Robot assisted radical prostatectomy in fit older patients compared to a standard population: Clinical characteristics, surgical, oncological and functional outcomes.

INTRODUCTION: To compare robotic assisted radical prostatectomy (RARP) in well-selected older patients with clinically localized prostate cancer, compared to a younger population. Primary endpoint was perioperative outcomes comparison and secondary endpoint were oncological and functional outcomes comparison to a younger population. METHODS: Single tertiary center cohort of consecutive patients treated with RARP (2017-2020) with retrospective analysis. Patients were classified by age in two groups: <75: control group (CG) and ≥75: study group (SG). Patients aged ≥75 had a comprehensive geriatric assessment (CGA) and only patients classified Balducci ≤2 were admitted to surgery. RESULTS: Two hundred and sixty-nine patients were included, 56 in SG and 213 in CG. Median follow-up was 9.8 months. Univariate analysis showed no statistically significant (SS) difference between the groups for patients' characteristics (PSA, digital rectal examination -DRE- and biopsy Gleason Score), perioperative data (operative time, hospitalization length, transfusions rate, immediate complications, Clavien-Dindo complications, 30-days re-interventions and 30-days re-hospitalisation), oncological (TNM, margins, extraprostatic extension, postoperative PSA, BCR, metastases, overall survival -OS- and cancer specific survival -CSS-) and functional outcomes. Median perioperative blood loss was lower in the SG: 200.00 cc IQR [100.00, 300.00] vs 200.00cc IQR [100.00, 400.00] in the CG (P<0.05). A multivariate regression considering age>75, DRE, GS, PSA, cardiovascular history and diabetes showed none of variables associated with early BCR. Limitations are retrospective design, small number of patients and short follow-up. CONCLUSIONS: RARP shows similar perioperative, oncologic and functional outcomes for older patients selected by a CGA when compared to younger patients. The SG shows a minor perioperative bleeding. LEVEL OF EVIDENCE: IV.

[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.

[Medico-economic evaluation of the impact of measures to adapt to the switch to surgery robot-assisted in urology]. / Évaluation médico-economique de l'impact de mesures d'adaptation au virage de la chirurgie robot-assistée en urologie.

INTRODUCTION: The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery. METHOD: We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison. RESULTS: Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year. CONCLUSIONS: Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term. LEVEL OF EVIDENCE: 3.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]. / Évaluation des mesures de triages de la première vague pandémique Covid-19 pour sélectionner les patients à opérer pour cancers et urgences urologiques.

INTRODUCTION: Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis. METHOD: We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients. CONCLUSIONS: Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening. LEVEL OF EVIDENCE: 3.

[Assessment of a post-emergency pathway with early urological regulation]. / Analyse d'un modèle de circuit court post-urgence avec une régulation précoce urologique.

INTRODUCTION: Urological emergencies represent 7 % of the outpatients at the emergency department (ED). We assessed the effect of setting up a post-emergency consultation (CPU) after deferred urological medical regulation. METHODS: All patients admitted to the ED in a university center over the period December 2017 to July 2018 and for whom a CPU was scheduled were included. The regulation concerned the date of CPU and supplementary exams. The main outcome was the ability to provide an efficient response according to a predefined grid of specific solutions. RESULTS: One hundred and twenty-eight patients were included. The median age was 57 years (18-97). Efficacy of the CPU was 76 %. This rate was lower in no-show patients or consulting for rare and complex motives (47 %, n=60). The no-show were not reachable on the first call in 51.6 % of cases, with a similar age and motives distribution to the others. Only 6,9 % (n=128) of all consultants (n=1863) had been referred to the CPU by emergency physicians. The decision was a second consultation in 70 % (48), a new exam in 10 % (7), deferred emergency surgery in 12 % (8) and finally 18 % (12) of no follow-up. CONCLUSION: CPU following early regulation by a urologist provides an effective response in 76 % of situations. Assessment of "no-shows" helped to identify groups at risk. LEVEL OF EVIDENCE: III.

Randomised clinical trial comparing clinically relevant sedation outcome measures in dogs after intramuscular administration of medetomidine in combination with midazolam or butorphanol for routine diagnostic imaging procedures.

The aim of this study was to investigate the sedative effects of medetomidine in combination with midazolam or butorphanol for routine imaging procedures in dogs. Eighty client owned dogs were recruited in a prospective, randomised, blinded clinical study and randomly assigned to receive one of four treatments intramuscularly (IM): (1) 30µg/kg medetomidine (Med30); (2) 20µg/kg medetomidine combined with 0.3mg/kg butorphanol (Med20But0.3); (3) 20µg/kg medetomidine combined with 0.3mg/kg midazolam (Med20Mid0.3); and (4) 10µg/kg medetomidine combined with 0.3mg/kg midazolam (Med10Mid0.3). The level of sedation was evaluated using a composite sedation scale assessed by one investigator (0=no sedation, 15=profound sedation). The number of dogs deemed to be adequately clinically sedated and the dose of propofol administered as rescue sedation were recorded. Mean±standard deviation sedation scores at 30min after the commencement of treatment in the groups that received Med20But0.3 (9.8±4) and Med20Mid0.3 (8.9±4.4) were not statistically significantly different from each other, but were significantly different from the group receiving Med10Mid0.3 (5.6±3.6). Only Med20But0.3 was significantly associated with adequate clinical sedation, while Med10Mid0.3 was associated with 85% sedation failure. The rescue sedation dose of propofol (1.5±1mg/kg) for the Med10Mid0.3 group was significantly higher than for other treatments. A sedation score≥10 out of 15 was a satisfactory cut-off to predict adequate clinical sedation. In healthy dogs, the combination of medetomidine with midazolam did not provide comparable sedation to the same dose of medetomidine in combination with butorphanol in a clinical setting.

Combined use of two supervised learning algorithms to model sea turtle behaviours from tri-axial acceleration data.

Accelerometers are becoming ever more important sensors in animal-attached technology, providing data that allow determination of body posture and movement and thereby helping to elucidate behaviour in animals that are difficult to observe. We sought to validate the identification of sea turtle behaviours from accelerometer signals by deploying tags on the carapace of a juvenile loggerhead (Caretta caretta), an adult hawksbill (Eretmochelys imbricata) and an adult green turtle (Chelonia mydas) at Aquarium La Rochelle, France. We recorded tri-axial acceleration at 50 Hz for each species for a full day while two fixed cameras recorded their behaviours. We identified behaviours from the acceleration data using two different supervised learning algorithms, Random Forest and Classification And Regression Tree (CART), treating the data from the adult animals as separate from the juvenile data. We achieved a global accuracy of 81.30% for the adult hawksbill and green turtle CART model and 71.63% for the juvenile loggerhead, identifying 10 and 12 different behaviours, respectively. Equivalent figures were 86.96% for the adult hawksbill and green turtle Random Forest model and 79.49% for the juvenile loggerhead, for the same behaviours. The use of Random Forest combined with CART algorithms allowed us to understand the decision rules implicated in behaviour discrimination, and thus remove or group together some 'confused' or under--represented behaviours in order to get the most accurate models. This study is the first to validate accelerometer data to identify turtle behaviours and the approach can now be tested on other captive sea turtle species.

A porcine model for robotic training harvest of the rectus abdominis muscle.

Conventional open surgical approaches for the harvesting of the rectus abdominis muscle carry a high risk of morbidity. It is possible to reduce these risks by using laparoscopy or robot-assisted techniques. This work hypothesizes that a porcine model could be used for learning the robot-assisted collection of the rectus abdominis. The rectus abdominis was taken in 3 stages in 3 pigs: installation of the robot, surgical approaches with 4 trocars, dissection and collection of the muscle. The average operating time was 1h20min and the average muscular length was 16cm. Our results showed a learning curve for the robot-assisted harvesting of the rectus abdominis on a porcine model.

Endoscopic robot-assisted C7 nerve root retrophalangeal transfer from the contralateral healthy side: A cadaver feasibility study.

Controlateral C7 nerve root transfer in brachial plexus palsy requires a nerve graft and large incisions. This study investigated the feasibility of transferring the right C7 to the left C7 nerve root, without a graft, via a minimally invasive retropharyngeal approach. After installation of 6 trocars of 1cm diameter in the supraclavicular space, a Da Vinci SI® robot was placed. After locating the right brachial plexus, the C7 root was sectioned flush with the clavicle, transferred behind the pharynx and sutured to the left C7 root severed at the foramen level. The duration of the procedure was 2h40min. No technical difficulties were encountered. The hypothesis of this work was verified since it was possible to carry out a transfer of the right C7 root on the left C7 root by direct retropharyngeal suture without graft and by a minimally invasive technique.

[Percutaneous nephrolithotomy for kidney stones in elderly patients: Meta-analysis of results and complications]. / Néphrolithotomie percutanée des calculs rénaux des personnes âgées : méta-analyse des résultats et complications.

INTRODUCTION AND OBJECTIVE: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for kidney stones regardless of age. Elderly patients (EP)≥65years old, in growing numbers, have more comorbidities than the general population, may alter results of PCNL. The aim of this meta-analysis was to compare efficacy and complications of this procedure between EP and young patients (YP). METHODS: Original studies of prospective and historical cohorts, in English or French, presenting PCNL series published on PubMed until 2015 were identified using the keywords percutaneous nephrolithotomy, elderly patients, kidney stones and staghorn calculi. Our analysis focused on therapeutic efficacy, defined by absence of residual fragment or the presence of residual fragments<4mm at 3 postoperative months, and postoperative complications according to patient age: YP<65 years old and EP≥65 years old. Binary qualitative data were analyzed using odds ratio (OR) and quantitative data by estimating the difference of means. RESULTS: In total 397 studies were identified among which 23 were checked and 8 included in the meta-analysis for methodological quality corresponding to 4995 YP and 820 EP. No efficacy difference (OR=0.96; [IC95 %: 0.80; 1.17]; P=0.71), operating time (+1.15min in EP [IC95 %: -2.83; 5.12]; P=0.57) and average length of stay (+0.29 days in EP [IC95 %: -0.14; 0.72]; P=0.19) has been reported. It was a trend to more urinary infections (OR=2.24; [IC95 %: 0.74-6.80]; P=0.16) and a significantly increase of postoperative blood transfusions in EP (OR=1.41; [IC95 %: 1.00-1.97]; P=0.04). CONCLUSIONS: PCNL for kidney stones n EP is effective with a significantly increase the risk of postoperative blood transfusions compared to YP.

[Elastography shows promise in testicular cancer detection]. / Apport de l'élastographie en temps réel pour la caractérisation des masses testiculaires.

PURPOSE: Elastography is a novel imaging technology that shows promise in the identification of anatomic structures. The widespread use of ultrasound for screening testicular tumors in patients with cancer risk factors highlights unclassified testicular micronodules. We investigated the ability of elastography to accurately diagnose testicular nodules. MATERIAL: Patients with clinical testicular nodules were assigned to undergo elastography in a prospective study. The imaging was carried out by a single radiologist using a static elastography unit with a 9-14MHz frequency linear transducer, to identify hardness score, loss of architecture of testicular parenchyma, and surrounding effect. When orchidectomy was required, the corresponding specimens were subjected to hematoxylin and eosin staining for histologic correlation. RESULTS: We imaged 34 testicular lesions: 26/34 (76%) malignant tumors and 8/34 (24%) non-tumor lesion including 4 hematomas, 3 orchitis and 1 ischemia. Se, Sp, PPV and NPV of hardness in elastography in differentiating between malignant and benign tissue was found to be 96.2%, 37.5%, 83%, and 75%, respectively. Further, for recognizing cancer, the loss of architecture of the testicular parenchyma detecting in elastography was 92.3%, 75%, 92.3%, and 75%, respectively, and the surrounding effect was 84.6%, 87.5%, 95.6% and 63.6%, respectively. CONCLUSION: Elastography may be a promising tool at diagnosing testicular tumor when the loss of architecture and the surrounding effect were present. Further studies are needed to evaluate whether the utility of elastography is worth pursuing to identify of unclassified testicular micronodules. LEVEL OF EVIDENCE: 3.

[Salvage HIFU after radiotherapy and salvage radiotherapy after HIFU in locally recurrent prostate cancer: Retrospective analysis of morbidity]. / Traitements de rattrapage par HIFU après radiothérapie première et par radiothérapie après HIFU première dans la récidive locale du cancer de prostate: analyse rétrospective de la toxicité

OBJECTIVES: To evaluate the toxicity of therapeutic sequences High Intensity Focused Ultrasound (HIFU)-salvage radiotherapy (HIFU-RT) or radiotherapy-salvage HIFU (RT-HIFU) in case of locally recurrent prostate cancer. MATERIALS AND METHODS: Nineteen patients had a local recurrence of prostate cancer. Among them, 10 patients were treated by HIFU-RT and 9 patients by RT- HIFU (4 by external beam radiotherapy [EBR] and 5 by brachytherapy [BRACHY]). Urinary side effects were assessed using CTCAE v4. RESULTS: At the time of the initial management, the median age was 66.5 years (53-72), the median PSA was 10.8ng/mL (3.4-50) and the median initial Gleason score was 6.3 (5-8). Median follow-up after salvage treatment was 46.3 months (2-108). Thirty percent of the patients in the HIFU-RT group and 33.3 % of the patients in the RT-HIFU group, all belonging to the sub-group BRACHY-HIFU, had urinary complication greater than or equal to grade 2. Among all the patients, only 1 had grade 1 gastrointestinal toxicity. CONCLUSION: BRACHY-HIFU sequence seems to be purveyor of many significant urinary side effects. A larger database is needed to confirm this conclusion.

[Ipsilateral dual kidney transplantation: a monocentric experience about 15 cases and literature review]. / Bi-transplantation rénale par abord ipsilatéral: expérience d'un centre à propos de 15 patients opérés consécutivement et revue de la littérature.

OBJECTIVE: Our study aimed to support the viability of the concept of Ipsilateral Dual Kidney Transplantation (DKT) by presenting our initial experience and proposing a review of the literature in this subject. METHODS: Fifteen ipsilateral DKT were performed at Nice University Hospital between August 2010 and March 2012. We have described our skin incision preferences, the vascular anastomoses, and the uretero-vesical reimplantation. We have analyzed the operative duration, the cold ischemia time (CIT) of both transplants, the blood transfusion volume, the intraoperative and postoperative complications, the time to diuresis recovery, the hospital stay, and the kinetics of the creatinine clearance until the third postoperative month. We have compared our results with those of the literature. RESULTS: The average CIT of the first transplant (T1) was 17.5 ± 3.3 hours, and that of the second (T2) was 18.4 ± 3.3 hours. The mean operating time was 234 ± 67 minutes. Patients received an average of 2 units of blood during surgery [0-4] and 1.8 units in the postoperative period [0-15]. The complications rate was 26.7% and included an intraoperative T2 artery thrombosis and 3 postoperative complications consistent with a hematoma, a T2 ureteric necrosis and a T2 venous thrombosis. Two transplants were lost (6.7%) and one death (6.7%) was reported on day 40. The average length of hospital stay was 20.9 ± 7.8 days. The mean creatinine clearance values were 12.6 mL/min at D2, 35.6 mL/min at D7, 44.9 mL/min on discharge, and 48.2 mL/min at D90. CONCLUSION: Our results supported the viability of the dual kidney transplantation concept. Furthermore the ipsilateral approach shortened the procedure and limited the surgical trauma by preserving the contralateral iliac fossa, without compromising renal function recovery or increasing morbidity.

[Inflatable penile prosthesis: satisfaction rate, result, prognostic factors. Prospective study on 50 primooperated patients in CHU of Nice between 2000 and 2009]. / Implants péniens hydrauliques: enquête de satisfaction, résultats et complications. Étude rétrospective portant sur 50 patients consécutifs primo implantés au CHU de Nice entre 2000 et 2009.

OBJECTIVE: To evaluate satisfaction rates and results in patients with penile prosthesis (5 PP). MATERIALS AND METHODS: From January 2000 till 2009, 50 patients with organic erectile dysfunction (ED) were implanted with hydraulics penile prosthesis by the same surgeon. Medical records were collected retrospectively. We analysed demographic characteristics, type of prosthesis used, per- and postoperative complications, prosthesis explantations and satisfaction rate measured by EDITS modified. RESULTS: Mean age of patients was 60.2 ± 8.46 years (35-75). Thirty implanted patients (60%) were diabetics. We used a peno-scrotal incision in all patients. Three types of prosthesis were used; AMS Ambicor, AMS 700, Titan OTR. A bi-compartment and three-compartment prosthesis were implanted respectively in 24 and 26 patients. The prosthesis was retrieved in two patients secondary to a mechanical failure, in three patients for prosthesis erosion, in two patients for prosthesis infection. In four out of the seven explanted patients, a second prosthesis was implanted. The EDITS questionnary was realized by telephonic interview in 47 patients after a mean follow-up of 45 months (5-114). The response rate was of 83%. The satisfaction rate was of 81%. CONCLUSION: In our series, the satisfaction rate was better for the three-compartment prosthesis. After 45 months of follow-up, 73% (31/42) of patients had a functional prosthesis. The non-satisfaction most frequently found were patients who have complications as sepsis; mechanical failure, and prosthesis erosion, and subjective feeling of penile length reduction.

The emerging role of connexin 43 in testis pathogenesis.

Direct intercellular communication is mediated by gap junctions and their constitutive proteins, the connexins, which are organized in a hexameric arrangement forming a channel between adjacent cells. Connexins are essential for cell homeostasis and are also involved in many physiological processes such as cell growth, differentiation and death. Spermatogenesis is a sophisticated model of germ cell proliferation, differentiation, survival and apoptosis, in which one connexin isoform, connexin 43, plays an essential role as evidenced by the targeted genetic deletion of Cx43 gene. A controlled balance of germ cell growth is a prerequisite to maintain either normal level of spermatozoa necessary for fertility and/or to limit an uncontrolled and anarchic germ cell proliferation, a major risk for germ cell tumor cell development. In the present review, we highlight the emerging role of connexins in testis pathogenesis, specifically in two intimately interconnected human testicular diseases: azoospermia with impaired spermatogenesis and testicular germ cell tumors, whose incidence increased during the last decades. This review proposes the gap junction protein connexin 43 as a new potential cancer diagnostic and prognostic marker, as well as a promising therapeutic target for testicular diseases.

[Cosmetic surgery of the male genitalia]. / Chirurgie cosmétique de l'appareil génital masculin.

OBJECTIVES: To describe the indications and results of techniques to change the appearance of the penis for aesthetic reasons. Provide recommendations concerning cosmetic surgery of the male genitalia. MATERIAL AND METHODS: We have selected from Medline Database, articles published between 1990 and 2011. Forty articles have been selected excluding papers reporting populations less than five cases per type of procedure. RESULTS: There is no consensus on the size below which it is justifiable to accept or attempt to modify the size of the penis. Length of the penis in maximal tension less than 9.5 cm or 10 cm in erection can be considered as an acceptable limit, in a patient who suffers from it. The assessment of men asking for penile enlargement must include a psychosexological or psychiatric evaluation, looking for a dysmorphophobia or another psychiatric condition. Penile extenders under medical control must be the first-line treatment option for patient seeking penile lenghtening procedure when justified. In case of failure, three techniques can be used alone or in combination: penile lengthening by section of the suspensory ligaments and suprapubic skin advancement, lipectomy of Mons pubis and scrotal webbing section. The results are modest, the rate of complications significant and satisfaction low. Girth enlargement techniques by injection of autologous fat give inconsistent aesthetic results and satisfaction rates are low. All other techniques remain experimental. CONCLUSIONS: Cosmetic surgery of the penis is associated with a high risk of forensic exposure and surgery should be only proposed after a multidisciplinary consensus, followed by a time of reflection given to the patient after full disclosure. Applications for the purpose of reconstruction surgery after trauma or consequences of cancer treatment are justified.