 37%, (n=26) vs CD ≥3: 22%, (n=20); P=0.045). CONCLUSIONS: A high frequency HoLEP procedures, set as one case per week, appeared to accelerate learning curves by improving operative efficiency. A high CD was also associated with reduced rates of early SUI. LEVEL OF PROOF: 5.

Sacral neuromodulation in the management of non-obstructive urinary retention: Test phase and predictive factors.

AIM: The aim of this study is to evaluate the success of the test phase of sacral neuromodulation in management of chronic non-obstructive urinary retention and the factors predictive of good response. MATERIALS AND METHODS: This is a retrospective study carried out on a cohort of patients followed up in a tertiary University Hospital in France. Fifty-two patients with chronic non-obstructive urinary retention were included in this study. These patients were seen over the past 20 years, from the year 2000 to 2020. The initial evaluation of patients included a summary of medical and surgical history, age, BMI, history of pelvic floor disorders, initial voiding pattern, physical examination, voiding diary, initial uroflowmetry and a urodynamic study. Postoperative follow-up and analysis of complications were also carried out. RESULTS: A total of 52 patients were included in this study, 13 males and 39 females. Out of these patients, 17 patients (32.7%) with a median age of 47.3 years±18.1 benefited from definitive implantation of the sacral neuromodulation. The univariate analysis showed that age was the only significant variable in this study and the optimal age threshold was<58.5 years. CONCLUSION: SNM is a therapy with significant clinical benefits and low morbidity for patients with chronic non-obstructive urinary retention. The results obtained need to be confirmed with a prospective study with a larger number of patients.

[Bladder pain syndrome: Long-term results (15 years) of a single-center experience]. / Syndrome de la douleur vésicale : résultats à long terme (15 ans) d'une expérience monocentrique.

INTRODUCTION: The management of bladder pain syndrome (BPS) in our center is standardized although there is no real consensus and recommendations. The objectives of our study were to assess the effectiveness of the treatment offered and to identify predictive factors of response to treatment. PATIENTS AND METHODS: Single-center retrospective study including all patients with BPS. Patient and outcome measures included ICSI and ICPI scores, daytime voiding interval (DVI), nocturnal pollakiuria (NPK), and subjective satisfaction (SS). The complete care protocol (CCP) was based on a hydrodistension test followed by a cimetidine treatment then by 6 instillations of dimethyl sulfoxide followed by a maintenance treatment with pentosan polysulfate. The main objective of our study was the patient's SS at 3months and at medium term. One of the secondary objectives was to study the predictive factors of response to treatment. OUTCOMES: From 2002 to 2019, 211 patients (90.5% women) were treated for BPS. Sixty-nine patients (35%) underwent the CCP that provided significant improvement in ICSI, ICPI, DVI and NPK and SS of 52.2%.). In the medium term, 149 patients were reassessed with a median follow-up of 99.6months (±3.6): 71.8% were satisfied and 54.2% were no longer receiving treatment. Among the 49 patients who initially received PSC, 74% were satisfied at 89.8 months of median follow-up (±2.9). In multivariate analysis, patients with a pain perception disorder (HR=0.17 IC95=0.05-0.52; P=0.002) or consuming anxiolytics (HR=0.3; IC95=0.13-0.69; P=0.004) had a statistically greater risk of not being satisfied. CONCLUSION: In our study, the CCP achieves subjective medium-term satisfaction in nearly 75% of patients with BPS. These data deserve to be confirmed on a larger scale in a prospective protocol.

[Artificial urinary sphincter in patients with urinary incontinence after High Intensity Focused ultrasound]. / Sphincter urinaire artificiel chez les patients présentant une incontinence urinaire après High Intensivity Focused Ultrasound Therapy.

INTRODUCTION: Urinary incontinence after High Intensity Focused ultrasound (HIFU) is a poorly documented issue. To our knowledge, no study has evaluated the outcomes of artificial urinary sphincter (AUS) after HIFU. The aim of this study was to evaluate the functional outcomes of AUS for post-HIFU urinary incontinence. METHODS: The charts of all male patients who underwent an AUS implantation between 2004 and 2020 in 13 centers were reviewed retrospectively. Only men with a history of HIFU were included. The primary endpoint was social continence at 3 months defined as wearing 0 to 1 pad per day. RESULTS: Out of 1318 procedures, nine men were implanted with an AUS after HIFU including four men with an history of pelvic irradiation: 3 pelvic radiation therapy and 1 prostatic brachytherapy. The patients were divided into two groups, 5 in the HIFU group without a history of pelvic irradiation, 4 patients in the HIRX group with a history of pelvic irradiation. The median age was 74 years (IQR 71-76). There was no perioperative complication. The median follow-up was 47.5 (IQR 25-85.5) months. Social continence at 3 months was 75% in the total cohort: 80% in the HIFU group and 67% in the HIRX group. CONCLUSION: AUS implantation may provide satisfactory long-term functional outcomes in the treatment of stress urinary incontinence resulting from HIFU. Larger series are needed to confirm these findings. LEVEL OF EVIDENCE: 4.

[Voiding dysfunction after TVT: A 20-year experience TVT-placement under local anesthesia and sedation]. / Troubles mictionnelles après pose de TVT : 20 ans d'expérience de pose sous diazanalgésie et anesthésie locale.

BACKGROUND: Trans-vaginal tape has become the gold standard for the cure of urinary stress incontinence, but post-operative voiding dysfunction is frequently reported. The purpose of this study is to assess the incidence of voiding dysfunction, dysuria, chronic urinary retention, and necessity of reoperation after retropubic TVT placement under local anaesthesia and sedation. MATERIAL AND METHOD: We perform a retrospective study of a cohort of patient treated with the placement of a retropubic TVT under local anaesthesia and sedation between 1999 and 2019 for a SUI. Post-operative voiding dysfunction and necessity of reoperation were reviewed to access the principal aim of this study. RESULTS: Three hundred and two patients who met the eligibility criteria were included in the study. At 3 months, the dysuria rate and chronic urinary retention rate was 4.3% and 1%. At 12 months it was 2.6% and 0.3% respectively. The 12-month sling section rate was 1% and long-term self-catherization rate was 0.3%. The objective cure rate was 93% and subjective cure was 92%. CONCLUSION: TVT placement under local anaesthesia and sedation resulted in few voiding dysfunctions at medium/long-term, necessity of re-operation for refractory obstructive disorder and well functional results. Even if these results support more frequent use of this type of anaesthesia, it would be interesting to be able to follow them in a prospective study to conclude. LEVEL OF EVIDENCE: 4.

Pregnancy and Delivery in Women with Lower Urinary Tract Reconstruction: A National Multicenter Retrospective Study from the French-Speaking Neuro-Urology Study Group (GENULF) and the Neuro-Urology Committee of the French Association of Urology.

PURPOSE: Management of pregnancy and delivery in women with lower urinary tract reconstruction is challenging and the currently available literature is insufficient to guide clinical practice. We report pregnancy and delivery outcomes in this specific population. MATERIALS AND METHODS: We conducted a national multicenter retrospective study (16 centers) including 68 women with 96 deliveries between 1998 and 2019. These women had at least 1 successful pregnancy and delivery after augmentation enterocystoplasty, catheterizable channel creation and/or artificial urinary sphincter implantation. Maternal and fetal complications during pregnancy and delivery were reported, as well as postpartum functional outcomes, according to the delivery mode. The chi-square test and Student's t-test were used to compare categorical and continuous variables, respectively. RESULTS: Overall 32% of reported pregnancies were complicated by febrile urinary tract infections, 13.5% by renal colic and 14.6% required upper urinary tract diversion. In addition, 10% of patients reported transient self-catheterization difficulties and 13.5% reported de novo or increased urinary incontinence. The preterm delivery rate was 35.3%. Elective C-section was performed in 61% of pregnancies. Twenty complications occurred during delivery (20%), including 19 during elective C-section. Urinary continence at 1 year was unchanged for 93.5% of deliveries. Delivery mode (p=0.293) and multiparity (p=0.572) had no impact on urinary continence. CONCLUSIONS: In this population C-section appeared to be associated with a high risk of complications. In the absence of any obstetric or neurological contraindications, vaginal delivery should be proposed as the first line option to the majority of these women.

[Influence of urethral self-dilatation on the morbidity of the artificial urinary sphincter after endoscopic treatment of recurrent stenosis of the vesicourethral anastomosis]. / Impact des autodilatations urétrales sur la morbidité du sphincter urinaire artificiel, après le traitement endoscopique de la récidive de sténose de l'anastomose vesico-uretrale.

OBJECTIVE: To analyze the morbidity of the practice of daily self-dilatation (SD) in patients undergoing total prostatectomy, who have had artificial urinary sphincter (AUS) for urinary incontinence (UI) and who have had a recurrence of endoscopically treated vesicourethral anastomosis (VUS) stenosis. MATERIALS AND METHOD: One hundred and thirty-eight patients with SUA for urinary incontinence (UI) fitted between 1998 and 2007 were divided into two groups. Thirty-five patients have had used self-dilatation (SD) for recurrent anastomotic stenosis (SD group) and 103 patients did not perform SD (non-SD group). These two groups were compared for explantation rate (erosion-infection), revision rate (urethral atrophy and mechanical failure) and 2-year functional results. The uni- and multivariate statistical analysis taken into consideration confounding factors such as age and radiotherapy history. The functional assessment was done by the validated IQoL, Ditrovie and MHU tests. RESULTS: Patients in both groups were comparable except for the importance of urinary incontinence assessed by PAD test and questionnaires. The explantation rate was significantly higher in the "SD" group (28.5% vs 7.77%) and (OR=4.68, 95% CI [1.490-15.257], P=0.006). There was no significant difference between the two groups in the surgical revision rate (32% vs 20%, OR=0.44, P=0.09). The functional results at two years did not show any significant difference. CONCLUSIONS: The use of self-dilation for recurrence of stenosis of vesicourethral anastomosis after prostatectomy exposes patients fitted with an SUA to a higher explantation rate. LEVEL OF EVIDENCE: 3.

[Percutaneous MR-guided prostate cancer cryoablation: Predictive factors and oncologic outcomes]. / Cryothérapie totale de la prostate sous IRM par voie périnéale : résultats carcinologiques et facteurs prédictifs.

OBJECTIVE: To determine the pejorative predictive factors on oncologic outcomes of percutaneous MR-guided whole gland prostate cancer cryoablation (CA). METHODS: Medical records of patients treated from 2009 to 2012, to assess medium-term oncologic outcomes, were reviewed. Prostate biopsies were performed in local recurrence suspicion (biochemical failure, MR follow-up failure). RESULTS: Among 18 patients, mean age of 72.6 (61-78), 2 (11 %) and 7 (38.9 %) biological and reported biopsy-proven local recurrence respectively with our initial technic of CA. Mean follow-up and recurrence were 56.3 (±21.7) and 20.7 (±13.9) months respectively. A previous treatment of prostate cancer (P=0.5), pre-treatment PSA (P=0.2), pre-treatment Gleason/ISUP score (P=0.4), nadir PSA post-CA (P=0.22) were not associated with recurrence. Bilateral positive cores appears as a pejorative predictive factor (P=0.04). However mean pre-treatment positive cores percentage, 25 (±16.5) in responding patients versus 40.7 (±25.2) in case of recurrence, and maximum percentage of cancer extent in each positive core, 10.6 (±9.3) in responding patients versus 18.7 (±16.5) in case of recurrence, seemed associated with local recurrence after prostate CA but our analysis wasn't able to find a difference (P=0.09 and P=0.3 respectively) due to a lack of power. CONCLUSION: Bilateral positive cores appears as a pejorative predictive factor. In our experience, important tumor volume seem to be a pejorative predictive factor for oncologic outcomes after PCA whereas treatment, PSA, Gleason/ISUP score, nadir PSA are not. LEVEL OF EVIDENCE: 4.

[Augmentation cystoplasty: Perioperative management for urologic nurses]. / L'entérocystoplastie d'agrandissement : indications et principes de prise en charge pour l'IDE en urologie.

INTRODUCTION: Augmentation cystoplasty (AC) is a surgical option to restore a good capacity bladder reservoir able to fill at low pressure. METHODS: The authors present the main principles for perioperative management for urologic nurses. RESULTS: AC is usually made with a piece of ileum patched to the bladder. Patient education programs are very important and are usually managed by urologic nurses. It begins in preoperative phase with the self-catheterization learning and continue in the postoperative phase with advises and prevention of the urinary mucus. CONCLUSION: AC are tricky surgeries but management and education of patients by urological nurses are key points to avoid chronic infection, stones or AC perforation.

[Temporary urethral stents changes as an alternative treatment for neurological bladder]. / Les changements itératifs de prothèse urétrale trans-sphinctérienne chez le patient neurologique : une alternative à la sphinctérotomie ?

BACKGROUND: Patients with detrusor-sphincter dysynergia (DSD) who are unable to perform self-catheterisation can benefit from an endoscopic treatment. We chose regular urethral stent changes as an alternative to sphincterotomy in this kind of patients. The purpose of this study is to show that temporary urethral stents changes represent a treatment option with a reasonable morbidity for patients with DSD. METHODS: We retrospectively reviewed patients in our center who had been treated with urethral stents from April 2005 to September 2017. The stent changes were performed every 12 to 18 months depending on urethrovesical fibroscopy findings. The primary endpoint was treatment continuation. RESULTS: A total of 44 patients were enrolled in our study and the average follow-up duration was 46 months [18.5-53.25]. Primary treatment failure was seen in 14 (32%) patients mainly due to problems related to equipment (n=3) and urinary retention (n=2). Four patients died before their first stent change. The treatment was successful in 30 (68%) patients, of whom 10 (33%) subsequently adopted a voiding mode change. We lost sight of 5 patients (11%) during follow-up. The main complications were urinary retention (29%), urinary tract infections (27%) and stent migration (18%). Fifteen (34%) experienced grade III-IV complications. CONCLUSIONS: Regular urethral stent changes represent an alternative treatment option for patients with DSD but with a significant morbidity. LEVEL OF EVIDENCE: 4.

[The dimethyl sulfoxide under general anesthesia: An alternative after failure without anesthesia in the painful bladder syndrome/interstitial cystitis?] / Le diméthyl sulfoxide (DMSO) sous anesthésie générale : une alternative après échec du DMSO sans anesthésie dans le syndrome de la douleur vésicale ?

INTRODUCTION: The intravesical instillation of dimethyl sulfoxide (iDMSO), performed without anesthestic, is a therapeutic option for the painful bladder syndrome/interstial cystitis (PBS/IC). Some patients are against those iDMSO because of bad tolerance. Our study evaluates the tolerance and the outcome of the iDMSO under general anesthetic (GA) after the failure of the iDMSO without anesthetic. PATIENTS AND METHODS: From May 2013 to April 2016, 11 patients with a PBS, 9 women (81.8 %), have been treated by iDMSO without anesthetic, without improvement because of bad tolerance and no possibility to have a one hour contact between the bladder and the DMSO. The 11 patients were evaluated by mictional calendar and Sant O'Leary score. All the patients had a hydrodistension and a per os treatment without improvement. OUTCOMES: Six new iDMSO were performed under general anesthetic in ambulatory surgery with good tolerance for the 11 patients. The frequency and the nocturia before iDMSO without anesthetic and after iDMSO under general anesthetic were 32.2minutes [15; 60] and 6.3 per night [3; 10] and 126.9minutes [25; 240] and 3 per night [2; 6], so a variation respectively of 96.4minutes [0; 180] and of 3.75 per night [2; 6]. The symptom score and the problem index were 17.5 [13; 20] and 15.5 [13; 16] before and 13.5 [4; 20] and 12 [1; 16] after iDMSO under general anesthetic; a variation of 3.2 [0; 9] and 4 [0; 12]. CONCLUSION: The iDMSO under general anesthetic seems to improve objectively and subjectively the patients who are not improved by the instillations without anesthetic because of bad tolerance. LEVEL OF EVIDENCE: 4.

[Ablative therapy in kidney cancer: Indications]. / Thérapies ablatives dans le cancer du rein : indications.

BACKGROUND: Ablative therapies (AT) in kidney cancer are rising. It's important to evaluate the situation of this therapy. The aim of this study is to identify the best indications for AT treatment for kidney cancer. METHODS: Review of literature using Medline and Embase databases. Study were selected based on scientific relevance. Clinical keys centered on the best requirements to indicate ablative therapies. RESULTS: AT is indicated according to specific tumor and patients criteria. A good initial evaluation is essential (imaging, pathology, renal function and general condition of the patient). AT gets the best results when applied to the following tumor criteria: solid tumor, length<3cm, exophytic localization, RENAL score<8. In few cases, AT could be discussed as an alternative to the reference treatment, sparing surgery: life expectancy evaluated between 3 and 7 years, chronic renal failure or single kidney, transplanted kidney, familial tumors. AT can be used in first line, post-surgery after local recurrence or for distant metastasis. Like every other innovative technic, indications of AT would be adjust with learning curve and cost-effectiveness. CONCLUSION: AT have to be included as a valid treatment for kidney cancer<4cm. The respect of actual indications and collection of results of AT compared to surveillance and surgery, would determinate the evolution of AT indications in the future.

[Ablative therapy in urology: Good practice and perspective]. / Traitement ablatif en urologie : recommandations actuelles et perspectives.

INTRODUCTION: To expose the main point of discussion from present ablative therapies' guidelines and propose global perspectives. MATERIALS AND METHODS: A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com/) using different associations of keywords "ablative therapy" ; "prostate cancer"; "kidney cancer"; "guidelines"; "hybrid operating room". Publications obtained were selected based on methodology, language and relevance. RESULTS: Present guidelines on ablative therapies in urology are, considering authors and organs, either particularly prudent (EAU guidelines for prostate and kidney) or relatively optimistic (CIRSE guidelines). This discrepancy is related to a low level of proof. So, a new approach is mandatory: more homogeneous in methodology, and especially more open to a new organization sparing economic efficiency. The objective will be to get multifunctional and multidisciplinaries platforms, in facts and in minds. It will induce, in the future, a deep reflection about training and boundaries' specialties. CONCLUSION: Ablative therapies represent a crucial stake for urology and a clear example of medicosurgical evolution in future, based on new technologies (energy, robotic, imaging). A serious and deep reflection is necessary to prepare it and be deeply involved in.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]. / Traitement ablatif pour cancer du rein : modalités d'évaluation pré-, per-, post-intervention et prise en charge adaptée.

OBJECTIVES: Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management. METHODS: We searched MEDLINE®, Embase®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance. RESULTS: Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance. CONCLUSION: AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.

[Ablative therapy in kidney cancer: Oncological, functional, perioperative outcomes and cost]. / Thérapies ablatives dans le cancer du rein : résultats oncologiques, périopératoires, fonctionnels et médico-économiques.

INTRODUCTION: The incidence of kidney cancer has increased significantly over the past few decades presumably due to the increased use of imaging. The aim of this article is to describe contemporary outcomes of ablative therapy and to compare them to other therapeutic options in terms of oncological, functional, perioperative outcomes and cost. MATERIAL AND METHODS: We searched MEDLINE®, Embase®, using (MeSH) words; from January 2005 through May 2017, and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance. RESULTS: Ninety-one articles were analyzed. We described the outcomes of ablative therapy in relation to the energy used and the approach, and compared these outcomes to the other therapeutic options in terms of oncological, functional and perioperative outcomes. We analyzed these studies in order to search for predictive factors influencing the results of ablative therapy. We also analyzed the economic burden of small renal tumor management. CONCLUSION: The strength of evidence is based almost entirely on retrospective studies and is susceptible to the inherent limitations of this study design. Although, the evidence was low among studies, our revue showed that, in elderly patients treated with ablative therapy for cT1a tumors, the cancer-specific survival was comparable to partial nephrectomy with differences in overall survival that are explained by competing risks of death in the old population. Considering the functional results, the renal function preservation seems to be comparable between the 2 groups while the perioperative morbidity is higher in the partial nephrectomy group. The evidence base medicine at this time cannot support the extension of the indications of ablative therapy beyond the actual implementations.

[Is nephron-sparing surgery relevant for unilateral Wilms tumors?] / Néphrectomie partielle pour tumeur de Wilms unilatérale chez l'enfant : est-ce pertinent ?

BACKGROUND: Wilms tumors (WTs) are the most frequent renal tumors in children. Radical nephrectomy (RN) remains the gold-standard surgical treatment for this type of cancer. Excellent results in overall survival (>90%) make it possible to consider nephronic preservation. The objective of this systematic review is to evaluate the relevance of nephron-sparing surgery (NSS) for the treatment of nonsyndromic unilateral Wilms tumor (UWT) in children. METHODS: Articles in English related to "unilateral Wilms tumor, unilateral nephroblastoma, partial nephrectomy, nephron-sparing surgery, renal function" identified in the Medline library were screened and data were extracted to perform a qualitative systematic review. RESULTS: We identified 377 articles, 14 of which were integrated into the analysis. Data on 4288 children were included, 3994 (93.1%) underwent RN, whereas 294 (6.8%) underwent NSS. Stage I anatomopathology resulted in 55.1% RN and 79% NSS. Overall survival and event-free survival were similar: respectively 95.7% and 92.8% after RN and 96 and 90.5% after NSS. Positive margin status was higher after NSS (8.5% vs 0.5%), but tumor rupture and local tumor recurrences were similar. The rate of mild to moderate renal function was higher after RN (42% vs 10% after NSS). DISCUSSION: NSS is regularly performed for WT in case of bilateral or syndromic tumors, but the literature considering UWT does not show consensus. The superiority of NSS for renal outcomes has now been fully evaluated, but the main problem of this surgery in case of UWT is to ensure oncologic outcomes as good as outcomes after RN. WTs are usually massive tumors for which partial nephrectomy is contraindicated, but studies showed that chemotherapy before surgery could reduce tumor volume and make NSS possible. This review shows that NSS results seem to be as good as RN results and that preoperative chemotherapy should be highlighted for its participation in the reduction of the positive margin status. Although radiotherapy is used with caution because of its side effects, some studies showed that it gave excellent results for oncologic salvage after local recurrence. Constant progress in medical imaging and detection systems has led to the emergence of a new type of assistance for surgeons such as image reconstruction and vessel or urinary tract system segmentation. Virtual simulation of the operation based on a real case should help evaluate the feasibility of complex procedures in the near future. CONCLUSION: NSS for UWT seems to be a credible therapeutic alternative. New technologies such as 3D reconstruction should help surgeons define the best parameters to select ideal tumors for this surgery in the near future. For the moment, small tumors (<4cm), distant from the renal hilum (ideally on the upper pole) that respect at least 50% of the renal parenchyma (ideally superficial with exophytic development) seem to be the perfect indication for NSS.

Minimally invasive repair of pectus excavatum in children: Results of a modified Nuss procedure.

INTRODUCTION: Pectus excavatum (PE) is the most common deformity of the anterior thoracic wall. The Nuss technique allows the thorax to be reshaped with the aid of a retrosternal metallic bar. The aim of this study is to evaluate and compare the complication rate between the original Nuss technique and a lightly modified approach. MATERIAL AND METHOD: We performed a retrospective single-center observational study based on the medical files of patients operated for PE in the Pediatric Surgery Unit between July 2004 and July 2015. We divided two patient groups according to the operating technique employed: the Nuss group (NG) and the modified Nuss group (MNG) with supplementary subxiphoid incision and bilateral thoracoscopy. RESULTS: Twenty-seven patients were included: sixteen in the NG and eleven in the MNG. No significant differences were found between the two groups for all kinds of complications: total complication rate (50% for the NG versus 54% for the MNG, P>0.05), early (31% vs 46%, P>0.05), late (19% vs 9%, P>0.05), non-serious (37% vs 36%, P>0.05) or serious (13 vs 18%, P>0.05). There was no life threatening complication in the MNG, contrary to the NG. In the two groups, a significant difference was found (P=0.029) regarding the operating time: longer operating times (80±25min) were correlated with a higher complication rate. CONCLUSION: The modified Nuss technique does not cause more complications than the original technique described by Nuss and it has the advantage to minimize the risk of heart damage.

[Long-term results and satisfaction of the mid-urethral slings among women]. / Résultats et satisfaction à long terme de la bandelette sous-urétrale trans-obturatrice chez la femme.

OBJECTIVE: The mid urethral sling (MUS) has become as the gold standard treatment for stress urinary incontinence (SUI) in female. The aim of this study was to assess the outcome of the SUI Transobturator Tape after 10 years follow-up. METHODS: Retrospective study of 73 patients who underwent a mid urethral sling-transoburator tape (MUS-TOT) between November 2002 and November 2004. These patients were followed up by phone call and by mail, 10 years after the surgery. The indication of the MUS-TOT was a stress urinary incontinence, yet 26 patients (35.6 %) had a mixed urinary incontinence. RESULTS: Out of 73 patients, 5 patients were excluded. Sixty-eight patients were contacted. The rate of responders was 72 %. Thirty-four patients (69.3 %) described episodes of urinary incontinence (52.9 % SUI, 47.1 % urgency). Fifteen patients (30.7 %) were continent. Among the patients who had incontinence, 26 (76.5 %) needed protections during the day and 18 (52.9 %) had to change them at least once. Twelve patients (35.3 %) needed protections at night and 3 (8.8 %) had to change it at least once. Thirty-nine patients (79.6 %) were satisfied. Twenty-nine patients filled up the Ditrovie questionnaire (42.6 %). The mean score of Ditrovie questionnaire after 10 years was 1.6±0.7, with a real improvement in comparison with the preoperative score (P<0.05). CONCLUSION: Ten years after MUS-TOT treatment, the continence rate was low, even though the patients included in this study had high satisfaction rate. Several limitations should be taken into consideration in this study. LEVEL OF EVIDENCE: 4.