[Oncological and functional results of focal treatment of localized prostate cancer with HIFU]. / Résultats oncologiques et fonctionnels du traitement focal du cancer de prostate localisé par HIFU.

INTRODUCTION: In recent years, improved diagnosis of prostate cancer has allowed the development of focal therapy, in order to reduce the morbidity of treatments. Our study assesses the medium-term oncological and functional results of FocalOne® HIFU treatment in localized prostate cancer. METHODS: This is a retrospective, multicentre study including patients with low- or intermediate-risk localized prostate cancer treated with Focal one HIFU between November 2014 and December 2019. The primary endpoint was the retreatment rate and subgroup analyses were performed to identify predictive factors of retreatment. RESULTS: One hundred and thirty-seven patients were included with a median follow-up of 25.5 months. Seventy percent of patients had clinical stage T2, 64% had an ISUP score of 2 or 3 on initial biopsies and 38% were treated with hemi-ablation. Follow-up biopsies were performed in 76.6% of patients during follow-up with 21.8% having clinically significant cancers. The retreatment rate at 24 months was 37.2%, with positive biopsies being the primary criterion for retreatment. Patients with a PSA>8ng/mL had a significantly higher retreatment rate. Finally, morbidity remained acceptable with 5.8% of patients requiring reoperation for complications and 21% for de novo erectile dysfunction. CONCLUSION: Our results are in agreement with those of the literature, seeming to indicate a lower morbidity of the focal treatment by HIFU compared to the radical treatments while offering an acceptable oncological control. Prospective randomized trials are ongoing.

Successful salvage of kidney allografts threatened by ureteral stricture using pyelovesical bypass.

Ureteral stricture is the most common urologic complication after renal transplantation. When endourologic management fails, open ureteral reconstruction remains the standard treatment. The complexity of some of these procedures makes it necessary to explore other means of repair. This study evaluated the intermediate-term outcome of subcutaneous pyelovesical bypass graft (SPBG) on renal transplant recipients. We reviewed 8 patients (6 male and 2 female; mean age 52 years) with refractory ureteral strictures postrenal transplantation, who received SPBG as salvage therapy. All patients failed endourologic management and half failed open management of their strictures. After a mean follow-up of 19.4 months, 7 out of 8 renal grafts have good function with mean GFR of 58.5 mL/min/1.73 m(2), without evidence of obstruction or infection. One patient lost his graft due to persistent infection of the SPBG and one patient developed a recurrent urinary tract infection managed with long-term antibiotics. SPBG offers a last resort in the treatment of ureteral stricture after renal transplantation refractory to conventional therapy.

Outcome of surgical treatment of patients with upper versus lower urinary tract urothelial carcinoma: stage-by-stage comparison.

OBJECTIVES: It remains controversial whether we can apply similar principles in the management of upper urinary tract urothelial carcinoma (UUT-UC) based on the behavior of bladder urothelial carcinoma (B-UC). We sought to assess whether UUT-UC and B-UC have similar biology and performed a stage-by-stage comparative analysis of outcome between the 2 groups. METHODS: A retrospective review was performed on patients who underwent nephroureterectomy for UUT-UC and radical cystectomy for B-UC from 1991 to 2006. Standard variables were collected and recurrence-free and overall survival (OS) rates were calculated. RESULTS: 280 patients with a median age of 69 years were included (99 UUT-UC treated via nephroureterectomy and 181 B-UC treated via radical cystectomy). Median follow-up was 29 months. None received neoadjuvant chemotherapy. Patients with UUT-UC presented less commonly with invasive disease compared to those with B-UC (44 vs. 77% were >pT2). Overall, 5-year OS for the B-UC group was significantly lower than for the UUT-UC group (60.8 vs. 74.5%, p = 0.02). However, when patients were stratified by stage (>pT2), patients with B-UC had similar OS compared to those with UUT-UC (54.6 vs. 60.8%, p = 0.74). CONCLUSION: Invasive UUT-UC appears to have similar tumor biology compared to B-UC. Whether we can safely extrapolate on the benefit of neoadjuvant and adjuvant strategies to patients with UUT-UC requires further investigation.

[Laparoscopic nephrectomy in a living donor]. / Néphrectomie laparoscopique sur donneur vivant.

Kidney transplantation is the therapeutic option of choice for patients with end-stage renal disease. With the advent of safer harvesting techniques and immunosuppression, both donor and recipient outcomes have markedly improved in recent years. Kidney donation from Living donors remains the single most important factor responsible for improving patient and graft survival. The laparoscopic donor nephrectomy has revolutionized renal transplantation, allowing expansion of the donor pool by diminishing surgical morbidity while maintaining equivalent recipient outcome. This technique is now becoming the gold-standard harvesting procedure in transplant centres worldwide, despite its technical challenge and ongoing procedural maturation, especially early in the learning curve. Previous contraindications to laparoscopic donor nephrectomy are no longer absolute. In the following analysis, the procedural aspects of the laparoscopic donor nephrectomy are detailed including pre-operative assessment, operative technique and a review of the current literature delineating aspects of both donor and recipient morbidity and mortality compared with open harvesting techniques.

Preoperative evaluation of laparoscopic living renal donors with computerized tomography and its effect on donor morbidity and graft function.

OBJECTIVE: To assess the efficacy of CT angiography (CTA) in evaluating the renovascular anatomy in 50 patients who underwent laparoscopic donor nephrectomy, and to correlate results with donor morbidity and recipient outcome. METHODS: Forty-eight patients were evaluated by CTA prior to laparoscopy. Donors with aberrant renovasculature and their respective recipients were divided into: 1) accurate preoperative CTA ("predictive group", PG), 2) inaccurate CTA ("non-predictive group", NPG). Warm ischemia times (WIT), estimated blood loss (EBL), operative time (OT), and the open conversion rate were compared. Recipient creatinine values on post-operative day 1 and 3 months were recorded with the rate of delayed graft function (DGF) and ureteral complication. Statistical significance was calculated using the student's T-test. RESULTS: Among patients with aberrant vasculature (48%, 23/48) at laparoscopy, 14 were accurately predicted by CT angiography (11 arterial, 3 venous). NPG consisted of 5 duplicated arteries, 1 early arterial branching, and 3 anomalous veins. CT accuracy was 85%. The sensitivity and specificity of the arterial imaging were 65% and 100% respectively, while those of venous imaging were 50% and 100%. EBL, WIT, OT, number of open conversions, and ureteral complications were statistically insignificant between groups (p= 0.05, 95% C.I.). The mean decreases in creatinine between NPG and PG on post-operative day 1 and at 3 months were 45.4% and 54.8%, and 71.5% and 79.1% respectively, both statistically insignificant. Two of 8 in the NPG experienced DGF as compared to 1/8 in the PG. CONCLUSIONS: Despite the lower sensitivity of this study, the discordance between imaging and laparoscopy did not augment donor morbidity or increase adverse recipient outcomes. This may indicate that regardless of the shortcomings of 2-D CTA for living donors, it represents a safe and effective imaging modality when coupled with meticulous laparoscopic dissection and central intraoperative involvement of the transplant surgeon.

Optimization of cardiac preload during laparoscopic donor nephrectomy: a preliminary study of central venous pressure versus esophageal Doppler monitoring.

BACKGROUND: While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. METHODS: Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO(2) pneumoperitoneum (12-15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (+/-SD). Data were analyzed using repeated measures ANOVA. RESULTS: Lateral positioning and pneumoperitoneum significantly increased CVP from baseline ( p < 0.01), while the FTc did not change ( p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. CONCLUSION: CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study.

Intraoperative fluid management in laparoscopic live-donor nephrectomy: challenging the dogma.

BACKGROUND: Patients undergoing laparoscopic live donor nephrectomy (LLDN) commonly receive large amounts of fluid intraoperatively to counter the negative effects of pneumoperitoneum on renal function. Our aim is to demonstrate that a low-volume fluid management strategy does not adversely affect donor or recipient outcomes. METHODS: Fifty-two patients underwent LLDN between December 2000 and January 2004. Data were collected in prospective databases, and augmented with retrospective medical record review. Donors were divided into two groups: the fluid-load group (n = 24) received > 10 ml/kg/h of intravenous crystalloids intraoperatively, while the fluid-restriction group (n = 28) received < 10 m/kg/h. RESULTS: Donors in the fluid-restriction group had a lower intraoperative urine output. There were no differences in postoperative creatinine levels (117.5 micromol/L vs 121.5 micromol/L, p = 0.8) or complications (4.2% vs 7.1%, p = 0.9). In the recipients, there were no differences in postoperative creatinine levels up to 12 months, incidence of delayed graft function (18% vs 10%, p = 0.7) or acute rejection (9% vs 5%, p = 1.0) between groups. CONCLUSION: Lower volume fluid management strategies in LLDN do not appear to worsen recipient outcomes nor are they detrimental to the donors.

In vivo model mimicking natural history of dog prostate cancer using DPC-1, a new canine prostate carcinoma cell line.

BACKGROUND: Dog prostate cancer is usually considered to be highly relevant to human prostate cancer. We report the isolation of a new canine prostate cancer epithelial cell line designated DPC-1. METHODS: Primary cultures were established from a canine poorly differentiated prostatic adenocarcinoma. Population doubling time was determined by counting nuclei after cell lysis. Tumorigenicity was assessed in nude mice and in one adult immunodeficient dog. Immunoscintigraphy was performed in both models using a monoclonal antibody (mAb) raised against the [44-62] sequence of human PSMA. RESULTS: DPC-1 cells have a rapid growth in vitro (doubling time, 27 hr) which is not stimulated by androgens. In addition, DPC-1 displays immunoreactivity to human PSA and PSMA. DPC-1 was found to be highly tumorigenic not only in nude mice but also for the first time after orthotopic seeding in an immunodeficient dog. This allograft mimicked, in a compressed form, the aggressive biological behavior of spontaneous dog prostate adenocarcinoma. Immunoscintigraphy using a (131)Iodine-labeled PSMA mAb clearly visualized induced tumors in nude mice and in the dog allograft. CONCLUSIONS: This study suggests that DPC-1 may constitute a powerful model for assessing new diagnostic and/or therapeutic tools in the management of prostate cancer.

A new prostatic stent for the treatment of benign prostatic hyperplasia in high-risk patients.

OBJECTIVES: The objective of this study was to evaluate the efficacy and safety of a new prostatic stent (Trestle((R)), Boston Scientific Microvasive) for the treatment of BPH in patients with complete urinary retention and considered to be inoperable. METHODS: The efficacy of the stent was evaluated in terms of return of micturition, level of patient satisfaction, uroflowmetry and residual urine. Any stents removed were examined by infrared spectrophotometry for the presence of crystalline encrustations. RESULTS: From December 1997 to April 1999, 20 stents were inserted under local anaesthesia in 17 patients aged 54-90 years. Stents remained in place for an average of 3.5 months. Two migrations were reported. The mean maximum flow rate was 13.7 ml/s and the mean residual urine was 110 ml. The infrared spectrophotometry study revealed a glycoprotein film on stents in place for 1-6 months, accompanied by uric acid crystals on stents in place for 9 months. CONCLUSION: The Trestle prostatic stent is effective and constitutes a good alternative to surgical treatment in patients with a high operative risk.

Gene transfer to urethral strictures in rabbits: a preliminary report.

OBJECTIVE: To assess the rationale for virus-mediated gene transfer into the urethra in vivo and in vitro, using a rabbit model, as this is an attractive approach to prevent recurrence after the endoscopic management of urethral strictures. MATERIALS AND METHODS: Primary cultures of rabbit urethral stromal cells were infected with adenoviral and retroviral solutions carrying a nucleus-targeted beta-galactosidase (beta-Gal) reporter gene (respectively 109 and 107 plaque-forming units/mL). In addition, to mimic the human clinical situation, a model was developed of thermally induced stricture in rabbit urethra which produced fibrotic stenosis within 15 days. Using a prototype channelled balloon catheter, these strictures were endoscopically dilated and then instilled with the beta-Gal adenoviral or retroviral constructs. RESULTS: The application of recombinant adenovirus and retrovirus harbouring a nucleus-targeted beta-Gal reporter gene to cultured rabbit urethral stromal cells resulted in a high transduction efficiency of up to 90% and 96%, respectively. Five days after infection, histochemical and immunohistochemical staining of the strictured urethrae showed a 3% rate of transfection targeted to stromal cells within the fibrosis, confirmed by polymerase chain reaction (PCR) analysis. Adjacent and distal spread of the virus was excluded by histochemistry, immunohistochemistry and PCR. CONCLUSION: These results represent the first report of endoscopic adenovirus and retrovirus-mediated gene transfer to the urethra. Although at a low rate, transduction reached stromal cells transmurally within the induced strictures and was site-specific.

[A case of lymph nodes involvement in malakoplakia of the bladder]. / Malakoplakie vésicale et ganglionnaire: à propos d'un cas.

This case illustrates the involvement of lymph nodes in a patient with histologically proven malakoplakia of the urinary bladder. The nodes appeared hyperdense at CT and hyperintense at MR.

Telomerase activity as a potential marker in preneoplastic bladder lesions.

OBJECTIVE: To assess telomerase activity (involved in cell immortalization and detectable in most malignant tumours but not in normal somatic tissues) as a marker in cancer diagnosis. PATIENTS AND METHODS: Tissue telomerase activity was assayed by two different techniques, the telomeric repeat amplification protocol-polymerase chain reaction (TRAP-PCR) and a telomerase PCR-enzyme linked immunosorbent assay. Malignant and inflammatory bladder lesions and their adjacent normal tissues were assessed for telomerase activity in a group of 18 patients, 14 of whom had urothelial carcinoma and four a nonspecific inflammatory lesion of the bladder. RESULTS: Eleven of the 14 tumour samples analysed were telomerase-positive and two of the three telomerase-negative tumour samples had a detectable 'telomerase inhibitor'. In the apparently normal tissues next to bladder tumours, four of the 14 specimens were telomerase-positive. Interestingly, these lesions were always next to high-grade muscle-invasive bladder tumours (pT2G3). Two of the four nonspecific inflammatory lesions (one of cystitis glandularis and one of severe dysplasia), known to be preneoplastic lesions, were also telomerase-positive. CONCLUSION: These results strongly suggest that the reactivation of telomerase may be an early event in bladder carcinogenesis, preceding morphological changes related to malignant transformation. Telomerase activity may therefore be useful both as an indicator of malignant potential in preneoplastic lesions, e.g. cystitis glandularis and severe dysplasia, and as a prognostic marker of bladder tumour relapse or progression.

[Comparison of biomechanical properties of the vaginal fixation in bladder neck suspensions according to the Burch technique and a percutaneous technique]. / Comparaison des propriétés biomécaniques de l'ancrage vaginal dans les suspensions du col vésical selon la technique de Burch et une technique percutanée.

UNLABELLED: Bladder neck suspension or colpo-suspension can be performed via retropubic or percutaneous transvaginal approaches. A higher success rate is observed for retropubic procedures. One of the hypotheses proposed, but not yet verified, is that the retropubic approach allows better quality vaginal fixation than the percutaneous approach. OBJECTIVE: The objective of this study was to compare the biomechanical properties of vaginal fixation according to the Burch procedure and according to a percutaneous technique (Vesica; Boston Scientific). MATERIAL AND METHODS: We performed bladder neck suspension according to the Burch technique (2 points) on the left and according to the Vesica percutaneous technique on the right, on 6 fresh cadavers (mean age 8-5 years), using the same suture material. Vaginal fixations were subsequently excised. The depth of penetration into the vagina was measured and a computerized traction test (Lloyd Instruments, France) was performed on these fixations. The maximum force of traction before rupture was measured. RESULTS: No significant difference was demonstrated for any of the measurements. CONCLUSION: Vaginal fixation of bladder neck suspension performed according to the Burch technique or via a percutaneous technique (Vesica) present equivalent biomechanical properties.

An experimental model of bulbar urethral stricture in rabbits using endoscopic radiofrequency coagulation.

OBJECTIVES: To develop an experimental model of endoscopic urethral stricture mimicking the human clinical situation. METHODS: Twenty-four New Zealand male rabbits were included. Eighteen animals (study group) underwent videourethroscopy with a pediatric resectoscope, and a 3 to 5-mm-long circumferential electrocoagulation of the bulbar urethra was performed, without postoperative urinary diversion. Six animals underwent the same procedure without application of electrocautery (control group). Each animal was assessed for urethral stricture on day 15 and day 30 by videourethroscopy and voiding cystogram. Among the study group, 8 animals were killed on day 15 and 10 on day 30 for histologic evaluation. All the control animals were killed on day 30 for histologic examination. RESULTS: Nine animals (50%) in the study group developed a significant bulbar stricture (reducing the lumen by more than 50%) at day 15. Histologic examination confirmed the presence of hyalin fibrosis mutilating the urethral wall. No spontaneous improvement of the stricture was observed on day 30. None of the controls developed urethral stricture, and histologic examination showed a normal urethra in each case. CONCLUSIONS: Endoscopic electrocoagulation of the urethral wall provides a reproducible model of stricture in the rabbit.

Ureteral gene transfer to porcine induced strictures using endourologic delivery of an adenoviral vector.

PURPOSE: Direct gene transfer to the ureter is an attractive approach to prevent restenosis after endourologic management of ureteral strictures. We therefore assessed the rationale for adenovirus-mediated gene transfer in the ureter in vitro and in vivo using a porcine model. MATERIALS AND METHODS: Primary cultures of porcine ureteral epithelial and stromal cells were infected with an adenoviral solution carrying a nucleus-targeted beta-Galactosidase (beta-Gal) reporter gene (6.5 10(8) pfu/ml.). In addition, in order to mimic the human clinical situation, we have devised a model of thermally-induced stricture in porcine ureter which produced tight fibrotic stenosis within 8 days. Using a purposely designed channelled balloon catheter prototype, these strictures were endoscopically dilated and then instilled with the same beta-Gal adenoviral construction. RESULTS: Application of recombinant adenovirus harboring a nucleus-targeted beta-Gal reporter gene to cultured porcine urothelial and stromal cells resulted in high transduction efficiency of up to 99% and 84% respectively. Seven days after infection, X-Gal staining of the strictured ureters demonstrated transfection up to 2 mm. depth within the fibrosis, confirmed by polymerase chain reaction (PCR) analysis. Adjacent and distal spread of the virus was excluded by histochemistry (X-Gal staining) and PCR. CONCLUSION: This data represents the first report of adenovirus-mediated gene transfer to the ureter. It remained site specific by endourologic retrograde clinically applicable techniques.

Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia.

OBJECTIVE: To evaluate the safety and efficacy of holmium:YAG laser vaporization v transurethral electroresection (TURP) for benign prostatic hyperplasia. PATIENTS AND METHODS: Thirty-six patients were randomized. Two laser procedures (60 to 80 W) were performed for one TURP. Symptom Score, peak flow rate, potency, and ejaculation status were measured at baseline and at 1, 3, 6, and 12 months. RESULTS: The mean operative time was 75 minutes for laser and 56 minutes for TURP (P = 0.0407). With a mean laser energy delivered of 103.6 kJ, hemostasis was satisfactory during vaporization. The mean catheterization time was 1.7 and 2.1 days in the laser and TURP group, respectively. For the laser and TURP groups, the mean AUA Score improved from 20 preoperatively to 7 and from 24.1 to 5, respectively, at 12 months. The mean peak flow increased from 8.4 to 19.5 mL/sec and from 7.6 to 16.8 ml/sec, respectively, at 12 months. These results are not statistically different. No significant initial dysuria occurred. No significant difference between the groups appeared in potency or ejaculatory status during the follow-up. One patient in the laser group (Day 5) and two in the TURP group (2nd and 6th month) had to undergo a second procedure to relieve obstruction. CONCLUSION: Although taking slightly longer to accomplish, holmium:YAG laser vaporization of BPH provides early results very similar to those of TURP with a shorter catheterization time and no initial dysuria or pain.

Thermal radiofrequency induced porcine ureteral stricture: a convenient endourologic model.

PURPOSE: To establish a reliable model of iatrogenic ureteral stricture mimicking the human clinical situation in order to experiment with new site-specific endourologic treatment concepts. MATERIALS AND METHODS: After cystoscopic insertion of a 7F right ureteral catheter, we induced external thermal radiofrequency injury to the right upper third ureter at low power setting (10 W) using an open surgical approach in 13 pigs. Three pigs considered as controls underwent the same procedure without application of electrocautery. All 16 animals were initially assessed at 8 days; 3 study animals and the 3 controls were followed for 6 weeks. RESULTS: No control animals had strictures. Significant upper third ureteral strictures with marked hydronephrosis where achieved in all study animals after a mean interval of 9 days, as evidenced by ultrasound examination and retrograde ureteropyelography. Endoscopic retrograde access to these strictures was always possible (mean length 1.4 cm.). Histologic examination displayed severe disorganization of the muscular layer by dense fibrosis composed of collagen bundles with few scattered fibroblasts. No spontaneous improvement of the stricture was observed in the 3 animals reassessed at 6 weeks. CONCLUSIONS: Externally applied radiofrequency energy to porcine ureter provides a reproducible model of fibrous stricture resembling its clinical counterparts.

Urethral graciloplasty for treatment of female intrinsic sphincter deficiency: rationale for the transvaginal approach: an anatomical study.

PURPOSE: To compare the retropubic and transvaginal approaches in terms of the length of gracilis muscle available for female urethral graciloplasty. MATERIALS AND METHODS: Two groups of female cadavers were submitted to bilateral gracilis muscle dissection, followed by urethral graciloplasty using either the standard retropubic approach or the transvaginal approach. The two groups were studied in terms of various muscle characteristics, in particular the length of muscle that could effectively be wrapped around the bladder neck. RESULTS: Because muscle transfer to the perineum was more direct, the transvaginal approach provided a greater functional length of gracilis for effective periurethral wrapping than the retropubic approach (mean: 8.4 cm. versus 5.2 cm., p = 0.0022). CONCLUSION: The transvaginal approach allows a more "proximal" graciloplasty and should therefore be evaluated clinically to provide circumferential bladder neck support without tension.

[Endoscopes in urology: disinfection, sterilization, labeling and tracking. Circulars and decrees. Modes of application and commentary. The Committee of Infectious Diseases of the French Association of Urology. Congressional forum UFA--Paris, November 1996. DGS Circular 20 October 1997]. / Les endoscopes en urologie: désinfection, stérilisation, marquage et traçage. Circulaires et décret. Modalités d'application et commentaires. Comité d'infectiologie de l'Association Française d'Urologie (CIAFU). Forum Congrès AFU-Paris, novembre 1996. Circulaire DGS 20 octobre 1997.

Administrative texts published in 1995, 1996 and 1997, have reinforced materiovigilance and impose disinfection precautions for endoscopes. The steps of disinfection of non-sterilizable endoscopes are: preliminary treatment, rinsing, actual disinfection, final rinsing, storage (see: Progrès en Urologie, 1997, 7, 505-507). Each procedure from collection of the endoscope until storage must be defined by written standard operating procedures validated by CLIN. The risk of transmission of Creutzfeld-Jakob disease requires autoclaving, which is only possible, at the present time, with the most recent rigid endoscopes. Until disinfection has become generalized, the traceability of endoscopes (labelling, utilization files) must be established on the model recommended for haemovigilance (circular of 02/04/96).