Evaluation and comparison of scoring systems for predicting stone-free status after flexible ureteroscopy for renal and ureteral stones.

OBJECTIVE: To evaluate four predictive scores for stone-free rate (SFR) after flexible ureterorenoscopy (f-URS) with holmium-YAG laser fragmentation of renal and ureteral lithiasis. METHODS: We carried out a retrospective analysis of 800 f-URS procedures performed in our institution between January 2009 and December 2016. For each procedure, a single surgeon calculated the following scores: S.T.O.N.E score; Resorlu Unsal Stone Score (RUSS); modified Seoul National University Renal Complexity (S-ReSC) score; and Ito's score. RESULTS: Overall SFR was 74.1%. Univariate analysis demonstrated that stone size (p<0.0001), stone volume (p<0.0001), stone number (p = 0.004), narrow lower pole infundibulopelvic angle (IPA) (p = 0.003) and lower pole location + IPA <45° (p = 0.011) were significantly associated with SFR. All scores differed between the stone-free and non-stone-free groups. Area under the curve of the receiving operator characteristics curve was calculated for each score: 0.617 [95%CI: 0.575-0.660] for the S.T.O.N.E score; 0.644 [95%CI: 0.609-0.680] for the RUSS; 0.651 [95%CI: 0.606-0.697] for the S-ReSC score; and 0.735 [95%CI: 0.692-0.777] for Ito's nomogram. CONCLUSION: All four scores were predictive of SFR after f-URS. Ito's score was the most sensitive. However, the performance of all scores in this analysis was lower than in developmental studies.

Effects of Obesity on Postoperative Complications and Graft Survival After Kidney Transplantation.

OBJECTIVE: The objective of this study was to analyze the effects of obesity on postoperative complications and patient and graft survival after kidney transplantation. METHODS: We retrospectively included 506 patients who received a kidney transplant in our center during eleven years. Obesity was defined by a body mass index ≥ 30 kg/m2 based on World Health Organization criteria. Using univariate and multivariate analyses, we evaluated the impact of obesity on surgical complications according to the Clavien-Dindo classification up to 30 days after surgery. The impact of obesity on graft and patient survival was assessed using a Cox proportional regression model. RESULTS: Seventy-one patients were obese (14%), and mean follow-up was 63.1 months (59.7-66.5). By multivariable analysis, obesity was associated with delayed graft function (hazard ratio [HR] = 2.60 [1.31-5.02], P = .004). Obesity was not associated with surgical complications, but cardiovascular history was (HR = 1.68 [1.09-2.99], P = .048). By Cox regression analysis, obesity was significantly associated with a higher risk of graft loss (HR = 1.55 [1.06-2.99], P = .042) but not with patient survival (HR = 1.82 [0.88-3.79], P = .106). CONCLUSION: Obesity was associated with delayed graft function and graft loss. However, it was not associated with surgical complications. Kidney transplantation remains the best therapy for obese patients suffering from end-stage renal disease, despite shorter graft survival.

Flexible Ureterorenoscopy for Renal and Proximal Ureteral Stone in Patients with Previous Ureteral Stenting: Impact on Stone-Free Rate and Morbidity.

OBJECTIVE: To analyze results (stone-free rate [SFR]) and complications after flexible ureterorenoscopy (f-URS) for renal or lumbar ureteral lithiasis in patients with a previous ureteral stenting (US). PATIENTS AND METHODS: We conducted a single-center retrospective study, including all f-URS procedures achieved in our department, between January 2004 and December 2010, for renal or lumbar ureteral urinary lithiasis. In total, 497 procedures were performed: 316 procedures in patients with a ureteral stent placed before the surgery for renal colic, sepsis, or renal failure (group 1) and 181 procedures in patients without US (group 2). Success was defined as a complete SFR at 6-month follow-up. Surgical morbidity was defined using the Clavien-Dindo grading system. RESULTS: Groups 1 and 2 were well balanced in terms of demographic data, number, and size of stones. Ureteral location was significantly higher in group 1 (30.2% vs 16.3%, p = 0.0006). Surgery characteristics were similar in both groups. By univariate analysis, SFR tended to be slightly higher in the group with prior ureteral stenting (72% vs 63%, p = 0.05). SFR for ureteral location was also higher after previous ureteral stenting (81.5% vs 59.4%, p = 0.023). By multivariate analysis, only stone size and number were correlated with f-URS failure. Complication rate was comparable in both groups (10.7% vs 11.8%, p = 0.7). CONCLUSION: Technical aspects of the f-URS procedure were not modified by ureteral stenting. We found that f-URS in patients with ureteral stenting was not associated with a better SFR, except in case of ureteral location in univariate analysis. Ureteral stenting was not independently related to f-URS outcome by multivariate analysis.

Comparison of the efficacy and morbidity of flexible ureterorenoscopy for lower pole stones compared with other renal locations.

BACKGROUND AND PURPOSE: Flexible ureterorenoscopy (f-URS) for lower pole stones (LPS) compared with other renal locations can be challenging because of anatomic and technical considerations. We aimed to compare the stone-free rate (SFR) and surgical complication rate with f-URS for LPS vs other renal locations. PATIENTS AND METHODS: We performed a retrospective, single-center study including 371 f-URS for renal stone retrieval performed in our institution between January 2004 and December 2010. Among the 371 procedures included in this analysis, 139 were performed for stones located in a single renal location other than the lower pole (group 1), and 232 for at least one stone located in the lower pole (group 2). We compared the efficacy (SFR) and the morbidity of f-URS between the two groups. The success of the procedure was defined as a complete SFR 6 months after f-URS. RESULTS: Age, sex, history of urolithiasis, body mass index, and preoperative stent placement did not differ between the two groups. No differences in stone characteristics were observed between both groups except stone size under 10 mm that was significantly higher in group 2 (P=0.018). Technical aspects of the procedure did not differ between the groups, except for more frequent use of an access sheath in group 2 (P=0.007). SFR was comparable between groups (P=0.774). The complication rate was similar in both groups, as was the severity of complications. By multivariate analysis, stone size >10 mm (P<0.0001) and multiple stone locations (P=0.001) were associated with f-URS failure, but lower pole location did not impact on SFR. CONCLUSION: In our study, stone location, in particular LPS, did not have any impact on efficacy and morbidity of f-URS. Only multiple locations and stone size >10 mm seemed to significantly decrease the SFR, without impacting morbidity.

Ureterorenoscopy with holmium-yttrium-aluminum-garnet fragmentation is a safe and efficient technique for stone treatment in patients with a body mass index superior to 30 kg/m2.

PURPOSE: The aim of the study was to analyze results and morbidity after flexible ureterorenoscopy in patients with a body mass index (BMI) >30 kg/m(2) and to compare with results obtained in a large cohort of nonobese patients. PATIENTS AND METHODS: We conducted a retrospective study including all flexible ureterorenoscopy performed for stone retrieval in our institution between January 2004 and December 2008. During the study period, 224 procedures were performed, of which 18 had to be excluded because of missing BMI data. Thus, a total of 206 procedures were included in the final analysis (34 in 29 obese patients, 172 in 149 nonobese patients). Characteristics of the patients (age, BMI, previous treatment), stones (nature, location, number), and procedures (operating time, morbidity, outcome) were analyzed. Success was defined as clear imaging (completely stone free) on renal tomography and ultrasonography at 1, 3, and 6 months follow-up. RESULTS: Mean BMI was 34±0.6 kg/m(2) in obese patients (OP) and 24±0.2 kg/m(2) in nonobese patients (NOP). Mean stone size, location, and composition were not significantly different between groups. Operative time was also similar in OP and NOP (102.5±6.1 min vs 103±3.4 min, P=NS). The rate of minor complications (fever, hematuria, flank pain) was similar in OP (11.8%) and NOP (11.4%). No major complication necessitating prolonged hospital stay or new surgical procedure was observed. The overall stone-free rate was not significantly different between OP (79.4%) and NOP (70%). CONCLUSION: Flexible ureterorenoscopy is an appropriate treatment for use in obese patients and achieves excellent stone-free rates with low morbidity.

Wegener's granulomatosis: a rare cause of hydronephrosis.

A seventy-one-year-old woman was hospitalized at our institution for a right-sided "renal colic" associated with an infectious background. Alithiasic ureterohydronephrosis was diagnosed by imaging. A urinary diversion was thus performed using a double J endoureteral stent. The etiologic assessment of the hydronephrosis showed the presence of a periureteral mass that caused extrinsic ureteral compression. After surgical excision of the ureteral lesion, the Wegener's granulomatosis diagnosis was established. This report is the clinical description of a case of "atypical" Wegener's granulomatosis revealed by the onset of a ureteral disease mimicking a neoplastic process.

Collagen fleece-bound fibrin sealant is not associated with an increased risk of thromboembolic events or major bleeding after its use for haemostasis in surgery: a prospective multicentre surveillance study.

BACKGROUND: Topical haemostatic agents are used to help achieve haemostasis during surgery when standard surgical techniques are insufficient. The objective of this study was to confirm the safety profile of an equine collagen patch coated with human fibrinogen and human thrombin with particular focus on the occurrence of thromboembolic events (TEEs), major bleeding and immunological events. METHODS: This was a non-interventional, multicentre, prospective, surveillance study in which a collagen fleece-bound fibrin sealant was prescribed in accordance with its marketing authorisation. The decision to use the sealant was based solely on current surgical practice. All patients that received the sealant and provided informed consent were included. TEEs (any coagula-based occlusion in a vessel or the heart identified by symptomatic clinical signs and/or verified by paraclinical examination), major bleeding (any bleeding that required intervention), and immunological events (hypersensitivity including anaphylaxis) that occurred during surgery, post-operative hospital stay or 6 months of follow-up were reported as adverse events. The primary endpoint was the proportion of patients experiencing a confirmed TEE. RESULTS: A total of 3098 patients were recruited at 227 centres in 12 European countries. The most frequent types of surgery were hepatic (33%), gastrointestinal (16%) and urological (14%) and the main indication for surgery was for primary (35%) or secondary (20%) malignancy. Forty-six patients (1.5%, 95% CI 1.1-2.0%) had at least one TEE during the study. The most commonly reported TEEs were pulmonary embolism or post-procedural pulmonary embolism (n = 18) and deep vein thrombosis (n = 9). There were 64 major bleedings in 62 patients and 9 immunological events in 8 patients. CONCLUSION: Collagen fleece-bound fibrin sealant does not appear to be associated with an increased risk of TEEs, major bleeding or immunological events in patients undergoing surgery. TRIAL REGISTRATION: Clinicaltrials.gov number: NCT00285623.

Expression analysis of VEGF-A and VEGF-B: relationship with clinicopathological parameters in bladder cancer.

The present investigation was conducted first to determine whether correlation exists between VEGF-A and -B mRNA levels and clinicopathological parameters and to assess their prognostic value in bladder cancer, then to clarify the expression level and biological significance of VEGF-A isoforms. Total RNA was isolated from 37 specimens of bladder cancer. Northern blot analysis revealed that VEGF-B mRNA was not expressed either in normal urothelium or in bladder cancer and detected three VEGF-A transcripts of 5.2, 4.5 and 1.7 kb in length, respectively. The VEGF-A transcript levels were greater in cancer tissues than in normal urothelium. They were significantly higher in pT2-T4 than in pTa and pT1 urothelial tumors and thus, were correlated to the pathologic stage. Contrary to the 4.5 kb transcript, elevated expression of the 5.2 and 1.7 kb transcripts was correlated with the histologic grade and the presence of carcinoma in situ. Patients with higher VEGF-A mRNA levels had a significantly shorter survival without progression compared to those with lower levels. Three VEGF-A splice variants were detected by southern blotting namely, VEGF121, 165 and 189. The expression intensity of each isoform was evaluated by quantitative real-time RT-PCR in 20 new fresh frozen recent tumors. VEGF121 and VEGF165 were expressed at the similar level. On the contrary, they were significantly more expressed than VEGF189 (p<0.05). The three isoforms were higher expressed in pT2 bladder cancers than in pTa tumors (p<0.05). There was only a significant correlation between the increased expression level of VEGF121 and 165 and the histological grade of the lesion (p<0.05). To conclude, VEGF-A mRNA level is a potential prognostic indicator of progression in bladder cancer as well as the expression level of the different VEGF-A splice variants.

Accuracy of ultrasonography in diagnosis of testicular rupture after blunt scrotal trauma.

OBJECTIVES: The aim of this study is to determine the accuracy of ultrasonography for the diagnosis of testis rupture after scrotal trauma and its sensitivity and specificity for testis rupture, tunica albuginea breach, testicular hematoma, testis avulsion, epididymis injuries, and hematocele. METHODS: Between 1996 and 2006, 33 patients underwent surgical exploration for blunt scrotal trauma. All these patients had an emergency scrotal ultrasonography with the use of a 7.5 or 10 MHz linear transducer. Ultrasonographic findings were compared with surgical findings to calculate sensitivity and specificity of ultrasonography for each type of lesion. RESULTS: Of 33 patients, 16 presented a testis rupture. Testis rupture was in all cases suspected ultrasonographically by the loss of contour of the testis and heterogeneous parenchyma. Tunica albuginea breach was visualized in only 8 patients. Sensitivity and specificity of ultrasound for testis rupture were 100% and 65%, respectively. Moreover, ultrasonography allowed diagnosis of hematocele (sensitivity: 87% and specificity: 89%), testicular hematoma (sensitivity: 71%, specificity: 77%), and testis avulsion (sensitivity: 100%, specificity: 97%). Ultrasonography results for epididymis injuries were poor. On 7 patients, 3 epididymis lesions were misdiagnosed by ultrasound examination. CONCLUSIONS: Ultrasonography can distinguish various scrotal injuries. Testicular rupture is probably the most severe injury that needs early surgical treatment to improve testis salvage rate. In our work, ultrasonography is highly sensitive in the diagnosis of testis rupture and can provide information on the scrotal contents integrity that can help the physician to determine the optimal treatment.

[Vascular prostheses and renal transplantation]. / Protheses vasculaires et transplantations rénales.

OBJECTIVE: To evaluate the complications, the morbidity and mortality of renal transplantation in patients with a vascular prosthesis inserted either prior to or at the same time as renal transplantation. PATIENTS AND METHOD: Between January 2001 and January 2006, six renal transplantations were performed in patients with arterial vascular prostheses or requiring concomitant insertion of a vascular prosthesis during renal transplantation. The mean age was 58 years [range: 47-69 years]. In each case, we evaluated operative difficulties, complications and postoperative course (morbidity, mortality) and the renal functional result. RESULTS: The mean operating time was 230 minutes [range: 130-380 minutes] with a mean blood loss of 390 ml [175-750 ml]. Three patients required another surgical operation for femoral thrombosis, iliofemoral thrombosis and compressive haematoma. The median length of hospital stay was 21 days [range: 9-78 days]. Graft function was restored immediately in all six patients, and one case of graft loss was observed. The morbidity was higher than that usually observed after renal transplantation. With a mean follow-up of 26 months, the vascular and renal results are satisfactory. CONCLUSION: Renal transplantation in patients with a history of vascular prosthesis or requiring replacement of the vascular prosthesis at the same time as renal transplantation can be performed with satisfactory results but with an increased morbidity. The vascular treatment must be part of a multidisciplinary strategy in the context of transplantation.

[Conservative management of Corynebacterium urealyticum encrusted cystitis]. / Cystite incrustante a corynebacterium urealyticum: traitement conservateur.

The authors report the case of a 75-year-old patient who developed Corynebacterium urealyticum encrusted cystitis six months after open prostatectomy, complicated by vesicocutaneous fistula, which required bladder catheterization for several days. Encrustation of the bladder wall induced marked bilateral ureteropyelocaliceal dilatation without renal failure. Medical treatment by antibiotic therapy and oral acidification of the urine allowed regression of the plaques and resolution of the dilatation.

[Simultaneous embolization of a large arteriovenous fistula and a renal pseudoaneurysm]. / Embolisation simultanée d'une large fistule artério-veineuse et d'un pseudo-anévrysme rénal.

The authors report the cases of a 41-year-old woman with a large arteriovenous fistula between a branch of the renal artery and the main renal vein in the renal hilum and a peripheral pseudoaneurysm secondary to a knife wound to the kidney. These lesions were successfully treated by embolization. In the light of this case, the authors illustrate the possibility of performing more than one embolization on the same kidney and emphasize the successful embolization of a large, high-flow arteriovenous fistula.

N-cadherin as a novel prognostic marker of progression in superficial urothelial tumors.

PURPOSE: Loss of intercellular adhesion and increased cell motility promote tumor cell invasion and spreading. In bladder cancer, loss or reduced E-cadherin expression has been associated with poor survival, and aberrant expression of N-cadherin has been associated with the invasive phenotype of bladder carcinoma cells. The purpose of this study was to investigate whether N-cadherin expression was associated with the bladder tumor progression. EXPERIMENTAL DESIGN: E-cadherin and N-cadherin expression was evaluated by immunohistochemistry in 101 tumors (pT1 and pT2-T3) and by reverse transcription-PCR analysis and immunohistochemistry in 28 other fresh frozen tumors (pT(a), pT1, and pT2-T3). RESULTS: N-cadherin expression was absent in normal urothelium, appeared in stage pT1, and increased in pT2-pT3 tumors. In most cases, increased N-cadherin expression in invasive tumors was associated with loss of E-cadherin expression. Progression-free survival and multivariate analyses revealed that N-cadherin expression is an independent prognostic marker for pT1 tumor progression. Analysis of the 28 frozen tumors by immunohistochemistry and reverse transcription-PCR showed a good correlation between protein and gene expression in pT1 and pT2-T3 tumors. Interestingly, in pT(a) tumors, N-cadherin was not immunodetected, whereas mRNA was present in 50% of cases. CONCLUSION: Regulatory defects in the N-cadherin promoter, abnormalities at the translational, or protein processing levels could explain the discrepancies between protein and mRNA expression. Most importantly, this study identified N-cadherin as a novel prognostic marker of progression in superficial urothelial tumors. Clearly, N-cadherin acts in an invasive mode in bladder cancer, but whether it has a primary role in urothelial neoplastic progression has yet to be investigated.

[Bladder leiomyoma treated by transurethral endoscopic resection]. / Le léiomyome de vessie traité par résection endoscopique transuréthrale.

We report a case of intravesical bladder leiomyoma in a 47-year-old patient presenting with recurrent macroscopic haematuria. The diagnosis was strongly suspected on CT and cystoscopy. Treatment consisted of transurethral resection of the mass. No recurrence has been observed with a follow-up of two years. In the light of this case, the authors discuss the diagnosis and treatment of bladder leiomyoma.

Expression in bladder transitional cell carcinoma by real-time quantitative reverse transcription polymerase chain reaction array of 65 genes at the tumor suppressor locus 9q34.1-2: identification of 5 candidates tumor suppressor genes.

Frequent deletions on 9q34.1-2 were reported in bladder transitional cell carcinoma. High deletion mapping studies delimited a critical interval between markers D9S61 and D9S66, which is highly susceptible to contain a tumor suppressor gene. Expression level of the 65 genes localized in this region was analyzed by real-time quantitative RT-PCR, comparing tumor to normal urothelium. Five genes exhibited a significantly reduced expression level: C9orf9, KIAA0625, ABL1, LAMC3 and KIAA1857-netrin-G2, which exhibited the most significant downregulation (p=0.0007). KIAA1857-netrin-G2 belongs to the netrins and might then be a tumor suppressor gene in bladder cancer, as netrin1 receptor DCC has been implicated in tumorigenesis.

[Genetic cause of male infertility and molecular biology]. / Infertilité masculine de cause génétique et biologie moléculaire.

At the present time, 15% of couples experience reproduction difficulties. Surgical collection of spermatozoa associated with the intracytoplasmic sperm injection technique (ICSI) resolves the problems of male infertility formerly considered to be irreversible, regardless of its aetiology. Molecular biology now allows evaluation of the genetic dimension of male infertility. Although it demonstrates the multiple aetiologies of male infertility, it also reveals the gaps in our knowledge and the extent of the task that has yet to be accomplished. Microdeletion of the Y chromosome, detected in 2% to 20% of infertile patients with a disorder of spermatogenesis, has already been well documented. All of the genes involved on the Y chromosome (DAZ, RBMY, etc.) in infertile patients have been shown to be involved in spermatogenesis. Testing for other genes of the genome would also be useful. However, the unknown outcome of these abnormalities with successive generations raises a number of questions. In this article, the authors describe the main genes involved in spermatogenesis as demonstrated by molecular biology.

[Management of severe renal trauma]. / Prise en charge actuelle des traumatismes graves du rein.

OBJECTIVE: To analyse the progress in the management of severe renal trauma (Chatelain stage 3 and 4) over a period of 11 years. PATIENTS AND METHODS: From December 1989 to June 2001, 21 patients were treated for severe renal trauma. Up until 1995, all patients were operated urgently or on the 7th day (n = 12). After 1995, patients were operated (n = 3) or managed nonoperatively (n = 6). We retrospectively studied the age, gender, type of trauma (open, closed), associated lesions, radiological assessment performed, treatment and complications. RESULTS: 20 males and 1 female with a mean age of 30.3 years were managed for severe renal trauma (17 stage 3 and 4 stage 4; 20 cases of closed trauma, 1 case of open trauma). The radiological assessment comprised ultrasound (13 cases), abdominopelvic CT (19 cases) and IVU (4 cases). Thirteen patients presented with multiple injuries with associated visceral (8 cases), bone (7 cases), or mixed (3 cases) lesions. Six patients were managed nonoperatively and 15 patients were operated: 6 urgently (4 total nephrectomies), 9 on the average of the 7th day (conservative treatment). Five patients developed long-term complications (4 cases of renal atrophy, 1 urohaematic pseudocyst). The median follow-up was 13.5 months. CONCLUSION: The current approach to stage 3 renal trauma tends to be surveillance and nonsurgical management (carefully selected, haemodynamically stable patients). Vascular repair before the 5th hour is recommended for stage 4 trauma. Cases of delayed diagnosis of arterial thromboses are monitored.