Preparing for the Worst: Management and Predictive Factors of Open Conversion During Minimally Invasive Renal Tumor Surgery (UroCCR-135 Study).

Background and objective: Data regarding open conversion (OC) during minimally invasive surgery (MIS) for renal tumors are reported from big databases, without precise description of the reason and management of OC. The objective of this study was to describe the rate, reasons, and perioperative outcomes of OC in a cohort of patients who underwent MIS for renal tumor initially. The secondary objective was to find the factors associated with OC. Methods: Between 2008 and 2022, of the 8566 patients included in the UroCCR project prospective database (NCT03293563), who underwent laparoscopic or robot-assisted minimally invasive partial (MIPN) or radical (MIRN) nephrectomy, 163 experienced OC. Each center was contacted to enlighten the context of OC: "emergency OC" implied an immediate life-threatening situation not reasonably manageable with MIS, otherwise "elective OC". To evaluate the predictive factors of OC, a 2:1 paired cohort on the UroCCR database was used. Key findings and limitations: The incidence rate of OC was 1.9% for all cases of MIS, 2.9% for MIRN, and 1.4% for MIPN. OC procedures were mostly elective (82.2%). The main reason for OC was a failure to progress due to anatomical difficulties (42.9%). Five patients (3.1%) died within 90 d after surgery. Increased body mass index (BMI; odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, p = 0.009) and cT stage (OR: 2.22, 95% CI: 1.24-4.25, p = 0.008) were independent predictive factors of OC. Conclusions and clinical implications: In MIS for renal tumors, OC was a rare event (1.9%), caused by various situations, leading to impaired perioperative outcomes. Emergency OC occurred once every 300 procedures. Increased BMI and cT stage were independent predictive factors of OC. Patient summary: The incidence rate of open conversion (OC) in minimally invasive surgery for renal tumors is low. Only 20% of OC procedures occur in case of emergency, and others are caused by various situations. Increased body mass index and cT stage were independent predictive factors of OC.

Standardized technique for ejaculation preservation during prostatic endoscopic ablative surgery.

PURPOSE: Ejaculatory dysfunction is the most common side effect of benign prostatic hyperplasia surgery. Modified techniques have emerged with the aim of preserving antegrade ejaculation without compromising obstruction relief. None are standardized or validated. The PARTURP study is a randomized study investigating partial versus complete prostate resection. We conducted an investigator consensus meeting to define the ideal surgical technique to achieve both correct obstruction relief with ejaculation preservation. METHODS: An expert consensus meeting involving all investigators of the PARTURP study took place to define a common technique using the nominal group methodology. The objectives were to define the areas to be resected and the areas to be preserved; to define the criteria for proper obstruction relief; to define the criteria for proper ejaculation preservation. RESULTS: All investigators (n = 15) attended the consensus meeting, and agreement between all the participants was obtained. The anatomical landmarks to be preserved are located around the verumontanum and along the posterior part of the prostatic urethra. These structures must be preserved up to 2 cm from the verumontanum. The participants agreed on the need to preserve the urethral mucosa in all the areas to be preserved and to reach the enucleation plane in the areas of resection. CONCLUSIONS: Anatomical landmarks for ejaculation-sparing surgery have been defined by the investigators of the PARTURP randomized study. These landmarks will be used during the study, and the clinical outcomes of this ejaculation-sparing technique will be compared with complete resection with up to 3 years follow-up.

Clinical trial protocol for P-NeLoP: a randomized controlled trial comparing the feasibility and outcomes of robot-assisted partial nephrectomy with low insufflation pressure using AirSeal versus standard insufflation pressure (UroCCR no. 85 study).

Robot-assisted partial nephrectomy (RAPN) is the standard of care for small, localized kidney tumors. This surgery is conducted within a short hospital stay and can even be performed as outpatient surgery in selected patients. In order to allow early rehabilitation of patients, an optimal control of postoperative pain is necessary. High-pressure pneumoperitoneum during surgery seems to be the source of significant pain during the first hours postoperatively. Our study is a prospective, randomized, multicenter, controlled study which aims to compare post-operative pain at 24 h between patients undergoing RAPN at low insufflation pressure (7 mmHg) and those operated on at standard pressure (12 mmHg) using the AirSeal system.This trial is registered in the US National Library of Medicine Trial Registry (NCT number: NCT05404685).

Oncocytoma on renal mass biopsy: is it still the same histology when surgery is performed? Results from UroCCR-104 study.

PURPOSE: To describe clinical features of patients with oncocytoma on renal biopsy (RMB), correlation with final histology on surgically treated patients, and predictive factors of discrepancy between RMB and final histology. METHODS: This was a retrospective study conducted in the framework of the UroCCR project (NCT03293563). All tumors with oncocytoma on RMB were selected and all pathological reports were reviewed. Patients with the RMB simultaneously performed with a focal treatment, synchronous bilateral tumors and ambiguous RMB report were excluded. Discrepancy between RMB and definitive histology was evaluated using a uni- and multivariable logistic regression analyses model. RESULTS: Overall, 119 tumors with oncocytoma on RMB, from 15 centers, were included. Of those, 54 (45.4%) had upfront surgery and 65 (54.6%) had active surveillance (AS). In renal masses with initial active surveillance, with a median follow-up of 28 months, 23 (19.3%) underwent surgery, 4 (3.4%) received focal treatment and 38 (31.9%) remained on AS. On final pathology, only 51 of the 75 surgically treated tumors (68.0%) had oncocytoma, while 24 presented malignant tumors (mainly chromophobe carcinoma (19.2%), and hybrid oncocytic/chromophobe tumor (HOCT) (6.8%)) leading to a discrepancy of 32.0% between RMB and final pathology. The only predictive factor of a discrepancy between RMB and definitive histology was a biopsy done outside of the center (Odds ratio: 3.22 [95%-confidence interval: 1.08-9.61], p = 0.03). CONCLUSION: Despite the increase of RMB in more and more centers, histologic discrepancy between RMB and definitive histology remains significant. This information should be discussed with patients and taken into consideration before treatment decision.

Climate-smart Actions in the Operating Theatre for Improving Sustainability Practices: A Systematic Review.

CONTEXT: Surgical activity contributes to global warming though the production of greenhouse gases and consumption of resources. To date, no clinical practice guidelines have been made to promote and implement climate-smart actions. OBJECTIVE: To perform a systematic review of the available actions that could limit CO2 emission in the operating room (OR) and their potential benefits upon the environment, whilst preserving quality of care. EVIDENCE ACQUISITION: MEDLINE and Cochrane databases were searched from January 1, 1990 to April 2021. We included studies assessing carbon footprint (CF) in the OR and articles detailing actions that limit or reduce CF. EVIDENCE SYNTHESIS: Thirty-eight studies met the inclusion criteria. We identified six core climate-smart actions: (1) waste reduction by segregation; (2) waste reduction by recycling, reuse, and reprocessing; (3) sterilisation; (4) anaesthesia gas management; and (5) improvement of energy use. Quantitative analysis regarding the CF was not possible due to the lack of homogeneous data. For climate-smart actions, the analysis was limited by discrepancies in study scope and in the methodology of CO2 emission calculation. Improvement of education and awareness was found to have an important impact on waste segregation and reduction. Waste management is the area where health care workers could have the strongest impact, whereas the main field to reduce CF in the OR was found to be energy consumption. CONCLUSIONS: This review provides arguments for many climate-smart actions that could be implemented in our daily practice. Improving awareness and education are important to act collectively in a sustainable way. Further studies are mandatory to assess the impact of these climate-smart actions in the OR. PATIENT SUMMARY: We performed a systematic review of the available scientific literature to reference all the climate-smart actions proposed to improve the sustainability of surgical activities. Waste segregation, waste reduction and recycling, reuse and reprocessing, sterilisation, anaesthesia gas changes, and improvement of energy use in the operating room were found to be the main areas of research. There is still a long way to go to homogenise and improve the quality of our climate-smart actions.

Influence of holmium laser enucleation of the prostate on erectile function: results of a multicentric analysis of 235 patients.

PURPOSE: Preserved sexual function is one of the endpoints of the surgical management of lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Our aim was to investigate the evolution of erectile function (EF) at 3 and 12 months after holmium laser enucleation of the prostate (HoLEP). METHODS: A multicentric retrospective study was performed including 235 sexually active patients who underwent HoLEP between January 2016 and June 2017. Evaluation of EF was carried out with the five-item version of the International Index of Erectile Function (IIEF-5) completed before surgery and at 3 and 12 months after surgery. A change of more than five points in either direction in the IIEF-5 score compared to baseline was considered as an improvement or impairment of EF. RESULTS: No significant differences were found between median pre-operative IIEF-5 and median scores at 3 and 12 months (p = 0.15 and p = 0.45). At 3 and 12 post-operative months, respectively, 10% and 13% of patients reported an improvement, whereas 15% and 16% reported an impairment. The reduction in IIEF-5 score was only statistically significant within the sub-group of patients with normal pre-operative EF (p < 0.001). In this sub-group, 15% of patients reported a decrease of more than five points in total IIEF-5 score. CONCLUSION: This multicentric evaluation confirmed that median IIEF-5 score was not significantly impaired after HoLEP. However, for patients with normal pre-operative EF, a significant decrease in EF after HoLEP was observed. These results may be taken into account when counselling patients before HoLEP.

Predictive factors of urinary incontinence after holmium laser enucleation of the prostate: a multicentric evaluation.

OBJECTIVE: To evaluate predictive factors of urinary incontinence (UI) after holmium laser enucleation of the prostate (HoLEP). METHODS: Patients (n = 2346) were included in a retrospective multicentric study from April 2012 to November 2017. Patients' characteristics (age, BMI, percentage with diabetes), preoperative data (IPSS score, whole gland volume, urinary drainage), operative data (enucleation time, enucleation efficiency, tissue enucleated weight, total delivered energy) and postoperative data were recorded. Absence of UI was defined as no pads at 3 and 6 months. Surgeon experience was stratified in three categories: beginners (< 21 cases), intermediate (21-40 cases) and experienced (> 40 cases). Multivariate logistic regression analysis was performed. RESULTS: UI was observed in 14.5% of patients (340/2346) at 3 months (95%CI 13-16%) and in 4.2% (98/2346) at 6 months (95%CI 3-5%). On multivariate analysis at 3 months, increasing age (OR per SD = 1.3 [1.14-1.48]), elevated BMI (OR per SD = 1.23 [1.09-1.38]), preoperative urinary drainage (OR = 0.62 [0.45-0.85]), increasing enucleated tissue weight (OR per SD = 1.29 [1.16-1.45]) and experienced surgeon with at least 40 cases (OR = 0.56 [0.42-0.75]) were significantly associated with UI. At 6 months, increasing age (OR per SD = 1.25 [1.01-1.53]), elevated BMI (OR per SD = 1.25 [1.03-1.5]), increasing whole gland volume (OR per one SD log = 1.24 [1.01-1.53]) and diabetes disorder (OR = 1.7 [1.03-2.78]) were significantly associated with UI. CONCLUSION: UI after HoLEP was observed in 14.5% of patients at 3 months and 4.2% at 6 months, with stress UI in half of the cases. Surgeon experience with at least 40 cases was the main predictive factor of 3 months UI after HoLEP and diabetes disorder of persistent UI at 6 months.

Radical cystectomy for bladder cancer: morbidity of laparoscopic versus open surgery.

PURPOSE: We compared the morbidity and mortality of laparoscopic vs open surgery in radical cystectomy for bladder cancer. MATERIALS AND METHODS: This prospective, nonrandomized study was conducted between January 2003 and July 2007 in 68 patients (7 women and 61 men) who underwent radical cystectomy for bladder cancer. A total of 38 cystectomies were performed laparoscopically and 30 by open surgery. Mean patient age was 68.0 +/- 9.0 years. Median preoperative American Society of Anesthesiologists score was 2 (range 1 to 3) in both groups. RESULTS: Intraoperative blood loss and transfusion rate were significantly lower in the laparoscopic surgery group. Postoperatively the incidence of minor complications and mortality were also significantly lower. Postoperative opioid consumption was significantly less in the laparoscopic surgery group in amount and duration. Resumption of oral fluid and solid intake as well as return to normal bowel function were significantly more rapid in the laparoscopic surgery group, and mean hospital stay was significantly shorter. Mean patient followup was 30.5 +/- 17.2 months. CONCLUSIONS: Laparoscopic radical cystectomy for bladder cancer has a lower morbidity rate than cystectomy by open surgery. It allows more rapid resumption of oral fluid and solid intake as well as return to normal bowel function and shorter hospital stay.

[Laparoscopic cystectomy and transileal ureterostomy for neurogenic vesicosphincteric disorders. Evaluation of morbidity]. / Cystectomie laparoscopique et urétérostomie transiléale pour troubles vésico-sphinctériens d'origine neurologique. Evaluation de la morbidité.

OBJECTIVES: To evaluate the morbidity and mortality of laparoscopic cystectomy combined with transileal ureterostomy to treat neurogenic vesicosphincteric disorders. MATERIAL: Prospective study performed between february 2004 and april 2006 on 26 consecutive patients with a mean age of 55.0 +/- 12.7 years treated by laparoscopic cystectomy for neurogenic vesicosphincteric disorders. The underlying neurological disease was multiple sclerosis (MS) in 20 cases, spinal cord injury in 4 cases and transverse myelitis in 2 cases. The median preoperative ASA score was 3 (range: 2-3). RESULTS: No open conversion was necessary. One intraoperative complication was observed (vascular injury). No perioperative death was observed. The nasogastric tube was maintained postoperatively for an average of 8.69 +/- 5.9 hours. The mean time to resumption of oral fluids was 1.4 +/- 0.7 days and mean time to resumption of solids was 2.6 +/- 1.0 days. The mean time to resumption of bowel movements was 3.8 +/- 3.2 days. The mean intensive care stay was 3.9 +/- 1.1 days. Two postoperative complications were observed in the same patient (ileus and bronchial congestion). Postoperative narcotic analgesics were necessary in 60% of cases. The mean hospital stay was 10.3 +/- 4.1 days. Two late postoperative complications were observed in the same patient (two episodes of pyelonephritis). CONCLUSION: Laparoscopic cystectomy has a low morbidity in neurological patients, allowing early return of feeding and a moderate length of hospital stay.

[Conservative management of renal haemangioma: value of a synergistic combination of flexible ureteroscopy and CT angiography]. / Traitement conservateur d'un hémangiome rénal: intérêt de la synergie urétéroscopie souple et artériotomodensitométrie.

Renal haemangioma (RH) is a rare congenital vascular lesion that is frequently responsible for macroscopic haematuria. This lesion is difficult to diagnose preoperatively despite progress in imaging techniques. These diagnostic difficulties account for the high rate of radical treatment (nephrectomy or nephro-ureterectomy) due to a suspicion of renal carcinoma or upper urinary tract tumour. However, conservative diagnostic and therapeutic management can be performed by a combination of CT angiography, flexible ureteroscopy and selective embolization.

Uterus, fallopian tube, ovary and vagina-sparing laparoscopic cystectomy: technical description and results.

OBJECTIVES: The purpose of our study was to demonstrate, describe, and assess the results of the technique of laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina. PATIENTS AND METHODS: Between July 2004 and December 2005, 13 women with neurogenic vesical dysfunction (mean age: 53.3+/-13.0 yr) underwent laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina. A noncontinent transileal Bricker diversion was performed extracorporeally in each case. Parameters studied were the pre-, peri- and postoperative data. RESULTS: Mean duration of the operation was 325+/-36 min, and mean blood loss was 323.1+/-246.3 ml. No conversion was required. One perioperative complication was observed: a tear in a branch of the right hypogastric vein, which was sutured under laparoscopy. One patient was transfused during surgery (2 units of blood). No early or late postoperative complications were observed. One patient required transfusion of 2 units of red blood cell concentrate on the first day after surgery. None of the patients required opiate analgesia in the postoperative period. The analgesic regimen used was paracetamol and nefopam in all cases. The pain score on an analogic visual scale was less than 4 in all cases. Resumption of transit was not delayed in any of the patients. Mean hospital stay was 11.6+/-1.9 d. Over an average follow-up of 7.4+/-5.4 mo, none of the patients developed late complications. Before surgery, 77% of the women were sexually active; 80% of them were sexually active 4 mo after the surgery. CONCLUSIONS: Laparoscopic cystectomy sparing the uterus, fallopian tubes, ovaries, and vagina is feasible. This operation has low morbidity and requires only a limited stay in hospital.

[Linguistic validation of the "Brief Index of Sexual Functioning for Women"]. / Validation linguistique du "Brief Index of Sexual Functioning for Women". Application a l'etude de la sexualité dans une population de 93 femmes franaaises.

UNLABELLED: Application to the study of sexuality in a population of 93 French women. OBJECTIVES: This study was designed to linguistically validate the French version of the BISF-W (Brief Index of Sexual Functioning for Women) which provides a quantitative and qualitative assessment of female sexuality according to 7 dimensions. This version was then used to study the impact of recognized factors of sexual dysfunction on a control population. MATERIAL AND METHOD: The BISF-W a self-administered quality of life questionnaire developed by Rosen, was translated and linguistically validated. This questionnaire comprises 22 questions in 7 dimensions investigating all aspects of female sexuality: D1 (desire), D2 (arousal), D3 (frequency of sexual activity), D4 (receptiveness), 05 (pleasure, orgasm), D6 (relational satisfaction), D7 (problems affecting sexuality), Composite Score (CS) D1+D2+D3+D4+D5+D6+07. The French version was administered to a study population of 93 women: 49 derived from gynaecology or urology departments and 44 derived from the general population. We calculated and compared the scores of the various dimensions of the BISF-W according to factors able to modify sexuality, such as menopause, age or parity. RESULTS: The results of our study show an alteration of the various dimensions of sexuality in elderly patients (D2, D5, D6, CS; p<0.05) or postmenopausal patients (D2, D5, D6, CS, p<0.05) and in multiparous women. CONCLUSION: The French version of the BISF-W gives results in line with the literature and demonstrates changes of sexuality as a function of the above mentioned variables.

[Prospective study of iliac extraction of the kidney after laparoscopic nephrectomy]. / Extraction du rein par voie iliaque après néphrectomie laparoscopique.

INTRODUCTION: Various routes are used to extract the operative specimen during laparoscopic nephrectomy. The main points are compliance with rules of cancer surgery, when applicable, and minimum wall destruction. The objective of this study was to prospectively evaluate the low iliac approach. MATERIAL AND METHOD: Prospective follow-up of 23 laparoscopic nephrectomies (17 tumours and 6 living donor kidney harvestings) in which the kidney was extracted via a low iliac incision measuring 5 to 7 cm. RESULTS: The mean operating time was 188 +/- 50 min with a mean blood loss of 112 +/- 126 ml. The mean duration of the incision was 10 minutes. In the case of a tumour the mean weight of the operative specimen was 571 +/- 127 g in and the mean diameter of the mass was 5.7 +/- 1.9 cm. All grafted kidneys functioned normally. No surgical conversion was necessary. The mean follow-up was 9.6 +/- 1.2 months. No late postoperative complications were observed. CONCLUSION: Radical nephrectomy or living donor kidney harvesting can be performed via laparoscopy with extraction of the operative specimen via a low iliac incision. This incision ensures extraction of very large specimens while preserving the aesthetic and functional advantages of laparoscopy with no increased cancer risk. They are simple to perform and easily reproducible via a transperitoneal or retroperitoneal approach. Absence of muscle section maintains the integrity of the abdominal wall. No postoperative incisional hernia has been observed.

High prevalence of erectile dysfunction in young male patients after intramedullary femoral nailing.

OBJECTIVES: To evaluate, given the central role of the pudendal nerves in erection, the impact of potential infraclinical lesions on male sexual function. After intramedullary femoral fixation, countertraction on the fracture table has sporadically been involved in pudendal neurapraxia. Patients with tibial fractures served as controls. METHODS: A total of 168 patients treated for femoral or tibial shaft fractures by intramedullary nailing were mailed the International Index of Erectile Function questionnaire, which addresses all aspects of male sexual function and permits grading of the severity of erectile dysfunction (ED). Univariate and multivariate analyses were conducted to test for factors associated with ED. RESULTS: Of the 168 patients, 101 (60.1%) returned the questionnaire. A greater proportion of ED was observed in sexually active patients after femoral fracture than after tibial fracture (40.5% versus 12.5%, P <0.01). The differential prevalence of ED in both groups subjected to comparable high-energy trauma suggested that post-traumatic stress disorder was of marginal importance in ED occurring after femoral nailing. Greater intraoperative doses of curare were associated with better sexual functioning in sexually active patients after femoral fracture (10.6 versus 7.5 mg in patients without and with ED, respectively, P = 0.02), suggesting that postoperative ED could be partially prevented by optimal muscle relaxation during fracture reduction. CONCLUSIONS: Erectile dysfunction was shown to be highly prevalent after intramedullary nailing of femoral shaft fractures. Greater intraoperative curare doses, resulting in optimal relaxation and reduced pressure on the pudendal nerves by the perineal post, were associated with better sexual functioning.

[Symptomatic vesicoureteral reflux in kidney transplantation: results of endoscopic injections of teflon and predictive factors for success]. / Reflux vésico-urétéral symptomatique chez le transplanté rénal: résultats des injections endoscopiques de téflon et facteurs prédictifs de succès.

OBJECTIVES: Evaluation of the results of endoscopic Teflon injections for the treatment of symptomatic vesicoureteric reflux in renal transplant recipients and identification of prognostic factors. POPULATION AND METHODS: Between June 1997 and January 2002, out of a series of 408 renal transplant recipients, 15 patients (8 males, 7 females) with a mean age of 41.9 years were treated for symptomatic vesicoureteric reflux on the transplanted kidney by endoscopic Teflon injection. This treatment was indicated due to the presence of febrile or afebrile infections, possibly associated with deterioration of renal function. Reflux was demonstrated by retrograde cystography. The results of endoscopic treatment were evaluated by cystography at 3 months, and by clinical and laboratory examinations thereafter. RESULTS: The mean interval between renal transplantation and endoscopic treatment was 64.2 +/- 64.7 months. With a mean follow-up of 25 +/- 16.7 months, we observed a 53.3% success rate (8 patients), 13.3% of patients (2 patients) were improved and 33.3% of procedures were considered to be failures (5 patients). A lower number of preoperative infections, reflux < or = grade III and the absence of impaired renal function are predictive factors for the success of endoscopic treatment. The only complication was one case of renal colic due to meatal stenosis at 3 months, which responded favourably to endoscopic treatment alone. CONCLUSION: Endoscopic treatment of symptomatic vesicoureteric reflux on a transplanted kidney by Teflon injection is effective in two-thirds of cases. Due to the low morbidity of this minimally invasive procedure, this treatment should be proposed as first-line management for all cases of symptomatic vesicoureteric reflux on a transplanted kidney.

[Retroperitoneal laparoscopic nephrectomy fo polycystic kidney: preliminary results]. / La néphrectomie laparoscopique rétropéritonéale pour polykystose rénale: résultats préliminaires.

OBJECTIVES: To evaluate the morbidity and mortality of retroperitoneal laparoscopic nephrectomy for polycystic kidney. MATERIAL AND METHODS: Between June 2000 and March 2002, seven retroperitoneal laparoscopic nephrectomies for polycystic kidney were performed in six patients (three men, three women) with a mean age of 52.8 years. All patients presented end-stage renal failure treated by haemodialysis in five cases and by renal transplantation in one case. The ASA score was 2 in four cases and 3 in two cases. The indication for surgery was preparation for renal transplantation, episodes of macroscopic haematuria and pain in three cases, hypertension poorly controlled by medical treatment in two cases, preparation for renal transplantation in one case and pain associated with restrictive respiratory syndrome due to compression in one case. RESULTS: The mean operating time was 4 hours 35 minutes, and the mean blood loss was 400 ml. There were no intraoperative or perioperative deaths. An early postoperative complication occurred in two cases. The mean hospital stay was 11 days, with a mean stay of 2.4 days in the postoperative intensive care unit. No late complications were observed with a mean follow-up of 14 months. Preoperative pain, episodes of haematuria, hypertension and signs of compression resolved in each case. CONCLUSION: Laparoscopic nephrectomy for polycystic kidney is a technique that can be performed via a retroperitoneal approach without manual assistance and with low morbidity.