Machine-learning approach for prediction of pT3a upstaging and outcomes of localized renal cell carcinoma (UroCCR-15).

OBJECTIVES: To assess the impact of pathological upstaging from clinically localized to locally advanced pT3a on survival in patients with renal cell carcinoma (RCC), as well as the oncological safety of various surgical approaches in this setting, and to develop a machine-learning-based, contemporary, clinically relevant model for individual preoperative prediction of pT3a upstaging. MATERIALS AND METHODS: Clinical data from patients treated with either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1/cT2a RCC from 2000 to 2019, included in the French multi-institutional kidney cancer database UroCCR, were retrospectively analysed. Seven machine-learning algorithms were applied to the cohort after a training/testing split to develop a predictive model for upstaging to pT3a. Survival curves for disease-free survival (DFS) and overall survival (OS) rates were compared between PN and RN after G-computation for pT3a tumours. RESULTS: A total of 4395 patients were included, among whom 667 patients (15%, 337 PN and 330 RN) had a pT3a-upstaged RCC. The UroCCR-15 predictive model presented an area under the receiver-operating characteristic curve of 0.77. Survival analysis after adjustment for confounders showed no difference in DFS or OS for PN vs RN in pT3a tumours (DFS: hazard ratio [HR] 1.08, P = 0.7; OS: HR 1.03, P > 0.9). CONCLUSIONS: Our study shows that machine-learning technology can play a useful role in the evaluation and prognosis of upstaged RCC. In the context of incidental upstaging, PN does not compromise oncological outcomes, even for large tumour sizes.

Artificial intelligence to improve cytology performance in urothelial carcinoma diagnosis: results from validation phase of the French, multicenter, prospective VISIOCYT1 trial.

PURPOSE: Cytology and cystoscopy, the current gold standard for diagnosing urothelial carcinomas, have limits: cytology has high interobserver variability with moderate or not optimal sensitivity (particularly for low-grade tumors); while cystoscopy is expensive, invasive, and operator dependent. The VISIOCYT1 study assessed the benefit of VisioCyt® for diagnosing urothelial carcinoma. METHODS: VISIOCYT1 was a French prospective clinical trial conducted in 14 centers. The trial enrolled adults undergoing endoscopy for suspected bladder cancer or to explore the lower urinary tract. Participants were allocated either Group 1: with bladder cancer, i.e., with positive cystoscopy or with negative cystoscopy but positive cytology, or Group 2: without bladder cancer. Before cystoscopy and histopathology, slides were prepared for cytology and the VisioCyt® test from urine samples. The diagnostic performance of VisioCyt® was assessed using sensitivity (primary objective, 70% lower-bound threshold) and specificity (75% lower-bound threshold). Sensitivity was also assessed by tumor grade and T-staging. VisioCyt® and cytology performance were evaluated relative to the histopathological assessments. RESULTS: Between October 2017 and December 2019, 391 participants (170 in Group 1 and 149 in Group 2) were enrolled. VisioCyt®'s sensitivity was 80.9% (95% CI 73.9-86.4%) and specificity was 61.8% (95% CI 53.4-69.5%). In high-grade tumors, the sensitivity was 93.7% (95% CI 86.0-97.3%) and in low-grade tumors 66.7% (95% CI 55.2-76.5%). Sensitivity by T-staging, compared to the overall sensitivity, was higher in high-grade tumors and lower in low-grade tumors. CONCLUSION: VisioCyt® is a promising diagnostic tool for urothelial cancers with improved sensitivities for high-grade tumors and notably for low-grade tumors.

[French language validation of the SSIPI questionnaire assessing the satisfaction of patients with penile implant]. / Validation linguistique française du questionnaire SSIPI évaluant la satisfaction des patients porteurs d'une prothèse pénienne.

INTRODUCTION: The objective of this study was to propose a French version of the satisfaction survey for inflatable penile implant (SSIPI) questionnaire. MATERIAL: Questionnaire validation was performed in three steps: translation into French by two urologists, its validation by the committee of andrologist and sexual medicine (CAMS) and an independent translation in English by another urologist to exclude any distortion with the original version. Furthermore, the questionnaire was tested in few patients having penile implant. RESULTS: The andrology committee approved the French version of the questionnaire. The final version of the questionnaire was successfully tested on all patients. Every patient (n=10) confirmed the good comprehension and pertinence of the questions, and the easy response selection. CONCLUSION: This French version of the SSIPI questionnaire will allow French-speaking urologists to assess the satisfaction of their patients with a penile implant on a large scale. LEVEL OF EVIDENCE: IV.

Dementia Associated with Anticholinergic Drugs Used for Overactive Bladder: A Nested Case-Control Study Using the French National Medical-Administrative Database.

PURPOSE: We analyzed the relationship between use of anticholinergic drugs to treat overactive bladder (OAB) and risk of incident dementia in older patients, overall and for each drug separately. MATERIALS AND METHODS: We conducted a nested case-control study using the French National Medical-Administrative Database. We identified incident dementia cases and controls from January 1, 2013 to December 31, 2018 in individuals aged ≥60 years. Controls were matched 5:1 to cases by date of case diagnosis (index date), age, sex, and income. We set a 5-year exposure period ending 2 years before the index date (lag-time period to avoid protopathic bias). We quantified cumulative exposure to flavoxate, oxybutynin, solifenacin, trospium, and fesoterodine using defined daily doses (DDDs). We performed conditional logistic regression analyses adjusted for factors known to be associated with OAB and/or dementia including obesity, diabetes, stroke, coronary heart disease, and psychotic disorders. RESULTS: We analyzed 4,810 cases and 24,050 matched controls with a median age of 82 years. OAB anticholinergic use was associated with an increased risk of dementia (adjusted OR [aOR]=1.23, 95% CI 1.10-1.37) with a cumulative dose-response: aOR=1.07 (95% CI 0.91-1.25) for 1-90 DDDs, aOR=1.29 (1.05-1.58) for 91-365 DDDs and aOR=1.48 (1.22-1.80) for >365 DDDs. Considering each OAB anticholinergic separately showed a particularly marked increased risk of dementia for oxybutynin and solifenacin, but no increased risk for trospium. CONCLUSIONS: When treating OAB in older patients, OAB anticholinergics should be used with caution, taking into account the patient's cognitive status, the anticholinergic load, and the different therapeutic options.

Early Results of Unilateral Prostatic Artery Embolization as a Focal Therapy in Patients with Prostate Cancer under Active Surveillance: Cancer Prostate Embolisation, a Pilot Study.

PURPOSE: To evaluate the feasibility of prostatic artery embolization in patients with low-risk prostate cancer (PC) under active surveillance (AS). METHODS: This monocentric prospective pilot study, running from June 2018 to June 2019, included 10 patients with low-risk PC under AS, median age 72 years (range, 62-77 years), with a unilateral focal lesion visible on magnetic resonance (MR) imaging, with Prostate Imaging Reporting and Data System v2 score ≥3/5 confirmed by multiparametric MR imaging-targeted biopsy and Gleason score 6. The patients underwent unilateral prostatic artery embolization with 300-500 µm Embospheres in the affected prostatic lobe. The primary endpoint was technical feasibility (prostate and no off-target ischemia in the imaging). The secondary endpoints included safety, negative biopsies/MR imaging response/functional outcomes at 6 months, and oncologic efficacy at 1 year. RESULTS: Embolization was successfully achieved in all patients; prostate ischemia was confirmed on multiparametric MR imaging, and no off-target ischemia was reported. No major complications were reported. Four patients (40%) presented with both negative targeted and systematic biopsies at 6 months. No lesions were seen on the MR imaging in 30% of patients. The mean International Prostate Symptom Score and International Index of Erectile Function score were 7 and 19 and 5 and 20 at baseline and 6 months, respectively, with no significant difference. Nine patients (90%) were still under AS at 1 year. One patient (10%) had PC progression outside the target lesion and was switched over to curative radiotherapy. CONCLUSIONS: Prostatic artery embolization is feasible and appears safe for prostate cancer patients under AS, with no impact on erectile function or continence status. These results justify the pursuit of further studies.

What if artificial urinary sphincter is not possible? Feasibility and effectiveness of ProACT for patients with persistent stress urinary incontinence after radical prostatectomy treated by sling.

BACKGROUND: Stress urinary incontinence (SUI) is a major component of the post radical prostatectomy (RP) trifecta. Surgical treatments are sub-urethral slings, artificial urinary sphincter (AUS) and adjustable peri-urethral balloons (PUB) ProACT. All options are imperfect at best and persistent SUI is challenging when AUS is not manageable. AIMS: This study analyzed the cumulate experience of our 2 centers with offering PUB implantation for SUI post RP in patients with insufficient improvement from slings. MATERIALS & METHODS: This retrospective study reviewed all patients implanted with second line ProACT. The primary endpoint was continence, defined as 0 pads per day (PPD). The secondary endpoints were 50% decrease in PPD and increases in the Incontinence Quality of Life score (IQOL). Refilling and complications were reported. RESULTS: Between 2007 and 2016, 26 patients were implanted. Five patients have had adjuvant radiotherapy (18%). The mean follow-up was 36 months (±20; min 14-max 128). All patient presented with persistent SUI, using 2.3 PPD (±1; min 1-max 6), and only one sling was removed due to infection. After ProACT with an average 3 mL refilling (±1.2 min 2-max 6), 18 patients (66.7%) were continent. Eight of the remaining patients (29.6%) were improved; their number of PPD decreased from 2.6 to 1. The average IQOL score of those 8 patients increased by 20 points, from 53.4 up to 74.2 (P = .005). Overall 26 patients (96.3%) were improved. The remaining patient was not implanted because of an intraoperative urethral injury and is considered a failed case (3.7%). He had instead an AUS implantation. Three patients (14.8%) needed PUB replacement. CONCLUSION: The limited population of patients from both our centers who presented with persistent SUI after RP, despite sling placement, improved with PUB ProACT implantations without significant complications.

A Multicenter, Randomized, Placebo-Controlled Study Evaluating the Efficacy of a Combination of Propolis and Cranberry (Vaccinium macrocarpon) (DUAB®) in Preventing Low Urinary Tract Infection Recurrence in Women Complaining of Recurrent Cystitis.

OBJECTIVES: The purpose of the study was to compare the efficacy of a product containing cranberry and propolis (DUAB) to placebo for reducing frequency of cystitis in women with recurrent acute cystitis. METHOD: A multicenter, placebo-controlled, randomized study of women aged >18 years with at least 4 episodes of cystitis in the previous 12 months was performed. The number of cystitis episodes over a 6-month follow-up was the primary end point. RESULTS: Forty-two women were included in the cranberry + propolis group, and 43 women were in the placebo group. The mean age was 53 ± 18 years, with 6.2 ± 3.6 cystitis episodes in the previous year, with no differences between the 2 groups. The mean number of infections was lower in the propolis + cranberry group (respectively, 2.3 ± 1.8 vs. 3.1 ± 1.8). The total number of cystitis episodes in the first 3 months was lower in the propolis + cranberry group (0.7 ± 1.1 vs. 1.3 ± 1.1, p = 0.0257) after adjusting for water consumption. The mean time to onset of the first urinary tract infection (UTI) was also significantly longer in the propolis + cranberry group (69.9 ± 45.8 days vs. 43.3 ± 45.9, p = 0.0258). Tolerance to the treatments was good and comparable in both groups. CONCLUSIONS: We demonstrate for the first time that cranberry and propolis supplementation significantly reduces the incidence of UTIs during the first 3 months and delays the onset of an episode of cystitis.

Impact of hospital volume and surgeon volume on robot-assisted partial nephrectomy outcomes: a multicentre study.

OBJECTIVE: To assess the impact of hospital volume (HV) and surgeon volume (SV) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: All consecutive patients who underwent a RAPN from 2009 to 2015, at 11 institutions, were included in a retrospective study. To evaluate the impact of HV, we divided RAPN into four quartiles according to the caseload per year: low HV (<20/year), moderate HV (20-44/year), high HV (45-70/year), and very high HV (>70/year). The SV was also divided into four quartiles: low SV (<7/year), moderate SV (7-14/year), high SV (15-30/year), and very high SV (>30/year). The primary endpoint was the Trifecta defined as the following combination: no complications, warm ischaemia time (WIT) <25 min, and negative surgical margins. RESULTS: In total, 1 222 RAPN were included. The mean (sd) caseload per hospital per year was 44.9 (26.7) RAPNs and the mean (sd) caseload per surgeon per year was 19.2 (14.9) RAPNs. The Trifecta achievement rate increased significantly with SV (69.9% vs 72.8% vs 73% vs 86.1%; P < 0.001) and HV (60.3% vs 72.3% vs 86.2% vs 82.4%; P < 0.001). The positive surgical margins (PSM) rate (P = 0.02), length of hospital stay (LOS; P < 0.001), WIT (P < 0.001), and operative time (P < 0.001), all decreased significantly with increasing SV. The PSM rate (P = 0.02), LOS (P < 0.001), WIT (P < 0.001), operative time (P < 0.001), and major complications rate (P = 0.01), all decreased significantly with increasing HV. In multivariate analysis adjusting for HV and SV (model 3), HV remained the main predictive factor of Trifecta achievement (odds ratio [OR] 3.70 for very high vs low HV; P < 0.001), whereas SV was not associated with Trifecta achievement (OR 1.58 for very high vs low SV; P = 0.34). CONCLUSION: In this multicentre study HV and SV both greatly influenced RAPN perioperative outcomes, but HV appeared to have a greater impact than SV.

Testicular tumours discovered during infertility workup are predominantly benign and could initially be managed by sparing surgery.

BACKGROUND AND OBJECTIVES: To evaluate the pathological features and recurrence of incidental testis tumours treated by partial orchiectomy in a population of infertile men. METHODS: We retrospectively pooled, from four andrology referral centres, 32 patients diagnosed with testis mass during regular infertility workup. Patients included had an impaired sperm analysis and testis sparing surgery was performed to prevent secondary azoospermia or androgen therapy. RESULTS: Mean age was 36 (IQR, 32 to 37). The mean largest tumoral diameter was 8.5 mm (IQR, 5 to 10). A total of 25% (8 of 32) of patients had a malignant tumour (seminoma, 7 of 32, 22%; teratoma, 1 of 32, 3%) and 75% (24 of 32) had a benign lesion (Leydig cell tumour, 23 of 32, 72%; scar tissue, 1 of 32, 3%). Malignant tumours were then managed by total orchiectomy (six of eight) or by radiotherapy (two of eight). With a mean follow up of 26 months (IQR, 8 to 32), one patient (3%) had an homolateral recurrence, which was a Leydig cell tumour. Not a single patient developed metastasis. CONCLUSION: Seventy-five per cent of the tumours discovered during infertility management were of a benign pathology. A conservative approach could be proposed initially to avoid unnecessary orchiectomies. Orchiectomy and radiotherapy could be discussed as salvage therapies for malignant lesions.

Impact on quality of life and sexual satisfaction of continent cystostomy with enterocystoplasty in an adult neurologic population.

AIMS: To evaluate long-term general and urinary quality of life (QOL) and sexual satisfaction in adult neurologic patients undergoing continent cystostomy surgery associated with a bladder enlargement to treat neurogenic lower urinary tract dysfunction. METHODS: Monocentre, retrospective series of adult neurologic patients who underwent continent cystostomy with bladder enlargement and followed-up in the long-term. We assessed during follow-up, urinary and renal function and patients filled QOL questionnaires on general QOL, sexuality and urinary (short form Qualiveen) disability. RESULTS: Fifty-three patients were included and followed-up 77 months on average. Rates of patients' satisfaction, stomal and urethral continences were respectively of 98.7% (n = 51), 94.1% (n = 48), and 80.4% (n = 41). Impact of surgery on general QOL and autonomy were strong and positive (respective mean scores of 4.8 and 4.7 on a scale ranging from 1 to 5). Mean overall urinary Qualiveen QOL score was 0.8 (0.09-2.67) indicating a low negative impact of urinary disability on QOL. In patients <45 years, 52.6% (n = 10) reported a moderate to important improvement of their sexuality after surgery. Renal function remained stable during follow-up. CONCLUSION: In the long-term, continent cystostomy with bladder enlargement provides great satisfaction to almost most patients. It has a strong positive impact on general and specific urinary QOL, patients' autonomy and urinary continence. In young patients a positive impact on sexuality was also noticed. These encouraging data, that need to be confirmed, constitute interesting information to provide to neurologic patients to help them deciding whether they are willing to undergo continent cystostomy surgery.

Urinary Incontinence, Patient Satisfaction, and Decisional Regret after Prostate Cancer Treatment: A French National Study.

BACKGROUND: Complications of prostate cancer treatments have a substantial impact on the patient's quality of life. We evaluated the prevalence of urinary consequences and factors affecting patient satisfaction and decisional regret after treatment. METHODS: A retrospective self-administered questionnaire was sent to all members of the National Association of Prostate Cancer Patients in France. RESULTS: From the 226 completed questionnaires received, the following information was obtained: 110 patients underwent surgery only, 29 received radiotherapy plus hormone therapy, 28 received radiotherapy only, and 49 received other combination treatments. The median follow-up period was 58.1 months. After treatment, the presence of urinary incontinence was reported by 34.5% of patients treated by radical prostatectomy, by 10.3% treated by radiotherapy plus hormone therapy, by 17.8% treated by curitherapy or radiotherapy only, and by 38.7% treated by other combination therapy (p = 0.01). The main reasons for decisional regret were the fact that patients received incomplete information about prostate cancer (40%) and consequences of treatment that affected the urinary system (34%). The information received about cancer was considered complete in 32.3% of the satisfied group and 14.3% of the decisional regret group (p = 0.003) and with regard to urinary incontinence the information received was considered complete in 41.4 and 17.4% respectively (p < 0.01). CONCLUSIONS: Urinary consequences of prostate cancer treatment are common and impact the quality of life. Patients need clear information to be able to participate in therapeutic decision-making and to avoid subsequent decisional regret.

Long-term efficacy and safety of tension free vaginal tape in a historic cohort of 463 women with stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: We report retrospective data on the long-term safety and efficacy of the retropubic midurethral sling (MUS) in a large series of women with stress urinary incontinence. METHODS: In all, 517 patients were treated during the period January 2005 to June 2012 at a single centre in France. The Urinary Symptoms Profile score was used to identify women who were subjectively cured or improved or in whom treatment had failed. The rates of peroperative, and early (<30 days) and late postoperative complications were recorded. RESULTS: A total of 463 patients were evaluable at a mean (±SD) follow-up of 71 ± 23 months. At the last follow-up, 344 patients (74.3 %) demonstrated subjective cure, 55 (11.9 %) were improved and 64 (13.8 %) had treatment failure. Bladder perforations occurred in 33 patients (7.1 %); however, this had no effect on cure rate. In the early postoperative period, temporary intermittent self-catheterization was required in 10 patients (2.2 %) due to voiding difficulties. The most frequent long-term postoperative complication was de novo urge incontinence that was reported by 59 patients (12.7 %); seven patients (1.5 %) needed tape excision due to voiding difficulties and six (1.3 %) needed tape removal due to erosion or chronic pain. CONCLUSIONS: The retropubic MUS was shown to be durable at a mean follow-up of 71 ± 23 months, with a high success/improvement rate and no serious long-term tape-induced adverse effects.

Off-Clamp versus On-Clamp Robotic Partial Nephrectomy: A Multicenter Match-Paired Case-Control Study.

INTRODUCTION: The aim of this study was to compare the outcomes of on-clamp and off-clamp robotic partial nephrectomy (RPN). MATERIALS AND METHODS: The charts of all patients who underwent an RPN at 8 institutions between 2010 and 2014 were retrospectively reviewed. The patients who underwent an off-clamp RPN were matched to on-clamp RPN in a 1-4 fashion according to the following variables: RENAL score, tumor size and surgeon's experience. Pre-, intra-, and postoperative data were compared between both groups. RESULTS: Among 525 RPN, 26 were performed off-clamp (5%). They were matched to 104 on-clamp RPN. The complications rate (15.5 vs. 7.7%, p = 0.53), major complications rate (4.9 vs. 3.9%; p = 0.82), and transfusions rate (0 vs. 4.9%; p = 0.58) did not differ significantly between the clamped and unclamped groups. Conversely, estimated blood loss was higher in the off-clamp group (266.4 vs. 284.6 mL, p = 0.048) and so was the rate of conversion to radical nephrectomy (0 vs. 7.7%, p = 0.04). Postoperative preservation of renal function was comparable in both groups. CONCLUSION: Off-clamp RPN is feasible for a small subgroup of renal tumors without increased risk of postoperative complications but at the cost of higher estimated blood loss and increased risk of conversion to radical nephrectomy.

Postoperative drainage does not prevent complications after robotic partial nephrectomy.

OBJECTIVES: We aimed to assess the impact of a postoperative drainage after RPN. METHODS: A retrospective multicentric study included RPN performed at eight centers between 2010 and 2014. Three centers stopped using postoperative drainage early in their RPN experience, whereas other institutions systematically left a drain. Preoperative characteristics, complication rates, need for postoperative imaging or procedure (surgical or radiological) and length of hospital stay were compared between the two groups [drainage (D) and no drainage (ND)]. RESULTS: Among 636 RPNs, 140 were done without drainage (22 %). In the ND group, surgeons were more experienced (>50 cases: 55.7 vs. 15.1 %; p < 0.0001), and tumors were more complex (RENAL score: 7.6 vs. 6.5; p < 0.0001). Complication rates were similar in both groups (21.9 vs. 20.2 %; p = 0.67). The omission of postoperative drainage did not increase requirement of CT scan (RR = 1.03; 95 % CI 0.64-1.67). Length of hospital stay was shorter in the ND group (4.5 vs. 5.5 days; p = 0.007). There were six urinary fistulas: four in the D group (0.8 %) and two in the ND group (1.4 %; p = 0.49). A CT scan was done to confirm the diagnosis of fistula in every case. In multivariate analysis, the omission of drainage was not associated with increased need of postoperative CT scan or major complications but was a predictor of decreased length of stay. CONCLUSION: The omission of postoperative drainage does not seem to increase the risk of postoperative complications and could safely be omitted after RPN.

The use of hemostatic agents does not prevent hemorrhagic complications of robotic partial nephrectomy.

PURPOSE: To assess the impact of HA on robotic PN (RPN) outcomes. METHODS: We retrospectively analyzed data from patients who underwent RPN in eight centers between 2009 and 2013. Hemorrhagic complications were defined as the occurrence of a pseudoaneurysm, arteriovenous fistula or hematoma requiring transfusion. Patients were first divided into two groups: group A (use of at least one HA) and group B (no HA used), and then into five groups to assess the impact of each HA: group 1 (no HA), group 2 (Floseal(®) only), group 3 (Surgicel(®) only), group 4 (Tachosil(®) only) and group 5 (Surgicel(®) + Floseal(®)). The impact of HA was evaluated by univariate and multivariate analysis. RESULTS: Out of 515 RPN, 315 (61 %) were done using at least one HA (group A) and 200 (39 %) were done without any HA (group B). Patients in both groups had similar hemorrhagic complication rates (13 % vs. 15 %, p = 0.42) and postoperative complication rates (19 % vs. 23 %, p = 0.32). In multivariate analysis, the absence of HA was not a risk factor for hemorrhagic complications (OR 0.77, p = 0.54). When each type of HA was considered individually, none was associated with the occurrence of hemorrhagic complication either in univariate or in multivariate analysis. CONCLUSION: In this multicenter study, the use of HA was not associated with a lower risk of hemorrhagic or global complications.

Influence of preoperative factors on the oncologic outcome for upper urinary tract urothelial carcinoma after radical nephroureterectomy.

PURPOSE: To evaluate the influence of preoperative factors on the survival of patients diagnosed with upper tract urothelial carcinoma (UTUC) who underwent a radical nephroureterectomy (RNU). METHODS: A multicentre retrospective study was performed on all patients with UTUC who underwent a RNU. Multiple preoperative criteria were tested as prognostic factors for cancer-specific survival (CSS) using univariate and multivariable Cox regression analyses. RESULTS: Overall, 476 patients with a median age of 69.2 (IQR 60.8-76.5) years were included. The median follow-up was 27.8 months (IQR 10.5-49.3). At the time of diagnosis, 400 (84.1 %) patients presented with symptoms and 76 patients (15.9 %) were asymptomatic. Renal failure, altered general health, a preoperative locally advanced tumour and multifocal disease appeared to be preoperative prognostic factors for CSS (p = 0.01, 0.03, 0.001 and 0.03, respectively) in the univariate analysis. Only renal failure (p = 0.03), a preoperative locally advanced tumour (0.004), and multifocal locations (p = 0.01) were confirmed as independent factors of CSS in the multivariate analysis. The independent prognosticators of definitive muscle-invasive stage and non-organ-confined disease were preoperative renal failure (p = 0.02, 0.027, respectively), locally advanced stage (p < 0.001, <0.001, respectively) and positive cytology (p = 0.006, 0.003 respectively). Female gender was independent factor only for prediction of final non-organ-confined disease (p = 0.007). The addition of these parameters in our preoperative complex model permitted the prediction of muscle-invasive or locally advanced disease in 65.3 and 67.2 % of patients, respectively. CONCLUSIONS: Patients with preoperative impaired renal function, locally advanced stage and multifocal tumours before RNU had worse survival outcomes compared to other patients.

Testicular-sparing surgery for bilateral or monorchide testicular tumours: a multicenter study of long-term oncological and functional results.

OBJECTIVE: To review long-term oncological and functional outcomes of testicular-sparing surgery (TSS) in men presenting with bilateral or monorchide testicular tumours at one of five reference centres for testicular neoplasm and infertility. PATIENTS AND METHODS: We review 25 cases of bilateral synchrone and metachrone testicular tumours treated in five academic centres between 1984 and 2013. Clinical, biological, ultrasonography and pathological tumour findings, overall survival (OS) times, local or metastatic recurrence, pre- and postoperative hormonal profile, paternity and the need for androgen substitution were assessed. RESULTS: Eleven patients with a bilateral synchrone tumour and 14 patients with a testicular tumour on a solitary testicle underwent a tumorectomy. The mean (sem) patient age was 31.9 (1.04) years, total testosterone level was 4.5 (0.57) ng.mL and tumour size was 11.66 (1.49) mm. Tumour types were as follows: 11 seminoma, nine non-seminomatous or mixed germ cell tumours, four Leydig tumours, and one hamartoma. Frozen-section examination was performed in 14 patients, and matched the final pathological analysis in 11 patients. There was an OS rate of 100% and three patients (12%) presented with a local recurrence after a mean follow-up of 42.7 months. Radical orchiectomy was performed for six patients. No patient with a preserved testicle required androgen therapy; the mean postoperative total testosterone level was 4.0 ng/mL. No patient remained fertile after radiation therapy. CONCLUSIONS: TSS for bilateral testicular tumour is safe and effective in selected patients, and should be considered to avoid definitive androgen therapy. Adjuvant radiotherapy remains poorly described in the literature, leading to adjuvant treatment heterogeneity for testicular tumours.

Early unclamping technique during robot-assisted laparoscopic partial nephrectomy can minimise warm ischaemia without increasing morbidity.

OBJECTIVE: To compare perioperative outcomes of early unclamping (EUC) vs standard unclamping (SUC) during robot-assisted partial nephrectomy (RAPN), as early unclamping of the renal pedicle has been reported to decrease warm ischaemia time (WIT) during laparoscopic PN. PATIENTS AND METHODS: A retrospective multi-institutional study was conducted at eight French academic centres between 2009 and 2013. Patients who underwent RAPN for a renal mass were included in the study. Patients without vascular clamping or for whom the decision to perform a radical nephrectomy was taken before unclamping were excluded. Perioperative outcomes were compared using the chi-squared and Fisher's exact tests for discrete variables and the Mann-Whitney test for continuous variables. Predictors of WIT and estimated blood loss (EBL) were assessed using multiple linear regression analysis. RESULTS: In all, there were 430 patients: 222 in the EUC group and 208 in the SUC group. Tumours were larger (35.8 vs 32.3 mm, P = 0.02) and more complex (R.E.N.A.L. nephrometry score 6.9 vs 6.1, P < 0.001) in the EUC group but surgeons were more experienced (>50 procedures 12.2% vs 1.4%, P < 0.001). The mean WIT was shorter (16.7 vs 22.3 min, P < 0.001) and EBL was higher (369.5 vs 240 mL, P = 0.001) in the EUC group with no significant difference in complications or transfusion rates. The results remained the same when analysing subgroups of complex renal tumours (R.E.N.A.L. nephrometry score ≥7) or RAPN performed by less experienced surgeons (<20 procedures). In multivariable analysis, EUC was predictive of decreased WIT (ß -0.34; P < 0.001) but was not associated with EBL (ß -0.09, P = 0.16). CONCLUSIONS: EUC can reduce WIT during RAPN without increasing morbidity even for complex renal tumours or when being performed by less experienced surgeons.

Hereditary-like urothelial carcinomas of the upper urinary tract benefit more from adjuvant cisplatin-based chemotherapy after radical nephroureterectomy than do sporadic tumours.

OBJECTIVE: To evaluate the impact of 'hereditary-like' status in upper tract urothelial carcinoma (UTUC) on the survival of patients who have undergone radical nephroureterectomy (RNU) and adjuvant chemotherapy. PATIENTS AND METHODS: A multicentre retrospective study was performed on all patients with high-risk UTUC who underwent RNU and adjuvant cisplatin-based chemotherapy. Using a patient risk identification tool, we distinguished tumours suspected to be hereditary from sporadic tumours and compared survival rates. RESULTS: A total of 112 patients with a median age of 67 years were included. Hereditary-like tumour status was detected in 35 patients (31.3%), while 77 patients (68.7%) had sporadic tumours. The median age was significantly younger in the hereditary-like tumour group (56.0 vs 69.8 years, P < 0.001). Overall survival (OS) after chemotherapy was significantly better in the group with hereditary-like tumours than in the group with sporadic tumours (5-year OS: 48.2 vs 32%; P = 0.008). The cancer-specific survival (CSS) rate was significantly better in the group with 'hereditary-like' tumours than in the group with sporadic tumours (5-year CSS: 58 vs 35%; P = 0.006). Although there was a trend in favour of the hereditary-like tumours, we observed no significant difference regarding progression-free survival (PFS) between the two groups (5-year PFS: 71 vs 52%; P = 0.07). CONCLUSION: Adjuvant chemotherapy after RNU improves survival outcomes in patients with hereditary-like UTUC compared with those with sporadic tumours.