Renal cell carcinoma (RCC) in patients with end-stage renal disease exhibits many favourable clinical, pathologic, and outcome features compared with RCC in the general population.

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk of developing renal tumours. OBJECTIVE: Compare clinical, pathologic, and outcome features of renal cell carcinomas (RCCs) in ESRD patients and in patients from the general population. DESIGN, SETTING, AND PARTICIPANTS: Twenty-four French university departments of urology participated in this retrospective study. INTERVENTION: All patients were treated according to current European Association of Urology guidelines. MEASUREMENTS: Age, sex, symptoms, tumour staging and grading, histologic subtype, and outcome were recorded in a unique database. Categoric and continuous variables were compared by using chi-square and student statistical analyses. Cancer-specific survival (CSS) was assessed by Kaplan-Meier and Cox methods. RESULTS AND LIMITATIONS: The study included 1250 RCC patients: 303 with ESRD and 947 from the general population. In the ESRD patients, age at diagnosis was younger (55 ± 12 yr vs 62 ± 12 yr); mean tumour size was smaller (3.7 ± 2.6 cm vs 7.3 ± 3.8 cm); asymptomatic (87% vs 44%), low-grade (68% vs 42%), and papillary tumours were more frequent (37% vs 7%); and poor performance status (PS; 24% vs 37%) and advanced T categories (≥ 3) were more rare (10% vs 42%). Consistently, nodal invasion (3% vs 12%) and distant metastases (2% vs 15%) occurred less frequently in ESRD patients. After a median follow-up of 33 mo (range: 1-299 mo), 13 ESRD patients (4.3%), and 261 general population patients (27.6%) had died from cancer. In univariate analysis, histologic subtype, symptoms at diagnosis, poor PS, advanced TNM stage, high Fuhrman grade, large tumour size, and non-ESRD diagnosis context were adverse predictors for survival. However, only PS, TNM stage, and Fuhrman grade remained independent CSS predictors in multivariate analysis. The limitation of this study is related to the retrospective design. CONCLUSIONS: RCC arising in native kidneys of ESRD patients seems to exhibit many favourable clinical, pathologic, and outcome features compared with those diagnosed in patients from the general population.

Asymptomatic rectal and bladder endometriosis: a case for robotic-assisted surgery.

OBJECTIVES: To evaluate the feasibility and safety of robot-assisted laparoscopic partial cystectomy for the treatment of rectal and bladder endometriosis. MATERIALS AND METHODS: A 23 year-old female with history of infertility and pelvic pain was found to have a 4 cm bladder mass and rectal nodule on pelvic ultrasonography. Patient denied any other genitourinary symptoms. Cystoscopy and bladder mass biopsy revealed endometriosis. After failure to suppressive hormonal medical therapy a partial cystectomy and resection of a rectal lesion was performed with robotic assistance (da Vinci). The procedure included excision of an ovarian cyst and several peritoneal endometrioid implants. RESULTS: Robotic-assisted (da Vinci) partial cystectomy with concomitant excision of endometrial nodules from the rectum and ovarian cyst was performed in 185 min. The rectal lesion was excised and primary closure of the rectum was performed. Patient had an uneventful postoperative course and hospital stay. Oral intake was started on postoperative day 1 and follow-up imaging revealed no bladder extravasation or fistula formation. The patient became pregnant 2 years later with "in vitro" fertilization procedure. CONCLUSIONS: Robotic-assisted laparoscopic partial cystectomy with excision of rectal nodules for endometriosis can be safely performed.

[Evaluation of serum PSA in brain-dead subjects over the age of 50 before organ harvesting: organ donation and the risk of transmission of prostate cancer. Survey of the transplantation committee of the Association Francaise d'Urologie]. / Evaluation du taux de PSA sérique des sujets en état de mort encéphalique de plus de 50 ans avant prélèvement d'organes: risque de transmission du cancer de prostate et don d'organes. Enquête des Comités de Transplantation et de Cancérologie de l'Association Française d'Urologie.

UNLABELLED: Cancer in a brain-dead subject constitutes a contraindication to organ harvesting. However no data are available on prostatic assessment of brain-dead subjects prior to organ harvesting. The objective of this study was to evaluate prostate cancer screening by serum PSA assay in potential organ donors over the age of 50. METHODS: From February to May 2006, serum PSA assays were performed in all male donors in 5 different organ harvesting centres. The donor's age and the duration of bladder catheterization were also recorded. RESULTS: Of the 85 organ harvests performed, 30 (35.3%) concerned men over the age of 50 years (mean: 60.4 years, range: 50-82 years). The mean duration of catheterization was 3.1 days (range: 0.5-22 days). The mean PSA level was 8.7 ng/ml (range: 0.03-52.7) with a free PSA/total PSA ratio of 31% (range: 14-47). Twelve donors had a PSA level greater than 4 ng/ml (4.7 to 52 ng/ml), two others had a PSA level greater than 2.5 ng/ml (2.77 and 3.3 in subjects aged 72 and 57 years, respectively). There was no correlation between the donor's age, their PSA level and the duration of catheterization. CONCLUSION: The age of brain-dead donors is increasing and is reaching the age limit recommended by the Association Francaise d'Urologie for prostate cancer screening by digital rectal examination and PSA assay. Although the risk of transmission of prostate cancer after transplantation is currently unknown, at this stage when the majority of prostate cancers are discovered in a context of elevated PSA with normal digital rectal examination, the risk of transmission of a prostate cancer from the donor to the recipient is minimal or even non-existent. Digital rectal examination findings may be more relevant than PSA to contraindicate organ harvesting.

[Study of urothelial bladder tumours in renal transplant recipients]. / Etude des tumeurs urothéliales de vessie chez les transplantés rénaux.

OBJECTIVE: To study the prevalence, treatment and outcome of urothelial bladder tumours (UBT) in renal transplant recipients. PATIENTS AND METHODS: Multicentre retrospective study performed in 2004 by questionnaire sent to members of the AFU Transplantation Committee. RESULT: Seven centres returned the questionnaire with a total of 32 UBTs in 21 males and 3 females with a mean age of 63.2 +/- 10.1 years, with no history of UBT. The incidence was 255 per 100,000. The median interval between transplantation and UBT was 60 months (range: 5 to 259 months). 72% of UBTs were stage pT > or = 1 and 63% were grade 3. CIS was present in 20% of cases. 25% of patients were N+. In addition to resection of the UBT, 3 patients were also treated with mitomycin C and 1 was treated with BCG. 7 patients underwent cystectomy, with a palliative objective in 42% of cases, associated with radiotherapy-chemotherapy (2/3) or chemotherapy alone (1/3). Immunosuppressive therapy was decreased in 50% of cases. Six patients (25%) died from bladder cancer, 25% relapsed with a tumour progression rate of 50%. 46% of patients were in remission of their UBT 4% died from an intercurrent cause. 76% of survivors have a Junctional graft with no alteration of serum creatinine. CONCLUSION: Renal transplant recipients have an increased incidence of UBT, which are more aggressive and associated with a higher mortality compared to the general population. Increased surveillance and aggressive treatment therefore appear to be justified.

Initial experience with successful totally robotic laparoscopic cystoprostatectomy and ileal conduit construction in tetraplegic patients: report of two cases.

PURPOSE: To evaluate the feasibility and safety of totally robotic laparoscopic cystoprostatectomy for neurogenic bladder, with intracorporeal ileal-conduit urinary diversion in tetraplegic patients with severe neurogenic bladder complications. PATIENTS AND METHODS: Two men, 41 and 38 years old, with complete post-traumatic C7-C8 quadriplegia and poor lower urinary-tract condition underwent totally transperitoneally performed cystoprostatectomy and ileal-conduit urinary diversion with robotic assistance (Da Vinci). RESULTS: The procedures were completed without open conversion. The total surgical time was 9.25 and 6.75 hours, respectively. There were no intraoperative complications. In the postoperative period, both patients had mild complications (pulmonary and urinary infections) that were treated successfully medically. The postoperative hospital stay was 13 days in both cases. CONCLUSIONS: Our results demonstrate the safety and feasibility of robot-assisted laparoscopic cystoprostatectomy with ileal-conduit urinary diversion in two tetraplegic patients.

Laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction in patients with horseshoe kidneys: technique and 1-year follow-up.

OBJECTIVE: To report our experience with laparoscopic robotic-assisted management of pelvi-ureteric junction obstruction (PUJO) in patients with horseshoe kidneys. PATIENTS AND METHODS: Between January 2002 and May 2003, two men and a woman with horseshoe kidneys (mean age 44.6 years) had laparoscopic dismembered pyeloplasty with robotic assistance for PUJO with no division of the isthmus. Two patients had renal stones which were extracted during surgery. None of the patients had had previous abdominal surgery. RESULTS: The mean operative duration was 148.3 min, the mean estimated blood loss was <100 mL and the mean hospital stay was 7.6 days. Renal function was preserved in all three patients during the immediate and long-term follow-up as measured by intravenous urography. The three patients had durable clinical and radiographic success during a mean follow-up of 21 months. One patient needed complementary extracorporeal shockwave lithotripsy, and one had an episode of pyelonephritis, which was treated successfully. There were no other significant complications before or after surgery. CONCLUSION: Laparoscopic robotic-assisted pyeloplasty for horseshoe kidney is safe and feasible, offering the advantages of minimally invasive surgical procedures with enhanced laparoscopic skills related to the use of the robot.

Robot-assisted laparoscopic and open live-donor nephrectomy: a comparison of donor morbidity and early renal allograft outcomes.

BACKGROUND: Robot-assisted laparoscopic donor (RALD) nephrectomy, a new procedure for the removal of a kidney from a living donor, was performed on 13 subjects at our centre. METHODS: The immediate post-operative courses for these donors, and their respective recipients, were compared with those of 13 previous open live-donor nephrectomies (OPEN), performed in our facility. RESULTS: We found no significant differences between these two donor groups with respect to age, gender, body mass index or renal vasculature. The average operative times and the warm ischaemia times were greater in the RALD group, 185.5'' vs 113.4'' (P = 0.0001) and 7'15'' vs 1'41'' (P = 0.0001), respectively. There was no conversion to the open procedure in the RALD group. The estimated blood loss was slight in both groups. Following nephrectomy, deep venous thrombosis occurred in one RALD patient and acute pyelonephritis in one OPEN patient. The average duration of hospitalization was shorter after the RALD procedure (5.84+/-1.8 days vs 9.69+/-2.2 days, P = 0.0001). The estimated creatinine clearance rate (eClcreat) was equivalent for all donors, at 5 days and 1 month after nephrectomy. All kidneys started functioning immediately after the transplantation. The mean recipient eClcreat (ml/min) was 58.16+/-26.7 for OPEN group kidneys and 62.23+/-17.59 for RALD group kidneys (P = 0.65), 5 days after transplantation. CONCLUSIONS: RALD nephrectomies were associated with very low morbidity among donors, in which both the operative and warm ischaemia times were of longer duration, but had no observable adverse effects upon short-term graft function.

Laparoscopic robotic-assisted ileal conduit urinary diversion in a quadriplegic woman.

Urinary diversion is a therapeutic option in quadriplegic patients with poor lower urinary tract conditions, but it is an invasive procedure. Laparoscopic techniques are less invasive, but are technically demanding, and only a few surgical teams are able to complete such a complex procedure endoscopically. Robotics bring an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill to the laparoscopic approach. This complex case of laparoscopic ileal conduit in a quadriplegic woman was completed by our team with the Da Vinci system after 6 months of clinical experience in robotic surgery.

Kidney warming during transplantation.

The objective of the present study was to describe kidney temperature variations during transplantation and to identify the factors responsible for kidney warming. Kidney temperature was recorded steadily during transplantation. Kidney weight, body mass index (BMI), second warm ischemia time (t), and kidney temperature at the time of being placed in the recipient were analyzed so that we could evaluate their influence on kidney temperature and on kidney warming during transplantation. Kidney temperature at the time of removal from the container was 1.6 degrees C and 6. 3 degrees C when the kidney was placed in the recipient. Kidney temperature in the recipient depended on kidney temperature after serum washing (P<0.0001), but was independent of kidney preparation time (P=0.94). Then, kidney temperature (T) increased according to the logarithmic curve given in the following equation: T=7.2 ln(t)-0.6. Kidney temperature at the end of anastomosis was 26.7 degrees C. Kidney warming speed was 0.48 degrees/min and was dependent on the length of time of vascular anastomosis (P<0.0001). Kidney weight decreased the kidney warming speed (P=0.02). In conclusion, kidney warming increases slowly during ex vivo preparation. Kidney temperature stays below the damaging ischemic temperature of 18 degrees C. Because of its major impact on kidney warming, it is desirable that vascular anastomosis time be reduced, and, consequently, ex vivo kidney preparation needs to be meticulous.

[Robot-assisted (Da Vinci) laparoscopic uretero-pelvic junction repair. Results of experimental surgery in a series of 14 pigs]. / Cure de JPU coelioscopique assistée par robot (Da Vinci). Résultats en chirurgie expérimentale, à propos de 14 cas chez le porc.

OBJECTIVE: Experimental feasibility of repair of the ureteropelvic junction syndrome by robot. MATERIAL AND METHODS: 14 procedures were performed in 14 pigs by a laparoscopic technique using the Da Vinci robot in the experimental surgery laboratory. RESULTS: This robot provides real 3D vision by means of articulated intracorporeal instruments controlled from a console. It can be used to perform laparoscopic procedures almost as easily as open surgery. Operators with no previous experience of laparoscopic surgery were able to rapidly perform relatively complex procedures. CONCLUSION: This technique should allow a reduction of the learning curve and should facilitate operations that are difficult to perform by conventional laparoscopic surgery, especially when reconstruction is necessary, with decreased fatigue for the surgeon.

[Contribution of the latest generation CT in preoperative assessment of kidney cancer]. / Apport du scanner de dernière génération dans le bilan pré-opératoire du cancer du rein.

Technological progress in medical imaging runs in parallel to progress in computers, with an ever-increasing image acquisition rate and increasingly fine image reconstruction. Following the appearance, several years ago, of spiral acquisition CT, the multiplication of detectors (multi-array CT) has opened up new possibilities for investigation, especially in the field of renal tumours, where CT is now the first-line investigation due to the information obtained for characterization, vascular anatomical relations, and staging. The development of partial surgery (in which the detection of satellite lesions is essential) and minimally invasive laparoscopic surgery will be able to take full advantage of this progress in imaging by anticipating operative difficulties (number of tumours, situation and branches of arteries and veins or their collaterals, venous thrombus, relations with the urinary tract). Volume acquisition allows representation of these elements in the various dimensions, facilitating interpretation of the images.