[Renal-pleural fistula after radiofrequency ablation of renal tumor in VHL patient]. / Fistule réno-pleurale après radiofréquence d'une tumeur rénale chez une patiente avec un VHL.

Radiofrequency is a minimally invasive therapy allowing tumor destruction by applying physical means to the core of the lesion. There is a particular indication for the hereditary already surgically treated renal carcinomas like Von Hippel-Lindau's disease. We present a case of renal-pleural fistula developed after a percutaneous radiofrequency ablation under computed tomography (CT) guidance of a renal tumor in a VHL female patient with a renal cell carcinoma of the upper pole of the left kidney. The kidney manifestations begin at 20-year-old with the appearance of cystic lesion at the lower pole of the left kidney. At 30-year-old, a computed tomography study revealed a solid lesion arising from a cyst. The patient underwent a partial nephrectomy by flank incision. Follow-up studies discovered three solid lesions of the upper pole of the left kidney. The patient undertook a radiofrequency ablation of these lesions. Follow-up control showed a contrast enhancement of one of the three lesions treated. Under this condition another course of RF was performed, complicated by a renal-pleural fistula. A conservative management of this iatrogenic fistula was attempted combining a water restriction and the insertion of a ureteral catheter. Three weeks were necessary until the fistula completely regress.

[Papillary renal cell carcinoma: morphological subtypes, clinical and histopathological considerations]. / Particularités pronostiques, histopathologiques, génétiques et thérapeutiques du carcinome à cellules rénales tubulopapillaire.

PURPOSE: We reviewed papillary renal cell carcinoma (PRCC) epidemiology, radiological and clinical presentations, and specific features of morphological subtypes focusing on genetic defects, risk of local and metastatic recurrence and frequency of multifocality. MATERIALS AND METHODS: The MEDLINE database of the US National Library of Medicine was searched for pertinent studies. RESULTS: According to multivariate analyses, PRCC histology was not retained as a prognostic factor. Reported rates of multifocality in PRCC are 22 to 41% but distinction between histological subtype or hereditary forms are barely detailed. Multifocality frequency is independent of size, stage or grade and is not associated with ipsilateral or controlateral recurrence or death from RCC. Thus, PRCC multifocality is not an argument against nephron-sparing surgery. Antiangionenic therapies are being evaluated for the Metastatic PRCC. CONCLUSION: According to the literature, specific prognostic features of PRCC remain controversial due to the lack of distinction between different PRCC subtypes. Genomic and cytogenetic characterizations have been used to establish an evolving classification of PRCC subtypes and may be a source of new markers that will eventually enable us to precise prognosis and identify targets for new adjuvant therapies.

[The impact of partial nephrectomy on morbidity and on long-term oncological outcomes]. / Impact de l'indication impérative sur la morbidité et les résultats carcinologiques à long terme après néphrectomie partielle.

OBJECTIVE: To evaluate the impact of imperative indication on the rate of complications and long term carcinological results after partial nephrectomy (PN). PATIENTS AND METHOD: Between 1985 and 2005, all patients who had a PN for localized cancer in two centers were reviewed. The rates of global, hemorrhagic and urinary complications were compared between group I (elective indication) and group II (imperative indication). Rates of survival without recurrence and specific at 5, 10 and 20 years were compared between these two groups. A multivariate analysis using the Cox model was carried out to research factors associated with recurrence and death on the whole of the series. RESULTS: Three hundred and five patients were included in the study. No significant difference was found between group I and group II as far as global complications were concerned (17 vs 20%), the rate of hemorrhagic complications (3.5 vs 3.8%) and the rate of urinary complications (3.9 vs 2.5%). The patients who had been operated on for an imperative indication had survived specifically and without recurrence which was significantly lower at 5, 10 and 20 years. On the whole of the series, the imperative indication was the only independent factor associated with recurrence and death in a multivariate analysis. CONCLUSIONS: Even if the rate of complication does not appear to be significantly associated with the indication for operating, patients of imperative indication represented a heterogeneous group with a poorer prognosis. This factor should be taken into account in studies on the subject of PN.

[Laparoscopic partial nephrectomy: urology resident learning curve on a porcine model]. / Néphrectomie partielle laparoscopique: courbe d'apprentissage d'un interne en urologie sur un modèle porcin.

INTRODUCTION: Several teams have recently confirmed the technical feasibility of laparoscopic partial nephrectomy (LPN). However, this procedure is not widely performed because it is technically difficult and associated with a high rate of bleeding complications, even for experienced teams. The authors studied the LPN learning curve for urology residents using a porcine model based on analysis of the following criteria: operating time, warm ischaemia time and intraoperative and postoperative bleeding. MATERIALS AND METHODS: Forty LPN were performed by the same operator. All operations were performed after arterial clamping and heparinisation of the animal. The renal section was always the same, removing 40% of the kidney and always comprised the excretory tract. A continuous running suture on the excretory tract and interrupted sutures on the parenchyma were performed. Operating time and warm ischaemia time were recorded. Animals were monitored for ten days. Intraoperative and postoperative bleeding via drains was recorded and retrograde urography was performed on the 10th day to confirm the absence of excretory tract leaks. Linear regression statistical tests investigated a correlation between these various criteria and the number of cases performed. RESULTS: The mean total operating time, warm ischaemia time and total bleeding (intraoperative and postoperative) were 108 minutes (70-140 minutes), 38 minutes (22-50 minutes) and 95 ml (10-300 ml), respectively. Linear regression analysis revealed a direct correlation between the number of cases performed and intraoperative bleeding (p<0.001) and warm ischaemia time (p<0.001). These parameters became stable after the 10th operated case. Two cases of urine leaks were observed on D10 out of a series of 40 operations, with no correlation with the number of cases performed. CONCLUSION: The operating time and warm ischaemia time are directly correlated with the number of cases performed. Training on a porcine model appears to be a good way to reduce the learning curve in man. Ten operations are necessary to acquire the various steps of the procedure.

Polyglactin tie added to nonabsorbable polymer locking clips to control artery in laparoscopic living donor nephrectomy: better safe than sorry.

As Teleflex Medical contraindicates the use of Hem-O-Lok clips in laparoscopic living donor nephrectomy (LLDN), we report the feasibility of a simple surgical artifice that aims to preserve the advantages of lockable clips with increased safety while respecting the manufacturer's legal recommendations. Since January 2009, a polyglactin-0 tie was placed on the renal artery in addition to the two usual Hem-O-Lok clips in LLDN at our institution (n = 10) using a pre-tied loop suture (Endoloop ligature, Ethicon) placed on the artery stump, proximally to the aorta, after kidney removal. This artifice increased operating time of 65 seconds (range, 35-85 seconds) with no modification of warm ischemia time and led to visually decreased aortic pulsation transmitted to the clips. Without evidence of increased safety, we assume that this ruse may protect surgeons from prosecution in cases of clip displacement. It certainly decreases the risk of clip slippage and should be considered as a cheap, easy artifice to reduce the already low-risk of hemorrhage in LLDN.

Factors that predict conversion in 69 consecutive patients undergoing laparoscopic ileocecal resection for Crohn's disease: a prospective study.

PURPOSE: This prospective study was designed to identify factors that could predict conversion in patients undergoing first laparoscopic ileocecal resection for Crohn's disease. METHODS: Between 1998 and 2004, 69 consecutive patients (32 males; mean age, 32 +/- 9 years) who had undergone a first laparoscopic ileocecal resection for Crohn's disease were included in a prospective study. Twenty-one patients (30 percent) were converted into laparotomy. Possible factors for conversion were analyzed by both univariate and multivariate analyses. RESULTS: No patient died. Four patients (9 percent; 2 in each group) required five reoperations because of intraperitoneal hemorrhage (n = 1), anastomotic fistula (n = 3), and small-bowel obstruction (n = 1). Mean hospital stay was significantly increased in converted compared with laparoscopic patients (9 +/- 4 vs. 7 +/- 3 days; P < 0.05). On univariate analysis, more than three episodes of acute flare of Crohn's disease (P = 0.02), male gender (P = 0.03), preoperative immunosuppressive drugs (P = 0.04), intra-abdominal abscess or fistula at the time of laparoscopy (P = 0.02), and resection of other intestinal segment (P = 0.02) were factors that predicted conversion. On multivariate analysis, recurrent medical episodes of Crohn's disease (odds ratio, 2; 95 percent confidence interval, 1-4), and intra-abdominal abscess or fistula at the time of laparoscopy (odds ratio, 15; 95 percent confidence interval, 4-78) were the two independent risk factors for conversion. CONCLUSIONS: This prospective study demonstrated that the severity of the disease increased significantly the conversion rate of the first laparoscopic ileocecal resection. Knowledge of these risk factors for conversion could be helpful in preoperative preparation and counseling of patients.